The emancipation of dentofacial orthopedics

EDITORIAL

The emancipation of dentofacial orthopedics David C. Hamilton, DDS, MS

New Castle, Pa.

The 1997 CDABO meeting held in Quebec was exciting and enlightening. Certainly it demonstrated foresight on the part of those who promoted the theme and carried it off so well. The meeting addressed the controversial issue of treatment timing, and more specifically the attempt to scientifically evaluate the possible advantages and disadvantages of early and two stage treatment. The officers, program chair, and committee responsible for this meeting are to be commended for what was a comprehensive and well-structured scientific program addressing the subject of "Early Treatment." The research presentations, particularly those by the Universities of Florida, North Carolina, and Pennsylvania, showed the giant steps taken toward an improved understanding of the outcomes and possible advantages of early treatment. The caliber of the research and the speakers on the program were impressive. Because of a somewhat different perspective on early treatment and because concerns about the overall challenge that faces our specialty go beyond those heard at the meeting, Editor Tom Graber requested this commentary. It is disconcerting that at this time when the specialty is about to celebrate the lOOth anniversary of the official founding of organized orthodontics, the American Association of Orthodontists, and at the same time the beginning of a new millennium that there was, at the CDABO meeting, absolutely no discussion of the possible need by the specialty to practice growth modification, facial orthopedics, and the prevention at an earlier age of the development of facial dysplasias. The primary rationale uniformly proffered by the advocates of early treatment is that "if the patient requires gr~wth modification, treatment must be accomplished prior to termination of facial/skeletal growth." This age differs by about 2 years in males (age 13 ±) and females (age 11 ±) approaching puberty. The discussion in Quebec essentially addressed whether beginning treatment "early" (at age 7 or 8) and in most cases obligating the need for a second stage of treatment at a later age or whether beginning treatment at later (at age 10 or 11) and attempting to treat in a single phase of treatment was more advantageous. In addition to discussion of the results and

quality of the care delivered by the two different methods, much of the comment in the breakout sessions at CDABO centered on the "economics" of "early" or what was considered to be "two stage" treatment as compared to the "economics" of one stage of treatment at a modestly later age. Time was also spent in the session I attended on the effects of these economics on the orthodontist and his or her practice, and on the effects on the parents or purchaser of the care. As we are aware, many parents either are reluctant, begrudge, or state that they were not adequately informed about the potential need for second stage treatment. The issue of single versus two stage treatment and the attendant economics of treatment' is particularly critical and sensitive, at this point in time. Many "management consultants" (several in lectures delivered at the AAO annual session in Philadelphia) and at least several "managed service organizations" are advocating, because of what they consider to be circumstances adverse to the financial growth of the practice, that orthodontists do not practice two-stage treatment. A few even dictate to their enrolled orthodontists that they do not practice such treatment. Although certainly it is imperative that, as orthodontists, we consider all aspects of the cost effectiveness of our treatment, it is of even greater concern that we might compromise the quality of our patient care simply to satisfY our personal or MSO-imposed financial goals. A currently prevailing consensus (right or wrong), also expressed at the CDABO meeting, would be that single phase treatment might best be initiated at just before or about the time that the primary second molars loosen and before they are lost. (This might make sense if there was no opportunity to treat the patient earlier.) At the same time, however, the American Board of Orthodontists, in their examination of candidates' treated cases, has placed significant emphasis and grading of the treated cases on the final position and occlusion of the permanent second molar teeth. Although there are those who disagree, the board obviously believes that this detail is critical to the overall quality of the treatment delivered. Attention by future candidates for Board certification will, unless the Board changes its posture, demand the appropriate banding of second 7

