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Tomorrow’s challenges for the science of orthodontics
Tomorrow’s challenges for the science of orthodontics Peter M. Sinclaira Los Angeles, Calif
I
f Edward Angle and Calvin Case were alive today and were to look back and see what the last century has brought to the science of orthodontics, their reaction might well be one of mixed pleasure and frustration. Although we have clearly made significant progress in the development of materials and techniques that have allowed us to move teeth more efficiently and more predictably than they ever could and although the development of surgical techniques has allowed us to manage severe skeletal problems that were beyond their wildest hopes, many of the core problems that frustrated them when the specialty was in its infancy are still with us today, unresolved! It is still true that the success of much of our patient treatment depends as much on the training, skill, and experience of the clinician, as it does on an understanding of the fundamental principles of orthodontic science. If we truly wish to improve the quality and predictability of orthodontic treatment for our patients in the 21st century, then many of the following challenges must be addressed and overcome: 1. The cause of malocclusion: nature or nuture? genetics or environment? If we are lucky, we can answer those questions for any specific malocclusion only 20% of the time. Perhaps the completion of the human genome project will give us insight into the cause of some of the genetically defined malocclusions. Though how much of a priority this will be compared with finding a cure for Alzheimer’s disease or cancer, and how this understanding can be translated into improvements in clinical treatment remains unanswered. Similarly, ill-defined environmental causes continue to defeat our ability to quantify them and to determine their overall contribution to individual malocclusions, let alone approach their treatment in a logical scientific manner. aDepartment
of Orthodontics, School of Dentistry, University of Southern California. Reprint requests to: Peter M. Sinclair, DDS, MSD, Department of Orthodontics, USC, School of Dentistry, Los Angeles, CA 90089-0641. Copyright © 2000 by the American Association of Orthodontists. 0889-5406/2000/$12.00 + 0 8/1/106339 doi.10.1067/mod.2000.106339
Peter M. Sinclair 2. Control mechanisms of craniofacial growth. How can you fix something if you don’t know how it works? Our level of understanding of the principles that control craniofacial growth has only improved slowly and modestly since the time of Angle and Case. Although the breakthroughs in molecular biology that have occurred in the last 2 decades of the century have started to cast light, at the microscopic level, on what occurs in the formation of the human face, this understanding has yet to be translated into scientific principles that explain the macroscopic changes, growth patterns, and interrelationships that produce the many craniofacial patterns that we see in our patients. The challenge is to bring this new knowledge from the level of PCR sequencer into the clinical realm. 3. What is the best treatment regimen or protocol to follow for a particular malocclusion? In contemporary medicine, clinical science has developed to the extent that many diseases have been aligned with specific treatment protocols and regimens, which 551
552 Sinclair
have been proven in double blind studies to be the most effective approaches for particular problems. Although such treatments certainly don’t work perfectly in all patients, they provide the highest potential pathway for success, which is, of course, modified by the individual clinician’s experience and each individual patient’s response. Today, in orthodontics, we are only starting to take our first faltering steps down the path of trying to analyze the outcomes of our treatment to determine if we are really performing the “right” treatment for our patients when we, for example, extract premolars or use headgear. Addressing such questions presents a major challenge and also a major opportunity, hopefully to be addressed by significant long-term allocation of funding to allow for coordinated multicenter studies comparing different approaches to treatment, in a serious attempt to put a lot more science into the art of clinical orthodontics. 4. What is the right time for treatment? Early versus late? Prepuberty or postpuberty? Before or after the second molars erupt? These are questions that we as clinicians face every day. Our answers are based on our education, opinions, experience, but, unfortunately, very few scientific facts. Today, although the problem of timing for Class II treatments is certainly being addressed by NIH-funded studies, there are many other problem areas, such as crowding, open bites, crossbites, etc, that cry out for similar randomized controlled studies that would determine what is the most proven and appropriate stage to intervene in each patient’s development to offer the greatest chance of success. 5. How do teeth move? Would Reitan, looking at the American Journal of Orthodontics and Dentofacial Orthopedics today, see any articles that represent a quantum advance in our understanding of the biology of tooth movement compared with those published by him many decades ago? Would any of these findings have translated into a way to move teeth
American Journal of Orthodontics and Dentofacial Orthopedics May 2000
faster? With more control? With less pain? With less root resorption? The answers would probably be rather discouraging. It is almost embarrassing for us as orthodontists to admit how little we really know about the teeth that we move every single day. Not all these questions will be easily answered, but the conquest of just one of them would result in a major improvement in our understanding of tooth movement and advance the quality of care that we will provide for our patients in the future. 6. Patient cooperation: an impossible goal? Although representing a much “softer” social science rather than a hard clinical or experimental problem, the question of how to ensure patient cooperation has vexed and plagued orthodontists even before the edgewise bracket was born. Will we ever be able to totally control our patients? Of course not! But a significant improvement in our understanding of what motivates them and how to ensure a basic level of cooperation, a determination of what will allow us to overcome their fears and anxieties, and how to decide on the most acceptable form of treatment for a particular patient would all represent major advances in our ability to deliver consistently high-quality care in the 21st century. Although the first few faltering steps have been taken in this direction, they definitely need to become a rapid march toward solving this most important challenge for the future. How do we solve some of these challenges? • Time: many of these challenges will take decades. • Money: focused targeted research from the National Institutes of Health and the American Association of Orthodontists Foundation. • Cooperation: among research centers and clinicians. • Dedication: from the many people who want to make sure that orthodontics is as much a science as an art in the future.
