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More ways than one

American Journal of Orthodontics and Dentofacial Orthopedics, 2021-07-01, Volume 160, Issue 1, Pages 10-10, Copyright © 2021 American Association of Orthodontists

You truly enjoy the Tuesdays you devote to teaching at a local university. Despite the numerous continuing education courses you’ve completed, your experience as a part-time educator has enriched your knowledge more than you could ever imagine. As you’ve often said to your residents, their interaction with you gives you much more than you bring to them. And the best residents are those who are insatiable when it comes to knowing why, when, and how. But you notice an increasing trend over the years you’ve been teaching. The XYZ distalizer seems to find an extensive application after a lecturer espouses its vast benefits. And subsequently, the ABC appliance soon replaces it after another proponent brings lunch and shares their slide presentation with the residents. You almost believe that the device displayed by the most recent or most alluring presenter suddenly reigns as the soup du jour of contemporary orthodontic therapy. You wonder how so many new ways to solve a clinical problem can be considered that much more effective than the last.

In appliance choice or treatment planning, everyone has their favorite hammer with which to hit the nail. Whether we promote surgically-assisted rapid palatal expansion with a Hyrax appliance or favor segmental osteotomies with rigid fixation to expand an adult’s maxilla might be irrelevant if they both produce results that are clinically superb and equally stable. Ditto, if our attempt is to avoid premolar extractions or if we never hesitate to write the extraction order regardless of how much parents flinch at the thought. Ideal treatment objectives should be approached without bias toward the appliance used to meet those objectives. Our fiduciary responsibility is to place the patient’s welfare above all else. Results vary not by appliance type but by the way we deliver a specific form of therapy, the care we take to execute it, and the compassion we provide to address patients’ physical and emotional needs. Before we initiate treatment, we must ask ourselves if the appliance is clinically effective, whether the risk-benefit ratio justifies our choice, and if less invasive intervention would equally meet our objectives. In addition, it is absolutely critical that we not bad-mouth other practitioners who use something that differs from ours as long as a combination of ample experience, evidence-based information, and respect for the patient’s values as well as ethics fundamentals prevail. When we criticize our colleague’s appliance or therapy, we criticize ourselves—and thus denigrate our entire specialty. What is vogue in orthodontic circles these days is irrelevant and immaterial; the vogue is what is best for that patient in the chair.

This is not a new concept. Almost a century ago, Milo Hellman, one of the greatest orthodontic luminaries of all time, admonished that treatment be delivered with respect for fundamental principles that are “backed by knowledge, skill, ability and guided by mature judgement.”

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Despite our most sincere intentions and earnest efforts to do our best for our patients, we’ve all found ourselves entangled in clinical situations that cannot be brought to satisfactory results regardless of the appliance we use. In these instances, the severity of the challenge supersedes our own—or anyone’s—expertise. Orthodontists who won’t admit that the treatment of some patients exceeds human capacity are fooling themselves. The late Harry G. Barrer, one of my favorite instructors, was a man of practicality as well as wisdom. He coined an adage that forever endures in my mind. He asserted that 20% of patients could be effectively treated by anyone; 20% could be treated by only Divine Providence; but the remaining 60% is dependent on the skill, knowledge, perseverance, and experience of the orthodontist (Barrer HG, personal communication, 1984).

Nothing has changed since I heard those words. I’m still pursuing that 60% with a passion.


  • 1. Gross R.: Helping the patient decide.2001.MosbySt Louispp. 73-97.
  • 2. Hellman M.: The future of orthodontia; a present-day problem for the orthodontist. Am J Orthod 1947; 34: pp. 1-17.