Paradigm shift in Orthodontics

Gabor Hermann DMD,Orthodontist, Hungary

drhermann.g@gmail.com

We have been giving beautiful smiles to our patients for many years

Our offices provide a workplace for many people at chairside and in administration

Our offices are being served by orthodontic laboratories…

…and by orthodontic companies

We are members of orthodontic study clubs…

…and associations nationally and internationally

We have orthodontic schools with a great reputation

We study constantly on courses and at conferences

We undertake researches and we publish the results in the peer review literature

In conjunction with our employees, labs, supporting companies, associations and schools we form the orthodontic industry…

…the oldest specialty of dentistry

Based on this, one might think that this specialty is very well organized, scientifically grounded and operates smoothly…

…And, also one might think that the only paradigm shift that I should talk about is that our specialty is entering the digital age

However, if we scratch the surface, there are really big changes happening

And, this is the real paradigm shift

Straight talk about straight teeth

These big changes started in the early 2000’s

Actually there were lots interesting changes in the specialty, that time, however here is something very important

David Sarver:

The new soft tissue based treatment planning paradigm

The importance of the soft tissues and the aesthetic parameters over the hard tissue parameters

This makes sense: Contrasting the cephalometric analysis this paradigm

suggested non extraction treatment many times (and mandibular advancement) which was more aesthetic for the patients

This language was a common language that was easily understood by the patient

However, if we focus on this change from another perspective it is going to be even more interesting

What else happened this time? Publications on the role of occlusion in the

development and treatment of TMD

Evidences on the role of the occlusion in the development of the periodontal problems

Challenges to find evidence from the functional perspective

How can we convince a patient to undergo an orthodontic treatment?

Occlusion/bite, vs. aesthetics?

Occlusional argument was weakly supported by the literature

On the contrary there already have been many publications on what a positive impact of straight teeth can make on the self-esteem

Aesthetics became a life preserver to the specialty

So our specialty adopted a new course - Taking the difficulty of proving the functional aspect

of the orthodontic treatment into account we started to focus on promoting the aesthetic aspect of the treatment

This can be called:

The aesthetic paradigm

By now we have explored almost everything about how to achieve a nice smile and how big impact it makes on the self-esteem -

Growing number of researches on smile and self esteem

Growing number of publications on how to achieve a nice smile

It makes sense -

If we know everything about what our patients want we can serve them on a higher level

From the business perspective we can gain more patients

So we entered the beauty industry

A relatively big slice from a small cake is smaller than a small slice from a very big cake

That time it seemed to be a very good way to position orthodontics But in a relatively short period of time we have seen 3

major problems

In fact, by today it became clear that the aesthetic paradigm was not a good way of positioning our specialty

We pretend that everything is really all right, but the symptoms have been obvious

Problems of the aesthetic paradigmNo.1: losing the market

2008 the bankruptcy of Lehman Brothers and the beginning of the Global Economic Crisis showed how vulnerable this concept was

People will postpone or cancel the orthodontic treatment in such a difficult time

Aesthetics can wait

In the beauty industry there is a huge amount of competition. It is really hard to compete with big companies and market players

The market is shrinking- “We have to prepare for smaller offices”

The number of new case starts decreased significantly

Marketing coaches tries to address this situation

By the way! What do orthodontic companies do in such a situation?

They went to Asia

They started to sell braces to general dentists

Have you ever seen such a great number of orthodontic courses that are offered to GPs today?

