Thank you for providing the opportunity to respond to the letter sent by Dr Michael Gunson regarding the above article (Angle Orthod. 2003;73:365–373). We certainly agree with much of Dr Gunson's comment and share his enthusiasm for an increased discussion of facial esthetics in the literature. Dr. Gunson was apparently concerned that we had made the general conclusion that the esthetic outcomes of orthognathic surgery and functional appliance treatment are equally favorable. As far as we can tell, we have not made such an absolute statement. Instead, our position is well-presented with the following quote from page 370 of the article:
It seems that if a Class II division 1 patient presents early enough for some sort of attempted growth modification treatment, it may be possible for the esthetic outcome of that treatment to be just as favorable as if that patient were to be treated later at the end of the growth phase by orthognathic surgery. However, only average findings have been reported in this study, and many clinical and cephalometric factors need to be considered when planning treatment for each individual Class II patient. It may, for instance, be reasonable to provide some form of attempted growth modification treatment for those patients, in whom there is doubt about the ultimate choice of treatment method, knowing that in not all patients will such attempted growth modification be successful. In these cases, patients may have to receive treatment later in the form of orthodontics combined with orthognathic surgery. The need for such treatment later perhaps should not be seen as a failure, but more as recognition of the wide range of individual responses to any form of orthodontic or orthopedic treatment.
We also stand by the conclusion that “Perceived esthetic outcomes in many (not all) Class II division 1 patients seem to be just as favorable whether they have been managed earlier during the useful growth phase or later, at the completion of growth by orthognathic surgery.”
We agree with Dr Gunson's observation that the facial photographs of the patients deemed to have been unfavorably treated highlight the fact that some sort of formal soft tissue analysis should be a critical component of any orthodontic planning exercise. We have, however, been honest in presenting the worst cases from each of the surgery and attempted growth modification groups. There is no doubt that both the surgery case (SM) and the growth modification case (AG) may well have been more favorably treated with different means. Having said that, we stand by the fact that functional appliance/fixed appliance treatment (with or without premolar extractions) does not inevitably lead to midface deficiency or to poor esthetic outcomes. In the majority of the patients in this study, there was a considerable esthetic improvement. That is not to say that some of those patients would not have had better outcomes if they had been treated with orthognathic surgery. Nevertheless, if we are able to treat a child satisfactorily during the growth phase and the outcome is considered favorable in terms of both facial esthetics and occlusal function, then we have served our patients well. In the few patients who do have an unfavorable outcome, the option of orthognathic surgery is fortunately still available to them. The key to this final assessment after the attempted growth modification phase is not to undertake obviously irreversible treatment, such as the extractions of upper premolars (case AG), before all the likely positive and negative outcomes of treatment have been discussed in detail with patients and their families. We are strong believers in the place of orthognathic surgery within the overall treatment armamentarium. However, we would find it difficult to convince parents to delay treatment in all cases until the cessation of growth allowed children to be treated surgically, when there is a strong possibility that attempted growth modification treatment, with its combination of anteroposterior and vertical dental, skeletal and soft tissue effects, would provide a favorable or even comparable result.