An occasionally irregular blog about orthodontics

30 years of orthodontics….what has changed?

By on September 20, 2016 in Personal opinion, Recent posts with 21 Comments
30 years of orthodontics….what has changed?

30 years of orthodontics….what has changed?

I have just returned from holiday and while I was taking a break I realised that it is 30 years since I completed my orthodontic specialist training.   I thought that I should write a post on the changes that have occurred in 30 years of orthodontics and I hope that you find this interesting.

So here they are, in no particular order of priority.

Evidence based orthodontics

When I was training we thought that retrospective studies and case reports were high levels of evidence. We accepted nearly every published paper as the ‘truth’ and quoted the various authorities with almost religious fervour. There were few randomised trials and no systematic reviews. When I look back, the most interesting work was being done by Lysle Johnston, who was using a discriminatory analysis approach in his studies. But this was too difficult for me to understand.

I did not start thinking about levels of evidence until the early 1990s when the teams at UNC and Florida started to publish the initial results of their Class II studies. At the same time Bill Shaw, in Manchester, was promoting the systematic review as a source of evidence. Momentum built quickly and I look back fondly at a golden period in our department, where nearly every patient was in a trial. This continued with many people carrying out trials. I feel that orthodontics now leads the way in trials and systematic reviews in dentistry. We can now practice evidence based orthodontics, if we want…

Brackets and wires.

I learnt standard (zero torque) Edgewise along with some Begg. We bent round wires for the early stages of treatment and put torque in rectangular wires. The developments in brackets and wires since then are self evident.  Providing orthodontic treatment is so much more effective now.

Functional appliances.

We made mandibles grow with Frankel and Bionator appliances. Now we do not grow mandibles with Twin Blocks and fixed functionals. We simply move teeth and provide good treatment.

Extraction and non extraction

We took out a lot of teeth and were trained to close spaces with appropriate mechanics.  As a result, we did not destroy faces.  Now we do not take out  many teeth and it all works out fine?

Early treatment

Early interceptive treatment was serial extraction. I do not know if this worked because we did not follow up our treatments. Now we practice early treatment for what appears to be unscientific and irrational reasons. Social media sites and case reports are full of interceptive treatment, for example, closing upper incisor spacing in 8-10 year olds, this all looks like normal development to me.  I am not clear why orthodontists are doing this?

Self ligation

We used the Speed bracket, but it was unreliable because of gate fractures. In the early 2000s the most amazing development was consistent reliable self ligation. This was not amazing because of the technology. What was amazing was the uncritical adoption of the advertising claims, the key opinion leaders, the philosophy and the almost religious zeal of the followers of the self ligating gods.  Even though contemporary research has shown that there is nothing special about self ligation, orthodontists still worship at symposia and on social media.

Orthognathic surgery

I and the surgeon would worry about single jaw surgery and we would wire jaws together after surgery. Orthognathic surgery is now routine and this remarkable development has made a real difference to our patients.

Aligner systems

There was a life before aligners. We just lined teeth up with fixed appliances. Aligners have changed orthodontics and opened up new avenues of treatment for many patients. But I still do not understand how this works. Maybe this is because I have not seen a single high quality piece of research on the effectiveness of aligners. Interestingly, I am not sure if I have seen a prospective case series, unless I am missing something? But now people can get aligner treatment without seeing a dentist. Orthodontics needs to beware, we are at the top of a very slippery slope. The silence from the orthodontic societies, apart from the BOS, is deafening. So where are you AAO, EOS and WFO, it’s time to step up and pass an opinion on this one?

Myofunctional orthodontics, orthotropics and dental breathing specialists.

I asked them for the evidence about these techniques 30 years ago….I am still waiting.

300px-ibm_px_xt_colorComputers, the internet and social media

We had a computer in our department, but it was only connected to a power supply and a printer. We used to switch it on and go and make a cup of tea while it booted up. The internet has changed everything. Information is now much more accessible to clinicians and patients. The good side is that this helps us help our patients. The bad side is that it allows people to make widespread claims for treatment that are simply not true. I am looking at you self ligators, dental vibrator salesmen, localised traumatisers and others who promote treatment without evidence.

Retention

We used removable Hawley retainers. Like many orthodontists I then started placing a lot of fixed retainers and then got tired of reviewing “retainer patients”. Now I use ESSIX retention at night only. It seems to work and the research evidence supports this regime. But retention and relapse is still our biggest mystery..

Summary

I hope that you appreciate this short list and please excuse my occasional cynicism. While I have been critical of some areas, I am certain that the good outweighs the bad and orthodontics has a great future. When I look back have have enjoyed every minute of my clinical career.  Since I qualified the changes have been immense and I look forward to the next discoveries that will help our specialty. I hope that this blog can contribute by disseminating this knowledge in a small way.

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  1. The orthodontic foot soldier says:

    Love it! Cynicism excused?