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molars and finishing of their cases to this standard of care. Treatment approaches or teaching that advocates that treatment be initiated before the loss of the primary second molars and not completed until all four second molars have erupted are banded and carefully positioned and occluded, would require that the patient be under treatment and wear some type of orthodontic appliances for an extended period of time, probably seldom less and frequently more than 3 years. Particularly in our female patients, this would infringe on the years when, from a social, peer-influenced time in their lives, they are least compliant and least willing to wear appliances. Properly managed two-stage treatment programs generally concentrate on early skeletal correction with optional consideration of aligning the upper or lower anterior teeth. A second stage of treatment might then be delayed until after the permanent second molars have erupted. Full treatment at that time, depending on the circumstances, might require less than 12 months and not require the use of highly patient compliant appliances, such as headgear or functional appliances. Treatment plans wherein the skeletal correction is accomplished at an earlier age, based on my experience produce a final result that is skeletally, dentally, and esthetically measurably superior and more stable. In 1985 the American Journal of Orthodontics astutely, largely through the efforts and influence of editor Dr. Tom Graber, and with the approval of the American Association of Orthodontists, changed its title to the American Journal of Orthodontics and Dentofacial Orthopedics. This seemingly modest change, unnoticed by many, was sagacious and hopefully still portends the future of the orthodontic specialty. It was not, however, until 9 years later, in 1994, that the AAO House of Delegates approved and the AAO officially changed the name of the specialty from "Orthodontics" to "Orthodontics and Dentofacial Orthopedics." In the same year, this change was approved by the American Dental Association thus making the new name official. Changing the titles of orthodontic departments, documents -bf the Association, and the names of related organizations such as the American Board of Orthodontics, is an ongoing slow process. Individual orthodontists are gradually updating their letterheads, professional cards, and Yellow Pages listings to reflect the change. The highest calling of any health care science and of any health care professional is the prevention of disease or deformity. The principles of basic biology and growth and development support, in every instance, the concept and efficacy of very early skeletal modification. The orthodontic specialty has an ethical responsibility, whenever possible, to prac-

American Journal of Orthodontics and Dentofacial Orthopedics January 1998

tice early growth modification and facial/skeletal orthopedics thus preventing, rather than treating at a later age, facial/skeletal dysplasias. European orthodontists have made, and continue to make, significant contributions to our understanding of early growth modification and early treatment. The specialty, however, still lacks the definitive scientific research and the basic diagnostic criteria and standards necessary for most orthodontists to comfortably address the diagnosis and facial orthopedic treatment of preschool children. Meanwhile, and perhaps because of this void of definitive information, the actual practice of facial orthopedics remains relatively quiescent with respect to any positive, enthusiastic recognition and acceptance or teaching of its practice by American orthodontists. In the meantime, in many communities, wellinformed and progressive younger dentists and pediatric dentists, aware of the biologic research and literature supporting early treatment, have been frustrated when attempting to refer their younger patients with severe facial or dental dysplasias to orthodontists for care that they perceive should be accomplished at an early age. Other dentists and many pediatric dentists interested in practicing orthodontics, many without appropriate training, have taken advantage of this void and have stepped in to fill the need and provide the treatment. Of even greater concern is the fact that in the United States and Canada with few exceptions, orthodontic departments and private practices are not even seeing, screening, or encouraging the referral of preschool (age 3 to 6) children. (Patients at that age are being seen by pediatric dentists with a defined interest in promotion of the "Gatekeeper" concept of patient management.) There is a significant difference between the treatment of 7-year-olds and the treatment of 3-year-olds. The term "early" is perhaps inappropriate when addressing treatment in the mixed dentition. An often repeated adage concerns the fact that had U.S. railroads, in the 1920s and 1930s, envisioned themselves as being in the "transportation" business as opposed to being in the "railroad" business, they might today very well own and perhaps successfully operate the airlines of the world. For years, orthodontists have envisioned themselves as being in the business of "straightening teeth," the "put your plaster on the table" syndrome. Orthodontists must entertain a paradigm shift. Orthodontics is the medical/dental specialty best qualified by education and experience to provide and teach facial orthopedics. Failure on the part of orthodontists to recognize that they are in the business of facial esthetics and facial orthopedics seriously inhibits the capacity of the specialty to appropriately and in a timely manner treat patients who demon-

American Journal of Orthodontics and Dentofacial Orthopedics Volume 113, No.1

strate severe facial dysplasias. Observing the patients during their growing years with the intent to perform orthognathic surgery or "camouflage" treatment at a later date is not the answer. Indeed, as third party health care benefit programs continue to deny benefits for orthognathic surgery, dentistry will be forced to seek preventive, less invasive, and less costly alternatives: An interesting paper was presented at the meeting by Dr. H. Asuman Kiyak. It should be of interest to all orthodontists and is published in this issue of the Journal. It stresses the importance of the provision of treatment at a time when the patient will provide maximum compliance. Because the appliances used to produce growth modification frequently involve either clumsy acrylic appliances (e.g., activator, bionator, Frankel, dual arch expansion appliance) or conspicuous extra oral appliances. (e.g., facebow, face crib), patients become much less cooperative as they grow older. A distinct advantage to treatment at ages 3 to 6 years is that the patients are still parentally controlled. It is not unusual, for example, to have a 4-year-old wear a maxillary protraction face crib 20 hours a day. The results are exciting. Finally, although ethics, state of the art treatment of our patients, and prevention are the primary reasons for seeking this critical paradigm shift, there are additional reasons having to do with the delivery of early preventive/interceptive facial/orthopedic growth modification that are also critical to the future of the orthodontic specialty. 1. There are organized groups and persons as-