I
f Edward Angle and Calvin Case were alive today and were to look back and see what the last century has brought to the science of orthodontics, their reaction might well be one of mixed pleasure and frustration. Although we have clearly made significant progress in the development of materials and techniques that have allowed us to move teeth more efficiently and more predictably than they ever could and although the development of surgical techniques has allowed us to manage severe skeletal problems that were beyond their wildest hopes, many of the core problems that frustrated them when the specialty was in its infancy are still with us today, unresolved! It is still true that the success of much of our patient treatment depends as much on the training, skill, and experience of the clinician, as it does on an understanding of the fundamental principles of orthodontic science. If we truly wish to improve the quality and predictability of orthodontic treatment for our patients in the 21st century, then many of the following challenges must be addressed and overcome: 1. The cause of malocclusion: nature or nuture? genetics or environment? If we are lucky, we can answer those questions for any specific malocclusion only 20% of the time. Perhaps the completion of the human genome project will give us insight into the cause of some of the genetically defined malocclusions. Though how much of a priority this will be compared with finding a cure for Alzheimer’s disease or cancer, and how this understanding can be translated into improvements in clinical treatment remains unanswered. Similarly, ill-defined environmental causes continue to defeat our ability to quantify them and to determine their overall contribution to individual malocclusions, let alone approach their treatment in a logical scientific manner. aDepartment
of Orthodontics, School of Dentistry, University of Southern California. Reprint requests to: Peter M. Sinclair, DDS, MSD, Department of Orthodontics, USC, School of Dentistry, Los Angeles, CA 90089-0641. Copyright © 2000 by the American Association of Orthodontists. 0889-5406/2000/$12.00 + 0 8/1/106339 doi.10.1067/mod.2000.106339
Peter M. Sinclair 2. Control mechanisms of craniofacial growth. How can you fix something if you don’t know how it works? Our level of understanding of the principles that control craniofacial growth has only improved slowly and modestly since the time of Angle and Case. Although the breakthroughs in molecular biology that have occurred in the last 2 decades of the century have started to cast light, at the microscopic level, on what occurs in the formation of the human face, this understanding has yet to be translated into scientific principles that explain the macroscopic changes, growth patterns, and interrelationships that produce the many craniofacial patterns that we see in our patients. The challenge is to bring this new knowledge from the level of PCR sequencer into the clinical realm. 3. What is the best treatment regimen or protocol to follow for a particular malocclusion? In contemporary medicine, clinical science has developed to the extent that many diseases have been aligned with specific treatment protocols and regimens, which 551
552 Sinclair
have been proven in double blind studies to be the most effective approaches for particular problems. Although such treatments certainly don’t work perfectly in all patients, they provide the highest potential pathway for success, which is, of course, modified by the individual clinician’s experience and each individual patient’s response. Today, in orthodontics, we are only starting to take our first faltering steps down the path of trying to analyze the outcomes of our treatment to determine if we are really performing the “right” treatment for our patients when we, for example, extract premolars or use headgear. Addressing such questions presents a major challenge and also a major opportunity, hopefully to be addressed by significant long-term allocation of funding to allow for coordinated multicenter studies comparing different approaches to treatment, in a serious attempt to put a lot more science into the art of clinical orthodontics. 4. What is the right time for treatment? Early versus late? Prepuberty or postpuberty? Before or after the second molars erupt? These are questions that we as clinicians face every day. Our answers are based on our education, opinions, experience, but, unfortunately, very few scientific facts. Today, although the problem of timing for Class II treatments is certainly being addressed by NIH-funded studies, there are many other problem areas, such as crowding, open bites, crossbites, etc, that cry out for similar randomized controlled studies that would determine what is the most proven and appropriate stage to intervene in each patient’s development to offer the greatest chance of success. 5. How do teeth move? Would Reitan, looking at the American Journal of Orthodontics and Dentofacial Orthopedics today, see any articles that represent a quantum advance in our understanding of the biology of tooth movement compared with those published by him many decades ago? Would any of these findings have translated into a way to move teeth
American Journal of Orthodontics and Dentofacial Orthopedics May 2000
faster? With more control? With less pain? With less root resorption? The answers would probably be rather discouraging. It is almost embarrassing for us as orthodontists to admit how little we really know about the teeth that we move every single day. Not all these questions will be easily answered, but the conquest of just one of them would result in a major improvement in our understanding of tooth movement and advance the quality of care that we will provide for our patients in the future. 6. Patient cooperation: an impossible goal? Although representing a much “softer” social science rather than a hard clinical or experimental problem, the question of how to ensure patient cooperation has vexed and plagued orthodontists even before the edgewise bracket was born. Will we ever be able to totally control our patients? Of course not! But a significant improvement in our understanding of what motivates them and how to ensure a basic level of cooperation, a determination of what will allow us to overcome their fears and anxieties, and how to decide on the most acceptable form of treatment for a particular patient would all represent major advances in our ability to deliver consistently high-quality care in the 21st century. Although the first few faltering steps have been taken in this direction, they definitely need to become a rapid march toward solving this most important challenge for the future. How do we solve some of these challenges? • Time: many of these challenges will take decades. • Money: focused targeted research from the National Institutes of Health and the American Association of Orthodontists Foundation. • Cooperation: among research centers and clinicians. • Dedication: from the many people who want to make sure that orthodontics is as much a science as an art in the future.