What is orthodontics?

This is a great new post by Padhraig Fleming and Jay Bowman, with input from Peter Miles.  It is their thoughts on the very nature of orthodontics.  I thought that this was great and very thought provoking.

Introduction

We feel like we should preface this post with an apology for posing a question that you may think is rhetorical, redundant and perhaps even somewhat indulgent. However, as avid perusers and reflective purveyors of orthodontics, it is hard not to perceive a step-change surrounding the provision and perceptions of orthodontics in recent decades. Specifically, appliances, the tools we use to affect tooth movement, are changing and taking ever-increasing precedence over the theoretical understanding and practical skills of highly trained operators. This development has helped to make ‘orthodontics’ more accessible, less intrusive and perhaps even attractive. And that, of course, is potentially very positive. This subordination, however, we fear is premature, may imperil the predictability and scope of what we offer, and might risk undermining our speciality.

So, what is orthodontics? Where better to start than with a definition? And in 2021, where better than to obtain this definition than Wikipedia? This source states that orthodontics is

“a specialty of dentistry that deals with the diagnosis, prevention, and correction of malpositioned teeth and jaws, and misaligned bite patterns. It can also focus on modifying facial growth; known as dentofacial orthopedics.”

But is this current definition sufficient? Does much of what is labelled ‘orthodontics’ fit this description? To (partially) spare you a treatise, we will confine this discussion to four points.

Knowledge- or Appliance-based?

The contemporary tendency to ‘cancel’ knowledge has recently permeated into orthodontics with a seeming preference among heuristic learners to eschew seminal textbooks and refereed literature published in non-predatory publications. Instead, many increasingly favour proprietary technique courses and related, often “sponsored” blogs, brochures and ballyhoo. Orthodontic decision-making should be solid, balanced and founded upon a thorough knowledge and understanding of growth and development, biological processes, biomechanical principles and force delivery systems. We firmly believe that those of us undertaking orthodontics cannot learn too much about these aspects. A deep immersion in orthodontic text and literature is undoubtedly a prerequisite for effective decision making, precise management of arcane and novel systems, and the provision of predictable and efficient orthodontics.

Conversely, a myopic focus only on proprietary appliances risks trivialising what we do. Some seem easily swayed by promoted successes of a “therapy,” but rarely are the travails and failures divulged. Isolated successful results may impress; notwithstanding, similar knowledge of the failures and struggles might be more instructive.

Orthodontics encompasses careful diagnosis of an array of factors spanning, but not limited to, patient concerns and desires; skeletal relationships; soft tissue morphology and responses; tooth size, and shape and position; and periodontal phenotype. The use of appliances typically constitutes what we consider to be orthodontic treatment. However, it is not a cure (as we treat “signs” and not a disease). Furthermore, our goals should not be to treat more, faster or more aggressively. Many patients do require appliances, but should we not aim to harness a knowledge of dental development and maturation to simplify the intervention, improve predictability, and minimise the adverse effects of appliance therapy?

Carefully planned

The Wikipedia definition of orthodontics refers to “diagnosis, prevention and correction” as well as “malpositioned teeth and jaws, and misaligned bite patterns”. These elements are undoubtedly relevant. Nevertheless, “orthodontics” is not a select few of these characteristics. True orthodontics, must of necessity, incorporate all of these aspects.

Orthodontics involves the management of the position of the dentition within a growing or maturing biological framework. As a result, we should direct treatment to position the dental arches (and occasionally underlying skeletal bases) in a position of health and aesthetics, but with an appreciation of the effect of these changes on the likely stability of the outcome. Alignment of teeth without thorough diagnosis and consideration of these features is not, therefore, orthodontics. It is a diluted version- ‘dental alignment’ or a form of somewhat ‘controlled tooth movement’. Is it time that we made this distinction?

A Victim of our Success

Whether “orthodontics” or “dental alignment” (often of just the ‘social six’) is offered within a publicly funded system or on a privately financed basis, its popularity is increasing, and demand significantly outstrips objective “need”.  While this helps to sustain the profession, it also obscures our ability to highlight the objective health benefit of much of what we do. We do not suggest that orthodontics is of limited benefit. We merely mean that those presenting with minor cosmetic detriment will predictably glean limited cosmetic improvement from orthodontics. Paraphrasing Lysle E. Johnston, Jr., “Orthodontics is a service, based on science, and has inherent value for the patients that want it.” Perversely, therefore, our popularity may dilute the measurable impact of what we do on a population level underpinning the need for more robust measures of treatment need and outcome.

A Slow Burner

Many of us have dedicated time and energy to optimising our efficiency while maintaining and indeed improving our treatment outcomes. However, it would seem undeniable that the nature of the biological processes underpinning tooth movement dictate that excellent treatment outcomes require both time and care to achieve. The time commitment associated with orthodontic treatment has spawned a range of surgical and non-surgical adjuncts while also arguably heralding the dilution of orthodontics and the dawn of the aforementioned “dental alignment,” a now commercial trend epitomized by direct-to-consumer plastics.

The gradual nature of orthodontics also dictates that time is required for changes to our practice to bear fruit or indeed to come back to haunt us, if we invest in analysing our own results and thought processes. ¹ This hiatus can lull us into stasis and an unswerving belief that our approach works. Of course, this stubbornness and cognitive bias offer us and, more importantly, our patient cohort, no actual value. Self-awareness, self-appraisal, and a passion for continued learning is, then, one of the most important attributes that we have – one that we believe dwarfs the putative effect of appliance type on our effectiveness or efficiency. As Robert Greene suggests,

“Mastery is not a function of genius or talent. It is a function of time and intense focus applied to a particular field of knowledge.” ²

On a personal level, orthodontics fascinated many of us as starry-eyed twentysomethings. Despite and perhaps because of the recent mutations, it continues to interest and excite some years later. This enthusiasm is, however, based on enquiry and appraisal. It is also predicated on an in-depth, learned understanding of the scope and limitations, opportunities and pitfalls, simplicity and complexity of orthodontics.

For us, that is the insulation that we require to undertake orthodontic treatment safely and predictably. We will therefore continue to be immersed in both the theory and practice of orthodontics, and technological advances as they arise and evolve. We owe that to our patients and students. However, we will also continue to focus on making well-informed decisions, on which we will continually reflect. This introspection and reflection will never grow old or lose relevance.

We started with a definition and conclude by attempting a revised definition to better represent orthodontics:

“A specialty of dentistry that deals holistically with diagnosis and management of malpositioned teeth and jaws. It comprises supervision of the developing dentition, occlusal and jaw relationships; and may involve appliance-based intervention.”

Minor detailing to the existing definition based upon thorough consideration- a refinement befitting of our shared and engaging endeavour, we hope!

References

1. Bowman, SJ. They still shoot horses, don’t they. Angle Orthod. 2018;88(3): 370-2.
2. Greene, R. Penguin Books.  New York, NY 2013.

Acknowledgement

We are very grateful to Peter Miles for generous, thoughtful input and insightful suggestions.