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I wonder what the implications of these regulations will be on functional appliances used to correct Class II skeletal patterns? Even the Frankel appliance is designed to encourage "expansion" of the upper dental arch.

Helen Jones

For the last 8 years of my practice life I used a variety of orthopaedic appliances to correct underdeveloped arch forms in order to avoid the need for dental extraction.

Much of my experience at the time was treating adult TMJ and cranial defects where the most commonly consistent factor had been the extraction of permanent teeth for orthodontic reasons in the early teens. Over that period in my practice life I have treated, successfully some 30 cases where arch expansion was considered necessary. I can recall two failures where the cause of failure was non-compliance by the patient. In all other cases there was a successful, long-term stable result. Indeed I treated three adult patients (one in their 50s and one in her 60s) with orthopaedic arch expansion appliances to correct quite severe cranial problems with great success.

In all three cases the treatment was carried out with the co-operation of a cranial osteopath. I have no doubt that the extraction of teeth to correct orthodontic problems in children is a seriously flawed treatment and any resultant damage can only be considered iatrogenic.

David Cheetham

Outrageous - and totally WITHOUT scientific foundation.

I suspect this is simply an attempt to at least get something through with the DPB since they are facing a restriction to IOTN 4s and 5s

It certainly is not scientific best practice and indeed many members of the BOS practice otherwise; it is a badly thought out wrong 'un

Chas Lister

I must say that the guidelines don’t exactly surprise me, coming from the NHS, but the fact that the BOS are a party to it is excedingly worrying. We usually assume that it is the faceless beaurocrats who determine NHS policy, and I am sure that there are many good 'proper' orthodontists out there who are not happy with this. I have just rescued a young man from the clutches of the hospital ortho service, mild class III, narrow upper arch with crowding , well formed lower arch, yup, you guessed, they wanted to take out 2 upper premolars and make it 10 times worse. He's now in an ALF, and we'll finish him in an upper fixed. He'll look quite handsome when I've finished, instead of looking like a retard. They obviously read the guidelines, and decided to give him a cross-bite, as they were not going to be paid for correcting his upper arch form.

Teresa Day

A crossbite is due to a mismatch either in position, size or shape of either the maxilla or the mandible, though usually the former is involved. This may be either in an AP plane, or bilateral or unilateral in the sagittal plane. However there can be an underdeveloped maxilla without a crossbite (e.g) as in class 2 or crowded upper and lower in Class I. If it is acceptable to develop a small maxilla to correct a crossbite, why is it not acceptable to develop it in other instances?

Granny

They are quoting established wisdom which they could only support

with negative evidence. There are plenty of scientific papers that have shown that expansion is a realistic possibility and that relapse is only partial. More to the point the Practice Board do not have the right to say how treatment should be done unless it is ineffective or harmful; I established this point in the high court (Mew 1987). Their job is to approve payment, and they can refuse to do so if the result is unsatisfactory afterwards, leaving you to appeal if you disagree. As far as I can see if they approve payment by one method (fixed) and it is done by another (functional) they must also pay up if the result is satisfactory, but this does not give you the right to deliberately mislead them.

John Mew.