GUEST EDITORIAL

Emerging paradigms in orthodontics--An essay

Joseph G. Ghafari, DMD*
Philadephia, Pa.
Near the end of the first cent ury of organi zed orthodontics,
several concept s are emergi ng, some of whi ch may become
state of t he art, whi l e others need val i dat i on or furt her devel -
opment. They encompass a range of areas, i ncl udi ng the tim-
i ng of earl y treatment, force appl i cat i on, modal i t i es and out-
come of treatment, research, educat i on, and the del i ver y of
ort hodont i c care.
1. TI MI NG OF EARLY TREATMENT
Treat ment in late chi l dhood in one rather than two phases,
but individual variations may require an earlier intervention.
Cont r over sy about the t i mi ng of early t reat ment exists at
t wo l evel s of deci si on:
1. Treat earl y (in t he deci duous or mi xed dentition) in the
bel i ef that early i nt ervent i on bri ngs natural forces to normal
function.~-4 Many quest i oned the advant age to be gai ned f r om
earl y t reat ment and advocat e t reat ment in t he permanent den-
tition. 4,5 The essence of this cont r over sy is best summar i zed
by t hese statements of Edwar d H. Angl e, that appeared in the
7th edi t i on of his book in 19071: . . . the proper time to begin
t reat ment is as near the beginning of the variation f r om the
normal in the process of devel opment of the dental apparatus
as possible. This may date f r om the eruption and locking of
the f i rst permanent mol ars into distal occlusion [. . . ] or into
mesi al occl usi on [...], or it may in rare instances have an
even earlier begi nni ng- in the mal -l ocki ng of the deciduous
teeth. It has al ways been argued by the writers o f the "old
school " that this is a most unpromi si ng age f o r t reat ment
[. . . ] f avori ng the peri od o f life bet ween the ages of twelve
and seventeen years ....
2. At anot her l evel , cont r over sy exists about the t i mi ng of
earl y t reat ment itself, namel y how earl y? In t he deci duous
dentition, the early, mi d, or late mi xed dent i t i on? Some au-
thors, l i ke Angl e, suggest starting t herapy as early as the de-
vel opi ng mal occl usi on is i dent i fi ed, even in the deci duous
dentition. 2 Others consi dered i nt ercept i ng a mal occl usi on at
vari ous stages of the mi xed dentition. 68
The l i mi t at i ons of early t reat ment i ncrease wi t h mal occl u-
si ons associ at ed wi t h skel et al di scr epanci es, par t i cul ar l y
mesi ocl usi ons. Unfort unat el y, l ongi t udi nal studies establish-
*Professor of Ort hodont i cs, Uni versi t y of Pennsyl vani a.
Am J Or t hod Dent ofac Ort hop 1997; 111:000-00.
Repri nt request s to: Dr. Joseph Ghafari , Depar t ment of Ort hodont i cs, School
of Dent al Medi ci ne, Uni versi t y of Pennsyl vani a, 4001 Spruce St., Phi l adel -
phi a, PA 19104-6003.
Copyr i ght 1997 by the Amer i can Associ at i on of Orthodontists.
0889-5406/ 97/ $5. 00 + 0 8/ 1/ 80284
ing the val ue of early intervention are not yet available. Knowl -
edge of l ong- t er m effect s is needed to j ust i f y or t hodont i c
t her apy t hr oughout chi l dhood and pos s i bl y i nt o ear l y to
mi dadol escence. The issue ext ends beyond severi t y of mal -
occl usi on to the t i mi ng of treatment, whi ch requires, part i cu-
larly in the presence of skeletal dysplasias, eval uat i on of den-
tal and skeletal ages. 9 Prel i mi nary fi ndi ngs of a r andomi zed
pr ospect i ve cl i ni cal trial on the earl y t reat ment of Class II,
Di vi si on 1 mal occl usi on i ndi cat e that t reat ment in late child-
hood may be as ef f ect i ve as that in mi dchi l dhood. ~ Thus treat-
ment in late chi l dhood may be more pract i cal and cost -effec-
t i ve, because it reduces the total l engt h of t i me a chi l d has to
be seen by an orthodontist. Act ual l y, the results of our re-
search 1 and that by other investigators 1114 tend to concur about
the val ue of early t reat ment in late chi l dhood as t he first phase
of a one-st age treatment. Thi s concl usi on pertains to the cor-
rect i on of the di st ocl usi on but also to space management wi t h-
in the dent al arch. 1, 15, 16 The opt i mal t i mi ng of t reat ment in
the late mi xed dent i t i on woul d correspond to t he t i me j ust
bef or e the loss of the deci duous second molars. Nance 6 ex-
pressed si mi l ar vi ews earl i er in this century.
