January 03, 2022

New Year’s Orthodontic Hopes and Dreams

Happy New Year! This post is my usual start to the New Year. It outlines our hopes for the blog and orthodontics for the following year. When I write this post, I always look back to see what I wrote in my previous “Hopes and Dreams post”. I spotted that I stated that “Life, in general, is more important than orthodontics”. My opinion, of course, was influenced by the stage of the COVID pandemic. Unfortunately, we are still in a state of great uncertainty, but with a sign of “light at the end of the tunnel”. So I shall not be too gloomy in this post! Here are my orthodontic hopes and dreams for 2022.

Conferences

I am very optimistic that face-to-face orthodontic conferences will return this year. While some meetings were held at the end of last year, there is still a chance that new variants may result in further changes. But let’s keep our fingers crossed.

I am looking forward to doing my last conference presentation in June. This will be to a small meeting of orthodontists. The meeting will be held in the Welsh village of Portmeirion, and I think that I will have trained and/or worked with most of the delegates. This is a fitting way to end my lecturing career.

New year

You may not think that this is a typical Welsh village, it is a strange but brilliant place.  You can find more details here.  

Online lectures

I promise that I will post all my lectures on this blog. I know that I said I was going to do this last year. However, I got side-tracked by COVID isolation and lost some motivation. I also worked as a vaccinator in a mass vaccination centre. This was a great experience but took up a fair amount of my time. I am still doing this, but I hope it is more under control! I will do my best to post the lectures up as soon as possible.

Blog posts

Padhraig and I will continue to publish a weekly post. We will still concentrate primarily on trials and systematic reviews. However, we will also discuss interesting and well-done retrospective studies if they add to knowledge and discussion. I also hope that we can attract more guest posts. These are very interesting and provide a variety of viewpoints and add significantly to the blog.

Promoting good orthodontics

We take great pride in being orthodontists and in our work. Orthodontics has so much to offer. We can predictably make very meaningful, lasting occlusal and sometimes facial changes in the right patients. We do not need to chase down rabbit holes such as breathing or body posture to prove our worth. We genuinely believe that we can change many of our patients’ lives by practising sensible, evidence-based care. We will continue promoting and discussing studies that evaluate this type of intervention and outcome.

Finally, we will continue to vigorously challenge those who promote the orthodontic fringe and market-driven orthodontic techniques with little evidence supporting these concepts.

Importantly, we will continue to challenge the highly-paid KOLs. However, I have reflected on the past, and I will try not to make my comments so personal.

Breathing, expansion, and other lies

Over recent years, we have witnessed optimistic claims relating to “novel” appliances and techniques. The latest “new” treatment appears to be expansion. Nowadays, expansion seems to be accompanied by largely speculative claims for curing breathing problems, bedwetting and other systemic ailments. We will be paying particular attention to the research into breathing this year.

Final comments

These are still challenging times, and I am concerned that I appear downbeat. I am sure that this reflects the current state of COVID. Nevertheless, we do have great hopes and dreams for this year. Let’s look forward to improving our patients’ lives for another year and another constructive year for this blog.

Have your say!

  1. Excellent and thank you very much ☺️

  2. Hello Kevin,
    I have been following Dr John Campbell out of the UK for a number of months ( at least peak of Delta wave). I think you will find his posts on you tube based on the very latest information, statistics and science when it is available. I am sure this will lift the spirits of all who are caught in the COVID gloom of the present.
    I am sure we are not done with Covid yet, but John’s blogs do provide information that indicates the world will be in a better place very soon.
    Take care

  3. Excellent. Happy New Year Kevin! Say hello to the ” New Number 2″ in The Village” in June!

  4. Dear Kevin,
    Greetings of the season. Would love to go to Wales for the meeting in June, however, she who must be obeyed has put a kibosh on our overseas travel for the time being. Stay safe and KOKO.
    Smile,
    Joe

  5. Happy New Year Kevin from a retired dinosaur and Slainte Mhath Padhraig!
    Yours’s is the only ortho website I visit now – promise to add some to the coffers this year too!
    Best Regards
    Roger

