A comparison of surgery and orthodontics in

"borderline" adults with Class II,

Division I malocclusions
Donald W. Cassidy, Jr., MDM, MSD," Eugenio G. Herbosa, DMD, MMSc, b
Kenneth S. Rotskoff, DDS, MD, b and Lysle E. Johnston, Jr., DDS, PhD °
Presque Isle, Me., St. Louis, Mo., and Ann Arbor, Mich.

From a pool of 108 former patients, discriminant analysis was used to identify a homogeneous
borderline prognostic subgroup of 27 adult orthodontic and 26 adult surgical Class II patients who,
before treatment, were similar with respect to the characteristics on which the orthodontic/surgical
decision appears to have been based. The fact that some had been treated orthodontically,
whereas others had been treated surgically, was taken as empirical evidence that the patients in
this stratum were equally susceptible to the two treatments and that the actual choice was largely a
function of whose office they happened to contact. The former orthodontic patients were recalled
an average of 7.1 years after treatment; the former surgical patients, 4.7 years after surgery. Each
subject was evaluated with respect to skeletal and dental stability, profile esthetics, and
temporomandibular function. Although there were dramatic differences in the nature of the
correction (dental versus skeletal), both groups of patients generally thought that their profiles had
been improved by treatment. As judged by data generated from visual analogue scales, the mean
difference beween the orthodotnic and surgical patients' evaluations of their treatments was small
and nonsignificant. Moreover, the "borderline" Class II orthodontic and surgical patients showed no
significant differences in craniomandibular function and incisor stability. There was, however, one
profound difference beween treatments: 3 of the 26 surgical patients underwent extensive relapse,
probably as a result of condylar resorption. From the standpoint of estimated probabilities and
utilities for the various outcomes, the present results imply that orthodontics would be the better
choice for the borderline adult Class II patient, whereas surgery would be appropriate for the more
severely affected patient. (AM J ORTHODDENTOFACORTHOP1993;104:455-70.)

A l t h o u g h the refereed literature has lit-
tle to say on the subject of orthognathic surgery as
a cause of craniomandibular disorders (CMD), it is
commonly held by many nonspecialists that CMD
can result from condylar displacement (mesial, dis-
tal, lateral, or inferior, depending on the school of
conjecture) and that these displacements are often
the result of "surgery." Despite the fact that our
critics have thus far failed to muster much in the
way of data to support their various contentions,
Based in part on a thesis submitted in partial fulfillment of the degree of
master of science in dentistry, St. Louis University. Dr. Cassidy was the
recipient of a 1991 Award of Special Merit from the American Associa-
tion of Orthodontists.
Supported by NIDR grant DE08716 and by donations from the Orth-
odontic Education and Research Foundation (St. Louis).
"In private practice of orthodontics, Presque Isle, Me.
bin private practice of oral and maxillofacial surgery, St. Louis, Mo.
CRobert W. Browne Professor of Dentistry and Chairman, Department of
Orthodontics and Pediatric Dentistry, The University of Michigan.
Copyright © 1993 by the American Association of Orthodontists.
0889-5406/93/$1.00 + 0.10 $/1/48257
their influence among our colleagues in general
practice, combined with a willingness to go to court,
have had a profound chilling effect on the practice
of orthodontics in North America. Indeed, much of
the specialty's current malaise appears to stern
from a frustrating inability to respond in real time
to the improbable criticisms of the "functional
orthodontists." Who, for example, could have fore-
seen that there would be a need to answer the
argument that maxillary incisors are never protru-
sive, that humans have a premaxillomaxillary su-
ture, or that mandibles can be grown ad libitum?
Fortunately, some aspects of the problem have
already been examined. Human beings have
evolved no new sutures, 1 and premolar extraction
once again can be viewed as an occasionally useful,
largely benignant treatment a d j u n c t 9 Although
the literature thus contradicts many of our critics'
accusations and claims, there are enough real ques-
tions to warrant a serious, long-term examination
of the effects of treatment. For example, we know

455
 456 Cassidy e t al.
less than we might about the perceived esthetic
impact and long-term stability of conventional orth-
odontics, and recent reports indicate that condylar
resorption, fibrous ankylosis, and osteoarthritis are
potential sequelae of Class II surgical treat-
ments. 41° Whatever our reasons for wishing at last
to study the impact of contemporary treatments, it
soon becomes apparent that comparative analyses
are complicated by the u n e x p e c t e d - a n d largely
unacknowledged-difficulty of applying familiar
medical models to the study of orthodontic
treatments.
In medicine, prospective randomized trials con-
stitute a time-honored "gold standard"; in orth-
odontics, their use is compromised by a host of
practical problems: The difficulty of assigning treat-
ments at random and, at the same time, meeting
the ethical requirements of informed consent
("You could be treated orthodontically, but we
drew straws and it came up two-jaw surgery; sign
here . . . . "), probable sample attrition, the distor-
tions produced by known participation in a clinical
trial (the so-called "Hawthorne effect"), protracted
time frame, gradual obsolescence of the working
hypothesis, and cost. The alternative approach, the
use of retrospective comparisons (say, extraction
v e r s u s exigansion, treatment versus control), can
easily provide timely, ethical data. Unfortunately,
this type of study is commonly conducted without
much planning and thus is often fatally flawed by a
variety of biases, most notably that of susceptibility.
Certain types of malocclusion seem to demand
a particular treatment: Severe skeletal dysplasias
are uniquely susceptible to surgery; crowding and
protrusion, to extraction. Thus, in a retrospective
comparison, any difference one might encounter
would be virtually impossible to interpret because
the patients were probably different even before
they received any treatment. Fortunately, many of
the theoretical strengths of prospective, random-
ized trials can be achieved retrospectively and in a
timely manner by employing a design in which the
admission criteria are similar to those of a conven-
tional prospective trial. As noted by Feinstein11:
If all of the important variables that affect a clini-
cian's choice of treatment have been suitably arranged in
the prognostic subgroups.., and if treatments are ap-
praised within these subgroups, the comparisons of non-
randomized treatment should be relatively free from
bias.
American Journal of Orthodontics and Dentofacial Orthopedics
November 1993
Accordingly, if one can determine the charac-
teristics that determined the original treatment
decisions, it would then be possible to identify a
coterie of former patients, both orthodontic and
surgical, who were so similar before treatment that
they belonged to a single prognostic subgroup and
thus were susceptible to either treatment. If the
patients started out roughly the same, then any
long-term differences that might develop can be
ascribed to the treatments. The identification of
equally susceptible subgroups, however, requires
some sort of empirical characterization of the cri-
teria that governed treatment assignment.
Treatment planning is multifactorial. As a re-
sult, discriminant analysis, a multivariate technique,
would seem ideally suited to the problem of defin-
ing equally susceptible pretreatment subgroups. 12
Specifically, it can be used to determine empirically
how a given sample of orthodontic and surgical
patients tended to differ before treatment. This
information is then used to generate individual
"confounder summarizing" discriminant scores
that serve to define subsamples of "borderline,"
equally susceptible patients. Recall data from these
subjects would thus support a relatively bias-free
comparative evaluation of the competing treatment
strategies. In the present report, this multivariate
technique will be used to conduct a long-term
comparison of the effects of orthodontics and sur-
gery in the treatment of adult patients with Class II
malocclusions.
PATIENTS AND METHODS
After approval of this study by the Institutional
Review Board (IRB) of St. Louis University Medical
Center, approximately 800 surgical and 8000 orthodontic
records, both from the graduate clinic and from a surgi-
cal fellowship program, were surveyed for potential sub-
jects: Class II, Division 1 malocclusion (at least a half-
step); white, 18 years or older; complete records; ade-
quate postsurgical/posttreatment interval-surgical, at
least 2 years; orthodontic, at least 4 years. In all, 125
surgical and 180 orthodontic patients were identified and
approached, either by letter or, in the absence of a
response, by telephone (at least five attempts). Our goal
at the outset was to identify subjects who would be
willing to return for a follow-up appointment, if discrim-
inant analysis of their pretreatment cephalometric and
model data were to identify them as being part of
the borderline, equally susceptible stratum. Ultimately,
50 surgical and 58 orthodontic patients agreed to partic-
ipate.
American Journal of Orthodontics and Dentofacial Orthopedics Cassidy et al. 457
Volume 104, No. 5

