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The myth of Janus: orthodontic progress faces orthodontic history

2003; Elsevier BV; Volume: 123; Issue: 6 Linguagem: Inglês

10.1016/s0889-5406(03)00251-8

1097-6752

Marc Bernard Ackerman,

Digital Imaging in Medicine

As a third-generation orthodontist, I am often asked by the parents of my patients to explain how the practice of orthodontics has changed over the past century. Many of the children I treat are second or third generation orthodontic patients, so this question is especially probing. The parents are asking, in effect, how will their child’s orthodontic experience differ from their own? To answer this question, we must view today’s mode of orthodontic practice in light of a century of orthodontic history. Traditionally, the key attributes of a clinical orthodontic practice have been the infrastructure (office equipment and materials), the clinical staffing, the diagnostic technique, the treatment-planning regimen, the clinical treatment rendered, and the philosophy of retention. Each component contributes to how we treat a malocclusion. But missing from this list is the individual orthodontic patient with his or her chief concern and physiologic and anatomic limitations. Today, the patient is the single most important element in orthodontic treatment planning. Without summarizing the numerous advances in orthodontic office design, staff training, material science, bioinformatics, and information technology, I will examine our progress in clinical orthodontic practice. The doctrine of informed consent and the emphasis on the interaction between the orthodontist and the patient shifted our practice paradigm in the 1990s.1Ackerman J.L. Proffit W.R. Communication in orthodontic treatment planning bioethical and informed consent issues.Angle Orthod. 1995; 65: 253-262PubMed Google Scholar Before then, patients and orthodontists were thought to have the same goal in treatment: an occlusion characterized by the interdigitation of the mesiobuccal cusp of the maxillary first permanent molar into the buccal groove of the mandibular first molar with little overjet and overbite within the framework of acceptable esthetics and reasonable stability. Orthodontists took a paternalistic stance, viewing all deviations from this ideal as disease and the patient as needing a cure. Although some clinicians defined malocclusion as more of a malformation than a malady, mainstream orthodontics was still wed to the idea of disease. Wylie2Wylie W.L. Malocclusion—malady or malformation?.Angle Orthod. 1949; 19: 3-11Google Scholar defined malocclusion as “disproportion between facial parts—parts which in themselves may be within the limits of normal variation, but which are disproportionate when combined with other facial structures and lead therefore to a disproportionate whole.” The central tenet in Angle’s paradigm3Angle E.H. Angle system of regulation and retention of the teeth and treatment of fractures of the maxillae. 5th ed. S.S. White, Philadelphia1897Google Scholar was that attaining the occlusal ideal would concomitantly produce harmony and balance in the face. Summa’s skull, referred to as Old Glory or Secretum Apertum, was the basis for “ideal” dentoskeletal hard tissue relationships, and the face of Apollo Belvedere was the model for soft tissue facial beauty, balance, and harmony. Even without the aid of modern computer analysis, one can readily discern the lack of correlation between the bimaxillary dentoalveolar pattern of Summa’s skull and the orthognathic facial profile of Apollo Belvedere. Aligning all 32 teeth would not ensure a beautiful profile, as Angle had thought. Although Tweed’s reintroduction of extractions as part of orthodontic treatment was clearly an advance, his reduction of the decision-making process to a simplistic formula, ie, FMIA, was as dogmatic as Angle’s nonextraction philosophy. Today, with the reemergence of the soft tissue paradigm in orthodontics,4Sarver D.M. Ackerman J.L. Orthodontics about face the re-emergence of the esthetic paradigm.Am J Orthod Dentofacial Orthop. 2000; 117: 575-576Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar we recognize that facial appearance and animation, in particular the smile, are multifactorial. When did orthodontic practice diverge from assessing and integrating soft and hard tissue interrelationships? I would argue that the advent of cephalometric radiography was central to this disconnect. Broadbent5Broadbent B.H. A new X-ray technique and its application to orthodontia.Angle Orthod. 1931; 1: 45-66Google Scholar and Hofrath6Hofrath H. Bedeutung der rontgenfern und abstands aufnahme fur die diagnostik der kieferanomalien.Fortschr der Orthod. 