November 19, 2018

My top 10 research papers.. 

One of my most popular posts was about the top ten orthodontic papers. I did this two and a half years ago and I thought that I would update it.  I hope that you find this interesting.

Some readers may feel that these may not be the “best” research papers, however, they are the papers that made me think about orthodontics. The list also contains papers that changed practice. You will see that some of them are rather old. But I think that  it is very worthwhile for us to look back at studies that challenged the thinking at that time. They are not in any order of importance or quality but I have started with some recent trials that should change practice.

A multicentre randomised controlled trial to compare the self ligating bracket with a conventional brackets in the UK population:

Lian O’Dywer; Simon J. Littlewood; Shahla Rahman; R. James Spencer; Sophy K. Barber; Joanne S. Russell.

Angle Orthodontist: 2016;86:142–148.

This team based in the North of England did this study on the overall duration of treatment with Damon v conventional appliances. They found that there were no advantages in self-ligating brackets.  I particularly liked this study because it was a multi centre trial. Importantly, they looked at the final outcome of treatment.  I think that this study provided great information that “put the last nail in the coffin” of self ligating brackets.

Effects of supplemental vibrational force on space closure, treatment duration, and occlusal outcome: A multicenter randomized clinical trial

DiBiase et al

Am J Orthod Dentofacial Orthop 2018;153:469-80

In a similar way to the previous paper this paper should have changed practice. A team based in the beautiful south of England did this trial. Again it was multi-centred and looked at the effect of AcceleDent on reducing the duration of orthodontic treatment.  They found that there was no evidence that AcceleDent had an effect. Interestingly, I think that this led to the decision by the UK advertising standards authority to state that AcceleDent advertising was misleading.

Early class III protraction facemask treatment reduces the need for orthognathic surgery: a multi-centre, two-arm parallel randomized, controlled trial.

Nicky Mandall, Richard Cousley, Andrew DiBiase, Fiona Dyer, Simon Littlewood, Rye Mattick, Spencer J. Nute, Barbara Doherty, Nadia Stivaros, Ross McDowall, Inderjit Shargill & Helen V. Worthington

Journal of Orthodontics, 43:3, 164-175, DOI: 10.1080/14653125.2016.1201302

This was simply a great paper. Another UK based team did this trial, with very little resource. While it may be easy to criticise their methodology. I was really struck by the simplicity and clinical relevance of their outcome measure. They randomly allocated 8 year old children with Class III malocclusion to early treatment or control. They followed them through until they were in adolescence. Then a panel of orthodontists evaluated the need for orthognathic surgery from their records. I thought that it was very interesting and clinically relevant that they showed that early treatment reduced the perceived need for orthognathic surgery.

Equilibrium theory revisited

Proffit WR.

Angle Orthod. 1978 Jul;48(3):175-86.

This is a paper which I still suggest all postgraduates and residents read. I also used it in my blog post about the recent death of Bill Proffit. In my opinion this is still one of the finest orthodontic papers written and is timeless.   Bill Proffit outlines the rationale behind the factors that influence the position of the teeth.  While most of this is personal opinion, it is very hard to put forward an alternative hypothesis.  This is still highly relevant paper as we still agonise over the need for retention.

 Dental and social effects of malocclusion and effectiveness of orthodontic treatment: a review.

Shaw WCAddy MRay C.

Community Dent Oral Epidemiol. 1980 Feb;8(1):36-45.

Apart from this paper being a classic, it means a lot to me, because when I was applying to the orthodontic program at Manchester, one of the orthodontic registrars at Newcastle (where I was based) suggested that I should read it. This was because Bill Shaw  had recently been appointed to Manchester and was bound to be  interviewing me. So I  got out the paper and read it on the train journey to Manchester.

In fact, they did not ask me any questions about it!   Even though I did not understand much of the subject area, I found it interesting.  I have read this many times since then and it certainly is a classic paper, because it stated the case that the need for orthodontic treatment was not clear cut. Importantly, this work led to much of the work that developed IOTN and PAR.   Interestingly,  many of the questions that they raised in the paper are still unanswered today

Methods used to evaluate growth modification in Class II malocclusion.

