Centennial inventory: The changing face of orthodontics
2015; Elsevier BV; Volume: 148; Issue: 5 Linguagem: Inglês
10.1016/j.ajodo.2015.08.011
ISSN1097-6752
Autores Tópico(s)Digital Imaging in Medicine
Resumo•Organized orthodontics is nearly 115 years old.•Basic knowledge is still needed.•Unchanged goals are accurate diagnosis, and balance of esthetics, function, and stability.•Controlled, fast tooth movement and discreet appliances are desired.•Changes in orthodontics are also related to developments in dentistry. The American Journal of Orthodontics and Dentofacial Orthopedics celebrates its centennial, safeguarded by the nearly 115-year-old American Association of Orthodontists. This journey witnessed the rise and demise of various developments, concepts, and procedures, while basic knowledge is still needed. Various periods can be defined in the past century, but the goals remain to obtain more accurate diagnosis through precise anatomic imaging, more controlled and faster tooth movement, more discreet appliances, and the balance of esthetics, function, and stability. The most recent technologic advances have buttressed these goals. Cone-beam computed tomography has brought 3-dimensional assessment to daily usage, albeit the original enthusiasm is tempered by the risk of additional radiation. Temporary anchorage devices or miniscrews have revolutionized orthodontic practice and loom as a solid cornerstone of orthodontic science. Decortication and microperforation promise to speed up tooth displacement by stimulating vascularization. The concept of the regional acceleratory phenomenon has touched upon even the timing of orthognathic surgery. The burden of esthetic appliances remains, with the demand for "cosmetic" appliances and clear aligners. Have these developments changed the face of orthodontics? Have we engaged in another turn wherein certain treatment modalities may fade, while others join mainstream applications? These questions are addressed in this essay on the challenges, promises, and limitations of current orthodontic technology, enhancement of biologic response, and personalized treatment approaches. The American Journal of Orthodontics and Dentofacial Orthopedics celebrates its centennial, safeguarded by the nearly 115-year-old American Association of Orthodontists. This journey witnessed the rise and demise of various developments, concepts, and procedures, while basic knowledge is still needed. Various periods can be defined in the past century, but the goals remain to obtain more accurate diagnosis through precise anatomic imaging, more controlled and faster tooth movement, more discreet appliances, and the balance of esthetics, function, and stability. The most recent technologic advances have buttressed these goals. Cone-beam computed tomography has brought 3-dimensional assessment to daily usage, albeit the original enthusiasm is tempered by the risk of additional radiation. Temporary anchorage devices or miniscrews have revolutionized orthodontic practice and loom as a solid cornerstone of orthodontic science. Decortication and microperforation promise to speed up tooth displacement by stimulating vascularization. The concept of the regional acceleratory phenomenon has touched upon even the timing of orthognathic surgery. The burden of esthetic appliances remains, with the demand for "cosmetic" appliances and clear aligners. Have these developments changed the face of orthodontics? Have we engaged in another turn wherein certain treatment modalities may fade, while others join mainstream applications? These questions are addressed in this essay on the challenges, promises, and limitations of current orthodontic technology, enhancement of biologic response, and personalized treatment approaches. Happy centennial anniversary, American Journal of Orthodontics and Dentofacial Orthopedics (AJO-DO), the American journal of worldwide orthodontics. You have been the meeting place of minds across the universe of orthodontists and their prime reference. A reverend salute to a mission accomplished with dedicated editors, writers, and thousands of unknown soldiers, along with millions of smiles. An anniversary is an intersection of memory and outlook, with their loads of meditation and inspiration: what have we achieved, and where are we going? At some level, it holds in its folds the grains of a tabula rasa (clean slate) to invite rejuvenation. This centennial invites contemplation of a rich heritage and a projection of destination. Three periods may be defined in the past orthodontic century, based on 2 major panels—technologic developments and treatment modalities—both with obvious correspondence in the respective temporal periods (Fig 1). Imaging represents a parallel theme that deserves distinction, albeit defined in technology. Bracketed between the turn of the 20th century until the 1970s, this long phase was dominated by Edward Angle's technologic breakthrough with the edgewise bracket, except for the Begg bracket/technique "interlude," which in essence was more an extraction treatment mode. Thus, the period can be entitled the "latest and best" edgewise spill-over, in reference to Angle's famous quote regarding the edgewise bracket: "the latest and the best; use it." Originally embraced by Angle's nonextraction approach to achieve Class I occlusion, maintenance of the full dentition at the expense of stability or esthetics was tested after Angle's death (1930) by one of his students, Charles Tweed, who reintroduced tooth extraction in the United States, and later in Australia by another student, Raymond Begg. Tweed's retreatment of patients with the extraction of 4 first premolars influenced American orthodontists to do more extractions (nearly half of orthodontic treatments in the 1960s).1Moorrees C.F.A. Orthodontics during the last 50 years.in: Moorrees C.F.A. van der Linden F.P.G.M. Evaluation and future. Proceedings of the International Conference on the occasion of the 25th anniversary of the Orthodontic Department. University of Nijmegen, Nijmegen, The Netherlands1988: 15-45Google Scholar The rationale was that discrepancies between tooth and jaw sizes were genetically determined.2Tweed C.H. The Frankfort-mandibular incisor angle (FMIA) in orthodontic diagnosis treatment planning and prognosis.Angle Orthod. 1954; 24: 121-169Google Scholar The extraction pendulum swung too far, affecting facial esthetics toward a "dished-in" profile or an "extraction look" (Fig 2). The debate on extraction or nonextraction reached far into the minds and skills of orthodontists to a point where lines were drawn between extractionists and nonextractionists. Accompanying these developments were key radiographic innovations. Cephalometry (1931) at a minimum supported the clinical findings but also elevated them to more comprehensive diagnosis, justification for treatment planning, and evaluation of treatment outcome. Later, panoramic radiography (about 1960) considerably facilitated assessment and became the trademark record to evaluate perfection in treatment through root parallelism. This period was shorter than the first, probably because, in the first period, World War II interrupted the flow of developments in science and technology, which picked up speed exponentially in the last quarter of the 20th century, if only gauged by the arrival of the personal computer in offices and homes. The mid-1970s ushered in a series of technologic developments that mark orthodontics to this day. The introduction of the straight-wire method with prescription brackets, along with the 6 keys of normal occlusion by Andrews,3Andrews L.F. The six keys to normal occlusion.Am J Orthod. 1972; 62: 296-309Abstract Full Text PDF PubMed Scopus (673) Google Scholar had an initial impact of "dialing a treatment" that was tempered with daily practice. But the introduction of the "smart wires" made possible by a by-product of space exploration, the nickel-titanium alloy wire, stole the show, warranting the nickname of this second period as "space-age spill-over." The promises with such developments were gentler tooth movement and more comfort for the patient. The latter was yet to be served by the incoming lingual braces. These unseen appliances, as well as ceramic brackets, provided answers to the demand for less noticeable and thus more esthetic appliances. The practitioner was provided with faster, more practical techniques (eg, bonding replaced or complemented banding, and elastomeric attachments with color-on-demand supplanted the more time-consuming ligatures). Self-ligating brackets were introduced in this era and expanded in the next, with the premise of better controlled mechanics, greater patient comfort, and improved practice management. However, their use remained more limited than the still thriving "regular" brackets, probably owing to mixed research outcomes, cost, and operator variables. On the treatment front, physics was formally injected into the science of tooth movement, thanks to the leading works of Burstone,4Burstone C.J. Applications of bioengineering to clinical orthodontics.in: Graber T.M. Vararsdall R.L. Orthodontics: current principles and techniques. 4th ed. C. V. Mosby, St Louis2005: 293-330Google Scholar who with coworkers also carried the clinically applicable concepts to wire architecture (beta-titanium alloy wire). While gnathologic concepts were permeating dentistry, Roth5Roth R.H. Functional occlusion for the orthodontist.J Clin Orthod. 