mm (diameter height) were encapsulated in each magnetic

housing (upper and lower). After we installed the magnets in

the magnetic housing, we used a laser welder to weld the
bottom lid (also stainless steel) to the housing. This process
sealed and protected the magnets from salivary assault because of the high corrosive susceptibility of rare earth
permanent magnets. The interface stainless steel layer was 0.2
mm thick to obtain maximal magnetic attractive force when
the upper and lower magnetic housings contacted each other
(at 0.4 mm gap). The upper and lower magnets were oriented
in attractive configuration, and the maximal magnetic force
was 3N.
I disagree with Dr Blechmans comment that publishing
the effect of a new drug without describing its chemical
constituents is unscientific. Since JAMA was mentioned in his
comment, I chose an article from JAMA that deals with a very
hot issuethe clinical effect of anthrax.1 This excellent
article reports, in detail, all symptoms of the disease and its
clinical course. However, although the pharmaceutical agents
are mentioned (ciprofloxacin, rifampin, and clindamycin),
neither their chemical constituents nor the dosages were
mentioned.
This example was selected to emphasize that a major
problem of orthodontic articles is not, as Dr Blechman
suggested, lack of information but, rather, superfluous or
irrelevant data. Most often, lack of focus on the objectives of
the study and redundancy of well-known information are
symptomatic of superficial articles. A scientific paper should
to be short, precise, and describe and discuss only its own
new findings.
Alexander Vardimon, DMD
Tel Aviv, Israel
REFERENCE
1. Mayer TA, Bersoff-Matcha S, Murphy C, Earls J, Harper S, Pauze
D, et al. Clinical presentation of inhalational anthrax following
bioterrorism exposure: report of 2 surviving patients. JAMA
2001;286:2549-53.
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doi:10.1067/mod.2002.123338

Evidence-based orthodontics
In their September 2001 letter to the editor, Drs Courtney
and Leigh very succinctly drove home the point about more
of us basing our decisions on an ability to assess evidence and
then applying it to orthodontic practice. The necessity of
well-designed studies is inescapable; if clinicians study the
evidence on functional appliances, they will have to be more
guarded, not just in their promises of a better posttherapy
profile but also in claiming to actually modulate mandibular
growth.
A relevant and comprehensive new study from the
Harvard School of Dental Medicine, the University of California Medical Center, and the Forsythe Institute puts to rest
some of the controversies on mandibular growth and the
efficacy of functional appliances.
For that study, a MEDLINE search for the years 1966 to
1999 found a total of 23,393 articles, and identified 155 that
could be categorized as RCT/meta-analysis and 6 that met the
validity criteria. There were no significant differences be-

tween the controls and the functional appliance group for the
parameters studied. The number needed to treat (NNT) was
45, meaning that there was no clinically significant effect of
appliance therapy. Definitive answers on appliance efficacy
are still difficult because of confounding variables such as
age, treatment duration, lack of controls, patient compliance,
and accountability, but the directions are well defined.
It is apparent that there will be a need for our specialty to
acquire new skills in handling scientific information and
processing it to end use. But perhaps the primary need is to
understand what is required in terms of clinical studies and
their design, and it is left to the majority of orthodontists to
understand what constitutes evidence and to generate it. We
need to evolve.
Anmol S. Kalha, OSRE(Oman), BSc, BDS, MDS
Davangere, India
0889-5406/2002/$35.00 0 8/8/122857
doi:10.1067/mod.2002.122857

Editors note: The study cited by Dr Kalha has been submitted to the AJO-DO and is currently being considered for
publication.

Evidence-based orthodontics and the

Twin-block appliance
Referring to the letter of Drs Coutney and Leigh (September 2001), I would like to comment on the choice of
control patients in my Twin-block appliance study.1
First, any treatment group is bound to be biased, because
of referral patterns and case selection. Randomization produces 2 very similar groups, both biased before randomization.2 By using normative data, only the treatment group is
biased compared with an unbiased sample of the general
population. This may well be considered a more accurate
reflection of normal growth and a better baseline for comparison. Depending on the research question to be answered,
randomization is clearly preferable in deciding whether functional appliance A is more or less effective than appliance B.
However, if the research question is whether functional
appliances produce a response greater than baseline normal
growth, then surely normative data are more representative.
Second, normative data have been used as acceptable
baseline references for general body height, weight, and head
circumference in pediatrics for many years.3
Third, my study produced similar results to other Twinblock appliance studies, despite different types of control
groups (Table). Mills and McCulloch4 and Toth and McNamara5 used matched growth study data, and Lund and
Sandler,6 Illing et al,7 and Tu mer and Gu ltan8 all used Class
II Division I untreated patients.
Finally, treatment changes that were statistically significant and clinically noteworthy were large relative to the
control group changes (ANB change column in the Table).
This applies to whatever type of control group is selected and
whatever the sources of bias.
M. J. Trenouth
Preston, United Kingdom

