A paper about orthotropics in preventing canine impaction.
The advocates of orthotropics make many claims about their treatment. This paper looks at whether orthotropics is effective at interception of canine impactions.
I have discussed orthotropic treatment before. John Mew, a UK based orthodontist developed this form of treatment. The basis of this treatment is that the aetiology of malocclusion is mostly environmental. As a result, orthotropics addresses the environment of the teeth and jaws as part of treatment. They do this with removable appliances and muscle exercises. A course of treatment costs £7,500. For more detailed information have a look at their website.
Recently, John Mew’s son, Mike, who is a specialty trained orthodontist (Aarhus)has joined him. They have recently been very active and developed a YouTube channel with videos, such as this one involving a discussion on Mark Zuckerberg’s potential sleep apnoea. They teach orthotropics at the London School of Orthotropics and give courses internationally.
I have challenged them to prove their theories and I have not seen good evidence on orthotropics. However, John Mew pointed me to this paper that they both wrote. I thought that I should have a look at it.
CANINE IMPACTION: HOW EFFECTIVE IS EARLY PREVENTION?
John Mew and Mike Mew
STOMA.EDU J (2015) 2 (2) 114-119.
I am not familiar with this journal.
This is a video of John Mew talking about this research and the claims for orthotropics.
In their introduction they point out that the early prevention of canine impaction is rarely practised. Paradoxically, they mention that extraction of primary canines is carried out but for a high proportion of children this is not successful. They suggest that orthotropic treatment which involves moving the maxilla forwards may be a treatment for impacted canines. They set out to answer this question;
” What is the effect of orthotropics on the ratio of impacted canines within a given population”?
What did they do?
They noticed that in their clinic canines impactions were rare. As a result, they carried out an audit. They did not provide any information on how they carried out this audit. Normally, when you plan an outcome for a research project, you choose an outcome that is reproducible and valid. In this case, it would be the number of impacted canines in a certain caseload or population. They did not do this. The outcome that they chose was the number of impacted canines that they remembered in their clinic.
“Impacted canines tend to be a memorable feature of orthodontic treatment because of the problems they generate and hence are unlikely to be forgotten.
Approximately 1,500 patients had been treated by Orthotropics over this recorded 5 year period and yet there was not one incidence of a child who had started orthotropic treatment before the age of ten developing an impacted canine”.
“the traumatic consequences of impacted canines are so great that it seems unlikely that all five clinical staff would have forgotten every such incident”.
I took this to mean that they based their data on the fact that they could not remember any patients with impacted canines? If I am wrong, perhaps they could let me know?
What did they find?
They could not remember any patients younger than 10 years old who had impacted canines. They then compared this data with general population data that suggested canine impactions ranged from 1.5-4.5%. Finally, they concluded that this difference was “highly significant on the basis of any statistical analysis”.
In their discussion they showed some case reports with radiographs that they made unclear because they drew on them. Their final conclusion was
“expansion and proclination of incisors before the age of 10, coupled with postural training may reduce and prevent canine impaction”.
What did I think?
Firstly, we do need to consider that recent research has shown that making space for impacted canines is likely to result in their eruption. I have posted about this before. As a result, this treatment may have an effect because they procline the upper incisors. But, can they make the claim that orthotropics is effective in reducing canine impactions from this paper? I feel that they cannot.
We need to consider that if this is the best evidence that they have for promoting their treatment, then their evidence is lacking. This study has the following major issues;
- They did not review their records to record the number of impactions. I think that they simply used their memory. This is clearly not the way to measure an outcome in any type of research.
- This was a referred population to a clinic that practices “alternative” orthodontics. As a result, the population may be different from a normal population.
In my academic opinion, this paper is not even at the level of audit. I am surprised that they feel that this is evidence. Perhaps, there is other information and they can let me have additional papers to review?
Emeritus Professor of Orthodontics, University of Manchester, UK.
Have your say!
Thank you for posting this so-called audit Kevin. I think this perfectly encapsulates the abysmal lack of quality rife in the many branches of pseudoscience including orthotropics. When one cannot even execute the simplest of study designs appropriately, what validity could their claims possibly have? Obviously this audit would never be accepted in any reputable scientific journal. They don’t even have the evidence to prove that their intervention actually moved the maxilla forward! Orthotropics has once again proven to be based on fallacy rather than fact.
I have had a nearly identical experience as Dr. Mew. I treated crowded arches with early upper and lower expansion over a period of 30+ years and do not remember a single case where the canines became impacted. However, this is only anecdotal. The information presented by Dr. Mew would warrant a true RCT, to see if this hypothosis can be proven. We are, after all, scientists.
I agree with you, Kevin:
Another interesting parameter to test would be the number of cases that finished treatment with a full set of 32 erupted teeth, preferably in occlusion and without the need to extract impacted third molars – to me, that’s the holy grail –
Best wishes –
They stated that they couldn’t remember anyone who started the treatment before the age of ten that had developed an impacted canine. You stated that they could not remember anyone under the age of 10 years old developing an impacted canine. There’s quite a difference in these two statements. Even so, their methods of research seem to leave a lot to the imagination. It is certainly doubtful that their paper would be published in any reputable dental journal. To use the ones memory as the only source of validation for their theory is poor research technique at best and laughable if not for the amount of money charged for this procedure.
I don’t know what kind of practice management software or note keeping system this crew operate, but I have some sympathy.
If you asked me to pull the records for all my impacted canines for the last decade, I couldn’t do it other than by memory. I don’t think my management system allows me to search my records by keyword, so unless I assigned everyone some special coding from the start, I can’t really search by malocclusion or feature of malocclusion.
The most reliable method I would have would be to search all the word documents for the referral letters for canine surgery, but that would only turn up the ones that were referred for this.
I use one of the world’s best known practice management software systems and I pay thousands per year for the privilege.
On the other hand, my phone and its operating software, which would be given free in return for my phone contract, and many of the apps on it which are free to the user, such as WhatsApp and Facebook and GMail, allow me to search almost instantly through gigabytes of data.
I think there is a loss to our collective knowledge of the vast numbers of patients treated outside the formal academic setting by not being able to call on huge numbers of patients that were treated by individuals that weren’t intending to analyse the treatments beyond their own self-reflection/review. Admittedly this is more in the area of retrospective study but the sheer volume of patients would give some insight into treatments carried out and their outcomes – which has to be useful in the more rare conditions.