Re: Long-term skeletal and dental effects and treatment timing for functional appliances in Class II malocclusion. The Angle Orthodontist 2013(2) 334–340

To: Editor, The Angle Orthodontist

What do patients want?

Patient's wishes are simple: an attractive face and smile achieved without discomfort or damage, which lasts a lifetime. Is this always achievable? If not, how should we balance the priorities?

One of the problems is that we have become so involved in aligning the teeth that we sometimes fail to look at their owner. In last month's journal, Franchi, Pavoni, Faltin, McNamara and Cozza1 showed that functional appliances can achieve “a significant long-term elongation of the mandible” but also “an increase in lower anterior facial height”. This confirms numerous previous findings that most treatment, fixed or functional increases vertical growth.2–8 Other research has suggested that longer faces are less attractive.9

This point can be illustrated with an example taken with permission from the Journal of Clinical Orthodontics (Figure 1).10 This case was treated by a fixed functional as part of a case presentation. It was later included in an unpublished study in which the aesthetics of both the teeth and face were rated by lay and orthodontic judges. Six orthodontic judges ranked this result as 12^th out of 32 patients, but 6 lay judges placed it 32^nd. The teeth seem to be near ideal so what is the problem?

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The public seem exceptionally sensitive to increases in lower anterior facial height and yet a glance through treated cases shows that this is common side effect of orthodontics. How should benefits be balanced against risks and, of more importance, who should make that choice? We need to remember that our duty is to the public.