These concept s i mpl y that in the t reat ment of Class II,
Di vi si on 1 mal occl usi on, t he i mper at i ves of dent al devel op-
ment may dictate a t i mi ng of t reat ment i ndependent of the
requirements of craniofacial growth. Demi rj i an et a1.I7 reported
that dent al devel opment is not cl osel y rel at ed to skel et al ma-
turity or peak hei ght vel oci t y. They concl uded that t he mecha-
ni sms cont rol l i ng dental devel opment are i ndependent of so-
mat i c and/ or sexual maturity. Presumabl y, the correct i on of a
skeletal dyspl asi a underl yi ng a di st ocl usi on is best achi eved
during act i ve peri ods of growt h. 9 Thi s assumpt i on suggest s
that the relationship bet ween dental and skeletal devel opment s
must be det ermi ned in the i ndi vi dual patient. Ext r eme indi-
vi dual vari at i ons, such as a premat ure dent al devel opment
r el at i ve to a normal or del ayed skel et al mat urat i on, woul d by
necessi t y requi re earl y t reat ment to be a t wo- phase treatment,
the first stage i mpl ement ed in t he mi xed dentition, and t he
last in the per manent dentition, probabl y after a per i od of re-
tention.
Condi t i ons that af f ect occl usal de ve l opme nt or dent al
heal t h woul d also requi re t reat ment in earl y or mi dchi l dhood.
They i ncl ude: suscept i bi l i t y to t rauma of t he maxi l l ar y i nci -
sors because of a s ever e over j et , TM a f unct i onal post er i or
crossbi t e, Is,19 and devel opment al pr obl ems that endanger t he
i nt egr i t y of t he dent al arch, le'2 such as t he pr emat ur e loss of
deci duous teeth, par t i cul ar l y second mol ar s, or t he ect opi c
Ameri can Journal of Ort hodont i cs and Dentofaci al Or t hopedi cs/ May 1997 573
574 Guest editorial American Journal of Orthodontics and Dentofacial Orthopedics
May 1997
eruption of permanent teeth. The impact of early treatment
on psychosocial development, including self-perception and
self-worth, does not generally appear to warrant early inter-
vention] 3,14 However, such a relationship must be monitored
in the individual child. The correction of mild to moderate
anterior crossbites must also be instituted in early childhood,
unless the crossbite is part of a mesioclusion associated with
a severe skeletal dysplasia. In this instance, the long-term
benefits of early treatment are unknown and require judicious
study. Finally, several craniofacial anomalies are subject to
treatment regimens that include early intervention.
In summary, the benefit of early treatment, particularly in
avoiding extraction of permanent teeth, is no longer in ques-
tion. The advantage of early treatment and its timing in indi-
Vidual patients may be questionable. Hence early treatment,
and further studies of its effectiveness, should be focused on
individual variation (see section 7- Research).
2. ORTHODONTI C FORCES
Light intermittent forces may be optimal for tooth move-
ment.