American Journal of Orthodontics and Dentofacial Orthopedics /March 2002

13A

Table. Previous cephalometric outcome studies on Twin-block therapy (average changes in control values in
parentheses)

Author

Date

Twinblock n

Lund6
Mills4
Illing7
Tu mer8
Toth5
Trenouth1

1998
1998
1998
1999
1999
2000

36
28
16
13
40
30

Control group
Class II Div 1 patients
Burlington Growth Study
Class II Div 1 patients
Class II Div 1 patients
Michigan Growth Study
Kings Growth Study

Control n

Study type

SNA

SNB

ANB

27
28
20
13
40
30

Prospective
Retrospective
Prospective
Prospective
Retrospective
Retrospective

0.10 (0.30)
0.90 (0.10)
1.40 (0.30)
0.23 (0.15)
0.20 (0.30)
0.60 (0.28)

1.90 (0.40)
1.90 (0.30)
0.80 (0.20)
1.77 (0.31)
1.60 (0.30)
2.00 (0.57)

2.0 (0.10)
2.80 (0.20)
2.30 (0.40)
2.0 (0.19)
1.80 (0.00)
2.60 (0.31)

REFERENCES
1. Trenouth MJ. Cephalometric evaluation of the Twin-block appliance in the treatment of Class II Division 1 malocclusion with
matched normative growth data. Am J Orthod Dentofacial Orthop
2000;117:54-9.
2. Tulloch JFC, Philips C, Koch G, Proffit WR. The effect of early
intervention on skeletal pattern in Class II malocclusion: a
randomized clinical trial. Am J Orthod Dentofacial Orthop 1997;
111:391-400.
3. Tanner JM, Whitehouse RH. Clinical longitudinal standards for
height, weight, height velocity, weight velocity and the stages of
puberty. Arch Dis Child 1976;51:170-9.
4. Mills CM, McCulloch KJ. Treatment effects of the Twin-block
appliance: a cephalometric study. Am J Orthod Dentofacial
Orthop 1998;114:15-24.
5. Toth LR, McNamara JA Jr. Treatment effects produced by the
Twin-block appliance and the FR-2 appliance of Fra nkel compared with an untreated Class II sample. Am J Orthod Dentofacial
Orthop 1999;116:597-609.
6. Lund DI, Sandler PJ. The effects of Twin Blocks: a prospective
controlled study. Am J Orthod Dentofacial Orthop 1998;113:10410.
7. Illing HM, Morris DO, Lee RT. A prospective evaluation of Bass,
Bionator and Twin-block appliances. Part I: the hard tissues. Eur
J Orthod 1998;20:501-16.
8. Tu mer N, Gu ltan AS. Comparison of the effects of monoblock and
twin-block appliances on the skeletal and dentoalveolar structures.
Am J Orthod Dentofacial Orthop 1999;116:460-8.
0889-5406/2002/$35.00 0 8/8/123039
doi:10.1067/mod.2002.123039

The art of moving teeth in the 21st

century
I was excited to see the April 2001 issue of the Journal
with a colorful depiction of the antique orthodontic instruments developed and used by Dr Angle over a century ago.
As we celebrate the 100th anniversary of our specialty, I wish

to share with my colleagues and the readers of the Journal a

unique case.
A patient, the wife of a diplomat from a Central Asian
Republic (formerly in the Soviet Union), came to me asking
if I could do something to help her. She presented with upper
and lower fixed appliances placed by a dentist in her home
country to correct her bimaxillary proclination. She was shy
and hid her face with a handkerchief and seemed to be in
obvious distress about the condition of her teeth. The contraption placed on her teeth made the appliances of the Angle
era look modern and sophisticated (Fig).
The upper appliance consisted of 4 molded metal sheets
soldered to a 1.5-mm archwire that ended on a screw soldered
to a metal crown placed on the first molars. The molded metal
sheets were cemented to the upper incisors with self-cure
acrylic and extended to embed in an acrylic biteplate held on
the palatal surface of the upper anterior teeth.
The lower archwire was similar to the upper and was held
on the teeth with brass wires lassoed around the lower
anterior teeth. The wire ended on a screw soldered to a metal
crown placed on the lower first molar on the left and the
second molar on the right; 4 premolars had been extracted.
Communication with the patient was a problem, but an
interpreter from her embassy helped me to reassure her that
her teeth could be salvaged but would require a saner
appliance, time, patience, and expertise. She was happy and
agreed to have it done the right way.
As we celebrate a century of progress and development of
orthodontics, we must not forget that we still need to reach
out to the teeming masses who are being maltreated by
dentists who claim to be orthodontists!
Noeen Arshad
Islamabad, Pakistan
0889-5406/2002/$35.00 0 8/8/122858
doi:10.1067/mod.2002.122858

Figure. Appliances of Angles era look modern and sophisticated in comparison.

14A

American Journal of Orthodontics and Dentofacial Orthopedics /March 2002