One of my recent columns on CBCT generated many comments about my call for a new vision for orthodontics. I had stated that the introduction of CBCT and its ability to measure airway and trace its dimensional change during treatment provided important advantages when treating young patients as well as adults.
Many comments suggested that my intention was focused on financial concerns rather than the care provided, and that this was not always in a patient’s best interest. Others thought that I focused on unneeded services driven by measurements, much like cephalometrics, which can push one into treatment for protrusion or crowding.
My call to action based on technology or observation is not new. I will agree that early adoption on occasion could lead to overtreatment—but that concern is not enough to justify avoiding the newest technology we have at our disposal.
The topic of Phase I orthodontics remains controversial. I provide Phase I orthodontics in a small percentage of my patients. The conventional thinking was that crooked teeth at a young age were common, and eventually we’d fix them quite well, in one uninterrupted phase, at a later date. This idea was supported in literature without too much controversy. Presently, visualization of airway and nasal cavities provides an important piece of information that can be used for diagnosing the need or advantage of treatment and the progression of care, as well as the final outcome.
Advanced diagnostic methods often lead to advanced treatments. One need only look at history—not a detailed, referenced paper, by the way—to see that many diagnostic tools have opened the door to treatments that, over time, provided advanced care. These diagnostic tools were used to justify and plan orthodontics for crowding and stability, TM disorders and occlusal therapy.
Let’s start with the cephalometer. After basing treatment on diagnostic casts for years, the introduction of the cephalometer gave us measurements to work from that allowed for a complete diagnostic picture. We could now quantify the findings like protrusion, retrusion and position of incisors, which led practitioners to initiate treatment based on averages, means and goals.
The same cephalometer allowed for progression measurements and the ability to check on stability and the final outcome. As many evaluation analyses exist as there are doctors to invent them. (Ever heard of the Grob analysis?) Diagnosis of the sagittal problem was obviously the main point of the various analyses, as well as position of teeth.
The panoramic X-ray allowed for early visualization of developing teeth, possible impaction and, of course, extra or missing teeth. Tooth positions and root parallelism came into view.
The question of third molars was addressed as well as, in many situations, condylar health. Treatments were often started with this X-ray with the goal of making room, allowing for exfoliation and avoiding impaction.
While not new to dentistry, the static and unyielding visualization of plaster on the table was replaced with the more dynamic measurements of articulated casts in the 1970s and ’80s. Diagnosis from centric relation was thought to be the solution to occlusal problems and would make you a better orthodontist. Yet these new casts were able to show detailed intercuspal relationships, shifting bites and predicted interferences during excursive movement.
Many (including myself) used this extra piece of information to design treatment around interincisal angles, functional occlusion and, of course, the desired mutually protected occlusal schemes.
Surgical predictions were done on these same casts to visualize and set up the casts to the patients’ ideal occlusal positions. (Not all felt this way, though. The legendary disputes between Roth and Rinchuse brought heated arguments and conflict.)
Stethoscopes and Doppler devices were popular during the 1980s and ’90s to identify early signs of temporomandibular dysfunction. These devices became mainstays in diagnosis rooms, and patients were impressed that a new finding was discovered by the dentist or orthodontist that could justify treatment for noisy joints—often not accompanied by any other disease process.
The Sectograph was an elaborate X-ray machine that led to many patients having their noisy joints evaluated for position of the condyle, often leading to elaborate, extensive and, need I mention, expensive treatment to properly position condyles in the fossa.
With X-ray doses off the charts by today’s standards, we found ourselves defending ourselves not only to patients but also to attorneys, because this rarely used machine was able to seemingly quantify TM joint position and disease.
The MRI X-ray utilized at the turn of the century put to rest many of these treatment justifications when we finally learned that TMD is a musculoskeletal problem with joint laxity, disc dislocation and associated muscular imbalance. These signs and symptoms were found to be similar to other musculoskeletal problems in the body, and treatments adopted at the time mirrored various treatments for other parts of the body—namely physical therapy, medication and other treatments utilized for orthopedic conditions.
EMG and Myomonitor were offshoots of the TMJ diagnostic phase. Electronic devices were used to pulse the masticatory muscles into a proper position, leading many treatments into bite opening and repositioning of the “bite.”
Intraoral scanning with cameras and imaging have become the mainstays of general dental offices as well as specialty locations. Whether it’s to show patients cracked or chipped teeth or to diagnose occlusal wear and tear, these electronic images of dentition certainly led to more complete care. Not only can clinicians visualize what needs to be done but patients are also able to see and comprehend proposed treatment.
Cerec scanning and milling devices have taken the general dental field by storm. Adopted by many but scorned by others, it’s hard to deny that same-day scanning and delivery of restorations have revolutionized the dental practice. For many, this six-figure piece of equipment is a necessary fixture in a new or existing practice, allowing for diagnosis, creation and production of restorations in record time.
Which leads us back to CBCT and the current state of orthodontics. What I have attempted to describe in this brief, unscientific and somewhat documented review of history is the advancements of our profession through the careful use of improved diagnostic instrumentation. Some of these technologies may have been overutilized at the outset or met with skepticism during their slow rise to credibility.
I do believe that all of the devices mentioned contributed to better care of patients at one time or another. It’s plain to see that advancements take time and need to go through a learning curve, extending for years at times, to arrive at consensus diagnosis and treatment. It’s only with a few breaking out of the status quo that new techniques and treatments are delivered.
So, let’s not be so quick to judge or make conclusions on the place of CBCT in modern-day orthodontics. Give it time, and like so many other pieces of technology that were once new to the profession, it too will prevail as a smart and practical choice for our patients—especially our youngest ones.