A. \

i r
r

" /:4

Fig. 1. Cephalometric analysis. A. Linear descriptive measures (overbite, overjet, C-Gn/C-A differ-
ence, Wits AO/BO, L1-APog not depicted). B, Angular measures. C, Linear measures of protrusion
relative to SE. Enumeration keyed to the first column of Table I. Tracings patterned after Fig. 5-11 of
Broadbent BH, Sr, Broadbent BH Jr, Golden WH. Bolton standards of dentofacial developmental
growth. St. Louis: CV Mosby, 1975:99.

Although some of the orthodontic patients had been
treated by private practitioners, the great majority were
from the Graduate Orthodontic Program of St. Louis
University. Similarly, most of the surgeries were per-
formed by the surgeons of the Dentofacial Deformity
Center, St. Louis, Mo. Given that both treatments were
rendered by a variety of clinicians, there would seem to
be no obvious proficiency bias to confound our between-
treatment comparisons.
Discriminant analysis
The goal of the present study was to compare the
effects of surgery and orthodontics only in a subset of
patients for whom there is empirical evidence of uncer-
tainty. To this end, discriminant analysis (subprogram
DISCRIMINANT, SPSS-X, release 3.1, SPSS, Inc., Chi-
cago, Ill.) was used to define the anatomic basis of the
orthodontic/surgical decision and then to use the result-
ing discriminant function to identify the borderline pa-
tients who would actually be recalled.
The cephalometric and model measures that consti-
tuted the independent variables were chosen to provide
an abstraction of practically any morphologic character-
istic on which the initial treatment decisions could have
been based. In addition to age and sex, there were 18
linear and 18 angular pretreatment cephalometric mea-
sures (most of which are illustrated in Fig. 1, A and B),
as well as midline deviation, depth of curve of Spee,
upper and lower intermolar and intercanine width, avail-
able space (measured in two segments per side), discrep-
ancy, arch depth, and lower anterior irregularity. A
transparent digitizer (Scriptel RDT-1212, Scriptel Corp.,
458 Cassidy et al. American Journal of Orthodontics and Dentofacial Orthopedics
November 1993

Class II
A. Parent Sample

Frequency

10 ] ~ Orthodontics (58)
o ( ~51 0 Surgery
) ~ ~' _ ~.

0~ - - T ~ - - r ~ r ~ - ~
-5.0 -4.0 -3.0 -2.0 -1.0 (3 ~ 1.0 2.0 3.0 4.0 5.0
Discrirninant Score
B. Borderline S u b s a m p l e s

Frequency
10
Orthodontics (27)
-- Surgery (26, ~ 1

-5.0
I I

-4.0 -3.0 -2.0 -1.0

I [

0.~
IAI

.
Discriminant Score
!!! I I I I I I I

2.0
I I F I ~

3.0
1

4.0
r r i~-

5.0

Fig. 2. Discriminant scores. A, Parent sample; B, "borderline" orthodontic and surgical subsamples
recalled for follow-up examination. Note that the patients who were recalled had discriminant scores
that fell in the area of surgical/orthodontic overlap in A. In each histogram, the upper arrows denote
the group means ("centroids"); the lower arrows, the mean of both groups, combined (approximately
zero).

