Current Dilemmas and Future Challenges in Diagnosis and Treatment Planning: The Scope of the Problem Dr. Samir Bishara The commentator for this session was Dr. Luther Cale. Patients are aware of the importance of facial esthetics in our modern society, and are more demanding of their orthodontists, general dentists and surgeons. Our profession responded with the introduction of esthetic dentistry, esthetic orthodontic appliances and new surgical procedures that are intended to provide the clinician with greater control and efficiency and in turn provide the patient with an optimal result. According to Proffit, (1986) the goals of orthodontic treatment extend beyond providing a good and stable occlusal relationship. In other words, it should be the creation of the best possible occlusion and the best possible facial esthetics for that individual. In order to optimally correct dentofacial discrepancies, we as orthodontists need to be cognizant of our abilities to perform complex treatment modalities. Our diagnostic, treatment planning and treatment skills have significantly improved in the last century by the introduction of an array of radiological and non-radiological imaging techniques. In biomechanics, we have seen the introduction of direct bonding, nickel-titanium, and similar archwires, of different sizes and shapes, wires that are flexible, rigid or heat sensitive, brackets of all colors and sizes, brackets with and without prescription and with an endless choice of degrees of angulations and torque. We also have acquired a better understanding of the biological foundation of tooth movements. Similar improvements occurred in areas related to our specialty, such as new surgical techniques, implants, on-plants, distraction osteogenesis and the list goes on and on. Inspite of all these technological and biological advances, we still have difficulty agreeing on specific diagnostic criteria that would allow us to come to the same diagnosis and treatment plan for a given case. More important, we are still unable to determine, or predict, the long-term stability of the treatment results. This is a dilemma that our profession has faced during the last century and the prospects of a break through in these specific areas does not seem promising in the foreseeable future. We are still arguing about extraction and non-extraction, orthodontics or orthopedics, early treatment or not, surgery or not, expand the arches or not expand and most important, how stable are any of these approaches long term. All these controversies still exist, inspite of the so many scientific studies published in the last 50 years and are readily available to all of us. We all know, that people are complex, they are different and they are born with different potentials. This applies equally to the patient and the clinician treating that patient. But how come after all the advances were made, we are still facing the same dilemmas related to diagnosis, treatment planning and long-term stability that we faced for the last 100 years. In order to simplify our discussion and give it some structure, we can categorize the factors that influence our results as being related to: The clinician, the patient and the procedures used, including the appliance. Moyers (1988) very astutely listed five areas that could limit the clinician's ability to provide optimal care including; 1) Aptitude, 2) Training, 3) Experience, 4) Adherence to poor methods, and 5) Attitude. These areas describe one or more of the dilemmas and challenges that we currently face in our profession. Aptitude is a readiness to learn and understand, it is a talent. The extraction - nonextraction debate is an example of how clinicians on extreme sides of the debate overlook or ignore some basic orthodontic principles. These clinicians take a narrow approach to diagnosis and treatment planning. As examples they may rely on one set of cephalometric measurements and apply them to all patients regardless of age, sex or distinct face types, disregarding the individuality of the patient. Or they may rely on the ability of one pet appliance or technique to move teeth in every direction without concern for the biological limitations and stability of the results. Orthodontic individualism is a problem when we become intellectually lazy and make our own new and subjective rules that are not based on biological, scientific foundations. Orthodontists must be critical thinkers, not blind followers. Technical training is an important need in the education of an orthodontist. Clinical experience is needed in orthodontics because of the length of treatment and the variety of malocclusions. Adherence to poor methods is a problem for the profession. Solutions to this problem include (1) new research, (2) improving treatment approaches, (3) avoiding untested approaches, (4) reading books and articles, (5) continuing education, and (6) Board Certification. Attitude must be properly oriented. An orthodontist must objectively criticize his/her own clinical efforts. We must look at our own treated cases. Taking the Board examination is a means to developing proper attitude.