  6. The members of BSSMD, and most probably many other healthcare practitioners with similar views, take great exception to your labelling them as ‘liars’.
    There is no question, scientific or otherwise, that malocclusion and orthodontic treatment are frequently linked to airway and breathing issues, and that dental arch expansion has been an everyday feature of dento-facial orthopaedics for several decades. In fact, in November you complimented a group of Brazilian researchers on their work on maxillary expansion, saying “it should be widely read and quoted”!
    We would suggest you take your head out of the sand and bring your brain into line with 21st century orthodontics. A little respect for your colleagues would not go amiss.
    Noel Stimson
    Patrick Grossmann
    Helen Jones
    Derek Mahony

    • Thanks for your comments. Let’s have a chat about this. We can start with a discussion. Can you let me have a reference to one single randomised trial that shows that orthodontic treatment can improve the airway? If you cannot do this, there is no need to reply. Thanks: Kevin

  7. We have at least 60 references that show the connection between airway and malocclusion/orthodontics. Can’t promise they are all RCTs, but as you have indicated many times, sound clinical experience is often sufficient validation.

  8. It’s NOT orthodontic tx that increases airway of course not. It’s orthopaedic tx that does. In other words by bringing the entire mandibular apparatus forward the airway is altered. Orthodontics is just a ‘tooth’ tx.

    • Again, just send me one RCT that shows the mandible can be brought forwards to a clinically significant degree.

      • I would have thought that as a Professor and with research students under your tutelage, it shouldn’t be too difficult to access the literature?. I’m not willing to do that for you. The fact that the UK is and has ben out of sync with the rest of the world for years regarding these topics speaks volumes. The high and mighty practise this eg. The late Prof Graber and Prof W Proffitt. It’s all out there in the literature but as my old mentor said ‘most people don’t read it!’
        Then you have to look also at the cohort
        of patients. NHS vs private. Different socio economic groups ? Anyway to keep asking for the definitive study you yearn for is not helping those of us who treat patients with very satisfying results.
        Kind regards Patrick Grossmann

        • I’m not asking you to access the literature for me. I am perfectly capable of doing this myself. I simply asked if anyone has evidence to back up the claims that they (you) are making. It appears that you have no evidence to support the theories and claims that you make.As a result, we stand by our comments in our blog post. You may not like them, but this is where we are at present.

          • As you say, theories by definition cannot be proved simply disproved. Fundamentals of physics. No?
            So it is for the academic Establishment to find evidence to disprove our
            findings and results?. Absence of evidence is not evidence of absence. The problem we as clinicians face when discussing anything with our learned academic colleagues is that they want watertight evidence along THEIR lines. We see the results at the ‘coal face’ daily as do our patients and to be perfectly honest that means so much to those of us trying our best to provide our patients with the best care we can offer.

          • Thanks. Do not forget that I am also a clinician, I may not be in private practice in central London treating a select group of patients. But, I did a good job. I worked in a tertiary referral Childrens hospital and treated many children with breathing disorders. Importantly, I always tried to provide evidence based care. I certainly, did not make extreme claims for my treatment.

            There is a fine dividing line between claims made for breathing, TMD and other disorders and snake oil. We highlighted this in our blog post. You seem to take exception to this. If you don’t like the blog don’t read it. Thanks for your comments.

        • I totally agree. Let the academic institutions run all the RCTs along the lines of what we in practice do! By the way I worked within the NHS for 25 years so have first hand comparison
          of the NHS and the private sector.
          This blogging is not going to change my view nor will it change yours so for that reason ‘I’m out!’ Best wishes for the future, Patrick

  9. As I write this blog, 3 days after my response to your challenge to produce evidence of the airway connection, I see you have not published it yet.
    Dear Kevin,
    Since your initial response issuing the challenge stated that ” If you cannot do this, there is no need to reply” then your declining to publish my reply gives the inaccurate impression to your followers that “I cannot do this”. This is untrue and unfair.