Columbus, Ohio) and a commercial cephalometrics pro-
gram (Dentofacial Planner, version 4.22A, Dentofacial
Software, Toronto, Canada) were used to generate the
individual measurements from the cephalograms (the
more technically demanding landmarks of which had
been traced on a 0.003-inch frosted acetate overlay) and
direct photocopies of the occlusal surfaces of the pre-
treatment models. Before digitizing the occlusal photo-
copies, the midline discrepancy and curve of Spee depth
of each patient were measured directly from the models
and then marked on the image of a ruler that was
photocopied along with the study models. Because they
were easier to see on the photocopies, points on the
lingual (rather than the buccal) embrasures were used to
calculate available arch length. As a result, estimates of
initial discrepancy are probably artificially high. The
follow-up models, however, were digitized at the buccal
embrasures so that the resulting estimates of available
 American Journal of Orthodontics and Dentofacial Orthopedics
Volume 104, No. 5
A,
(.J
Fig. 3. Averaged pretreatment tracings. A, Excluded (i.e., "extreme") subsamples; B, recalled
borderline subsamples. Thick lines, orthodontic patients; thin lines, surgical patients. Note the
morphologic similarity of the surgical and orthodontic patients in B. In this and all subsequent
superimpositions, orientation is along Frankfort horizontal; registration, on pterygoid vertical.
space and discrepancy can be compared with comparable
data from the literature.
Of the 53 discriminant variables employed here, a
linear combination of just five-age, L1-APog, PNS-A,
lower arch-length discrepancy, and Y-axis a n g l e - p r o -
vided a highly significant (P < 0.01) pretreatment dis-
crimination between the orthodontic and surgical pa-
tients. Judging from the size of its standardized coeffi-
cient, age was by far the most important discriminator:
Younger patients tend to be treated orthodontically;
older patients, surgically.
The discriminant function was then used to generate
discriminant scores for each of the 108 potential subjects
(Fig. 2, A). Note that the orthodontic patients tend to
have negative scores, whereas the surgical patients have
positive scores. The larger the absolute value of the
discriminant score, the higher the probability that, in
practice, only the alternative designated by the sign
would actually be employed. Scores close to zero, how-
ever, would be indicative of a type of patient whose
malocclusion could be treated either way and whose
follow-up data therefore would support a meaningful
between-strategy comparison.
Attempts were then made to recall the 30 orthodon-
tic and 30 surgical patients whose standardized discrim-
inant scores lay within about one standard deviatign of
zero. Seven of these patients, however, were lost to the
study: Three orthodontic and two surgical patients re-
versed their initial decision to participate, one surgical
patient had a missing postoperative cephalogram, and
one had already opted for a second surgery. In the end,
53 patients (27 orthodontic and 26 surgical; Fig. 2, B)
signed an IRB-approved consent form and returned for
lateral cephalograms, study models, a clinical examina-
tion, and an assessment of their perception of the short-
term esthetic impact of their own treatment; each was
paid $25 to defray incidental expenses.
Cassidy et al. 459
The 27 orthodontic patients (3 males, 24 females)
had been treated with the edgewise appliance (0.022
inch), either without extraction or according to a variety
of extraction protocols (e.g., upper first premolars, upper
first premolars and a lower incisor, upper first and lower
second, premolars, upper first premolars and one lower
second premolar). The 26 surgical patients (6 males, 20
females) had undergone mandibular advancement (14
rigid, 12 nonrigid; 6 two-jaw surgeries; 6 genioplasties).
The extent to which the discriminant functions led to
the recall of morphologically comparable samples (i.e.,
subjects relatively free of susceptibility bias) may be
judged from the superimposed tracings of the group
averages* depicted in Fig. 3 and the descriptive statistics
for the initial values of the various cephalometric and
study model variables summarized in Tables I and II.
The significant discriminating variables are numbered 1-5
(bold-face) in descending order of importance. As
judged by the cephalometric averages, both the orth-
odontic and surgical patients would probably be charac-
terized as having presented with moderately severe skel-
etal Class II malocclusions.
Final cephalometric analysis
A major goal of this study was to characterize thc
skeletal, dental, and soft tissue changes that had oc-
curred, both during and after treatment. Accordingly,
each patients' posttreatment and recall lateral cephalo-
grams were subjected not only to essentially the same
descriptive analysis that was used in the discriminant
analysis (Fig. 1, A, B), but also to a number of additional
measurements designed to characterize anteroposterior
change (Fig. 1, C). As a result, the initial (1) tracing had
*Prepared with the aid of "Average," a customization of Dentofacial
Planner, version 4.22, Dentofacial Software,Toronto, Canada.
460 Cassidy et al. American Journal of Orthodontics and Dentofacial Orthopedics
November 1993

Table I. S t a r t , f i n i s h , a n d r e c a l l : M e a n s a n d t s c o r e s (Ho:/.t, orth o = /Zsurg ) f o r r e p r e s e n t a t i v e

cephalometric and demographic variables

Start Finish Recall

Measure SDE SurgerylOrthodontics[ t SurgeryOrthodontics[ t Surgery Orthodontics I
Linear-APposition relative to SE perpendicular (mm)
1. ULip-SE 1.0 67.3 65.5 1.2 69.4 63.1 3.7** 66.0 62.4 2.2*
2. L1-SE 0.8 48.0 47.3 0.5 51.8 46.6 3,7** 50.3 45.2 3.5**
3. L6-SE 0.8 24.1 24.7 - 0.4 28.9 26.0 2.0* 28.6 26.1 1.8
4. U1-SE 0.8 56.0 53.9 1.4 54.9 49.3 3.9** 54.2 48.8 3.7**
5. Llip-SE 1,i 60.9 60.1 0.5 66.4 58.8 4.2** 61.7 57.9 2.2*
6. B-SE 0.7 40.4 40.7 -0.2 44.9 39.6 2.9** 43.6 39.8 2.0*
7. Pog'-SE 1.2 54.0 54.1 1.4 61.2 53.3 3.3** 59.0 53.8 2.2*
8. Pog-SE 0.9 42.2 42.6 -0.2 48.3 41.7 3.1'* 46.8 41.9 2.2*
Linear-descriptive (mm)
1. Overjet 0.5 8.3 7.0 1.5 3.2 3.0 0.8 4.2 4.3 - 0.4
2. Overbite 0.4 2.5 3.2 -1.0 0.7 1.6 -2.6* 1.8 3.5 -4.2**
3. Ar-Gn 0.7 107.8 108.3 -0.3 113.4 108.6 2.4* 111.7 108.6 1.5
4. C-Gn 0.9 115.0 115.4 -0.2 120.0 115.7 2.3* 119,3 115.6 2.0
5. C-A 1.3 88.8 88.8 0.1 88.8 88.3 0.4 88.7 88.5 0.1
6. (C-Gn)-(C-A) 1.2 26.2 26.6 -0.4 31.2 27.4 3.2** 30.6 27.1 2.9**
7. Wits A/B 0.9 5.2 3.5 2.6* 0.6 2.0 -2.1' 1.2 2.4 -1.7
8. Molar rela- 0.7 -2.2 -0.9 -2.0* 1.2 -0.5 2.1" 1.0 -0.8 2.6*
tionship
9. L lip-E-plane 0.5 -2.3 -2.9 0.7 -1.5 -4.1 4.0** -5.2 -5.4 0.2
10. U 1 - N A 1.2 4.5 4.0 0.6 4.0 0.3 4.7** 3.7 -0.5 5.4**
ll..L1-NB 0.3 6.0 5.3 1.1 6.3 5.6 1.0 5.8 4.0 2.7*
12. L1-APog (2) 0.6 0,4 0.5 -0.2 2.3 0.8 2.8** 1.6 - 1.0 5.2**
13. Pog-NB 0.3 2.9 2.8 0.2 3.8 3.2 1.2 3.9 3.3 1.0
14. PNS-A (3) 1.0 51.8 50.9 1.0 51.4 50.7 0.7 51.1 51.1 -0.0
15. ANS-Me 0.5 69.3 68.3 0.5 70.0 69.6 0.2 69.6 69.4 0.1
16. N-Me 0.5 121.8 121.2 0.2 123.5 122.5 0.4 122.1 122.3 -0.1
17. S-Go 1.0 76.0 77.3 - 0.7 76.4 77.7 - 0.7 73.7 77.8 - 2.0*
Angular (degrees)
1. SNA 0.8 82.8 81.7 1.2 82.3 81.1 1.2 82.0 81.3 0.7
2. SNB 0.4 76.1 76.2 -0.1 78.6 75.6 2.8** 77.9 75.7 2.0
3. ANB 0.7 6.7 5.5 2.2* 3.7 5.4 -2.6* 4.2 5.6 -1.9
4. Y-axis (4) 1.2 58.6 58.5 0.1 56.7 59.2 -2.3* 57.1 59.1 -1.8
5. GoGn-SN 0.8 33.9 33.0 0.4 33.4 33.8 -0.2 35.1 33.5 0.7
6. FOP-SN 1.3 16.6 17.2 -0.4 16.3 19.9 -2.5* 16.8 19.6 -1.7
7. 1/1 2.1 121.9 125.5 -1.4 121.9 130.7 -4.0** 124.0 139.7 -7.0**
8. UI-SN 1.5 106.2 103.6 1.0 107.6 95.3 5.1"* 105.7 91.7 6.4**
9. UI-NA 1.6 23.4 21.9 0.6 25.2 14.2 4.4** 23.6 10.4 5.7**
10. L1-NB 1.2 28.1 27.0 0.7 29.2 29.7 -0.3 28.2 24.3 2.2*
1l. IMPA 1.6 98.0 97.8 0.1 97.2 100.3 - 1.6 95.2 95.1 0.1
12. Z-angle (L) 1.9 74.0 76.3 - 0.8 76.7 78.5 - 0.7 83.6 81.7 0.7
13. Nasolabial 3.6 109.5 107.9 0.5 109.5 112.3 -0.9 109.9 111.4 -0.5
Demographic (years)
Age (1) 31.9 27.6 3.0** 34.1 29.6 3.2** 38.8 36.8 1.4