Light continuous forces seem to be the state of the art of
orthodontic mechanotherapy. Interrupted orthodontic forces
have also been shown to produce tooth movement similar to
that generated by continuous forces with less damage to the
structures of the periodontal ligament, zl In a series of ex-
periments, King and his associates 21-24 tested the relation-
ship between force magnitude, duration, and frequency. Sev-
eral conclusions emerged that supported previous research
findings by other investigators, or suggested new qualifica-
tions for orthodontic forces. Light short-term or cyclic force
applications can alter tooth position in a way comparable to
light continuous forces. Significant amounts of bone turn-
over and remodeling events consistent with the direction of
loading, and associated with tooth movement, continue for
an indeterminate period after appliance decay, or appliance
removal. 24
These findings are consistent with the findings of Rubin
and Lanyon 25that minimal exposures 'to forces at physiologi-
cal levels (four consecutive loading cycles per day totaling 8
seconds) could stimulate bone modeling (inhibiting resorption)
significant enough to prevent disuse osteoporosis in immobi-
lized avian wings. In a series of experiments, z5-3 they removed
the epiphyseal ends of the ulna in turkeys and roosters, thus
freeing the remaining diaphysis from any regular functional
strains. The vascular and nervous elements entering the bony
shaft were left intact. Stainless steel pins were then inserted
into each end of the bone, protruding through the skin, and
permitting the application, at different magnitudes and fre-
quency, of mechanical loads to the ulna. In the absence of any
applied stress, gradual loss of bone mass occurred, 2v while the
daily application of four loading cycles maintained bone mass.
In contrast, continuous loads had no effect on the ulnar model-
ing and caused resorption. However, when such loads were
applied intermittently for only a few minutes daily, bone mass
increased substantiallyY The degree and nature of bone re-
modeling was directly related to the magnitude of applied bone
strain, demonstrating the existence of a threshold of force mag-
nitude necessary for enhanced osteogenesis on both periosteal
and endosteal surfaces. 26 Similar interactions between force ap-
plications and bone remodeling response are at play in orth-
odontic tooth movement.
To explain these biologic responses, Skerry et al. 28proposed
that the large proteoglycan molecules are a likely stress-sensi-
tive element in bone matrix. This group observed a strain-me-
diated change in the direction of the proteoglycan molecules,
which needed almost 48 hours to regain their original three-
dimensional tree-like configuration. Thus a strain memory is
described as strain is maintained in bone matrix long after re-
moval of the externally applied stress. Seemingly, bone cells
most affected by matrix strain are the osteocytes, which, in
turn, through cell-cell communication mediated by gap junc-
tion protein (connexin 43), can activate bone surface cells. 29,3
Different ranges of optimal orthodontic forces have been
described (20 to 26 gm/cm 2 according to Schwartz; 3183 gin/
cm 2 according to Miura32). Even the lighter forces may cause
large strains in the periodontal ligament, perhaps inducing an
injury rather than an "adaptive" response. Research by Rubin,
Lanyon, and their associates regarding force magnitude would
suggest that smaller strains (<100 B~ ) than currently used may
be appropriate for tooth movement, if induced at the right fre-
quency (Hz). Recently, Tuncay et al? 3 suggested that ultra-
sound waves, applied for relatively short periods of time, mimic
the inflammatory conditions in the gingival tissues necessary
for orthodontic tooth movement.
The impact of the research by King and his associates, and
the support and probable explanations provided by the work
of Rubin, Lanyon, and their associates, challenge the present
dogma that advocates the use of light continuous forces for
tooth movement. Instead, light intermittent or interrupted
forces would be needed for physiologic movement. The
method of application of these forces would be altered from
current appliances. However, although examples abound to
illustrate the effect of short-term light forces on tooth posi-
tion, judicious clinical research is needed to test this hypoth-
esis. All the reported evidence was gathered from animal re-
search. As stated by Davidovitch, 34 several questions must be
answered: (1) Are occlusal forces detrimental to short-term
orthodontic forces? (Because in the experiments of King and
his associates, these forces were eliminated by the extraction
of teeth opposite the investigated teeth). (2) Is there evidence
of strain memory in the alveolar bone or, particularly, in the
periodontal ligament?