    If, as you say, you truly wish to open a discussion on this subject, then I suggest you respond appropriately so that the ‘discussion’ can take place.

    • Sorry for the delay. It is now Monday and you will see that I have replied, I was busy with other parts of my life over the weekend. Anyway, still waiting for the evidence from a trial.

  10. Work in progress. Give me a couple of days to pull it together. There are an awful lot of trials and studies!

  11. i think the functional matrix hypothesis and mewing are the best evolutionary environmental techniques at growing the craniofacial complex and expansive devices such as the biobloc if you can’t do it yourself because of the modern environment. claims made maxilla/palate expanders can also increase the functional airway too. only need to search google for ncbi studies and website pictures of differences in the face and airway although more conclusive research would be great and the younger treatment the better

  12. people already know malocclusion is primarily associated with loss of function and posture from the modern environment and lifestyle and that the primary step is to either reintroduce functional demand and posture yourself at a young age or to use posture expansion devices to bring both jaws forward and widen the airway with no relapse or retainers in most cases. helps to prevent the need for braces, jaw surgery and retainers at a later date which would otherwise be required.
    anyone who ignores this crucial early age treatment and only promotes braces which can relapse and doesn’t provide much airway benefit is currently fringe.
    not to mention the damage sugar and invasive treatments of the jaw can do to growth at an early age too i.e causing tinnitus and temporomandibular disorder.
    these people don’t enter into discussion, they delete the discussion because orthodontists have no evidence to back their claim that genetics is the primary influence of malocclusion instead of epigenetics.
    not to mention the contributory allergy and asthma epidemics related to breathing.
    orthodontists need to get with the modern time of primary airway orthodontics and expansion.
    anyone with credibility to back their claims would open into discussion. orthodontists primarily only treat the symptom and not the cause xD

    • Exactly right! Modern orthodontics merely addresses the symptom (actually the ‘sign’) of malocclusion, which is clearly caused by other underlying factors (cranium, orofacial muscles and growth – C.O.G). The reality is the teeth are the passengers in the process and have no inherent ability to change anything by themselves, unlike the 3 factors.
      Without addressing the aetiology, failure (relapse) is inevitable.

  13. ha must’ve struck a nerve. nothing like a “professor” shutting down a debate which he himself invited others into oh and check out my related website: the national institute of allergy and infectious diseases xD

  14. I am wondering if you have a reference for a RCT which confirms that malocclusion is a genetic problem.

    • Of course I have not. Trials are for interventions. This is also not relevant to the current discussion, which is about the role of orthodontics in breathing problems etc.

    • i would have liked to investigate this. myself but unfortunately i was never treated with an expansion device or any orthodontic device growing up. just ended up with all of the asthma, allergies, tinnitus, jaw joint and other problems as a result, also to do with harsh modern environmental conditions xD
      could it be different expansion devices are better than others? i would assume they don’t all work in the same way. high quality comparison studies are needed between different types of devices at young enough ages
      to me it makes sense considering these devices focus on widening and bringing forward both the upper and lower jaws.
      i have read lots of studies from verified offices which claim positive benefits on the airway but can’t say so myself. not something you usually think about as a child until you end up with problems as an adult
      only now my probably only option is awaiting braces and surgery which is tricky and requires retainers and relapse monitoring
      even so correcting these problems in the environment would be complex and could probably take multiple generations to do so
      one only needs to look at the modern diabetes and obesity epidemics to see this modern environmental removal of functional demand problem too

  15. My point is that if a malocclusion hasn’t been proven to be solely of genetic origin then it must, in part at least, be due to environmental factors. Some of these can have a negative impact on the development of the cranio-facial complex. Orthopaedic appliances can override epigenetic influences and allow the patient’s full potential to be expressed. The improvement of the airway is just one outcome of this approach to treatment.
    ENT surgeon professor Narinder Singh and ENT specialist Dr David McIntosh have certainly recognised this connection.

    • When we consider the aetiolgy of malocclusion, current thought is that it is a combination of genetics and environment. However, there is absolutely no strong evidence that orthodontic appliances can influence the way that a person grows.

