The journey from the past to the future

A hundred years! For a century now, the American Journal of Orthodontics & Dentofacial Orthopedics has formed the vital link between our colleagues’ research and the need for continuing education in our field. As the AJO-DO marks 100 years of service, it creates an opportunity for us to remember where we’ve been, consider where we are, and look at where we’re going.

It’s impossible to give enough credit to the early pioneers of orthodontics. With no experience, research, or examples to follow, it was definitely a “trial and error” specialty. Everyone was finding out for himself what worked and what didn’t. Dr Edward H. Angle is the Father of Orthodontics, but it was his most famous student, Charles H. Tweed, who changed everything by endorsing the extraction of teeth to create space for crowded arches. In fact, it was with a foundation in the Tweed technique that the evolution of edgewise orthodontics began.

How much have things changed? When I was in graduate school in Houston in the 1960s, there was still a question about whether orthodontics was possible in nongrowing patients. A few years later, adult orthodontics became an entirely new subspecialty. During this time, Drs A. P. Westfall (University of Texas) and Bob Gaylord (Baylor University) led the academic foundation in the Southwest. Dr Fred Schudy, among many others, discovered new mechanics for orthodontic treatment.

For those of us working in this evolving specialty, the knowledge gained by those who preceded us was instrumental. For me, Dr Tweed and others taught the fundamentals, including how to bend wire, how to control IMPA and mandibular intercanine width, and how to tip back mandibular molars to create anchorage and level the curve of Spee. In the early days of orthodontic mechanics, fitting bands and bending archwires were complicated and time-consuming procedures. We thought we were just moving teeth. From the beginning, many of us were always looking for a “better way.” The “KISS principle” (Keep It Simple, Sir) was foremost in my mind as I attempted to improve my delivery of orthodontic mechanics.

Then, after several years of trial and error, a routine archwire bending pattern of torque, in-out offsets, and angulation prescription evolved and was used to treat the vast majority of our patients. With time, archwire and bracket sequence became known as the “Vari-Simplex Discipline.” Over the years, certain adjustments have been made to fine-tune the system. The latest version is known as the Alexander Discipline: LTS (long-term stability). Virtually 100% of our patients are treated with this prescription. (Open bite malocclusion is an exception to the rule.)

In a typical sequence, our treatment begins in the maxillary arch with transverse expansion, if needed, by using rapid palatal expansion or a maxillary archwire. If the patient is skeletal Class II and growing, a cervical face-bow with the inner bow expanded is prescribed, to be worn 8 to 10 hours per night. Originally, the use of cervical headgear was experimental. Our intent was to distalize the maxillary first molars, not realizing that this also produced orthopedic correction in Class II skeletal patterns. Being blessed with growing patients who were cooperative with face-bow wear, I soon discovered excellent orthopedic changes in these patients. To this day, after several thousand Class II patient results, I believe that the best, most stable orthopedic results are possible with the face-bow. The simple requirement is a cooperative, growing patient. But, the doctor’s ability to motivate the patient is necessary for successful results. During the late 1900s, orthodontic changes centered around the patient’s ability or inability to cooperate and follow the doctor’s instructions. The focus was on treating the noncompliant patient. West Texas orthodontic giants Jim Reynolds and Jay Barnett introduced us to new and different approaches to motivating the patient, thus improving the finished results on many patients.

The downfall of the Tweed technique was the excessive number of premolar extractions that sometimes resulted in concave soft tissue profiles and decreased incisor torque. The challenge for me then became to better control the mandibular anterior teeth while creating adequate space to treat the patient without extractions. This was often accomplished by limited mandibular anterior and greater posterior expansion with a lip bumper or an expanded archwire. As Dr Tweed taught, do not expand mandibular intercanine width.

Two giant steps forward in orthodontic mechanics allowed us to become more effective and efficient. Direct bonding and preangulated, pretorqued brackets changed orthodontic “delivery” forever—in a positive way.

The last 50 years have changed our specialty from trial and error to the incorporation of the latest scientific research found in the AJO-DO . But have these changes taken orthodontics to a higher level? In which direction are we going? And better yet, where should we be going?

Comparing treatment in Tweed’s generation with today’s routine treatment is not fair. So many incredible advances in diagnosis and in understanding, predicting, affecting, and controlling growth have enhanced treatment plans. Much research regarding growth and development has changed theories into facts. Goals in treatment have been established that, if achieved, can produce predictable results that are stable, as well as cosmetically pleasing. Studies on long-term stability have shown that, if properly managed, long-term stability is possible.

I believe and teach that we must follow a set of specific goals. The discipline to achieve the goals can provide the desired results. These goals include (1) quality diagnosis and treatment planning; (2) cosmetics: balanced soft tissue profile, smile line, and so on; and (3) stability: positioning the teeth and jaws in specific positions. These goals can be based on what is right for the patient—not what is best for the practicing orthodontist.

In the past 20 years, new concepts in orthodontic treatment and philosophy are focusing on treatment mechanics that make delivery faster, not necessarily better! As an example, round, flexible archwires can rotate the teeth but do not control torque; instead, they can create unstable flaring of the teeth.

So where are we today … and where are we going? Does our specialty need reshaping? The answers to these questions revolve around a battle between efficiency and effectiveness. My belief is this: If your treatment is not effective, efficiency is meaningless. Efficiency is “doing things right.” Effectiveness is “doing the right things.”

Scientific research continues to tell us more regarding function and stability. The evidence-based studies from the “Room of Truth” have been substantiated with the “test of time.” In our “Room of Truth,” we have more than 15,000 pretreatment and posttreatment records, and 300 cases with those records and also long-term records. This room is located in our office building in Arlington, Texas, and all records are available for evaluation by graduate students from around the world. Over 50 research theses and 3 books have been written by people using these cases. I know of no other office or university that contains such comprehensive diagnostic records.

The next generation of orthodontists, including my 2 sons and nephew, has access to the long-term studies and should focus on quality treatment and retention. Then they can also achieve long-term stability. Teachers can teach it—doctors can practice it! Patients will appreciate quality treatment and help guide the treatment of future generations of patients by demanding quality results.

For those who do not believe in long-term stability, several factors should be addressed.

  • 1.

    What is your posttreatment responsibility? Do you inform the patient?

  • 2.

    Do you continue seeing the patient periodically, indefinitely?

  • 3.

    Do you charge a fee for these appointments (eg, retainer adjustment or replacement)?

  • 4.

    When relapse occurs, do you charge for retreatment?

Another ongoing question for all orthodontic specialists is the issue of nonorthodontists attempting to deliver orthodontic treatment. This age-old subject is more alive today than ever. The same technology that is improving our practices is also opening doors for nonorthodontists to offer additional treatment options. Again, as the patient becomes better educated, the choice of selecting an orthodontic specialist is improved. This is especially true when the specialist has long-term patients who can exemplify the quality results. These patients will bring their children and grandchildren back for treatment.

What is your impact factor? Do you see future generations as your potential patients? My challenge to you is to apply the stability rules to your treatment and observe the degree of success for future generations.

With the help of the AJO-DO as a continuing forum for dialogue, ideas, and orthodontic research, we commemorate our past and hail our future. Do you accept the Centennial challenge to leave it better than you found it? Here’s to the next 100 years!

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Apr 6, 2017 | Posted by in Orthodontics | Comments Off on The journey from the past to the future
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