Pacific Coast Society of Orthodontists Bulletin Spring 2020 - 38

Let's Talk About That

though perhaps not meeting the standards of
optimality, are at least not significantly harmed
due to the treatment.
How best to compromise will vary greatly from
patient to patient, but as a general rule, we try
not to take away anything that the patient has
that is already good (do no harm), such as a good
AP position of the maxilla and maxillary incisors.
We will often try to "spread the costs" by perhaps
doing a little bit of maxillary growth restriction
(high-pull headgear) coupled with a little bit of
AP dental compensation in each arch but not
enough in any one area to detract from health,
function, and/or appearance. If overdone, the potential consequences of a compromise could be
poor occlusion, loss of periodontal support, root
resorption, poor esthetics, negative impact on the
airway, or all of the above. Sometimes, leaving
excess overjet is the best compromise. When
compromises are designed, the ICD values in
opposing arches will often change relative to the
optimal treatment plan but are still unlikely to
be equal and opposite, so treatment within each
arch will still require a customized force system to
be developed that conventional, inherently reciprocal, interarch mechanics will not produce.
PT: How much do you rely on surgery for jaw
corrections?
WA: It is true that most patients have jaw
position discrepancies that preclude full and
complete correction that would satisfy all of the
six element treatment goals, often because of
the mandible's AP position. However, many such
discrepancies are small, meaning less than 4 mm
in any plane of space, and can be successfully
compensated for dentally or improved with minor
jaw growth modification. Serious consideration
should be given to orthognathic surgery for jaw
position discrepancies that exceed 4 mm. Oral
and maxillofacial surgeons who are familiar
with the six elements of orofacial harmony seem
to immediately grasp its utility. Using the six
element guidelines, patients with significant

skeletal discrepancies can be treated surgically to
predictably good outcomes.23
PT: How would you like to sum up part 1 of this
interview?
WA: The topics we have touched upon so far
are important ones: arch form, extraction/nonextraction, classification, growth modification,
and so on. The predominant theme underlying
all of these issues circles back to goals, landmarks, and referents. Until there is consensus
among orthodontists about goals, landmarks,
and referents, we expect that the specialty will
remain on its unfortunate current trajectory toward almost anything goes. We strongly believe
that only through the emergence of scientifically defensible treatment goals that can be shown
to enhance the health, function, and appearance of our patients will our specialty be set
apart from generalists who are focused mainly
on aligning teeth and neutralizing interarch
relationships.
Part 2 of this interview will appear in the next issue
of the PCSO Bulletin. Topics to be discussed include
appliances, occlusion, articulators, esthetics, smile
arc, face height, airway, and more.
References
1. Andrews LF. The six keys to normal (optimal) occlusion. Am J Orthod Dentofacial Orthop 1972;62:296-309.
2. Andrews LF. Syllabus of the Andrews Orthodontic Philosophy. San Diego, CA: Lawrence F. Andrews; 1990.
3. Andrews LF, Andrews WA. The six elements of
orofacial harmony. Andrews J Orthod Orofac Harmony
2000;1:13-22.
4. Trivino T, Siqueira DF, Andrews WA. Evaluation of the
distances between the mandibular teeth and the WALA
ridge in a Brazilian sample with normal occlusion. Am J
Orthod Dentofacial Orthop 2010;137:308-309.
5. Kong-Zarate CY, Carruitero MJ, Andrews WA. Distances between mandibular posterior teeth and the WALA
ridge in Peruvians with normal occlusion. Dental Press J
Orthod 2017;22:56-60.

PCSO Bulletin Spring 2020

Pacific Coast Society of Orthodontists Bulletin Spring 2020

Table of Contents for the Digital Edition of Pacific Coast Society of Orthodontists Bulletin Spring 2020