*P < 0.05; **P < 0.01.

to b e a m e n d e d in c o n c e r t with the execution of the traced to serve as t h e basis of cranial b a s e superimposi-

p o s t o r t h o d o n t i c / p o s t s u r g i c a l (2), a n d follow-up (3) trac-
ings. T h e most clearly s e e n maxillary a n d m a n d i b u l a r
first molars a n d c e n t r a l incisors were t r a c e d to f o r m
t e m p l a t e s t h a t were t h e n used to r e n d e r the d e n t i t i o n in
a consistent m a n n e r t h r o u g h o u t the series. Cranial b a s e
t r a b e c u l a e c o m m o n to ~djacent films (i.e., details t h a t
could b e seen b o t h in films 1 a n d 2 or films 2 a n d 3) were
tion. Pairs of widely-spaced fiducial h a s h m a r k s were
drawn a b o v e t h e cranial base of film 2 a n d t h e n trans-
ferred, a l o n g with SE point ( t h e p o i n t at which the
averaged g r e a t e r wings of the s p h e n o i d cross t h e p l a n u m
sphenoidale), porion, orbitale, a n d sella to tracings 1 a n d
3 by best-fit cranial-base s u p e r i m p o s i t i o n .
Pterygoid vertical ( P T V ) was u s e d to define a regis-
American Journal of Orthodontics and DentofacialOrthopedics Cassidv et at. 461
Volume 104, No. 5

Table II. D e n t a l - a r c h d i m e n s i o n s : M e a n a n d t s c o r e s (Ho:/Xortho = /Xsurg) for

between-treatment differences

Start Recall Net change

m m

Measure Surgery Orthodontics t Surgery I Orthodontics t Surgery I Orthodontics

I I
lntercanine width
Maxillary 30.4 30.5 -0.1 31.1 31.2 -0.3 0.7 0.7 -0.1
Mandibular 24.2 23.5 1.1 24.4 24.0 0.8 0.2 0.5 - 0.6
Intermolar width
Maxillary 45.9 45.3 0.7 45.2 43.6 2.1" - 0.7 - 1.8 1.4
Mandibular 41.7 41.7 - 0.0 40.3 39.2 1.4 - 1.4 - 2.5 1.3
Arch length
Maxillary 67.3 64.9 1.7 63.7 57.1 4.9"* - 3.6 - 7.8 3.4"*
Mandibular 58.0 56.8 0.9 54.6 50.4 2.7"* - 3.4 - 6.3 1.9
Discrepancy
Upper - 4.6 - 5.6 - 0.8 - 0.9 - 0.3 - 1.8 3.7 5.4 - 1.3
Lower (5) - 5.7 - 6.4 0.7 - 0.9 - 1.2 0.7 4.8 5.2 - 0.4
Irreg. index 5.0 6.1 -1.2 1.9 2.3 -0.8 -3.1 -3.9 -1.3

*P < 0.05; **P < 0.01.

tration point for superimpositions designed to depict
change; however, because this point was modified in the
six two-jaw surgeries, the cranial base fiducial crosses
(based on all cranial-base structures common to adjacent
films) were used to pass the initial PTV through to
tracings 2 and 3. Finally, on each tracing, a perpendicular
to Frankfort horizontal was erected through SE point
and used as a baseline from which to measure antero-
posterior (AP) change in the position of soft and hard
tissue pogonion, the lips (vermilion borders), upper and
lower central incisors (averaged incisal edges), the lower
first molars (averaged mesial contact point) and B-point.
Not all of the cephalograms in each series were taken
on the same cephalostat. As a result, 13 sets of records
contained one film in which the magnification seemed at
variance (by 1% to 3%) with the other films in the series.
Although the effect was probably of minimal significance,
it was easy to detect the one discrepant tracing (because
the patients were all nongrowing adults) and, on the
basis of the length of the anterior cranial base, S-N, to
adjust its magnification photographically. The tracings
(or the size-corrected photocopies) were then digitized
as before and the various measurements generated and
exported to a commercial spreadsheet for analysis (Qua-
tro Pro Version 4.0, Borland International, Inc., Scotts
Valley, Calif.).
With the aid of a table of random numbers, 10
three-film series (five surgical and five orthodontic) were
selected, retraced, redigitized, and remeasured. Dahl-
berg's formula, SD E = ,/ED2/2N, where D is the differ-
ence between double determinations and N = 30, was
then used to calculate the error standard deviation (SDe)
for each of the variables in the basic discriminant anal-
ysis. As may be seen in Table I, the descriptive linear
measurements generally have error standard deviations
that are less than 1 mm; the angular, less than 2 °. In
contrast, the measurements of protrusion relative to SE
perpendicular proved highly sensitive to variation in the
orientation of FH; however, because cranial-base super-
imposition was used to control the placement of porion
and orbitale within each series, the SD E for treatment
and posttreatment change relative to SE perpendicular
were generally less than 1.0 mm.
Model analysis
The various measurements of arch length, arch
width, discrepancy, and irregularity that were used in the
discriminant analysis were also obtained from digitized
photocopies of the occlusal surfaces of the recall models.
The posttreatment models were not analyzed.
Profile evaluation
At the recall appointment, the subjects individually
were shown a standard form that depicted, in random
order, tracings (at x0.4) of their pretreatment and
posttreatment profiles. For the surgical patients, the
profiles were traced from the 3 to 6 m o n t h follow-up
films to avoid the soft tissue distortion produced by
postsurgical swelling and edema. The subjects were not
told that the profiles were theirs (and few recognized
them as such) or that the profiles were in any way related
to their treatment. They were asked to choose the better
looking profile and then to quantify the strength of this
preference by placing a mark on a visual analogue scale
(VAS), a 10 m m line anchored on the left by "same" and
on the right by "very much better." The distance between
their mark and the left anchor was taken as an estimate
of the effect of treatment on the appearance of the
profile. The m e a s u r e m e n t was given a sign that reflects
the nature of the subject's choice: positive if the post-
treatment profile was preferred; negative if the pretreat-
ment profile was preferred.
462 Cassidy et al. American Journal of Orthodontics and Dentofacial Orthopedics
November 1993

