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A Clear View of the Future by Dr. Jeffrey Miller

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Categories: Orthodontics;
A Clear View of the Future

5 reasons orthodontics will return to the specialty arena

by Dr. Jeffrey Miller

Today more than ever, orthodontists are concerned about the future of their specialty. Although do-it-yourself orthodontics is not new, more technology-savvy companies are reintroducing “DIY” with a precepted “sophisticated” alternative to orthodontic treatment. With the oversimplified promotion of orthodontics to the general practitioner, and the complacency of our specialty in fighting this trend, it should not be surprising that for some providers, orthodontics has been dumbed down to merely the mechanical alignment of the clinical crowns.

Considering that the average young general dentist graduates with hundreds of thousands of dollars in student debt, taking a bite at the aligner orthodontic market to increase revenue appears to be the correct financial decision—especially when one considers the onslaught of aligner marketing directed at them.

However, even with all the present market forces, I believe our specialty is actually headed back in the direction of the specialist. This may sound counterintuitive at first, based on current events; however, I believe this change back to the specialty arena is happening before our eyes. It may take five-plus years to fully be recognized, but for sure it is coming.


A manageable margin of error
Before I begin to explain, let’s first review how the information derived from CBCT changes the way we evaluate finished orthodontic results.

We’ve all heard about the 0.6 mm of nonvisible bone hidden on our CBCT slices, but few actually understand what this means for orthodontics. Does this 0.6 mm margin of error discount CBCT as a proper diagnostic tool for dehiscence? Simply stated, the answer is no.

Most studies that review the accuracy of bone measurements taken on CBCT slices factor naturally occurring dehiscence and fenestrations in their sample, which are generally minimal and mostly do not have devastating gingival consequences. Orthodontically induced dehiscence (OID), however, is a different category of dehiscence by its higher magnitude and generalization (affecting cuspid to cuspid). While natural or minimal dehiscence and fenestration does not seem to be a major problem for our post orthodontic patients, OID does (Figs. 1a and 1b).
A Clear View of the Future
Fig. 1: Orthodontically induced dehiscence of significant magnitude, discounting the relevance of 0.6 mm of nonvisible bone argument. 1a: Sagittal view, orthodontically induced dehiscence of Tooth #23. 1b: Axial view, orthodontically induced dehiscence, showing the apical portion of Tooth #23 root entirely outside alveolar housing.

In a study published in the American Journal of Orthodontics and Dentofacial Orthopedics, Sun et al. state, “If there was a severe dehiscence on the CBCT image, there was probably a true dehiscence.”1 While smaller dehiscence was harder to accurately diagnose via CBCT, larger dehiscence and fenestration were easily and accurately diagnosed using CBCT (Figs. 2a–2c).
CBCT and Orthodontics
Fig. 2a: Lower left cuspid showing possible naturally occurring root dehiscence
CBCT and Orthodontics
Fig. 2b: Lower right central incisor, left central incisor and left lateral incisor, all showing orthodontically induced dehiscence
CBCT and Orthodontics
Fig. 2c: Clinical photo taken 20 years after active orthodontics, showing tissue dehiscence


For the purpose of this article, I am going to assume that CBCT can accurately diagnose OID of significant magnitudes and that the higher the magnitude of the OID, the more compromised the health of the tooth—i.e., the further the root is orthodontically pushed outside of the alveolar housing, the more compromised the long-term health.

Now, on to the five reasons I believe orthodontics is returning to the specialty arena.


1. CBCT technology will allow dentists and orthodontists to better visualize dehiscence and fenestrations for postorthodontically treated patients.
Consider a younger dentist who is purchasing X-ray equipment for a new office or more established dentists who need to replace their current panoramic X-ray machine. The cost difference between a digital panoramic X-ray unit and a CBCT is becoming smaller, but there are significant differences between the patient fee for a panoramic (around $100) and one for CBCT (which will generate a fee between $350 and $650).

Because revenue is a consideration when purchasing or upgrading new equipment, I believe many dentists will begin to see the value of an in-office CBCT and therefore make a decision to incorporate CBCT. Once these dentists acquire CBCT imaging, I think it’s safe to assume the CBCT will replace the panoramic X-ray. (This is already happening).

When the dentist takes a CBCT on a patient, someone is going to need to read the CBCT, whether it’s the dentist or an oral maxillary radiologist; OID may be present. Once the dehiscence is visualized, the very first question is likely to be, “Did you have orthodontic treatment?” At that point, it doesn’t take much to connect the dots.

Furthermore, traditional panoramic/ cephalometric imagining cannot diagnosis dehiscence or fenestration. It is simply not a tool for that—CBCT is.

To sum up by way of example: A 16-year-old patient with upper-lower crowding of 6 mm per arch receives treatment from one of the DIY aligner companies. The aligner prescription uses expansion to decrowd the teeth, because interproximal reduction or extraction is not an option. Proper alignment—a bit of a stretch for DIY—is achieved by intercuspid expansion (80%) and proclination (20%) of the anterior teeth.