  16. Kevin, I now have a selection of studies for you, RCTs, systematic reviews, etc. Currently the document runs to rather more than bloggable size; how would you like me to send it?

    • Thanks, can you email it to me directly at [email protected]. However, I am still surprised that it is rather large. Please remember that we are trying to answer a request that I made earlier in the discussion

      “Can you let me have a reference to one single randomised trial that shows that orthodontic treatment can improve the airway?

      Thanks Kevin

  17. Dear Kevin,

    As promised, I have discovered several studies for you, including 3 RCTs, 1 non-controlled trial, 4 systematic literature reviews, a multiple case report and 3 major teaching and research articles. However, since you have asked for a single RCT, that is what I am sending you. This has also reduced the size of this document for the blog.

    However, it is very interesting to note that of all the references I have now listed, none are of UK origin! All the publishing journals and most contributors mentioned are from European, American, or other non-UK sources.

    So why, Professor O’Brien, is there so little interest within the UK Orthodontic Establishment for information about the well-recognised links between airway, malocclusion and orthodontic treatment?

    • Airway,
    • Sleep disordered breathing
    • TM joints,
    • Craniofacial development,
    • Oro-facial muscles and the
    • Tongue. (ASTCOT)

    When I interrogated the Cochrane Review website, with various search combinations of malocclusion, orthodontics, airway, breathing, etc., I came up with “No results” every time. The only British RCT I could find is below, carried out in 2016 by BSSCMD member Dr Michael Trenouth, an English orthodontic consultant, now retired, though published in a US journal. This is the RCT I am sending you.

    I have several other references for you, and I am disappointed you seem to be uninterested in them as they provide a mass of supporting scientific and clinical evidence for the airway connection.

    Your devotion to the RCT is most commendable, but it can be very limiting in one’s view of what is actually happening. One has to acknowledge, as you have said many times, that clinical evidence can be almost as useful, and in some cases, maybe more so.

    One gets the very strong impression that the orthodontic establishment view is that the only important thing is straight teeth and a nice smile, and you only need to understand fixed appliances to achieve this. But we now understand that there is a whole lot more to malocclusion than just crooked teeth – they are simply a sign of something out of balance elsewhere in the craniofacial system such as:

    • Cranium,
    • Orofacial muscles and tongue, and
    • Growth (COG).

    The saddest aspect of this situation of minimalised (if any) dental school learning and GDC-suppressed post-graduate understanding, is that it matches with UK orthodontists’ views in general on early treatment in the mixed dentition (see Patrick Grossmann’s literature review in Cranio UK, Winter 2022), where UK orthodontists are clearly shown to be 3 times LESS LIKELY to treat at this age compared with the rest of the world, in spite of all the well-recognised and published advantages. Conventional studies (including Cochrane) of the procedure claim the only advantage is a reduction in the incidence of fractured incisors, which has to be an overt acknowledgement that early treatment can successfully treat malocclusion anyway!

    With regard to “Dental Sleep Medicine”, it has to be recognised that ‘disordered sleep’ is fundamentally a medical issue, though dental input, aetiologically or therapeutically, can be highly significant.

    A RANDOMISED CONTROLLED TRIAL
    1. M J Trenouth, S R Desmond. “A cephalometric evaluation of oropharyngeal airway changes during Twin Block treatment”; Int J. Dent and Oral Sci (IJDOS); May 2016. S4-004. 22-30.

