I daresay might have been somewhat different. We do notknow whether what the authors call “protruding incisors”means dentoalveolar protrusions in a favorable maxillaryhousing or merely linear differences of the overjet created bythe retrognathic mandibles and the same maxillary housing.There can be no question of a very positive patient responseto the former situation, but it takes real orthodontic skill withmoment/force ratios to properly retract incisors without cre-ating what could be an unfavorable response to their “dish-ing” of profiles or increasing toothiness by dropping theincisal edges in patients with short philtrums who opted forcamouflage. These detracting elements are generally absent insurgical correction.

Again, the response of the sexes is of critical importancein such a study. Because the camouflage group was over-whelmingly female and, by definition, the camouflage pa-tients had “less severe malocclusions,” these women wouldnaturally express great satisfaction facially and dentally withthe reduction of the overjet/overbite, in both the short andlong term. Whatever “less severe” mandibular deficiency waspresent might not be of that much concern to these patients,because they could easily think of some famous movie starsand models who have such a facial convexity and arealtogether feminine. The same result in a man could certainlyelicit a positive response in comparison with his originalproblem, but he still might secretly wish for a straighter, moremasculine profile featuring a more “manly” chin. Especiallycould he be forever troubled if shown in advance throughvideo imaging what might have been accomplished surgicallyhad he not settled for the less risky and far less expensivecamouflage.

I came from an era when maxillofacial surgery was moreor less in its infancy. Today, though still not without risks, itis much less traumatic and entails fewer side effects. Conse-quently, I teach offering it to all patients with skeletaldeficiencies. As the authors point out, patients are indeedhappier with their lower facial profiles. We are now in an erawhen many facially enhancing surgeries are routinely admin-istered, and esthetic orthodontic treatment is an integral partof it—not least because we are often the first one a patientseeks service from and are thus in a position to educate.

As an aside, I will longer offer dentally compensating anearly teenage markedly skeletal retrognath with premolarextractions or buccal segment distalization and thus eitherpreclude future surgery or force the patient into bimaxillaxysurgery. If a reasonable course of fixed functional (eg, Herbstor MARA) treatment is not successful, I will urge correctionlater. If the patient refuses for whatever reason and isaccepted elsewhere for camouflage, he or she might be lost,but I will sleep better.

Stanley P. Kessel, DDSHollywood, Fla

0889-5406/2003/$30.00 � 0doi:10.1016/S0889-5406(03)00496-7

Authors’ responseOur article emphasizes 2 things:

1. Adult Class II patients who are candidates for orthodontictreatment alone are, and must be, different from thoseselected for combined orthodontic treatment and orthog-nathic surgery. Milder problems can be treated withorthodontic retraction of protruding maxillary incisors, butsevere problems require surgery to reposition at least 1jaw. It would be unethical to set up a study in which ClassII patients were assigned at random to surgery or ortho-dontic treatment. No review committee would approvesuch a project, and it is highly unlikely that patients wouldconsent to random assignment. The patients in this studywere offered surgical or orthodontic treatment as deemedappropriate by clinical faculty at UNC, using their bestjudgment as to whether orthodontic treatment alone wouldsucceed. No patient who required surgery for a satisfactoryoutcome had orthodontic treatment instead, and as wedocument in the article, the surgery patients had moresevere problems.

2. The long-term (�5 year) outcome of orthodontic treatmentalone can and should be evaluated in the same way as thelong-term outcome of surgical treatment. This requires 2types of data: dental and skeletal stability, and the patients’evaluation of the outcome. At this point, the long-termstability of surgical treatment is better documented in theliterature than orthodontic outcomes, and patient percep-tions rarely have been studied as an outcome of orthodon-tic treatment. Our study shows that these orthodontics-only patients, who were selected for that treatment basedon the characteristics of their problems, compare favorablywith the surgery patients from both perspectives.

There are 2 extreme views of orthodontic camouflage ofClass II problems in patients who are too old for successfulgrowth modification. The first, to which Dr Kessel seems tosubscribe, holds that, unless nonextraction orthodontic treat-ment would be satisfactory, surgery is the only appropriatetreatment. The second, best labeled as the self-serving insur-ance-company fallacy, is that moving teeth to better occlusionis satisfactory treatment for any patient, regardless of skeletalcharacteristics. Neither of the extreme views is correct.

With the strong emphasis many clinicians have placedrecently on nonextraction orthodontic treatment, however,perhaps it is useful to note the successful long-term outcomeof orthodontic extraction in well-selected Class II patients.

Colin A. Mihalik, DDS, MSWilliam R. Proffit, DDS, PhD

Chapel Hill, NC0889-5406/2003/$30.00 � 0doi:10.1016/S0889-5406(03)00497-9

American Journal of Orthodontics and Dentofacial OrthopedicsJuly 2003

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