A posttreatment panoramic X-ray will show only the vertical heights of the interseptal bone, and therefore cannot comment regarding dehiscence or fenestration. The posttreatment cephalometric radiograph will likely look reasonable because it cannot evaluate changes in the cuspid position, which is where most of the decrowding space was created (Figs. 3a and 3b). CBCT would show not only OID of the cuspids but also unreasonable proclination of the incisors, which would be hidden by the ceph’s wide focal trough. I also believe the dentist is obligated to mention the OID to the patient and either follow or refer to the periodontist even in the absence of gingival recession.
A Clear View of the Future
A Clear View of the Future
Figs. 3a and 3b: CBCT showing changes to the lower cuspid position within the alveolar housing. These changes cannot be visualized with traditional 2D imaging. 3a: Patient decrowded by tipping/clinical crown expansion of lower cuspids. 3b: An untreated patient’s lower cuspid position for comparison.

Simply put, the orthodontic case that is finished today will likely have a CBCT taken within the next five years and therefore be evaluated for OID that was completely missed in a panoramic/cephalometric postorthodontic evaluation.

A short word about “standard of care,” which is relevant at the time the patient was in active treatment: I believe that regardless of the diagnostic tool used, OID has always been considered a breach of the standard of care. We were just were less mindful of it.


2. Online word and social media spreads fast—especially negative feedback, considering the current feedback for the DIY aligner companies.
This is an easy one to explain; look at online reviews for DIY aligner companies. Despite the encouragement to have their patients write positive online reviews, the negative reviews continue to grow and will likely overwhelm any positive postings.


3. We will better understand the correlation between dehiscence and gingival recession. There’s no question about the correlation between gingival recession
and orthodontic treatment. What we don’t completely understand is: At what point does the dehiscence result in gingival defect? How does gingival phenotype and oral hygiene contribute to the predictability of gingival defects? Can orthodontic expansion/constriction, which results in a “washboard” gingival appearance, change the gingival phenotype from thick to thin? Even with higher magnitude OID, the tissue recession seems to lag, taking five to 10 years to fully manifest.

Once we have a better understanding of the dehiscence/gingival recession relationship, orthodontists will need to carefully consider how much dental expansion/constriction is reasonable, adding an additional layer of complexity to even the simplest orthodontic case (Fig. 4).
A Clear View of the Future
Fig. 4: Orthodontically induced dehiscence. Note the generalized pattern from the first bicuspid to first bicupsid.


4. Poor treatment planning has consequences other than relapse and re-treatment.
As orthodontists, if we want to treat a case using a certain strategy and the case relapses, do we simply re-treat?

The problem with the preceding question: There are consequences to poor treatment plans. Once the tooth is orthodontically expanded (or constricted) outside the alveolar housing, adaptive resorption of the alveolar process occurs, leaving a smaller alveolar housing for future tooth repositioning (orthodontics).

Consider the aligner case in Fig. 5, where expansion was used to decrowd the lower incisors. The alveolar process resorbs to comport to the new position of the expanded root. If re-treatment is considered, this case is significantly more complex, limiting this patient’s orthodontic options.
A Clear View of the Future
Fig. 5: Overexpanded incisor position resulting from aligner therapy and poor treatment planning. Notice the adaptive resorption of the alveolar housing in an effort to comport to the overexpanded root position, therefore complicating re-treatment or root repositioning.


5. Lawyers will use CBCT to show potential damage in the absence of gingival recession.
I am sure I don’t need to remind anyone how lawyers operate and the herd mentality of “follow-the-money lawsuits.” All you have to do is think back to the 1980s, when there was a plethora of TMD-/orthodontic-related lawsuits.

Does anyone think the legal profession would hesitate to file plaintiff claims related to CBCT visualization of OID in the absence of tissue recession? If our periodontal colleagues are already making these exact claims (Fig. 6), how long before the attorneys make use of this information?
A Clear View of the Future
Fig. 6: Photo of a presentation slide at the 2016 American Association of Periodontists Annual Session. Note “Key Question: Dose Alveolar Bone Bend?” (Clearly from photos, the answer is no.)

In summary, I believe CBCT provides additional information that will ultimately benefit our orthodontic patients. However, this additional information not only challenges traditional orthodontic theory but also adds additional complexities to our treatments—complexities that could remove the perception that orthodontic treatment is simply a mechanical skill to align clinical crowns.

As orthodontists, we do not practice dentistry in a vacuum; we share patients with other dental specialties and general dentists. At some point in the near future, the orthodontic patients of today will have a CBCT scan taken, and this scan can be an additional evaluator for long-term successful outcomes.

It is my humble opinion that once the dental community begins to realize the potential damage of focusing only on the mechanical alignment of the clinical crowns without any consideration for the root position and alveolar housing, orthodontics will return to the specialty arena where it belongs.

Reference
1. Sun L, Zhang L, Shen G, et al. Accuracy of cone-beam computed tomography in detecting alveolar bone dehiscences and fenestrations. Am J Orthod Dentofacial Orthop. 2015; 147(3):313-323.

Author Bio
Dr. Jeffrey Miller Dr. Jeffrey Miller is an orthodontist in private practice in Maryland who speaks both nationally and internationally on CBCT topics related to orthodontics. Email: dr.miller@orthodonticassoc.com.




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