1981; 15 (44-51 contd): 32-40PubMed Google Scholar championed their application in orthodontics. Expanding from the dentition to understand and "treat" the associated structures (musculature, temporomandibular joint, and healthy periodontium), the age of the total occlusion—thus, interactive multidisciplinary treatment—was at the door, increasingly encompassing the treatment of adults rather than mostly children. Finally, the triple crown of function, esthetics, and stability helped push the envelope of orthognathic surgery beyond the seminal works of Harvard's Kazanjian (1879-1974), France's Tessier (1917-2008), and the University of Zurich's Obwegeser (1920-), when leading American surgeons modified and diversified the original surgical methods through critical research. The earlier problems of treatment relapse were addressed with the onset of rigid fixation.6Steinhäuser E.W. Historical development of orthognathic surgery.J Craniomaxillofac Surg. 1996; 24: 195-204Abstract Full Text PDF PubMed Google Scholar Underlying all those developments was the clear statement that orthodontics was dedicated not only to occlusal morphology and associated functions, but also at least equally to facial esthetics. By the 1990s, the trend to extraction had reversed to nonextraction but emphasized esthetics and stability and thus distalization mechanics, rather than proclination of anterior teeth. Yet, transverse expansion emerged, also reinforced by "smile esthetics" to reduce the black corridors between the posterior teeth and the corners of the mouth, and provide "consonance" of the lower lip and the maxillary anterior teeth curvatures.7Sarver D.M. Ackerman M.B. Dynamic smile visualization and quantification: part 2. Smile analysis and treatment strategies.Am J Orthod Dentofacial Orthop. 2003; 124: 116-127Abstract Full Text Full Text PDF PubMed Scopus (199) Google Scholar If any negative perception was held regarding orthodontics yielding an "extraction look" or a "dished-in" face, the American Association of Orthodontists campaigns featuring Miss America dispelled the stigma (Fig 3). These efforts were buttressed when the AJO-DO not only served as a vehicle reflecting through scientific publications the paradigm shifts worldwide, but also featured on its cover the "smile" label and, later, the smiles of actual patients every month. Orthodontics was at a new platform, ready for a new slate of developments at the eve of the 21st century, having crossed the 20th century under Edward Angle's shadow; kept pace with technologic developments (from imaging to high tech); engaged in research with increasing adherence to scientific rigor (eg, a series of randomized prospective clinical trials generated by the National Institutes of Health in the late 1980s and 1990s8Ghafari J. Shofer F.S. Jacobsson-Hunt U. Markowitz D.L. Laster L.L. Headgear versus function regulator in the early treatment of Class II, Division 1 malocclusion.Am J Orthod Dentofacial Orthop. 1998; 113: 51-61Abstract Full Text Full Text PDF PubMed Google Scholar, 9Tulloch J.F. Proffit W.R. Phillips C. Outcomes in a 2-phase randomized clinical trial of early Class II treatment.Am J Orthod Dentofacial Orthop. 2004; 125: 657-667Abstract Full Text Full Text PDF PubMed Scopus (193) Google Scholar, 10Dolce C. McGorray S.P. Brazeau L. King G.J. Wheeler T.T. Timing of Class II treatment: skeletal changes comparing 1-phase and 2-phase treatment.Am J Orthod Dentofacial Orthop. 2007; 132: 481-489Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar); accomplished excellent organization in its institutions (academia and associations); and built partnerships for scientific discovery between universities and associations (eg, through the American Association of Orthodontists Foundation and its Planning and Awards Review Committee [PARC]11Weber F.N. Behrents R.G. Vaden J.L. American Association of Orthodontists Foundation Endowment Fund Campaign.Am J Orthod Dentofacial Orthop. 1992; 102: 19AAbstract Full Text PDF PubMed Google Scholar), among universities (Graduate Orthodontic Residents Program experience), and among universities, associations, and industry. Yet in education, the century closed on a critical issue felt into the next period: while the benefits of technology entered the university classroom, the full-time academician became an "endangered species."12Ghafari J.G. The state of the academician.in: Ghafari J.G. Moorrees C.F.A. Orthodontics at crossroads. Harvard Society for the Advancement of Orthodontics, Boston1993: 87-95Google Scholar Recruiting and retaining junior faculty faltered for various reasons: lack of competitive salary with private practice; unsatisfactory university environment, including failure in departmental and school administrative leadership and even political influences; lack of or insufficient mentoring and protected time for professional development; work overload; unrealistic criteria for promotion; and lack of "qualifications and ambition for an academic career."12Ghafari J.G. The state of the academician.in: Ghafari J.G. Moorrees C.F.A. Orthodontics at crossroads. Harvard Society for the Advancement of Orthodontics, Boston1993: 87-95Google Scholar, 13Moorrees C.F.A. Reflections on an academic career in teaching and research.Am J Orthod Dentofacial Orthop. 1993; 104: 516-522Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 14King G.J. Solving the faculty shortage might require more than money.Am J Orthod Dentofacial Orthop. 