If these questions, along with clinical research, support
the concept of short-term application of light forces, orthodon-
tic treatment as we know it today will be significantly modi-
fied. Presumably, a single, short period of low-amplitude strain
stimulus rather than the continuous, large signal would effect
tooth movement. The intermittent application of orthodontic
forces may not be practical to both patient and orthodontist;
however, technologic developments with families of "smart"
wires and other attachments should accommodate the require-
ments of intermittent pressure if it emerges as the optimal
method of treatment. An outgrowth of this theorem would be
American Journal of Orthodontics and Dentofacial Orthopedics Guest editorial 575
Volume 111, No. 5
the avoi dance of some compl i cat i ons of orthodontic t reat ment
(such as root resorption, loss of anchorage) wi t h light i nt er-
mi t t ent forces that woul d favor direct surface resorpt i on and
mi ni mi ze hyal i ni zat i on and its side effects.
3. CAMOUFLAGE AND ADJUNCTI VE SURGERY
Limited compensation short of the ideal surgical treat-
ment, and of a Class I occlusion, may be the appropriate cam-
ouflage as the severity of skeletal discrepancy increases.
Treat ment of mal occl usi ons underl i ned by skeletal discrep-
ancy ranges from dent oal veol ar compensat i on or camoufl age
to adj unct i ve orthognathic surgery. The basi c i dea of camou-
flage i nvol ves extraction of teeth to correct mol ar and i nci sor
rel at i onshi ps of a Class II or Class III mal occl usi on, despite
the under l yi ng j aw discrepancy. Orthodontic camoufl age i m-
plies a favorable, at least nondet ri ment al effect on facial es-
thetics. 35 A l ong-prevai l i ng tenet among orthodontists is that
achieving a Class I occl usi on is a measure of success, although
i n many i nst ances this goal is reached at the expense of facial
esthetics. In the last decade, the pendul um has swung toward
adj unct i ve orthognathic surgery as the onl y, albeit ideal, al-
ternative to camouflage, i f facial esthetics were to be i mproved
or not worsened by excessive compensat ory t i ppi ng of teeth.
An emer gi ng concept may be t ermed limited compensa-
tion (for proper camoufl age). I n essence, it is t reat ment to-
ward, but not necessari l y achi evi ng Class I occlusion, com-
mensurat e with favorable facial appearance, i f the pat i ent does
not opt for the ideal surgical t reat ment or, as is i ncreasi ngl y
the situation, i nsurance coverage for the surgery is denied.
Thi s concept i mpl i es that, i n a Class II mal occl usi on for ex-
ample, an excessive overjet is onl y part i al l y reduced to avoi d
"fl at t eni ng" the profi l e by i nordi nat e dent oal veol ar compen-
sation. If teeth are extracted to maxi mi ze compensat i on and
should the pat i ent decide to undergo surgery later i n life, dec-
ompensat i ng the compensat ory i ncl i nat i ons of the teeth be-
comes a task that is bot h more demandi ng and prone to more
therapeutic side effects such as root resorption. Therefore lim-
ited camoufl age or l i mi t ed dent oal veol ar compensat i on i n-
volves, perhaps as much as any therapeutic approach, the rec-
ogni t i on of i ndi vi dual t reat ment objectives and limitations.
The chal l enge for the cl i ni ci an is to reach an educat ed deci-
sion to bal ance i ndi vi dual di agnosi s and expectations wi t h
the anticipated out come and side effects of treatment, i ncl ud-
i ng a serious consi derat i on of the benefi t s and risks (compro-
mi sed esthetics, root resorption, bone fenestration, gi ngi val
recession, l engt hy treatment) of alternative approaches (see
section 9).
4. THE THREE- DI MENSI ONAL FACE AND OCCLU-
SI ON
Beyond Angle's classification, achieving a multidimen-
sional balance.
