Current Dilemmas and Future Challenges in Treatment Dr. James Vaden Dr. Vaden discussed several dilemmas that face clinicians such as the decision to treat a patient with orthodontics alone or with a combination of maxillofacial surgery and orthodontics. A complicating factor is the patient who needs surgery as part of the treatment, but who also refuses to have surgery. The decision whether or not to start treatment early or late, and whether or not to extract teeth can also present dilemmas. Dr. Vaden described the diagnosis and excellent treatment of four patients who presented with very difficult skeletally based malocclusions. The audience joined in a discussion of the case reports.