2015; 148: 200-201Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Articles in the AJO-DO and other American orthodontic journals reflect the academic retention problem: increasingly more research articles were from international non-American institutions, albeit this development also echoed a healthy scientific globalization. The present third period picked up on 4 intersecting tracks: esthetic means of treatment delivery, faster treatment, improved anchorage, and more precise imaging (diagnosis and treatment simulation). Technologic developments may be classified under information technology spill-over, while treatment has solidly moved, along with all areas of medicine, toward personalized delivery. Three main technologic headlines emerged in this period. "The latest and best in anchorage control," orthodontic miniscrews, also known as mini-implants and (nonosseointegrated) temporary anchorage devices, may be viewed as the revolution of the orthodontic century, "the holy grail of orthodontics," a solution to both compliance and controlled anchorage.15Graber T.M. Have we finally found the holy grail of orthodontics?.World J Orthod. 2002; 3: 107Google Scholar A rush-hour melée about types, heads, widths, and lengths of screws was followed by corresponding research before more order set in regarding dimensions, properties, and indications. The pierced metal devices succeeded thanks to the biologic tolerance of bone and the surrounding soft tissues, where the story of tooth movement truly unfolds. This solid success has led to the use of mini-implants at younger ages in the permanent dentition because their insertion in the mixed dentition is hazardous to unerupted permanent teeth. In this perspective, an important question arises, warranting research for answers: would the distalization of the maxillary arch against implants generate the orthopedic differential growth between the jaws similar to that engendered by headgear in the correction of Class II malocclusion?8Ghafari J. Shofer F.S. Jacobsson-Hunt U. Markowitz D.L. Laster L.L. Headgear versus function regulator in the early treatment of Class II, Division 1 malocclusion.Am J Orthod Dentofacial Orthop. 1998; 113: 51-61Abstract Full Text Full Text PDF PubMed Google Scholar, 9Tulloch J.F. Proffit W.R. Phillips C. Outcomes in a 2-phase randomized clinical trial of early Class II treatment.Am J Orthod Dentofacial Orthop. 2004; 125: 657-667Abstract Full Text Full Text PDF PubMed Scopus (193) Google Scholar, 10Dolce C. McGorray S.P. Brazeau L. King G.J. Wheeler T.T. Timing of Class II treatment: skeletal changes comparing 1-phase and 2-phase treatment.Am J Orthod Dentofacial Orthop. 2007; 132: 481-489Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar Operator difficulties and cost, if not compromised results, prevented a wider application of various modes of lingual appliances, now stratified into 2-dimensional and 3-dimensional (3D) modes. On the other hand, clear aligners augured an esthetic revolution. The concert of various computing, imaging, milling, and robotic technologies brought about a variety of aligners, known popularly by the brand that eventually became the generic household name Invisalign (Align Technology, San Jose, Calif). Research has disclosed limitations in success and compromised excellence in more complicated malocclusions: the aligner alone does not seem adequate to achieve high-quality results but, rather, requires multiple adjunctive approaches for various clinical situations.16Bressler J.M. Hamamoto S. King G.J. Bollen A.M. Invisalign therapy—a systematic review of lower quality evidence.in: Huang G.J. Richmond S. Vig K. Evidence-based orthodontics. Wiley-Blackwell, Hoboken, NJ2011: 167-179Crossref Google Scholar Accordingly, case selection and awareness of limitations are critical to the operator, who must amass experience and competence after an initial learning curve, and use proper sequencing of movements to reduce the need for case refinement. Diagnosis and treatment planning were enhanced by 3D imaging (cone-beam computed tomography [CBCT]), outcome simulation, and mouth scanners. Computed tomography became user-friendly in orthodontics and implant dentistry by the advent of CBCT, but the risks of additional radiation prompted the recommendation of a commissioned panel by the American Academy of Oral and Maxillofacial Radiology against its routine use.17American Academy of Oral and Maxillofacial RadiologyClinical recommendations regarding use of cone beam computed tomography in orthodontics. Position statement by the American Academy of Oral and Maxillofacial Radiology.Oral Surg Oral Med Oral Pathol Oral Radiol. 