  2. Daniele Raviglia says:

    Dear Prof. Kevin O’Brien,
    I am very happy when I read your post … but unfortunately I believe that when we look around you seem to preach in the desert!
    I would like to ask you a question: since “now we do not grow Mandibles with Twin Blocks and fixed functionals. We simply move teeth ..” I believe that we can simply go back to using class II elastic!. Is too simple? Is too cheap?
    Best regards
    Daniele Raviglia

  3. R.Mortadha says:

    Dear Prof\
    Would you kindly comment on distalization (now and then) for the maxillary teeth and maybe on for the mandibular dentition as well.

    Best regards,
    R.Mortadha

  4. Hi Kevin,

    I thought I would add to your list from a patients perspective.

    In my experience, the relationship between clinical staff and patients has changed significantly. I recall some very negative and difficult experiences trying to access orthodontics as an adult patient in the 80’s when there appeared to be less appreciation of why someone would willingly seek treatment. I’m sure patients feel a lot more valued now.

    Widescale acceptance of adults undergoing orthodontic treatment from others has made the experience so much easier as we don’t feel the need to justify our decisions in the same way as previously.

    Access to orthodontics has improved both with treatment options available and the wider range of practices offering solutions. This does also mean that it has become more confusing for the patient with the line between short term orthodontics and more conventional treatments becoming blurred.

    Technology and social media has made access to information so much easier which has improved the ability of the patient to really understand the benefits and limitations of the treatments offered. Previously, to learn more about orthodontics required a visit to a specialist library or large bookseller. I recall buying a copy of Contemporary Orthodontics from Foyles just to understand a little more before approaching an orthodontist for my first round of treatment as a young adult.

    And finally, digital scanning has, in part, replaced the need for alginate impressions which for some of us, must represent the worst aspect of orthodontics!

    I’m sure there is a lot more that has changed in the last 30 years from a patients perspective but maybe an interesting thought would be what will the next 30 years look like? Maybe an idea for a future post!

  5. ross hobson says:

    Kevin
    i too am nearing the 30 mark….

    with my pre dental days being in science (i studied physics and chemistry pre dentistry) i remember often being “put down” for daring to question research quality esp studies with 2 or 3 subjects. I was VERY VERY lucky to have David Stirrups and John Clarke as my trainers who put up with me asking why?… and why? and more why? They allowed me to read widely, not subscribe to blind adherence to the orthodontic guru’s and to question and discuss everything
    eg the 1990’s great MBT publicity drive which has pushed UK into a singular 0.022 bracket system.
    I too remember bending arch-wires for standard edgewise brackets – which IMHO are still appropriate in some complex cases eg hypodontia

    I remember in the 1990’s often discussing with fellow UK academics (inc your good self) why they did not participate in the cranio-facial/ortho group of IADR/BSDR. I am still at at a loss why so many UK orthodontic academics do not participate in IADR/BSDR. Personally I have learned far more new concepts and ideas by mingling with fellow researchers from other disciplines, than attending the annual UK BOS ‘social meeting’ which IMHO still has far too much ‘opinions’ and insufficient evidence based presentations.

    The biggest changes to me has been developments in materials : –
    NiTi archwires
    reliable set-on-demand composites (remember the days of Right-On… right off!)
    Ceramic brackets that don’t fracture enamel on debond
    pre programmed brackets

    I never rated ‘the ‘self ligating and zero friction publicity… seems that cynical me was right to not to believe the publicity.

    I was (i believe) an early adopter of ‘wear your functional full time’ rather the the ’14+ hours day’ advice that was given to patients in the 1990s. However, i was slower on picking up and questioning that they didnt grow faces, but spotted that they only worked well in motivated young adolescents who ‘grew favourably’ : thankfully you and your team gave us the evidence that was staring us in the face, whilst i looked at enamel etching, bond strengths and dental material science stuff

    Aligners – as a long standing IADR member there was almost a whole ortho side of part of one meeting in late 1990s/early 2000’s that had a lot of ‘research’ on aligners as part of the early Invisalign drive… that found no differences/advantages : this was research that was buried and never published in the journals, but is available in the IADR conference abstracts.

    Technology has certainly changed… my first computing was back in the late 1970s (physics and chemistry degree + computing as a side option) and getting in trouble for printing Mini Mouse on the chain drive printer – took nearly 300 PASCAL punch cards and best part of 30 minutes printer time to do it! At the time one the staff gave a lecture predicting that in 20 years time everyome would have a computer, people would have them in their pockets and be wearing them,and they would not need separatist programmers to make them work.
    He was laughed off the lectern!

    i believe we now have got to this grand old age (i’m “32” now) that we can consider ourselves GODs (Grumpy Old Dentists) with the experience and the evidence to be cynical of so many things… now we need the Gods In Training (GITs) to continue to take our profession forward.

    Ross

  6. Owais Durrani says:

    We used to band second molars and were patient in moving teeth, now the youngsters want to put an implant in every extraction case

  7. Essex is not a retainer. It actually avoids the occlusion to fully interdigitate. You should continue putting fixed retainers and keep them until the third molars either fully erupted or extracted. Or you better move your office every 5 years and don’t inform your old patients :))

  8. sunanda says:

    Dear Professor Kevin,
    I think TADs deserve a mention here because of the way the envelope of discrepancy has changed after their use

  9. Sergio Valverde says:

    You forgot mini implants and mini plates! 😀
    Big change for me!