Cephal omet ri cs is a needed tool i n orthodontics, but his-
torically has been restricted to the sagittal vi ew of the face,
perhaps refl ect i ng the cl i ni ci an' s emphasi s on the sagittal de-
vi at i ons of the dent i t i on accordi ng to Edward Angl e' s classi-
fi cat i on? 6 Yet i nf or mat i on from the front al vi ew is particu-
l arl y i mport ant to integrate i n the formul at i on of a proper di-
agnosi s for the i ndi vi dual patient, because "man meets his
fel l ow men i n front al confront at i on. ''36 The i ncreased aware-
ness of the mul t i di mensi onal nat ure of face and occl usi on has
led to a cycle of nonext ract i on t reat ment and to further con-
sideration of arch expansi on, at t i mes requi ri ng orthopedic
means, i ncl udi ng sur gi cal l y assi st ed pal at al expansi on i n
nongr owi ng patients. As wi t h most therapeutic cycles, the
pendul um tends to swi ng too far i n one direction, but two
basi c pri nci pl es are offered as the rat i onal e for arch expan-
sion: space creation and esthetic consideration. The latter per-
tains to the rel at i onshi p bet ween a narrow maxi l l ary arch and
the smile. A space bet ween the maxi l l ary lateral teeth and the
corner of the lips duri ng smi l e appears as a bl ack or dark space,
or "corridor," and may detract from facial at t ract i venes; the
way a flat profile does. A narrow maxi l l ary arch may resul t
from orthodontic therapy, part i cul arl y when maxi l l ary teeth
(often premolars) are extracted. On the other hand, wi deni ng
of the maxi l l ary arch through orthodontic and/ or orthopedic
means, as may be indicated, may enhance the esthetics of a
smile.
The argument about extraction of teeth for orthodontic align-
ment is clearly related to the issue of arch expansion and is
r e mi ni s c e nt of ol der debat es t hr oughout t he hi s t or y of
orthodontics. Edward Angl e' s statements about the issue i n
1907, discussed i n the context of facial esthetics, reflect the
lasting controversy37: ...the best balance, the best harmony,
the best proportions of the mouth in its relations to the other
[facial] features require that there shall be the full comple-
ment of teeth, and that each tooth shall be made to occupy its
normal position-normal occlusion . . . . [the] unfortunate and
inartistic results [of extraction] may be seen in every commu-
nity. It is gratifying, however, that this fallacious teaching and
pernicious practice are rapidly passing ....
At issue is balancing i n the i ndi vi dual patient, the esthetic
requi rement s wi t h the requi rement s of funct i on, stability, and
peri odont al health. Ext ract i on of per manent teeth may be re-
qui red to achieve this bal ance. The goals and l i mi t at i ons of
dent oal veol ar compensat i on or camoufl age, di scussed for the
sagittal and vertical planes, appl y i n the frontal di mensi on as
well.
5. USE OF PHARMACEUTI CAL SUBSTANCES TO
EFFECT ROOT RESORPTI ON, TOOTH MOVEMENT
AND ANCHORAGE
Local application may be problematic, but investigation
is proceeding.
Root resorption. Root resorpt i on is a common occurrence
duri ng orthodontic t reat ment that varies from mi croscopi c to
serious macroscopi c levels. Root short eni ng is unpredi ct abl e,
and the level of loss of tooth subst ance may not be ant i ci -
pated with certainty on the basis of any of the reported etio-
logic factors acting separately or i n combi nat i ons. Furt her-
more, the root resorpt i on process varies not onl y among per-
sons, but also wi t hi n the same person at different times, 38 as
wel l as bet ween different teeth i n the same person. 39
Among several solutions advanced to decrease the risk of
occurrence of root resorpt i on was the possi bi l i t y of arresting
576 Guest editorial American Journal of Orthodontics and Dentofacial Orthopedics
May 1997
root resorption by injecting substances that may inhibit the
resorptive process near the involved roots. 39 The basis for this
suggestion is that a considerable number of cytokines and
growth factors have been examined that modulate the activity
of both the osteoblast and osteoclast. 4 Inhibition of osteo-
clastic activity and up-regulation of osteogenesis may act to-
gether to shift the equilibrium between osteoclastic and os-
teoblastic activities away from resorption. A similar mecha-
nism may apply in the external root resorption model.