2013; 116: 238-257Abstract Full Text Full Text PDF PubMed Scopus (221) Google Scholar Accordingly, until it can be provided with less radiation, CBCT should be used when it supports better diagnosis and treatment; it is a perfect tool in various situations (eg, impacted canines). Journal editors and peer reviewers are sensitized to the issue and request clear institutional review board statements to prevent abuse, possible deception, and questionable statements in the literature. CBCT also has not on average provided growth and outcome data with major differences from 2-dimensional cephalometric findings. Outcome simulation, particularly helpful in orthognathic surgery, was further enhanced by the CBCT-provided 3D application. Although existing programs already provided a practical guideline for daily practice, prediction of treatment outcome has yet to become more precise, pending the generation of more data accounting for the vast individual variations. Soft tissue assessment has not reached routine evaluation comparable to that of hard tissues (bone and teeth) in most studies of treatment outcomes. A greater volume of such assessments is needed for the development of algorithms with more accurate applications. Mouth scanners are on the scene to replace dental casts in at least basic functions, also providing the benefits of better appreciation of soft tissue characteristics and 3D manipulation, space analysis, and dental simulations. The American Board of Orthodontics and other examining bodies (Angle Society) already allow the use of scanned models, which are expected to prevail with further developments and wider adherence by educational programs and practitioners. Treatment approaches of the ongoing third period maintain an anchor in esthetics and the smile and they increase, albeit slowly, reliance on biologic principles and individual variations, moving away from the more mechanistic modes. The pendulum stays swung toward nonextraction, with the dished-in (half-moon) extraction profile replaced by a fuller profile, most likely representing cultural trends of beauty preferences. The possibility of extractions without profile flattening remains, but the extraction (including early removal) of third molars still does not figure in the statistics of extraction. "Accelerated osteogenic orthodontics" through interproximal surgical cortical cuts (decortication) is but another application of the regional acceleratory phenomenon, yielding faster results than regular similar treatment, regardless of agreement with the treatment plan, the perfection of finishing, or the possibility of periodontal recession.18Wilcko M.T. Wilcko W.M. Pulver J.J. Bissada N.F. Bouquot J.E. Accelerated osteogenic orthodontics technique: a 1-stage surgically facilitated rapid orthodontic technique with alveolar augmentation.J Oral Maxillofac Surg. 2009; 67: 2149-2159Abstract Full Text Full Text PDF PubMed Scopus (208) Google Scholar Adjunct microperforation19Park Y.G. Kang S.G. Kim S.J. Accelerated tooth movement by corticision as an osseous orthodontic paradigm.Kinki Tokai Kyosei Shika Gakkai Gakujyutsu Taikai, Sokai. 2006; 48: 6Google Scholar, 20Alikhani M. Raptis M. Zoldan B. Sangsuwon C. Lee Y.B. Alyami B. et al.Effect of micro-osteoperforations on the rate of tooth movement.Am J Orthod Dentofacial Orthop. 2013; 144: 639-648Abstract Full Text Full Text PDF PubMed Scopus (197) Google Scholar was presented as a viable alternative to forego the "aggressiveness" of decortications, aiming at generating inflammation-enhanced tooth movement.20Alikhani M. Raptis M. Zoldan B. Sangsuwon C. Lee Y.B. Alyami B. et al.Effect of micro-osteoperforations on the rate of tooth movement.Am J Orthod Dentofacial Orthop. 2013; 144: 639-648Abstract Full Text Full Text PDF PubMed Scopus (197) Google Scholar Initial animal and human studies demonstrated the potential of the method to promote faster movement, but several questions remain regarding the frequency of microperforations (how often should they be repeated) and the number of microperforations (how many times should they be repeated and should the rate be variable in different patients). At a practical level, commercial microperforation kits are available allowing the orthodontist to "dial" the depth of microperforation (eg, 2-3 mm). This method can also be applied through the repeated insertion and withdrawal of orthodontic miniscrews (Fig 4). The application of the regional acceleratory phenomenon has been extended to the selective performance of orthognathic surgery before orthodontics as a major stimulation of vascular and inflammatory input to speed up tooth movement. However, more research is warranted before clear guidelines can be formulated.21Hernández-Alfaro F. Guijarro-Martínez R. Peiró-Guijarro M.A. Surgery first in orthognathic surgery: what have we learned? A comprehensive workflow based on 45 consecutive cases.J Oral Maxillofac Surg. 2014; 72: 376-390Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar Microvibrations through a mouthpiece that the patient bites into (eg, for 20 minutes per day) represent another auxiliary means to speed up the biologic response. Research studies have not yielded definitive evidence on their effectiveness. Whereas the second period witnessed the rooting of patient consent in practice, replacing the older paternalistic approach by reinforcing the patient's