Table Ul. C r a n i o m a n d i b u l a r index: M e n u of Clinical examination

items surveyed at recall (after Fricton Our clinical examination used the 62 items of the
and Schiffman 1`) so-called "Craniomandibular Index" (CMI) of Fricton
Scale J Items N and Schiffman. m4 These measures (Table III) provide a
systematic evaluation of both the presumed signs and
Dysfunction (D)-26points symptoms of joint dysfunction (mandibular movement,
Mandibular movement Opening 16 items; temporomandibular joint noise, 4 items; tem-
(MM) < 40 mm 1 poromandibular joint capsular palpation, 6 items) and
Passive stretch < 42 mm 1 muscle pain (extraoral palpation, 18 items; intraoral
Restricted 1 palpation, 6 items; neck muscle palpation, 12 items). The
Painful 1 clinical examinations were performed in equal measure
"Jerky" 1
by D.W.C. and E.G.H., after both had been calibrated in
S-deviation > 2 mm 1
Lateral deviation 1 the use of the CMI measures by John Rugh at the
> 2mm University of Texas Health Science Center at San Anto-
Locks open 1 nio. At the outset, nine patients were examined sepa-
Locks closed 1 rately by both workers. The resulting differences served
Protrusion as feedback to minimize interrater variation, an impor-
Pain 1 tant consideration given that D.W.C. examined 22 of 27
Limitation < 7 mm 1 orthodontic patients, and E.G.H. examined 19 of 26
Laterotrusion (R/L) surgical patients.
Pain 2
Limitation < 7 mm 2 Statistical analysis
Rigidity 1
TMJ noise (TN) Click (R/L) 2 Differences between means for the initial, posttreat-
Crepitus/popping (R/L) 2 ment, and recall data, and for the treatment, relapse, and
TMJ capsule palpation Lateral (R/L) 2 overall changes were analyzed by means of completely
(TP) Superior (R/L) 2 randomized t tests; a Z test was used to test for between-
Posterior (R/L) 2 groups differences in the proportion of patients who
Palpation (P)-36points thought treatment had improved their profiles. The
Extraoral.palpation (EP) Temporalis (R/L) Mann-Whitney U statistic, corrected for ties, was used to
Anterior 2
test for significant (P < 0.05) between-groups differ-
Deep 2
Middle 2 ences in the number of positive scores on the 26 joint-
Masseter (R/L) dysfunction (D) and 36 muscle-palpation (P) items, as
Anterior 2 well as their component subindices. '5
Deep 2
Inferior 2 RESULTS
Posterior Digastric (R/L) 2 As has already b e e n noted, the two samples,
Medial Pterygoid (R/L) 2
Vertex (R/L) 2 although chosen on the basis of only five variables,
Intraoral palpation (IP) Pterygoid (R/L) were morphologically similar b e f o r e treatment. At
Lateral 2 the end of t r e a t m e n t , however, a n u m b e r of differ-
Medial 2 ences w e r e seen, m a n y of which w e r e still present
Temporalis Insertion (R/L) 2
at recall (Tables I, II, and IV; Figs. 4 and 5).
Neck muscle palpation Sternocleidomastoid (R/L)
(NP) Superior 2 Dentally, the orthodontic patients showed: (1) sig-
Middle 2 nificantly g r e a t e r u p p e r incisor and u p p e r lip re-
Inferior 2 traction (at a b o u t a 2:1 incisor-to-lip ratio), (2) the
Trapezius (R/L) vertical s e q u e l a e of adult Class II m e c h a n i c s (Fig.
Upper 2
4, A), and (3) a reduction in maxillary arch length.
Insertion 2
Splenius Capitus 2 On average, the surgical patients u n d e r w e n t a va-
riety of p r o f o u n d t r e a t m e n t changes (Fig. 4, B) that
reflect the effects of the m a n d i b u l a r a d v a n c e m e n t s
(4.5 m m ) and the eight genioplasties (on average,
Profile tracings, rather than full-face photographs, 1.5 m m ) . D e s p i t e m a r k e d differences in the impact
were used because we did not want extraneous factors, of t r e a t m e n t on the p o s t t r e a t m e n t profile (Fig.
such as hairstyles, clothing, or make-up, to influence the 4, C), the patients s e e m e d to like b o t h results
evaluation. (Table V): T h e V A S scores w e r e mostly positive
American Journal of Orthodontics and DentofacialOrthopedics Cassidy et al. 463
Volume 104, No. 5

Table IV. T r e a t m e n t , post-treatment, and net change: Means a n d t s c o r e s (Ho:/.~orth o = /Zsurg) f o r

representative cephalometric and demographic variables

Treatment Posttreatment Net

Measure Surgery Orthodontics t Surgery Orthodontics t Surgery Orthodontics t

Linear-APposition relative to SE perpendicular (mm)