This issue leads us to the second problem Orthodontics is equal to giving smile to our patients

(this is the core message)

Meaning, occlusion is not a primary goal - tooth alignment and creating nice smile are the primary objectives

Orthodontics is simple (look at the company flyers)

Anybody can do it…

Orthodontics is simple “With SmartClip and Forsus

orthodontic treatment is like a cookbook”

The key to your beautiful smile is putting Damon braces on: “ Ask for it by name”

“You will get the same bite in the mouth that you see on the set-up” (customized braces, like Incignito, Insignia)

Problems of the aesthetic paradigmNo.2: losing the competition with general dentists

We accepted that aesthetics is the primary goal

We need patients for survival

So we want to serve them by giving them what they want

They want a nice smile

They prefer invisible treatments

They definitely want the fastest treatment possible

So orthodontics has been trying to do its best to reduce treatment time …And get our patients back

Wilckodontics

Acceledent

Early elastics

Customized braces and pre-adjusted archwires from the very beginning

Advansync

But if the occlusion is the goal the treatment time will still be around 12 months

But who cares about Class 1?

“Patients are coming for a nice smile but not for a class I occlusion”

“If you can put on a rubber dam clasp on the upper second molar, you will be able to put braces onto the same teeth”

Six months braces

5 months smile

Inman aligner in 9-12 weeks

This competition has increased tremendously. We accepted the rules of the game

But who will win in this competition? Instant

orthodontics

If we compete with general dentists on a smile makeover course we haven’t got a chance Especially due to the fact that we can only do orthodontics

while they can also do cosmetic dentistry

AAO spends thousands of USD for consumer campaigns every year

but

What do we have that they don’t?

What do we do differently compared to how GPs do orthodontics?

We both can align teeth…

This issue leads us to the third problem

Problems of the aesthetic paradigmNo.3: Losing the identity

If we accept that the nice smile is the primary goal…

Orthodontic treatment is purely alignment

In fact occlusion is not responsible for the development of TMD -

Occlusion is not responsible for the development of the periodontal problems -

So the role of occlusion as a functional parameter is not so important

This will not help us to built our self esteem -

Namely, from the identity standpoint this provokes 3 very important questions:

1. Why should we treat our cases to Class1? In what circumstances do we

call an occlusion norm-occlusion and malocclusion if there is no evidence on functional relationships?

Class I is better just because it looks better?

A= Nice1

C=Less Nice II

D=The least Nice III

How can we defend the full mouth treatment concept?

2. Why do we have 3 years of postgraduate study if we just align teeth as general dentists do?

What is the value added to our treatment compared to the treatment provided by GPs?

Will our treatments have more favourable results?

Will our treatment be more stable?

What do we learn during our ortho program that will make us different?

Who are we?

Cosmetologist or medical doctor?

These are very hard questions. However, in the meantime, in everyday practice we have been treating our patients based on what we find appropriate

Are these treatments experience based or evidence based?

3. What do we call evidence based in contemporary orthodontics?

We have been using this term very often

Many times we use this in order to stigmatize those, whom we do not agree with

What is “evidence based medicine”? “The conscientious, explicit and judicious use of current best

evidence in making decisions about the care of individual patients."[1][2] Trisha Greenhalgh

Evidence based medicine is not "cookbook" medicine. Because it requires a bottom up approach that integrates the best external evidence with individual clinical expertise and patients' choice, it cannot result in slavish, cookbook approaches to individual patient care.

But still what would you expect from the expression “best evidence”?

Guidelines, standards, best practice

Best evidence in orthodontics? How does it work?

Let us see a typical case

How would you treat this case?

Class II subdivision non-growing individual

Chief complaint: sticking out upper fronts

Everybody has his/her own concept, but where is the best evidence? What is the best diagnosis?

What is the best treatment plan?

What is the best appliance?

What is the best treatment sequence?

What is the best timing?

What is the best retention protocol?

There are highly successful techniques with a great reputation Alexander, MBT, Bioprogressive, Andrews, Roth,

Damon…

There are treatment modalities each with a lengthy history of success Distalization, extraction, surgery, Herbst, elastic pull…

But what is the best treatment for this particular patient?

There can be around 20 different treatment plans for this individual

What are the similarities in these treatment approaches?

Class I cuspid

But where this occlusion should be in this patient’s head from the health persective?

Are the results the same by aesthetics and function?