Tulloch JF, Medland W, Tuncay OC.

Am J Orthod Dentofacial Orthop. 1990 Oct;98(4):340

This paper was one of the first systematic reviews into the effectiveness of orthodontic treatment and was the basis for the study into early orthodontic treatment carried out at the University of North Carolina. I felt that this was a fascinating paper because it made the orthodontic research community aware of the problems that were arising from our use of traditional retrospective methods. This paper is a ” must read” for all aspiring orthodontists.

 Cephalometrics in perspective

Hixon EH.

Angle Orthod. 1972 Jul;42(3):200-11. and

This was a paper that help me start to understand cephalometrics  and also develop a rather cynical viewpoint to their use. It also probably has the best start to any orthodontic paper that has been published.

 “If  one could sit on the moon and look at the activities of the 3500 different millions of humans each trying to obtain elbow room and food on a rather small planet in the third-rate solar system and ask himself “what have cephalometrics contributed?”.

A long-term comparison of non-extraction and premolar extraction edgewise therapy in “borderline” Class II patients.

Paquette DEBeattie JRJohnston LE Jr.

Am J Orthod Dentofacial Orthop. 1992 Jul;102(1):1-14.

When I was starting on a rather evangelical point in my career and I had “discovered” clinical trials, I was putting a viewpoint forwards that the only type of research of value was a clinical trial. While this is still my opinion. I have mellowed and realised that other well-controlled studies, while not providing the same high level of evidence to a trial, may still help us reduce uncertainty about our treatment. I still wonder if this is the way forwards for orthodontic research.

This paper addresses a difficult question by careful selection of matched cases in a retrospective sample. This was also the first time I came across Lysle Johnston, and his very logical questioning approach to orthodontics.

The effect of early intervention on skeletal pattern in Class II malocclusion: a randomized clinical trial.

Tulloch JF, Phillips C, Koch G, Proffit WR.

Am J Orthod Dentofacial Orthop. 1997 Apr;111(4):391-400.

This paper is simply a classic. It was a preliminary report on the first large scale RCT in orthodontics.  This led the way for many researchers to start using RCT methodology.

Consistency of orthodontic treatment decisions relative to diagnostic records

Unae Kim Han, Katherine W.L. Vig, Jane A. Weintraub, Peter S. Vig, Charles J. Kowalski

American journal of orthodontics and dentofacial orthopedics  September 1991 (volume 100 issue 3 Pages 212-219)

Again, this is a paper that questioned current dogma at that time and orthodontics.  It still stands close scrutiny and its central message is still very relevant today, particularly with the development of CBCT.


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Have your say!

  1. Per the Tulloch Cl II paper’s mention:

    ‘Although not unanimous, a consensus seems to be appearing in the orthodontic literature that, in spite of large variations within groups and small mean differences, functional appliances do produce modest (and sometimes statistically significant) amounts of increased mandibular growth,….. decreased maxillary growth, ….’

    Prof. O’brien, given what McNamara showed us about propensity of many skeletal cl II pts as being pre-Tx bi-maxillary retrusive (Angle Orthod 1981), do you think the functional appliance Tx effect of ‘….decreased maxillary growth…’ (i.e., ‘headgear effect’) is a good thing for class II patients? That is, do you think that maxillary protrusion is a significant component of the class II skeletal phenotype problem?

    • A consensus would be a nice thing to have but I don’t really see much sign of one. Despite the evidence that we do have there seems little change in clinical behaviour. With regards to functionals a quick tour of websites shows plenty advocating functionals to grow jaws etc etc. There are people out there using functionals, class 2 elastics, upper extractions and probably other modalities and I’m not sure which works best ie gives the most predictable result in the shortest time. If the jaw is going to grow (or not) anyway maybe we should just wait until after growth like in Class 3 cases. Any consensus would be really appreciated.

  2. Hi Kevin, thank you for your greta review. Is it possible to get access to these 10 articles?
    Kind regards

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