Ulip-SE 2.1 - 2.4 7.6** -3.4 -0.7 -5.4** -1.3 -3.1 3.4**
L1-SE 3.8 - 0.7 7.3"* -1.5 -1.4 -0.3 2.3 -2.1 8.1"*
L6-SE 4.8 1.3 4.5** -0.3 0.1 - 1.1 4.4 1.4 4.2**
U1-SE - 1.0 -4.6 4.2** -0.8 -0.5 -0.9 -1.8 -5.1 4.3**
Llip-SE 5.4 - 1.3 7.2** -4.6 -0.9 -5.6** 0.8 -2.2 4.0**
B-SE 4.5 - 1.1 9.1"* -1.2 0.2 -2.8** 3.2 -0.9 7.8**
Pog'-SE 7.2 - 0.8 8.4"* -2.1 0.4 3.6** 5.1 -0.4 6.2**
Pog-SE 6.1 - 0.9 8.0"* -1.4 0.3 2.6* 4.6 -0.6 6.6**
Linear-descriptive (mm)
Overjet -5.1 -4.0 - 1.1 0.9 1.3 -0.9 -4.1 -2.7 -1.8
Overbite - 1.9 - 1.6 -0.4 1.2 1.9 -1.4 -0.7 0.3 -1.4
Ar-Gn 5.6 0.3 7.7"* -1.7 0.1 -3.0** 3.9 0.3 4.5**
C-Gn 5.0 0.3 7.3** -0.7 -0.1 -1.4 4.2 0.2 5.7**
C-A - 0.0 - 0.5 0.8 -0.2 0.2 -0.7 -0.2 -0.3 0.2
(C-Gn)-(C-A) 5.0 0.8 5.6** -0.6 -0.3 -0.5 4.4 0.5 4.6**
Wits A/B -4.6 - 1.5 -4.1"* 0.6 0.4 0.4 -4.0 - 1.1 -3.8**
Molar relationships 3.4 0.5 4.0* * -0.2 -0.3 0.2 3.1 0.1 4.2**
L lip-E-plane 0.7 - 1.2 2.9** -3.7 -1.3 -5.4** -2.9 -2.5 -0.7
UI-NA - 0.5 - 3.7 4.0** -0.3 -0.9 1.3 -0.8 -4.5 5.1"*
L1-NB 0.2 0.3 - 0.1 -0.5 -1.6 3.9** -0.3 -1.3 2.3*
L1-APog 1.9 0.3 2.8* * -0.7 -1.8 3.3** 1.2 -1.5 5.8**
Pog-NB 1.0 0.4 1.1 0.1 0.1 -0.3 1.0 0.5 1.0
PNS-A - 0.3 - 0.1 - 0.4 -0.3 0.4 -2.1" -0.7 0.3 -1.8
ANS-Me 0.6 1.2 - 0.7 -0.3 -0.2 -0.3 0.3 1.1 -0.9
N-Me 1.7 1.3 0.4 -1.4 -0.2 -2.8** 0.3 1.1 -0.9
S-Go 0.5 0.4 0.1 -2.7 0.1 -4.5** -2.3 0.6 -4.6**
Angular (degrees)
SNA - 0.5 - 0.6 0.4 -0.3 0.2 2.2* -0.8 -0.4 -0.9
SNB 2.5 -0.6 8.0** -0.7 0.1 -2.6* 1.7 -0.5 6.8**
ANB -2.9 -0.1 -6.5** 0.4 0.2 0.9 -2.5 0.1 -5.5**
Y-axis - 1.8 0.7 - 5.3** 0.4 -0.1 1.4 - 1.5 0.6 -4.4**
GoGn-SN - 0.6 0.8 - 1.7 1.7 -0.3 3.0** 1.1 0.5 0.8
FOP-SN - 0.4 2.7 - 4.1" * 0.6 -0.3 1.6 0.2 2.4 -3.1"*
1/1 0.0 5.1 - 1.6 2.2 9.1 -4.1"* 2.2 14.2 -4.8**
U1-SN 1.4 - 8.4 3.5* * -1.9 -3.6 1.7 -0.5 -12.0 4.7**
U1-NA 1.8 - 7.7 3.5** -1.6 -3.9 2.1' 0.2 -11.6 4.8**
L1-NB 1.1 2.7 - 0.9 -1.0 -5.4 3.6** 0.1 -2.7 -2.2
IMPA - 0.8 2.5 - 1.6 -2.0 -5.2 2.6* -2.8 -2.7 -0.0
Z-angle (L) 2.7 2.2 0.3 6.8 3.3 3.4** 9.6 5.5 2.4*
Nasolabial - 0.0 4.4 - 1.7 0.4 - 0.9 0.7 0.3 3.5 - 1.4
Demographic (years)
Age 2.2 2.0 0.2 4.7 7.1 -4.2** 6.9 9.1 -4.1"*

*P < 0.05; **P < 0.01.

(surgical, 22 of 26; orthodontic, 22 of 27), had a ( F i g . 5, B ) , h o w e v e r , averaged 25% to 30% of the

high average (+ 50 to 60), and were not signifi- mandibular advancement ( F i g . 4, B ) . S i g n i f i c a n t l y ,
cantly different between groups. much of this relapse can be attributed to three
At recall, the orthodontic relapse was relatively patients (two nonrigid, one rigid) who, as judged
minor (incisor uprighting and a loss of some of the from the standpoint of data from all sources (not
overbite correction; F i g . 5, A ) ; t h e s u r g i c a l r e l a p s e just the cephalograms), appeared to have under-
464 Cassidy et al. American Journal of Orthodontics and Dentofacial Orthopedics
November 1993

Fig. 4. Treatment change-averaged tracings. A, Orthodontic; B, surgical; C, orthodontic and

surgical outcomes compared. In A and B, the thin lines denote the pretreatment tracing; the thick
lines, posttreatment tracing. In C, the averaged surgical tracing is depicted by thin lines; orthodontic,
' by thick lines.

,)

Fig. 5. Relapse. A, Orthodontic, B, surgical. Averaged posttreatment tracing, thin; recall, thick. Much
of the postsurgical soft-tissue procumbency is due to transient swelling and edema.