    “Introduction: The research hypothesis under test was that functional orthopaedic treatment with the Twin-block appliance increases the oropharyngeal airway as well as correcting the jaw relationships in class II division 1 patients.
    Method: 20 cases, 10 male, 10 female. Age range: 11-18 years, average treatment time 9.4 months were randomly selected from the records of a previously completed prospective trial. Cephalometric radiographs taken before and after treatment were analysed. p, the shortest distance between the soft palate and posterior pharyngeal wall and t, the shortest distance between the tongue and the posterior pharyngeal wall were measured.
    Results: There was a statistically significant increase in both p and t after Twin-block appliance treatment (p=0.000). A control group selected from normative data matched individually for age and sex and treatment time showed no change over the same growth period.
    Conclusions: In Class II division 1 malocclusion, the oropharyngeal airway is already reduced compared to Class I and Class II. Treatment involving premolar extraction and incisor retraction further reduces the airway as does headgear and is contraindicated. Functional appliance treatment is the method of choice as it enlarges the oropharyngeal airway reducing the potential for obstructive sleep apnoea.”

    • So, you found one. But do they measure breathing? I have read this before and they measure simple 2D distances from cephs. This is not breathing. What do you think? Do you want me to do a blog post on this?

  18. You asked me for an RCT on ‘airway’ which what I have done. Breathing is a related though separate issue which will require further research. I will ask Mike Trenouth if he wishes to have his study reviewed by you.
    Personally I would have thought that an enlarged airway would probably improve breathing in any case – the two tend to go together I presume? So I am not sure what you are wanting to prove or disprove.

    • Thanks for the comments. I will wait to see if Mike wants his study to be reviewed, then I am happy to do this. However, you also need to know that this is a predatory journal that charges for publication. Papers in these journals are generally not of high quality. I will wait to hear from you. Best wishes: Kevin

    • I have just had a look at the paper you suggested would provide evidence on the effect of orthodontic treatment on the airway. You will remember that I asked you to let me have one trial. Unfortunately, the paper that you suggested was not a trial. It was a study in which they selected a sample of patients from another study and then compared them to another sample selected from a growth study. It was therefore a comparison of retrospective case series. So I can conclude that at the moment there is an absence of strong evidence on the effects of orthodontic treatment on the airway. Best wishes: Kevin

  19. It looked like a ‘trial’ to me with data from a randomly selected group compared with a control group. Whatever your view, the results were impressive and conclusive in that it strongly indicates that “Functional appliance treatment is the method of choice (in the treatment of Class II div 1 cases) as it enlarges the oropharyngeal airway reducing the potential for obstructive sleep apnoea.”
    I have no problem with that.

    • You are not correct. This is not a trial. In fact, it is a very poor paper with a small sample size that has been published in a predatory journal. If this is the best that you can find, then I stand by my comments. That is there is no strong evidence to support the claims that orthodontic treatment influences the airway and breathing.

  20. Not wanting to be too pedantic, but I said “It looked like a ‘trial’ to me” which is different from saying “it is a trial”. I bow to your superior knowledge in this department. Not sure what you mean by ‘predatory’; that suggests preying naturally or being exploitative, neither of which makes sense in a scientific journal!
    There may not be an RCT yet about airway and orthodontics (more appropriately, dental orthopaedics), but there is a mass of other evidence together with hundreds of dentists around the world underlying the clinical significance off this kind of work.
    If ‘orthodontics’ is limited to merely straightening teeth (as it is by definition), then there will be no significant effects on the airway. But as Patrick Grossmann has correctly pointed out above, this can only be achieved with dento-facial orthopaedics which has the capability to change bone size and relationship (e.g. the Twin Block appliance, the ALF or RME). Maybe this explains why there is no RCT on the subject? But there is a stack of other studies. I have about 75 of them.

    • Thanks, but there are trials on Twib block and other functional appliances that show that they do not alter the skeletal pattern? I think that we should stop this exchange because it is clear to me that our knowledge of the literature and orthodontic treatment is different?

  21. I am deeply skeptical of trials that indicate that the Twin block, etc. cannot change skeletal patterns; I have used the Twin block appliance extensively to treat Class II cases since first listening to Bill Clark in 1994. A study or trial that tells me I have been wasting my time (on scores of successful cases!) fails to impress me. I suggest you look at some of the other studies for a more balanced view on this and the other issues we have mentioned.

    • Thanks, this sums up your views and knowledge of trials very nicely. As I said previously we should probably stop this exchange, as we are a long way apart in our beliefs on research evidence.

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