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.
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 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?
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.
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.
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.
Computers, 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.
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..
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.
Emeritus Professor of Orthodontics, University of Manchester, UK.