gone extensive condylar resorption (Fig. 6). The
remaining 23 patients lost an average of about
13%, the nonrigid contingent (Fig, 7, A) somewhat
more than the rigid (Fig. 7, B). The three instances
of presumed condylar resorption, along with the
effect of bite splint removal, led to a significant
mean reduction in p6sterior face height, whereas
resolution of the postoperative edema led to a
marked (3 to 5 mm) posttreatment lip retraction.
Despite extensive long-term between-treatment
differences (Fig. 8), there were no significant dif-
ferences in the prevalence of the putative signs and
symptoms of dysfunction catalogued in the CMI
(Table VI).
American Journalof Orthodontics and Dentofacial Orthopedics
Volume 104,No. 5
C.
(O
Fig. 6. Relapse apparently related to extensive condylar resorption in three patients. Postsurgical
tracings, thin; recall tracings, thick.
T a b l e V. Esthetic evaluations: Profile VAS scores-group means and percentage of subjects imprOved
Group t Mean VAS score
Surgery + 59.5 mm
Orthodontics + 49.5 mm
DISCUSSION
In the present study, borderline patients were
chosen for recall because they support a relatively
bias-flee comparison of treatments in precisely the
type of patient for whom the differences, if any,
would be important - m o r e extreme patients
would, for good or ill, be susceptible only to one
treatment; for them comparative data would be
largely beside the point.
In a previous investigation,2"3discriminant anal-
ysis was used to choose borderline extraction and
nonextraction patients. The variables that proved
significant were six common measures of crowding,
protrusion, and irregularity; as a group, they
formed what amounted to a clinically "logical"
treatment analysis. In the present study, however,
age, was by far the most important variable in the
discriminant function. Subsequent steps served
Cassidy et al. 465
(9 / , ~ + i
i
] t Worsened Improved z
4 22
0.64 5 22 0.22
only to account for the variability left over after the
inclusion of age and thus do not seem, as a group,
to make as much "sense" as did the extrac-
tion/nonextraction discriminators. Moreover, al-
though the discriminant scores for the orthodontic
patients are tightly grouped (implying that the
orthodontists generally had a common sense of
the capabilities and limitations of orthodon-
tics), the surgical scores were spread throughout
nearly the breadth of the distribution. Given this
wide range of facial types, it may be inferred that
both the surgeons who treated the present subjects
and the orthodontists who referred them viewed
surgery not as a "last resort," but, rather, as a
generally applicable answer to the problem of Class
II malocclusion in adults.
The surgical treatments produced profound,
long-lasting skeletal changes (Figs. 4, B, and 5, B);
 466 Cassidy et al.
A.
O I I (j
Fig. 7. Postsurgical relapse-averaged tracings. A, Nonrigid (N = 12); B, nonrigid (N = 14). Post-
surgical tracing, thin; recall tracing, thick.
I I
O
Fig. 8. Comparison of outcomes-orthodontics versus sur-
gery. Average surgical outcome, thin; average orthodontic
outcome, thick.
the orthodontic treatments merely retracted the
upper incisors (Fig. 4, A). Despite these differences
(Fig. 8); the patients, themselves, seemed to like
the profiles produced by both treatments. Although
the surgical scores were somewhat higher, the dif-
ferences were not significant. Similarly, even
though the surgical treatments occasionally pro-
duced marked changes in condylar form (Fig. 6)
and position (Fig. 7, A), there were no significant
between-groups differences in the overall preva-
lence of the signs and the symptoms that are
commonly through to" be characteristic of cranio-
mandibular disorders. Indeed, the present former
American Journal of Orthodontics and Dentofacial Orthopedics
November 1993
I I~
A
patients, both surgical and orthodontic, seem
broadly comparable to the normal controls of Fric-
ton and Schiffman. 14 It should be noted, however,
that it is not yet clear what mixture of signs must be
present for a patient to be an official TMD suf-
ferer. 16 Accordingly, we have chosen to present the
raw data for each patient in the hope that future
research will allow a more precise interpretation of
the present findings.
From the standpoint of profile esthetics and
function, the present results argue that a borderline
patient should be more or less indifferent to a
choice between orthodontics and surgery. Other
possible outcomes, however, complicate the deci-
sion making process. For example, in the present
study, condylar resorption was an unexpectedly
common finding. Unfortunately, its cause is largely
unknown, even though a number of workers have
recently suggested that postsurgical condylar "atro-
phy" may be caused by preexisting internal de-
rangement. 17-19For example, in a recent discussion
of various reports of "condylar diminution," Link
and Nickerson 19 concluded, "We believe it is likely
that most of these patients with 'condylar atrophy'
or 'idiopathic condylar resorption' had preexisting
internal derangements." Indeed, it has been re-
ported that internal derangement can lead to re-
sorption even in the absence of treatment. 2°
Clearly, there is more to the problem of internal
derangement and its long-term consequences than
can be settled here; however, for the time being,
the possibility of postsurgical condylar resorp-
tion/atrophy/lysis/diminution must be factored into
the treatment decision. Indeed, for the present
surgical patients, the possibility of condylar resorp-
tion was a prominent feature of an elaborate "in-
American Journal of Orthodontics and Dentofacial Orthopedics Cassidy et al. 467
Volume 104, No. 5

Table Vl. Joint and muscle evaluation: Positive responses for dysfunction and muscle palpation*

Sex NP

F 2 1 0 2 1 2 F 1 2 0 0 0 0
M 0 0 0 0 0 0 F 1 2 0 0 0 0
F 1 0 0 0 0 0 F 1 2 0 2 0 0
F 3 1 0 0 0 0 F 3 1 0 0 2 0
M 0 1 0 0 0 0 M 0 1 0 0 0 0
F 1 0 0 0 0 0 F 2 0 0 0 0 0
F 2 1 0 0 0 0 F 0 0 0 0 2 0
F 2 0 1 0 0 0 F 2 1 0 0 1 0
M 0 0 0 0 0 0 F 1 1 0 0 0 0
F 1 0 0 1 0 0 M 0 0 0 0 0 0
F 1 2 0 0 0 0 F 1 2 0 0 2 0
F 1 2 0 0 0 0 F 0 2 0 0 0 0
F 0 1 0 1 0 0 F 1 0 0 0 0 0
F 1 1 0 0 0 0 F 0 0 0 0 0 0
F 0 2 0 0 0 0 F 0 1 0 0 0 0
F 1 0 0 1 0 0 F 1 0 0 0 0 0
F 1 0 0 0 0 0 M 0 0 0 0 0 0
M 1 0 0 0 0 0 F 1 2 0 0 0 0
F 0 2 0 0 0 0 F 0 1 0 0 0 0
F 0 0 0 0 0 0 F 0 0 0 0 0 0
F 1 0 0 0 0 0 F 0 2 0 0 0 0
M 2 0 0 0 0 0 F 1 0 0 0 0 0
M 2 0 0 0 f 0 F 1 1 0 0 0 0
F 1 0 0 0 0 0 F 1 2 0 0 0 0
F 2 0 0 0 0 0 F 0 0 0 0 3 0
F 0 0 0 0 0 0 F 3 2 0 0 0 0
. . . . . . F 1 1 0 0 0 0
Total 2-6 1-4 ~ -5 --] -2 2--2 2--6 0 2 1--0

*See Table III.

formed consent" process. By its very nature, how-
ever, "consenting" is a lot harder for the average
patient than "informing" is for the average clini-
cian. We would suggest therefore that this delicate
and important process be reexamined in light of
formal decision t h e o r y . 21"24
The central feature of decision analysis-and
the reason for introducing it h e r e - i s that it re-
quires that explicit consideration be given to the
patient's preferences: What utility (i.e., what value,
positive or negative) does the patient place on
improved appearance? On root resorption? On
condylar resorption (atrophy)? On death? If these
personal preferences can be ordered on at least an
interval scale, one can calculate the "expected
utility" of a given outcome by multiplying its prob-
ability by the scale value assigned to it by the
patient. The algebraic sum of the expected utilities
for all outcomes constitutes the "payoff" of the
treatment in question: The "average" gain or loss
that would accrue to a large number of physically
similar, like-minded patients.
The present results and a few rough estimates
can be used to illustrate the application of decision
analysis to the problem of choosing between orth-
odontics and surgery for the borderline patient.
Initially, a utility of 1 was assigned to improvement;
0 to death. Presumably, no treatment would lie
somewhere in between. But where? The method of
John von Neumann and Oskar Morgenstern (see
Resnick 21 and Lapin 22) is commonly used to cali-
brate a subject's preferences by measuring the risk
he or she is willing to undertake to achieve a
desired outcome. To this end, the patient would be
asked to consider a graded series of hypothetical
lotteries whose "prizes" are improvement or death:
99% chance of improvement versus 1% chance of
death, 99.9% chance of improvement versus 0.1%
4611 Cassidy et al. American Journal of Orthodontics and Dentofacial Orthopedics
November 1993

Payoff
No treatment: U • O, P • 1
No p 0 0
Surgery
Improved: U • 40, P - 0.67

Tx?
+ M o d e r a t e comps.:

S e r i o u s comps.:

Death:
U. -20, P • 0.23

U • -50, P • 0.10

U • -40,000, P • 0.0001
27
-5

-5
-4
13

Yes
Orthodontics
Improved: U . 30, P - 0.81

~
P 24
M o d e r a t e comps.: U . -10, P • 0.18
P -2
S e r i o u s comps.: U - -50. P • 0.01 21
-1
Death: U , -40,000, P - 0
0

Fig. 9. Decision tree-orthodontics versus surgery. U = Utility of an outcome; P = its probability.

