American Journal of Orthodontics and Dentofacial OrthopedicsVolume 126, Number 4

Readers’ forum 21A

these lines. For example, there are different norms for PuertoRican and Dominican groups when assessing Latino popula-tions.

The DI was designed to be a simple tool for assessingtreatment complexity in patients by assessing the severity ofthe target disorders that must be addressed to achieve thetreatment goals. The cephalometric measurements were in-cluded in an attempt to answer questions such as, “ is this a bigClass II?” ; “ is there an openbite or deep overbite tendency?” ;“are the incisors flared excessively?” We believe that usingthe DI, with common sense in its application, helps to answerthese questions.

Dr Quinn also expressed concern that the curve of Speeand some other entities were not included in the “other”category. It would not be feasible to list every possible entityand assign a point value to it. The “other” category allowslisting things that have occurred with some frequency in casesthat the ABO has reviewed. We believe that the DI ascomposed represents about 85% of the most common targetdisorders. Incidentally, the curve of Spee receives consider-able attention in the board’s assessment of case management,which is one of the key elements, along with diagnosis andtreatment planning and final occlusion, in overall case eval-uation. It is here that arch form, arch width, facial esthetics,and overall record quality are assessed. The ABO is currentlydeveloping a form for evaluating case management that willbe introduced soon.

As the number of cases evaluated by the DI increases,changes in the entities scored and the number of pointsassigned to each will be subject to discussion and change ifnecessary.

We commend Dr Quinn for his astute observations duringthis early stage of his orthodontic career and congratulate himon his commitment to pursue ABO certification.

Thomas J. Cangialosi, DDSMichael L. Riolo, DDS, MS

S. Ed Owens, Jr, DDS, MSDVance J. Dykhouse, DDS, MSAllen H. Moffitt, DMD, MSD

John E. Grubb, DDS, MSDPeter M. Greco, DMD

Jeryl D. English, DDS, MSR. Don James, DDS, MSD

0889-5406/$30.00doi:10.1016/j.ajodo.2004.08.004

Substitution treatment for missinglateral incisors

I am responding to the request for input about substitutiontreatment for missing maxillary laterals. I have found thisoption to be quite useful in treating a particular population:children with clefts. Typically, there is absence or deformityof the maxillary laterals in such patients. There is usually alsosome maxillary skeletal hypoplasia with this absence. Thisalso seems to be true in noncleft patients who are missing

laterals. I have found this combination of dental and skeletalproblems lends itself nicely to substitution therapy.

It is typical for a child with a cleft to require alveolargrafting preparation, comprehensive orthodontic treatment,an orthognathic procedure, retention care, and prosthetictreatment to finalize care. This is lengthy treatment! Withsubstitution treatment, I make every attempt to eliminate orminimize the need for the latter phase.

These children typically have normal and robust mandi-bles, so I use Class III traction to advance the maxillaryposterior dentition in space closure. This typically worksnicely and is also ideal to prepare for an orthognathicprocedure. There is minimal or no retraction of the maxillaryanteriors and minimal advancement of the mandibular inci-sors.

The cosmetic concerns related to the difference in mor-phology of the canines and laterals are real, and I address thiswith a series of staged enameloplasties. I initiate these beforeappliances are placed. I typically start by reducing thebulbous labial surface of the canine, its cusp tip, and incisaledges. If the first premolar will be substituted for the canine,which I typically do, I start reduction of the lingual cusp tip.This cusp is shaped on a bevel. Lateral brackets are placed onthe canines and canine brackets on the first premolars. Toachieve the best cosmetic results usually requires 3 to 4additional enameloplasty procedures. To promote odonto-blastic activity, I avoid gross reduction with the secondaryprocedures. I integrate the shaping procedures with scheduledadjustment visits and sometimes take advantage of timeswhen the patient is seen to repair appliance breakage. Basi-cally, this is a dedicated part of the treatment plan that isreviewed with the patient and the parents as treatmentprogresses. This usually results in an acceptable cosmetic andfunctional result. If at the end of treatment additional cos-metic treatment is required, it can often be nicely addressedby the general dentist with the vast array of techniquesavailable today. Thankfully, most of these procedures providecomparable or improved cosmetics, and are less invasive andtime consuming than conventional fixed and removable pros-thetics. It seems that all of this nicely addresses the cosmeticconcerns associated with substitution therapy.

As for the concern that this treatment might significantlyalter respiratory physiology, I am not the one to address that,but I have not encountered this. On the contrary, it seems thatthis treatment in conjunction with orthognathic surgery im-proves function. If there is a true physiologic change associ-ated with substitution treatment, I would first suspect theneuromuscular complex associated with the maxillary skele-tal hypoplasia. It seems unlikely; I think the literatureimplicates mandibular hypoplasia with obstructive sleep ap-nea. As you stated, more research and evidence are neededbefore associating this treatment procedure with significantnegative physiologic changes.

I have often thought that one of the gratifying aspects ofbeing an orthodontist is the ability to manipulate natural andhealthy tissue to improve cosmetics, function, and health.What the orthodontist does with substitution therapy is slowly

American Journal of Orthodontics and Dentofacial OrthopedicsOctober 2004

22A Readers’ forum

perform an autogenous graft, placing a dental implant that hasa biologically viable epithelial attachment and periodontalligament—all of which have excellent prognoses. This seemsfar superior to conventional prosthetic options and basicallyembodies the epitome of what orthodontics is all about. Forthe cleft child, this is particularly helpful. These children havebeen treated from birth, and this provides a gentle, healthy,

and cosmetic finish to that treatment with minimal prostheticburdens over a lifetime.

Thank you for the opportunity to have input on this issue.Joseph M. Waldron, DDS

Gainesville, Fla0889-5406/$30.00doi:1016/j.ajodo.2004.08.002