1931; 1: 231-258Google Scholar gave clinicians the ability to look within the dentoskeletal complex and quantify hard tissue relationships. Although this tool was later applied to the integumental profile, it was better suited for measuring hard tissues. Cephalometric radiography allowed orthodontists to serially measure craniofacial growth. Growth studies in Cleveland, Ann Arbor, and Philadelphia used this new technology to create normative data sets. Cephalometric analyses abounded in the 1940s and 1950s, with angular and linear measures used to quantify craniofacial structures. Data from small cross-sectional studies and the large longitudinal growth-center databases were included with these analyses and labeled “norms.” It was hypothesized that if a patient’s hard tissue anatomical features were known, then treatment could be aimed at correcting the problem. This period has been characterized as the first “scientific” era in orthodontics. Cephalometric researchers, like the anthropometrists of a century before, thought that measurement alone represented scientific endeavor. We now realize that some of these measurements had no real meaning. The search for “anatomic truth” did not begin with cephalometric radiography. In 1915, Van Loon7Van Loon J.A.W. A new method for indicating normal and abnormal relationships of the teeth to the facial lines.Dent Cosmos. 1915; 57 (1093-1101, 1229-35): 973-983Google Scholar proposed a methodology for orienting the dental casts in the context of the facial and craniofacial complex. The proceedings of the First International Orthodontic Congress in 1926 reveal some remarkable discussions concerning orthodontic diagnosis and the evaluation of anatomic structures. Simon8Simon P.W. On the necessity of gnathostatic diagnoses in orthdontic practice. In: The First International Orthodontic Congress. C.V. Mosby, St. Louis1927Google Scholar presented the gnathostatic system for fabricating dental casts, which were trimmed and oriented to the anatomical planes of the face. He mistakenly argued that “the biometric dental norm, determined gnathostatically, is our safest and most indispensable plan, an indispensable model for our treatments. We may modify and individualize, if we have good reasons for so doing, but in most cases this will be unnecessary.” Lundstrom,9Lundstrom A.F. Some case reports and their bearing on diagnosis. In: The First International Orthodontic Congress. C.V. Mosby, St. Louis1927Google Scholar at this same meeting, presented a contrary view. He mentioned that the 2 prevailing schools of thought in orthdontics were the occlusionists and the dentofacial orthopedists, and he claimed that “the aim of all orthodontic activity is to give the denture the greatest possible efficiency, and also, to place it in the most favorable position in relation to the surrounding regions. Of the two schools of thought in orthodontics, the school of occlusion has deserved a lasting honor in laying stress upon the former side of the problem, while the school of dentofacial orthopedics is to be given due credit for its emphasizing the importance of the positions of the teeth as regards the facial appearance. Both have accused each other of being narrow-minded.” Lundstrom continued by explaining, “They have, however, one characteristic in common. In diagnosis, both limit their examinations of the case to be treated to the status presens, and consider themselves able to recommend the best treatment on the basis of such an examination. They resemble each other also in this, that both of them set up, so to say, a pattern or a model of a more universal character and try to remodel the denture after this ideal or place it in a position considered as anatomically correct, so that the final effect corresponds with the ideal of the respective doctrine.” Overall, he argued that orthodontic diagnosis should place a greater emphasis on problems related to the apical base as well as an integration of the occlusal and dentofacial doctrines. As far as treatment techniques and biomechanics, what do we possess in our orthodontic arsenal today that our predecessors did not have? Adhesive dentistry and the direct bonding of brackets; advances in bracket materials, including titanium and ceramic brackets, superelastic nickel-titanium wires, and other alloys; clear thermoplastic tooth-moving appliances; improved orthognathic surgical techniques; and computerized diagnostic imaging are just some recent advances. Are self-ligating brackets and orthopedic devices like the Herbst appliance and those used for distraction osteogenesis new? Papers delivered at the First and the Second (1931) International Orthodontic Congresses introduced many of these techniques. Griffin10Griffin E.M. The application of light