Where are the standards, guidelines?

What does the newest book say? The introduction verifies that we

should make our decisions based on evidence based guidelines

There is no chapter called diagnostic procedures

The book concludes that lifelong retention is necessary, so there is no guarantee for the stability at all

And how about the treatment of Class IIs?

What does the newest book say about evidence based Class II treatment? En-masse space closure is better

over two-step procedure

NiTi springs are better in space closure for appointment purposes

Appointment scheduling efficiency can be improved by using appropriate material selection

Early Class II correction is not proven to be stable

Is this all that we have?

How can I be evidence based when planning the treatment for this particular patient?

No answer

Sorry, but it can be even worse!

How about this sentence? “EBM seeks to assess the strength of the evidence of

risks and benefits of treatments (including lack of treatment) and diagnostic tests. This helps clinicians predict whether a treatment will do more good than harm”

This makes sense…

What does this sentence mean?

Are any of the above mentioned treatment plans better than the lack of treatment from the risk/benefit perspective?

If the patient is symptom free at the moment, how can the potential side effects of the treatment be measured? How about the risk/benefit ration?

Can we guarantee that there will not be gum recess, bone loss, TMJ problem, root resorption as a result of the treatment?

Can we guarantee that the result will be stable?

But more importantly…

Will the intensive full mouth treatment be worth it if aesthetics will be the only benefit?

Should we convince the patient to undergo the treatment?

Conclusions: We have to be cautious when using the term

“evidence based” in contemporary orthodontics

We need to reevaluate how successful the current paradigm is In finding evidences In finding the answer to stability In finding what is the best for a particular patient from the

health perspective

We need a change, we have to admit that the structural thinking has not been able to provide the answers

The change starts with the clear and honest investigation of the problem We are fully aware of the fact that the human body is a complex

system

We call it multifactorial (this is the term what we use in explaining the etiology of all the problems what we are encountered to)

After all we insist on limiting our activity to the orofacial area limiting our activity to unidisciplinary orthodontontics limiting our activity to structural changes

Altogether: we make changes on the human body without knowing what

consequences we produce we use very high forces without knowing what consequences we

produce

The current orthodontic paradigm Orofacial Structural Orthodontics

more precisely…

Unidisciplinary Orofacial Structural Orthodontics

Regardless, if we measure soft tissues or hard tissues, soft tissue paradigm did not change the overall structural focus

Can we make arbitrary borders in a complex system?The example of the specialist of the Sea of Japan

Can we make real assumptions in such an artificial system?

Can we make a prognosis if we don’t see the interdependence?

It is evident that we need a change to ensure the future of our specialty

We need another mindset

We need a new paradigm, that takes the complexity of the problems into account

We need to look at our patients from another perspective

What do we need to do to understand and treat the complex system? Enlarge the focus to the whole body

Cooperate with other specialties, working in an interdisciplinary TEAM

Accept and reinvestigate the functional aspects of the occlusion

The new functional paradigm Craniofacial

Interdisciplinary

Functional

Orthodontics

Craniofacial functional orthodontics, or craniofacial functional medicine

We have to operate on an interdisciplinary team Occlusion

Swallow

Breath

Posture

Integrity of the fascia and neuro reflexes (osteopathy)

We need to work in a team which also includes the patient

Interdisciplinary, patient-centric

Not unidisciplinary, structurally norm-centric (symptom-centric)

We have been giving beautiful smiles to our patients for many years –And we are also responsible for their overall health

We are a part of the oldest specialty of dentistry –We are also responsible for the future of this specialty

This is the time for significant changes

We need a new mindset

The new Functional Paradigm can bring us a new perspective

IFUNA can play a vital role in the future of orthodontics We have to work together to develop the new

protocols

It is not going to be easy

But we don’t have an alternative

Thank you for your attention!

How we imagined our specialization…

“Give me the teeth please”

“Sorry but the jaw goes with it. May I leave it as it is?”