The search for balance in the therapeutic decision-making process: the example of Class II malocclusion treatments in children and adolescents

Abstract

Therapeutic decision-making is essentially the key to our clinical practice, and its most medical feature. The history of orthodontics is studded with multiple intellectual debates and stand-offs between conflicting treatment philosophies, the authors of which all aspire to a balance guaranteeing optimal treatment for their patients. Among the wealth of published data, which items should we select to ensure balanced treatment decisions in our daily practice and how can we remain serene in the face of the uncertainty and loneliness engendered by therapeutic decision-making process? Evidence-based orthodontics is an aid to clinical decisionmaking. Its main features are illustrated by four clinical cases describing the treatment of class II malocclusions in children and adolescents. A search for the best pre-evaluated data on two-step treatments shows that : (1) a significant reduction in the prevalence of incisive trauma is observed in children when an increased overjet is corrected by an initial treatment phase, compared to single-stage treatments conducted in early adolescence; (2) the long-term impact of the first treatment phase on the amount of mandibular growth is at best weak and clinically insignificant. The evidence-based approach, particularly when performed in user mode, enables us to reach more balanced clinical decisions. However, the article points out the key role of the clinician and the double risk of reducing the evidence-based approach to a mere standard of care - which it is not - and the subordination of treatment management to the strict clinical application of data in the literature.