American Journal of Orthodontics and Dentofacial OrthopedicsNovember 2008

600 Readers’ forum

One must objectively question whether all the time andunsubstantiated blind procedures to reach certain treatmentoutcomes is justifiable, especially in this era of evidence-based dentistry.

Again, we thank Dr Takahaski for sharing this case withthe readers of the AJO-DO, and we appreciate this opportu-nity to discuss and debate the issues raised by his report.

Steven IszkulaPittsburgh, Pa

Sanjivan KandasamyPerth, Australia

Donald J. RinchuseGreensburg, Pa

Am J Orthod Dentofacial Orthop 2008;134:599-6000889-5406/$34.00Copyright © 2008 by the American Association of Orthodontists.doi:10.1016/j.ajodo.2008.09.005

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Author’s responseWas the total active treatment time too long? My only

answer is that this patient needed 63 months. The incorrectinitial care for her temporomandibular joint (TMJ) by anteriorrepositioning splint related to the difficulty of stabilizing herTMJ. I have seen many other TMJ patients treated by thesame philosophy. Some patients need 3 months, others need6, and I have even seen some who needed 12 months. Iwanted to emphasize in this case report that incorrect initialcare leads to the wrong result. After resolution of her chiefcompaint (pain), this patient could have chosen not to haveorthodontic treatment and orthognathic surgery and to con-tinue to use the stabilization splint while sleeping. The periodof care is not important; reproducibility for diagnosis is.Diagnosis when there is no reproducibility leads to the wrongdiagnosis. The important thing is skill and precision for thestabilization splint. How precisely doctors always give mu-turally pretected occlusion for TMJ patients by splint isimportant. For condylar position indicator (CPI) instruments,there is the same problem. When doctors use CPI instrumentsto monitor condyle position, long use of a splint sometimescauses changes in the mandibular dentition, and the initialmodel cast no longer fits the monitoring wax. In this case, anew one must be made for the patient, even if breakingconnection with initial cast. At this time, there is no betterclinical instrument than the CPI to monitor the mandibularposition precisely.

A building contractor should investigate the groundbefore planning the building. If the ground is not safe, then,when the building is done, excuses will not help it stand.

Ichiro TakahashiNara, Japan

Am J Orthod Dentofacial Orthop 2008;134:6000889-5406/$34.00Copyright © 2008 by the American Association of Orthodontists.

doi:10.1016/j.ajodo.2008.09.004