serting that orthodontists have no interest in treating patients of this age. They suggest further that their organizations or groups should assume this responsibility and be recognized as a specialty group responsible for the facial orthopedic treatment of younger patients. It has even been suggested by a few dentists that orthodontists should limit their treatment to "comprehensive treatment of patients with their adult dentition." There are many physicians, specialists in orthopedics, who, i>ecause of changes in the health care delivery system and the effects of managed care on medical practice, are looking for new opportunities and methods of expanding their practices. The above initiatives are not limited to the United States but exist in many other countries, some with even more serious implications. 2. As stated previously, many popular management consultants and at least several of the emerging publicly traded MSOs (management service organizations) either suggest or require that orthodontists enrolled in their

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programs, because it is "economically unproductive," refrain from providing any early or multiphase treatment. Such programs seriously challenge orthodontists health care orientation, ethics, and quality of care motivation versus their priority for financial gain. 3. State and federal Title IXX programs designed to provide care for deserving indigent or handicapped children frequently dictate that benefits be provided only to children over a certain age (e.g., 10 or 12 years). It is suggested by others that public moneys would be much more cost effectively expended on preventive treatment of children at an earlier age. Orthodontics should assume the responsibility to provide the outcomes research necessary to substantiate the effectiveness of earlier treatment. The AAO should then, if indicated, campaign to alter such legislation in the best interests of the patient and the tax-paying public. 4. A number of third parties and insurance companies that provide dental benefit plans that include orthodontic treatment are attempting to place age and modality of treatment (e.g., use ofremovable appliances) limitations. The AAO has taken a strong position with this respect and encouraged third parties and plan purchasers to eliminate orthodontic benefits entirely rather than provide plans that, either by limitation of benefits or limitation of reimbursement, jeopardize the orthodontists' ability to provide competent, quality care. Dental schools and graduate orthodontic programs must encourage and produce the diagnostic criteria, outcomes data, and research necessary to reinforce and expand our scientific knowledge and understanding of facial orthopedics, early treatment precepts, and early treatment techniques. Every orthodontic resident should be required to treat at least two preschool children as a part of their clinical program. Currently practicing orthodontists must develop their skills and enthusiastically accept their roll as facial orthopedists, expanding their practices to include this important scope of health care responsibility. Failure to make the shift in paradigms may seriously and adversely affect the future of the specialty. How many children, age 3 years, have you ever seen with a long-face syndrome? If the answer is "very few," then a logical second question is "If this is true, then when does the long-face syndrome develop?" Logical answer: "after age 3." With all of

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American Journal of Onhodontics and Denlofacial Onhopedics January 1998

our sophisticated diagnostic techniques and standards, is there not then a way of differentially determining which children will develop this facial dysplasia and more importantly, perhaps, is there a way it can be prevented? The same admonitions apply to other skeletal dysplasias. Facial orthopedics at an early age is a challenging concept worthy of our great specialty. There is so much of critical importance to be accomplished. My suggestions would be that this

entire issue be referred to the AAO's Council on Scientific Affairs, the Council on Education, and perhaps also to the Council on Orthodontic Practice. They should be charged with the responsibility of promoting possible workshops and producing research, possibly funded through the American Association of Orthodontists Foundation, necessary to study and to initiate the addressing of orthopedic concepts. Certainly the CDABO meeting is a good beginning.

AAO MEETING CALENDAR

1998 1999 2000 2001 2002 2003 2004

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Dallas, Texas, May 16 to 20, Dallas Convention Center San Diego, Calif., May 15 to 19, San Diego Convention Center Chicago, III., April 29 to May 3, McCormick Place Convention Center (5th IOC and 2nd Meeting of WFO) Toronto, Ontario, Canada, May 5 to 9, Toronto Convention Center Baltimore, Md., April 20 to 24, Baltimore Convention Center Hawaiian Islands, May 2 to 9, Hawaii Convention Center Orlando, Fla., May 1 to 5, Orlando Convention Center