resilient arches in conjunction with a special lock. In: The First International Orthodontic Congress. C.V. Mosby, St. Louis1927Google Scholar presented a clinic entitled “The application of light resilient arches in conjunction with a special lock.” Essentially, this was the first in the series of self-ligating brackets. Even more astounding was Griffin’s departure from using heavy forces in tooth movement. He stated, “The light resilient arch, being nonrigid, is made to conform to the size and shape of the true dental arch, and is so flexible that it can be readily sprung to the size and shape of the arch as it is, with the teeth in malocclusion. It is so resilient that it will, when properly locked to the teeth, carry them toward their proper places. The advantage is that the small gauge wire can be adjusted so that it will work through a long range of distance over a long period of time without at any time exerting more than a very slight pressure. It will continue to exert a light, even and continuous force which permits the extensive movement of teeth without soreness.” Bruhn11Bruhn C. The surgical-orthopedical removal of the deformations of the jaws. In: The First International Orthodontic Congress. C.V. Mosby, St. Louis1927Google Scholar contributed a paper on “The surgical-orthopedical removal of the deformations of the jaws.” He described a technique for treating micrognathia in which surgical incisions released the mandibular body and an intraoral-extraoral apparatus essentially distracted the mandible into a more anterior position. Herbst12Herbst E. New ideas and apparatus in orthodontics. In: The Second International Orthodontic Congress. C.V. Mosby, St. Louis1933Google Scholar delivered a paper titled, “New ideas and apparatus in orthodontics,” in which he summarized the advantages of his appliance as follows: (1) immediate adjustment of the position of the mandible in relation to that of the maxilla; (2) immediate normal occlusion; (3) immediate improvement in facial appearance; (4) immediate change toward normal functioning; (5) no alteration of the existing upright position of the mandibular incisors; (6) no alteration of the normal position of the mandibular premolars; (7) no alteration of the normal level of the teeth; and (8) complete automatic adjustment of both maxillary and mandibular teeth to normal occlusion. Reexamining the work of the past is crucial to our developing and testing the appliances of the future. Remarkably, in 2003, our orthodontic thinking is very similar to many concepts presented at the First International Orthodontic Congress in 1926. Despite our improved technology and accrued research in the biology of the stomatognathic system, we are still asking the same questions and approaching orthodontic treatment in the same manner. In the current era of evidence-based orthodontic treatment, Proffit13Proffit WR. Treatment timing: effectiveness and efficiency. In 28th Annual Moyers Symposium. Vol 39. Ann Arbor: University of Michigan Department of Orthodontics; 2002Google Scholar stated it clearly at the 28th Annual Moyers Symposium: “All treatment needs to be evaluated from 2 perspectives. The first is its effectiveness, defined as how well it works, ie, how successful it is in overcoming the patient’s problems. Since nothing works perfectly all the time and unlikely things occasionally succeed, effectiveness must be considered in terms of the average amount of improvement, or probably better in clinical studies, the proportions of patients with excellent, good, fair, and poor outcomes. Effective treatment produces large average improvement, and a high percentage of the patients have an excellent outcome. The second is efficiency, defined as how much benefit the patient receives relative to the costs and risks of treatment. In this sense, cost is broader than just money. There are also a host of factors—time in treatment, number of patient visits, discomfort or morbidity, emergency appointments to deal with problems—that impact both the patient and the doctor. Efficient treatment produces large benefits with minimal cost (in both senses of the word) and minimal risk.” A child’s orthodontic experience in 2003 should differ considerably in terms of methods of evaluation and treatment from that of his or her parents. Interactive problem-oriented diagnosis and treatment planning between doctor and patient not only define the desired treatment objective but also help to select the most appropriate mechanotherapy. A greater emphasis is now placed on evaluating the dynamics of soft tissue functionally, esthetically, and temporally. Clinical decisions, particularly in regard to treatment timing, should be based on the factors of effectiveness and efficiency.