  10. hero breuning says:

    Hello Kevin, a great overview, what i miss, is the use of TAD’s in orthodontics and the deveopments in the wires. (I finished my training in 1981)

  11. James Petterson DDSc says:

    You seem to harbour the same mindset that you criticise: you worship previous research as the only baron of truth and fail to realise that because there is no research of some thing, it does not necessarily mean that that thing does not work or is incorrect.

    As an example from another field, I have not seen reliable and conclusive evidence that carbohydrates are uniquely fattening, yet in many clinical settings a reduction in carbohydrate improves many physiological and disease risk factors across the board. Do I continue to demand more conclusive evidence before attempting to implement the findings in a clinical setting?

    I think it’s time you get back to practising “evidence based orthodontics”.

  12. “The Future is already here, it’s just not evenly distributed”

    thanks for the post. I think there are a few non-orthodontic things that have had a big bearing too -don’t estimate infection control, data protection and record management, advertising for dentistry, child protection legislation, and practice regulation/inspection, photographs in journals, cheap long distance transport enabling meetings and conferences and training away from home.

    I didn’t practice orthodontics 30 years ago, but I can do 20, and from what I see, I’d probably add Temporary Anchorage Devices and digital imaging on the technology side and I honestly think many of us plan treatment differently – notwithstanding the arguments about extraction and non-extraction, facial soft tissue profile is a much bigger deal, and the idea of planning around the lower incisors is certainly modified by considering where are they to begin with and where will it leave things if we do?

    Now it may be that TADs are hyped up and over played, and maybe CBCT is overprescribed, but I find that they can be useful and when I was a post grad student they were almost in the sci fi category – we knew they existed but that was only for “other people”.

    Not just digital radiographs, but digital photography is a total game changer. We take more photographs, we share more photographs.

    I grew up with light cured composite, but the composite curing lights are faster too.

  13. Kevin O'Brien says:

    These are all great and very useful comments on my post. I agree that I forgot to mention TADS and imaging and these are very important developments. I am planning to write some posts on these areas and will get these up in the near future. I hope!

  14. Judith Lewis says:

    Dear Kevin
    just love your outlook on orthodontics. As do many of us here in Oz [apart from the ‘alternative’ tribes]. Nearly 40 years in orthodontics for me, still loving it, and your observations on changes are spot on.
    One theory on the reason for early ‘treatment’ of normal development is that the patient is then more likely to stay on in your practice. Not an issue in the public sector where I work. Maybe protecting children from parents shopping for immediate aesthetic perfection.
    Thank you so much for the time and effort you put into the blog.

  15. Ola Morndal says:

    I just came back from the SIDO-conference in Florence and I must say that the best lecture was given by the only lecturer not present! Thanks!

    I suppose that one of the few way in which you and I are similar is the fact that we have practised orthodontics since the beginning of the eighties. I have long since forgotten what I once learned about statistical analysis and other aspects of the academic world. I might be lazy but I think it is fantastic to be able to update my knowledge by simply reading your views and clicking on your links.

    The only thing I find disturbing is the way you continuously pick on ”self-ligating” brackets (I take it you mean Damon.). I absolutely agree with you that a lot, if not actually most, that was said in the marketing is unsubstantiated or proven false. Most of the claims made definitely don´t work in my hands! But I find the bracket per se, and I´m sure a lot of other brands of self-ligating brackets, is a great leap forward in many ways. Especially the efficiency, the hygiene and the ”digital” way it works. By ”digital” I mean the great advantage of having a bracket that you either can close or can´t close. You can’t unintentionally engage a wire halfway. I simply think you should criticize the messengers of all the unsubstantiated claims rather than self-ligating brackets in itself. The actual bracket hasn´t been proven to be any worse when it comes to moving teeth than any standard twin-brackets (to my knowledge) which makes your persistent criticisms a bit unfair in my mind.

    I still sincerely thank you for your urge to improve the orthodontic profession and the way you make knowledge accessible to lazy clinicians like me.

  16. Geoffrey Wexler says:

    Kevin I adore your general objective and scientific approach. You are the best orthodontic clinical scientist in the world. But in a gentle way I want to say that somehow I think your view on self ligation is tainted. Because anything that saves time in a clinic is good for patient and service delivery organisations. This is self ligation. It saves time in changing wires. But I don’t think the studies have have shown this effect properly becuase they have not been done in representative settings of service delivery, or even in calm objective background environments. The most dramatic example is in lingual treatment using robotically bent, super elastic copper niti custom bent wires that were made in 3d patients own cbct made root and bone models. The productivity difference per appointment is so great that it makes the delivery of exceptionally high quality lingual orthodontic treatment economically feasible on a large scale compared with not economically feasible to most people. Its clear that the studies to prove this have not been done and are unlikely to appear any time soon. So in this ocean of missing high level evidence, I’ll continue to practice the way my personally aquired low level evidence guides me. This is like your own conclusion, after you read the study on tongue cribs for AOB. Unfortunately, we only have very small amounts of high level evidence to go on. And for the rest we need to rely on fallible human judgement.

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