I would like to comment on the guest editorial by W. Eugene Roberts, “Is the education worth the debt?” (Am J Orthod Dentofacial Orthop 2010;138:125-6). I am in full agreement that students master the essential skills as stated by Dr Roberts. Although I cannot support with hard evidence Dr Roberts’ comment that he has noticed a “progressive incidence of undesirable clinical outcomes that… reflect a less-than-optimal education,” I can relate to the basis of this powerful assertion. As a second-year orthodontic graduate student at the University of Maryland, I am finding my new specialty both exhilarating and troubling. In our seminars, we discuss the fundamental articles by the great thinkers in orthodontics; when I enter the clinic and attempt to apply this knowledge, maybe I am naïve and inexperienced, but it seems that the old truths are often discarded, and expediency rules.

Although I understand that borderline malocclusions can be treated with several approaches, I see wide disagreement between clinicians on some extreme cases. Twelve millimeters of crowding in an arch is treated with expansion by 1 orthodontist, whereas another insists that stability can only be achieved by extractions and maintaining the original arch width. Then some believe that preservation of all premolars is conservative treatment, yet they ultimately sacrifice the third molars. Why don’t they just call it “delayed” extraction?

Treatment plans seem to depend less on the particulars of the case and more on which orthodontic “religion” an orthodontist belongs to. The truth is that no matter which philosophy one follows, there will always be cases that are successful. Do good results depend on the practitioner’s dexterity and the method? Or could there be something more scientific or, rather, biologic at play?

We hear those who claim to grow mandibles using magical appliances. And then research shows that there is not much difference in the size of mandibles after the functional appliances are removed. So, does the functional appliance grow mandibles or is it a combination of growth, dentoalveolar changes, and possibly some condylar-fossa remodeling? Damon’s disciples claim that we can grow bone by using their protocol (reading the excellent “Ask Us” article on self-ligating bracket claims in the August issue of the AJO-DO , I was encouraged to offer my thoughts). They can show case after case of “arch development” and claim that a slow expansion modality causes bone remodeling and muscle adaptation. They claim that total treatment time is also less than with conventional methods. But would not a longer treatment be better, allowing the musculature even more time to adapt before the appliances are removed?

Consider the 3 planes of space. Many have no reservations about changing the transverse plane via a low-force, low-friction modality or a high-force, rapid palatal expansion, or the sagittal plane via functional appliances. The vertical plane is a more respected dimension. But some have no problem violating this plane also, which then has the consequence of relapse when we invade a patient’s natural freeway space or esthetic issues when we make a long face even longer.

We have all heard of the functional matrix theory, which acts in all 3 planes of space. To change any dimension, we should look at the patient’s overall musculature, facial tonicity, and muscle attachments. The way I see it, either a patient’s musculature determines the boundaries of the dental arches, or alveolar and basal bone can be grown and the facial musculature will adapt, but we cannot have it both ways. Expansion of both arches to resolve crowding or create a broader, more esthetic smile either is well tolerated and stable or will collapse unless retained for life. Pick your poison.

Common sense says that, when we remove our mechanisms, we will end up back where we started, unless the musculature and functional matrix have adaptable natures that can accommodate the changes. Although there will always be successful cases that flaunt the logic, it is only in an individual situation, not universally. So, in order not to take the risk of having to decide which patient will adapt and which will not, we require all of our patients to be on some sort of retainer for life. Then, when our patient finds lifetime wear impractical, does that absolve us of our responsibility to have striven for a stable result? A beautiful result at deband is no predictor of stability, yet those are the models we proudly display. We should treat to what’s currently known to be most stable, realize the individual patient variations, and modify treatment to suit.

I also humbly question whether there are truths to be found in cephalometric or model-analysis averages of population samples. We know the average female shoe size is about 8, but that means nothing to me with a shoe size of 7. So why treat mouths to 1-size-fits-all approaches? Our patients do not all live on the center of the bell curve but are often outliers in some aspect that need not be changed. Dr Mulligan coined the phrase years ago, but it might be time for our specialty to again revisit common sense and to make the education worth the debt.