Embrace Progress: Will the Pendulum Stop Swinging? by Dr. Daniel Grob

Adopting a new vision
It has been said before that if you’re in this profession long enough, you’ll witness major changes in thought. Sometimes those changes are based on science, sometimes on experience and sometimes on economics. We’ve seen orthodontics become a profession with non-extraction, then extraction of permanent teeth, and then, most recently, a more moderate methodology.

We’ve seen the rapid rise in surgical orthodontics, only to be replaced by cautious and less invasive approaches. Self-ligating appliances were to revolutionize the profession and eliminate the need for expansion and tooth removal. TADS are popular, but with an invasive approach and a definite failure rate, they have not taken over the need for conventional orthodontics.

Relatedly, various cephalometric analyses exist to diagnose and at times justify our moods and mechanics.

As I sit in a comfy chair at Chicago Midway Airport (one of only a few remaining chairs on an early Sunday morning), I feel compelled to share my experience this weekend at a meeting sponsored by (of course) some equipment and supply companies with vested interests but presented by doctors committed to bringing a vision of practice we all dream of. A vision that changes the lives of children forever is not concerned with how many aligners are needed or how quickly treatment can be completed. No, this vision is focused on the lives of growing young people so they have a chance to reach their true facial and medical potential. I’m speaking about CBCT and the impact it will have in our profession as it gradually becomes a part of every orthodontic practice.

While at the meeting, I sat with some experienced orthodontists who all agreed that 3-D was something thrust upon us. After all, how much justification is there for checking on the position of impacted canine teeth with a six-figure X-ray machine? My favorite oral surgeon always said that when in doubt, go to the palatal side, because the odds were that that’s where the tooth was.

At one point, TMJ health was a topic that, in our minds at least, justified an occlusion scheme and correction with orthodontics. Periodontal health is certainly improved, at least in the lower anterior segment with judicious orthodontics. Airway health is, I believe, the new justification and guiding force for treatment of malocclusion, and it is beginning to appear that airway volumes and measurements are improved with orthodontics.

Growing importance of Phase I
We have been aware of the improvement of nasal volume with rapid palatal expansion for years. Better airway health benefits patients with better breathing, alertness and energy. Breathing through the nose is important to filter and moisten the air, as well as to help reduce poor tongue posture and facial muscle balance. Reports of behavior changes are becoming more commonplace. Of course, looking at Phase I or early treatment this way necessitates a different view of ourselves and the logistical—or should I say business—side of the profession. Who knows? It may even change the profession to something we’ve envisioned.

If you are like me and have been in practice awhile, you probably agree that Phase I treatment is a wonderful service, but many times leads to extended treatment, runs into Phase II or in some instances, accomplishes things that easily could have been achieved during a patient’s adolescence. There are many published studies that attest to these statements and I am sure that many of you have anecdotes of your own.

What if our whole understanding of the transitional dentition changed, so that rather than just correcting cross-bites, closing gaps and making room for teeth, we were truly treating the individual’s developing airway, facial characteristics and proportions, and improving overall health? Would Phase I treatment still be given second-class status in the busy orthodontic practice? What if Phase I care became the most important part of the treatment equation? Imagine if what we accomplished in Phase I treatment was the essential objective of orthodontic practice?

In addition to a CBCT lecture, I recently attended the joint AAO/AAPD conference, where early treatment was encouraged to eliminate the infrequent occurrence of impaction of cuspids. I know that in my practice, Phase I care was responsible for only a small part of the revenue but many times a larger-than-proportional amount of chair time.

With the advent of CBCT and the resultant knowledge from sophisticated software analysis and treatment planning, this service may soon become a necessary part of orthodontic care, viewed as the “primary reason for care” only to be followed by the “cosmetic” or tooth alignment service. I am sure many of you have already discovered what took me this long to find out on my own.

Changing face
I will admit, I am part of the same group of orthodontists who views their job as to efficiently and cost effectively align teeth during the various stages of dentition. In addition, I have always worked to eliminate unhealthy habits, encourage healthy breathing and identify contributing medical conditions.

What we are realizing now, thanks to many reports and observations, is that the face indeed does change over time, making our value judgment about facial proportions and tooth position to be less accurate over time. We’re also witnessing an unprecedented number of adults subjected to airway and breathing treatments, many times following self-inflicted conditions (such as overeating and lack of activity), but sometimes—possibly by coincidence—orthodontic care.

I have questioned some message board treatment plans that are still driven by the magical Class I molar relationship at all cost, and lower incisor position that, with varying muscular habits, becomes less relevant over time.

My realization that Phase I treatment is now becoming of equal importance as a later phase of care is obviously coming in the autumn of my career, but hopefully, not too late for others. I am not limiting my discussion to only early treatment. With the rapidly developing software and ever lowering doses of radiation, it won’t be long before every patient is scanned for:

• Airway evaluation
• Growth projection
• Various appliances and indirect bonding
• Treatment simulation
• Superimpositions to evaluate the above results.

I am quick to admit that more research is needed to validate some of the comments I’ve made. I ask that clinicians reading this will begin to look at their patients with a different set of eyes and hopefully attend a CBCT lecture soon to see what is going on under their noses. I thank Sean Carlson, JC Quintero and others for contributing to my knowledge and challenging me and others to look further.