Squares represent "decision nodes"; circles, "chance nodes." Note that orthodontic improvement,
although prized about equally by the present patients, has been assigned a lower utility than surgical
improvement (30 versus 40) because surgery is capable of a more dramatic correction. Given the
utilities and estimated probabilities, the "payoff" of the orthodontic strategy (i.e., the sum of its
"expected utilities") exceeds that of the surgical alternative (and would do so even if no disutility were
• assigned to death).

chance of death, and so forth. The goal of this
exercise is to discover which of these "reference
lotteries" the patient would see as the equivalent to
no treatment. The probability of improvement in
this particular lottery would be taken as an esti-
mate of the utility of the patient's pretreatment
state.
For purposes of discussion, it was assumed that
a borderline patient might be indifferent to a
choice between his or her pretreatment condition
and lottery having a 0.999 probability of improve-
ment and 0.001 of death. In other words, the
patient would require better than a 0.999 probabil-
ity of improvement before agreeing to risk treat-
ment. No treatment therefore would have a utility
of 0.999 on a scale from 0 to 1. Linear, order
preserving transformations were then employed to
place no treatment at zero and to code improve-
ment to a utility of 40, an arbitrary positive number
chosen to make room for a slightly lower utility of
30 for a g o o d - b u t less d r a m a t i c - o r t h o d o n t i c re-
sult. Following these transformations, death would
have a disutility of approximately a negative 40,000.
As may be seen ~n the decision tree of Fig. 9,
this analysis argues that, in the long run, orthodon-
tics has a somewhat better payoff, largely because it
often does considerable good and can do little real
harm. Indeed, because the present subjects were
not severely affected, one could well argue that
they might not be willing to accept a 0.001 risk of
death (the reference-lottery probability used in Fig.
9). For example, if patients instead were to see
their initial condition as equivalent to a lottery
offering a 0.9999 probability of improvement and
only a 0.0001 probability of death, the resulting
scale would accord so great an expected disutility to
death that, for them, the surgical alternative would
have a negative expected payoff.
Given what appears to be a self-serving result, it
must be emphasized that our decision to list death
as a possible outcome of surgery should not be
taken as prima facie evidence of an antisurgery
bias. Although death is clearly the worst possible
result, its probability is so low that, in most analy-
ses, its impact is overshadowed by outcomes that
are more probable and less morbid (e.g., root
resorption, condylar resorption, paresthesia, and
the like). Indeed, as was suggested by an aggrieved
referee in response to an earlier version of this
article, the drive to the office may be more life
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 104, No. 5
threatening than the surgery itself. We mention the
unmentionable here only to emphasize that no
o u t c o m e - e v e n death itself-has a fixed utility in
formal decision analysis.
For example, the decision analysis for a more
severely affected patient who wants a larger skele-
tal change than orthodontics can produce (and who
is willing to take a small, but somewhat greater risk
to get it) would be markedly different. On the
initial 0 to 1 scale, the patient's pretreatment con-
dition would be shifted toward zero. Therefore,
after transformation, the resulting scale would as-
sign a greater utility to improvement and a lesser
disutility to the various surgical complications. The
final payoff would now favor surgery.
Given these few examples, it is clear that utility
scales are not a reflection of the value that orth-
odontists or surgeons attach to a given outcome or
how "comfortable" they may be with the risks that
accompany their own brand of treatment. A utility
scale is calibrated by the patient's preferences, not
those of the clinician. Unfortunately for the busy
orthodontist or surgeon, patients differ greatly in
their attitudes toward life and death, beauty and
ugliness, function and dysfunction.
The real challenge therefore is to discover the
value each patient places on improvement and the
risks he or she is willing to take to achieve it. Given
that no treatment alternative can guarantee a fa-
vorable outcome, this information, in combination
with data on the possible effects of the various
treatment options, would support treatment deci-
sions that are both fully informed and consistent
with the patient's personal value system.
SUMMARY
The present study was designed to compare the
effects of orthodontics and surgery in homogeneous
samples of borderline adult patients with Class II
malocclusions chosen by discriminant analysis. The
surgical patients were recalled an average of 4.7
years after treatment; the orthodontic patients, 7.1
years. Although surgery and orthodontics resolved
the malocclusions in markedly different ways (skel-
etally and dentally, respectively), both treatments
generally produced, at least at the end of treat-
ment, a perception of profile improvement that did
not differ significantly between groups. Nor were
there significant differences in craniomandibular
function and incisor stability. The surgical patients,
however, did differ in one important way: At recall,
3 of the 26 had undergone extensive relapse, ap-
parently as a result of condylar resorption. This
Cassidy et al. 469
surprising outcome prompted us to examine the
choice between surgery and orthodontics from the
standpoint of the probabilities and utilities of for-
mal "decision theory." Our analysis implies that, on
average, orthodontic treatment is appropriate for
the adult patient with Class II malocclusion who
can be treated either way, whereas surgery would
be the better choice for more seriously affected
patients who need changes of a magnitude that
only surgery can provide.
We greatly appreciate the assistance of Dr. James A.
McNamara, Jr.
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Reprint requests to:
Dr. Lysle E. Johnston, Jr.
Department of Orthodontics and Pediatric Dentistry
School of Dentistry
The University of Michigan
Ann Arbor, MI 48109-1078

AAO MEETING CALENDAR

1994--Orlando, Fla., April 30 to May 4, Orange County Convention and Civic Center
1995--San Francisco, Calif., May 13 to 18, Moscone Convention Center
(International Orthodontic Congress)
1996--Denver, Colo., May 11 to 15, Colorado Convention Center
1997--Philadelphia, Pa., May 3 to 7, Philadelphia Convention Center
1998--Dallas, Texas, May 16 to 20, Dallas Convention Center
1999 "--San Diego, Calif., May 15 to 19, San Diego Convention Center