When is enough enough?

Charles is one of your favorite patients, and your friendship with him has been a long one. He is an interactive young man, and, unlike some patients with unilateral cleft lip and palate whom you have treated, Charles demonstrated excellent oral hygiene and articulated his desire to achieve an optimal result. Recently, however, his cooperation and home-care levels have begun to erode, and he is increasingly eager to be debanded as soon as possible. It has been a long road for Charles, from multiple episodes of bone grafting to 2 phases of orthodontic therapy. You corrected his anterior crossbite when he was 7; now, at almost 14, he has spent more than 28 months in comprehensive orthodontic treatment, including additional protraction facemask therapy. Because of the position of his severe cleft, his maxillary left lateral incisor was lost despite his therapists’ best efforts. He is seated in your operatory for a final evaluation before you appoint him for retainer impressions. The family is satisfied with his esthetics, but you observe that his result could be further detailed. His maxilla remains slightly retrusive, and the buccal segments could use improved interdigitation—although this might not be possible with his anatomic limitations. You ask yourself how much farther should you push this treatment, considering the compromises that are inherent in his dentoskeletal profile.

In a classic article, Moorrees and Gron defined therapeutic modifiability in the context of orthodontic diagnosis as “the limitations of treatment . . . (given) the patient’s motivation for treatment, anticipated cooperation, dental health status, and the need for treatment to achieve optimal function and well-being.” They asserted that normal occlusion is “a range rather than a single set of characteristics.” In other words, the treatment plan for some patients should be tailored to realistic expectations because conditions beyond the clinician’s control can have a significant effect on the expected treatment outcome. If there was ever a situation where a universal, ideal objective might be elusive, the patient with a dentofacial deformity is the one.

Therein lies the gray zone that we encounter, not only in the concept of diagnosis as described by Moorees and Gron, but also in the treatment of those with craniofacial deformities. Although a textbook result should be our goal for every patient, certain individualized factors can limit the quality of our results. The recognition of such factors and the degree to which they influence treatment outcome can be assessed by evaluative judgments rather than factual judgments. Factual judgments provide answers or solutions that are right or wrong. For example, advising a patient to activate a maxillary expansion device 10 times daily for 3 days is wrong for factual reasons. In contrast, evaluative judgments require experience and knowledge of the circumstances pertaining to the specific case to determine the appropriate action. The orthodontist’s self-assessments, such as “given the maxillary-to-mandibular disharmony, can the occlusion be further optimized?” and “despite several minor imperfections, would prompt debanding compromise my result in any way?” are such examples. When we ask ourselves these questions, we are really asking whether we can do more for our patient, since our patient is entitled to nothing less.

The question of whether to conclude treatment for our patients is an ethical one if we believe in the principle of beneficence. After all, our patient and parents have entrusted us to exercise our judgment to maximize “good”—to provide them with the best possible result. They rely on us as professionals to make that judgment, since they cannot do it themselves. Yet, most would agree that a mildly compromised buccal segment relationship in this case would have an inconsequential impact on dental health. Such a decision should never be seen as an excuse for mediocre orthodontic therapy but, rather, as a dose of realism on a case-by-case basis. And if we decide to suggest termination of treatment, the recommendation should be shared with Charles and his parents to respect their collective autonomy.

It’s your “evaluative” call.

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Apr 8, 2017 | Posted by in Orthodontics | Comments Off on When is enough enough?
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