rights, privacy, confidentiality, and partnership, the last few decades have been characterized by the movement to center stage of evidence-based medicine, institutional reviews of ethical approaches to research, and, with the canvassing of genetic prints, the emergence of personalized medicine. First used in the genetic framework, personalized medicine essentially reflects the customization of health care whereby treatment decisions and procedures are molded to each patient. The concept eventually invaded all aspects of health care, superseding the earlier reference to "individualization." When extended to orthodontics, the principle of "steering patients to the right drug at the right dose at the right time" would imply applying the right treatment with the right approach at the right time, in itself an important challenge requiring early attention to the child and his/her growth.22Hamburg M.A. Collins F.S. The path to personalized medicine.N Engl J Med. 2010; 363: 301-304Crossref PubMed Scopus (1376) Google Scholar Personalized medicine forces the proper diagnosis, which must encompass the patient's constitution—thus the "structural and functional harmony and well being of the total person."12Ghafari J.G. The state of the academician.in: Ghafari J.G. Moorrees C.F.A. Orthodontics at crossroads. Harvard Society for the Advancement of Orthodontics, Boston1993: 87-95Google Scholar Conceptually and practically, this approach may yield a treatment outcome deviating from the normal Class I occlusion, upon which orthodontic or occlusal health has been based (Fig 5). In some patients who reject the ideal surgical treatment, limited compensation (for proper camouflage) targets a favorable facial appearance instead of the ideal Class I occlusion. Accordingly, rather than flattening the profile, an overjet is maintained.23Ghafari J.G. Emerging paradigms in orthodontics—an essay.Am J Orthod Dentofacial Orthop. 1997; 111: 573-580Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 24Ghafari J.G. Macari A.T. Component analysis of Class II, Division 1 discloses limitations for transfer to Class I phenotype.Semin Orthod. 2014; 20: 253-271Abstract Full Text Full Text PDF Scopus (6) Google Scholar In a tour-de-force essay on "the destiny of orthodontics written in the stars," Ackerman25Ackerman J.L. Was the destiny of orthodontics written in the stars?.Am J Orthod Dentofacial Orthop. 2015; 147: 290-292Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar solicited the minds of Darwin and Gatson in a fictional encounter with the young Edward Angle to question the latter's concept of orthodontia as "applied biology" on the basis that ideal occlusion remains the most fundamental concept. Similar to astrology, orthodontics, or the science of occlusion, which has been "more technologically driven than biologically or scientifically based," was more likely to be a pseudo-science until a hypothesis could be tested and validated to move the discipline away from morphology to physiology. Related to these doubts is a more seminal question posed by Wylie26Wylie W. Malocclusion: malady or malformation?.Angle Orthod. 1949; 19: 3-11Google Scholar nearly 70 years ago about malocclusion: "malady or malformation?" The immediate response to these reservations is to foster and adhere to the scientific method to achieve well-defined personalized goals and evidence-guided treatment. However, contrary observations must be noted, since available evidence is not always applied: despite results at the highest level of the evidence hierarchy pointing toward starting treatment in the late mixed dentition, earlier treatments are instituted (branded by some as overtreatment, yet possibly driven by the parents' desire for an "early fix)."8Ghafari J. Shofer F.S. Jacobsson-Hunt U. Markowitz D.L. Laster L.L. Headgear versus function regulator in the early treatment of Class II, Division 1 malocclusion.Am J Orthod Dentofacial Orthop. 1998; 113: 51-61Abstract Full Text Full Text PDF PubMed Google Scholar, 9Tulloch J.F. Proffit W.R. Phillips C. Outcomes in a 2-phase randomized clinical trial of early Class II treatment.Am J Orthod Dentofacial Orthop. 2004; 125: 657-667Abstract Full Text Full Text PDF PubMed Scopus (193) Google Scholar, 10Dolce C. McGorray S.P. Brazeau L. King G.J. Wheeler T.T. Timing of Class II treatment: skeletal changes comparing 1-phase and 2-phase treatment.Am J Orthod Dentofacial Orthop. 2007; 132: 481-489Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 24Ghafari J.G. Macari A.T. Component analysis of Class II, Division 1 discloses limitations for transfer to Class I phenotype.Semin Orthod. 2014; 20: 253-271Abstract Full Text Full Text PDF Scopus (6) Google Scholar, 27Gianelly A. Evidence-based therapy: an orthodontic dilemma.Am J Orthod Dentofacial Orthop. 2006; 129: 596-598Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 28Livieratos F.A. Johnston Jr., L.E. A comparison of one-stage and two-stage nonextraction alternatives in matched Class II samples.Am J Orthod Dentofacial Orthop. 