Although such a mechanism has not been explored, the
systemic administration of 0.5 gm Thyroid (Proloid, Parke
Davis) was reported in three patients by Loberg and
Engstr6m. 4~The maxillary incisors in all patients were sub-
jected to intrusion and lingual root torque. In a commentary
on this report, Christiansen 42 suggested that thyroxine admin-
istration, instead of lowering the frequency of root resorp-
tion, may have increased the rate of alveolar bone resorption,
thus indirectly decreasing root resorption. This report should
not be an invitation to start using thyroxine, albeit in minute
amounts, to reduce root resorption. Thyroxine reduces bone
mass, and the substance used in the reported patients is a bo-
vine product whose effectiveness may be questionable. Yet
the basic premise of using substances that alter the biologic
response to tooth movement seems to be a trend for at least
future investigation. Recently, Davidovitch 43 suggested that
the consumption of alcohol may be related to root resorption
during orthodontic treatment in adults by inhibiting the hy-
droxylation of vitamin D in the liver. The contribution of sys-
temic conditions, acting in concert with local factors, would
need careful exploration.
Anchorage and tooth movement. In a series of experiments,
the topical administration of a potent blocker of bone resorp-
tion, biphosphonate (risedronate), caused a significant and
dose-dependent reduction of tooth movement, and inhibited
relapse of tooth movement in rats. 44 These experiments sug-
gest that the topical, not only systemic, application of
risedronate may be helpful in anchoring and retaining teeth
during orthodontic treatment. Tetracycline may have a simi-
lar potential while presenting less side effects, since it may be
used in its nonantimicrobial form (analogue). 45 Other sub-
stances have been investigated that may affect the rate of tooth
movement, including prostaglandin 46'47 and vitamin D. 48,49
The routine use of topical substances as an aid in tooth
movement, retention, and avoidance of root resorption un-
doubtedly requires more research and definition. A basic prob-
lem for the application of such concepts in human beings is
dispensing these substances locally with minimal discomfort
to the patient. Although application in human beings may not
be imminent, the concept is gaining momentum for investi-
gation.
6. T E C H N O L O G I C A L AND T H E R A P E U T I C AD-
VANCES
"Smart" wires, glass ionomer, computerization, implants,
distraction osteogenesis.
Technologic advances always have the potential to gener-
ate shifts in paradigms. Several can be listed that affected the
development of orthodontics to this day: the advent of the
edgewise bracket, bonding, glass ionomer cements, cephalo-
metric radiography, video imaging, the use of computers to
help in treatment planning and practice management, pro-
grammed (prescription) brackets, nickel titanium or other al-
loy wires, and rigid fixation in orthognathic surgery. Although
most developments for several decades have been variations
on preexisting technology, it is equally true that major changes
in orthodontic therapy have been dictated by industries be-
hind such developments. At present, the advances that may
potentially affect a new direction in orthodontic treatment
relate tO implants and bone lengthening. The use of implants
to assist as anchorage units during tooth movement is still at
developmental or experimental stages) Onplants, small sur-
face-retained implants, may emerge as the method of choice
in orthodontics, 51although their use will probably be limited
to select conditions.
Bone lengthening through distraction osteogenesis, now in
use in the treatment of craniofacial anomalies, 52,53may emerge
as an orthopedic adjunct to orthodontic treatment of malocclu-
sions. The device used to lengthen bones is an extraoral con-
figuration. Successful mandibular lengthening with intraoral
devices was reported recently in primates, 54 and applications in
human subjects will undoubtedly follow, possibly leading to
the resolution of mandibular retrognathism through this osteo-
genic approach. This premise, however, will require extensive
research, including the exploration of advantages and disad-
vantages of correcting the skeletal problem through surgery
versus osteogenesis. Although both procedures affect bone
structure, the surrounding soft tissue envelope may be the criti-
cal limiting factor in success and stability of treatment.
7. RESEARCH
More clinical research;focus on individual variation; inte-
grating biology in understanding and monitoring clinical ad-
vances.
Trends in craniofacial research are changing primarily in
favor of more clinical research than before. Kinsey and
Kremenak 55 reported a sixfold increase in clinical reports at
the meetings of the American and International Associations
for Dental Research (AADR, IADR) between 1966 and 1992,
from 4% to 24%, respectively. Cell and molecular biology,
genetics and inheritance, growth and development, structure,
and physiology make up the rest of research areas.
