Advice for Solicitors

There have been some interesting developments in the areas of Orthognathic surgery (jaw surgery) and Orthodontics (tooth straightening). Currently there is a high level of professional disagreement in this field and several cases have failed because the judge was unwilling to adjudicate between expert witnesses with contrasting opinions. This type of division tends to exist between conventional hospital based consultants providing ‘orthodox’ treatment and general practitioners practicing ‘alternative orthodontics’. Recent cases have shown that the results can be a lottery.

A more certain result may be achieved by taking the ‘informed consent’ route. In a recent case a health authority refused to inform patients about alternate methods designed to avoid the need for surgery because their conventionally trained consultants considered them too unreliable. Patients who had been prescribed surgery were either not being informed about alternate options or were being told that there were no other options. Several of these patients subsequently found their way to an orthodontist in the same area who treated them with alternate methods without surgery. Certainly the cases demonstrated in this case showed equivalent if not superior results than would be expected from surgery and it was claimed that over 20% of the cases currently receiving surgery could be treated by other means, a higher percentage if treatment were started younger. This orthodontist has offered to provide a CD of these cases free of charge to any firm of lawyers.

Orthodontics itself is slightly to one side of orthognathic surgery but the issue of extraction treatment vis-à-vis non-extraction treatment is a frequent cause of professional disagreement. Currently many orthodontists are claiming to avoid extractions by moving some of the teeth to the back of the mouth to provide space for the others. However this increases need for the extraction of the back teeth which are twice as large as the front teeth. Apparently most orthodontic techniques result in the loss of four teeth at one point or another but many orthodontists are failing to provide fully informed consent on this point.

Of special relevance is the recent finding in the UK House of Lords where a patient had complained that they had not been told about alternative methods. The case was defended on the grounds that no alternative method could have been successful but the Judges, probably wishing to emphasise a point, decided that fully informed consent involves telling the patient about all other possible methods not just those that the clinician might consider appropriate.

A third point arises from the fact that research shows that orthodontic treatment tends to lengthen the face (Battagel 1996) (Lundstrom & Woodside 1980) (Melson et al 1999) (Toth and McNamara 1999). It also seems that longer faces look less attractive (Lundstrom et al 1987). This may be related to occasional complaints that orthodontic treatment has damaged facial appearance. Apparently if the face lengthens, the cheeks tend to become flat and the chin recedes but it is sometimes hard to find clear evidence of this as the pre-treatment photos are often inadequate or go ‘missing’. Patients are rarely warned that their face could be damaged although it is widely accepted within orthodontic circles that this is possible and research has suggested that in some situations the chance of this can be quite high (Mew 1999). The main issue of course is what warning was given but it is certainly wise for patients to obtain copies of the initial photographs before a complaint is lodged.