1995; 108: 118-131Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar Also, despite the repeated findings that treatment in the late mixed dentition should be started before the loss of the deciduous second molars, many patients are treated at younger ages, and many are referred for orthodontic treatment after the loss of all deciduous teeth, having lost the opportunity provided by the leeway space for space saving and correction of anterior crowding.23Ghafari J.G. Emerging paradigms in orthodontics—an essay.Am J Orthod Dentofacial Orthop. 1997; 111: 573-580Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 24Ghafari J.G. Macari A.T. Component analysis of Class II, Division 1 discloses limitations for transfer to Class I phenotype.Semin Orthod. 2014; 20: 253-271Abstract Full Text Full Text PDF Scopus (6) Google Scholar, 27Gianelly A. Evidence-based therapy: an orthodontic dilemma.Am J Orthod Dentofacial Orthop. 2006; 129: 596-598Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar The quest to define and test a biologic application is a challenging mission. If function is adopted as the overarching scientific paradigm, it should still be conceivable that the optimal treatment would be putting the teeth together in an ideal interdigitation, much like the way an orthopedic surgeon, by lengthening a shorter leg to match the other, would help to restore better function. But what if an occlusion short of the ideal interdigitation is functional and thus physiologic? Would biologically inclined academicians modify their teaching? Would the American Board of Orthodontics or the Angle Society deem the case "acceptable"? Would these examining boards accept a compromised occlusion short of a Class I yet corresponding to a more pleasing facial profile, much like a rhinoplasty that a plastic surgeon performs short of an ideal nose tip to prevent the unattractive sight of more vertically inclined nares? These interrogations and assumptions force the more general question of centennial inventory: where do we stand on the set goals of improving function, esthetics, and stability, even though technologic developments have allowed us to move toward more visualized diagnoses and more controlled tooth movements? Has the face of orthodontics changed in a century? We may have witnessed an impressive facelift rather than a change, given the predominance of the basic tools of daily practice (brackets and wires) that provide more predictable control and results in the midst of all innovations, and the absence of a biologic breakthrough to routinely shorten treatment. The changing face of orthodontics was to a great extent related to that of dentistry: both experienced a nearly total facelift in 4 major areas—imaging and simulation, implants, tissue engineering, and esthetics and cosmetics—with corresponding changes in practice, the conduct of research, education, and approach to the patient. In turn, many changes in dentistry have been related to developments in medicine. In this perspective, beyond the milestones achieved in orthodontics and the larger dental arena, the major challenge—a real change—would be engaging calls for the integration of dentistry into medicine, starting with disciplines placed closer in the medical territory than orthodontics, such as periodontics (which deals with infectious diseases treated medically and surgically) and oral-maxillofacial surgery, which is actually progressively moving in this direction. This issue is complex and at some level taboo because of the long-standing function of the present system and consequently entrenched stakeholders. Nevertheless, one question awaits a valid response from dental and medical academia and their corresponding professional organizations: why is the mouth the only part of the body divorced from the body, with independent dental schools rather than dental departments in medical centers like all medical specialties?29Ghafari J.G. The medical model in orthodontic education.Angle Orthod. 2006; 76: 538-539PubMed Google Scholar Even dental insurance is separate from medical insurance, although an association was reported between oral health and general health perceptions, reflecting a continuum in medical and dental health and health care.30Richmond S. Chestnut I. Shennan J. Brown R. The relationship of medical and dental factors to perceived general and dental health.Community Dent Oral Epidemiol. 2007; 35: 89-97Crossref PubMed Scopus (28) Google Scholar Obviously, dental organizations, like other specialty associations, will remain independent. In a reverse way, corollary questions are why can't a medical student specialize in a dental discipline, and why is dermatology or psychiatry not independent from medicine? Are we ready, both in dentistry and in medicine, to answer these challenging questions? As a first step, the questions are posed. They shall be answered in the biologic age of genetic spill-over.
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