The significance of clinical research in orthodontics is fur-
ther emphasized by the funding National Institutes of Health
(NIH) provided for clinical trials to investigate the efficacy
and efficiency of alternative approaches in the treatment of
malocclusions. Three prospective studies of the early treat-
ment of Class II, Division 1 malocclusions, two trials (one
prospective, one retrospective) on treatment with or without
extraction of teeth, and one study on measures of treatment
outcome were the first cohort of clinical trials to use rigorous
designs? 6 The prospective investigations involved random
assignment of patients to treatment groups to eliminate selec-
tion bias. Furthermore, the debate has shifted from evaluat-
ing the shortcomings of retrospective and prospective studies
American Journal of Orthodontics and Dentofacial Orthopedics Guest editorial 577
Volume 111, No. 5
to the potential contribution of each. In 1994 and 1995, three
symposia at the IADR and AADR meetings were an adequate
forum for this debate. A major byproduct of all these efforts
and activities is that the debate generated a focus on proper
scientific research method (design and conduct), irrespective
of the individual contribution of the various projects. This
focus enhances scientific discourse and its impact on orth-
odontic education, if properly channeled through orthodontic
programs and organized orthodontics, is immeasurable.
The shortcomings of retrospective and prospective inves-
tigations have increased the awareness for standardizing orth-
odontic records to organize a registry or data bank that would
be the basis for investigating major clinical questions? 7 The
standard of peer review has necessarily been raised by the
debate, and a new culture of increasingly more sophisticated
investigative procedures is infiltrating education through com-
munication of rigorous methods and designs of investigation.
Moreover, the nature of the debate has shifted from summary
discussions of variability in studies accounting for average
responses to the concept of discovering and characterizing
individual differences. 58
As clinical research increasingly adapts to rigorous
methodologic and statistical precepts, treatment results are
mostly evaluated with morphometrics, namely, measurements
through cephalometric roentgenography, the vernier caliper,
and lately the digitizer. 59 The findings represent descriptive
two-dimensional analyses, and some understanding of facial
growth and its modification by orthodontic and orthognathic
treatment, through cross-reference with findings from experi-
mental studies. Although the method of evaluating growth
and treatment has improved, more sophisticated tools that
explore the craniofacial complex need to be developed to re-
visit and address standing issues, particularly the behavior
and response of soft tissues to changing environmental con-
ditions. In the meantime, universal standards must be adopted
for existing technology, starting with the adoption of a global
standard film-to-object distance in cephalometry, or at least
the correction for radiographic enlargement, particularly when
data from different sources are compared.
Advances in molecular biology and its impact on knowl-
edge of cellular physiology will undoubtedly help under-
stand growth processes and therapeutic responses. The un-
derlying mechanisms of tooth movement and root resorp-
tion are rooted in biology, and understanding these mecha-
nisms, which can only emerge from sound basic biologic
research, will ultimately affect the choice of mechanotherapy.
This realization is enhanced by the increasing emphasis on
more medically oriented education. 59,6 Interestingly, a bur-
geoning trend is the integration of basic biologic research
and clinical research, clearly illustrated by the attempt to
gauge therapeutic progress through biologic means. This
premise is well documented in the analysis of crevicular flu-
ids to detect biologic factors, such as two potent bone re-
sorbing mediators, interleukin (IL) 1 ~ 6 1 , 6 2 and prostaglandin
E 62, to evaluate the progress of tooth movement in the indi-
vidual patient; or in the analysis of hormones, such as
the androgen hormone dehydroepiandrosterone sulfate
(DHEAS), 1 to assist in timing treatment or understand the
contribution of growth to specific treatment modalities, j
8 , E D U C A T I O N
Stated goals to educate scholarly clinicians are contra-
dicted by the decline of the full-time academician and other
consequences of economic pressure and institutional politics.
The specialty of orthodontics seemingly requires a differ-
ent approach to treatment, education, and research than the
rest of dentistry, 63 but the debate about orthodontic education
mirrors the general debate about dental education. At the end
of the twentieth century, both dental 6 and orthodontic 63 edu-
cation are estimated to be at Crossroads.
Because minimal requirements are defined by the Council
on Dental Education and enforced by accreditation reviews,
the basic argument is whether the definition of "minimal com-
petency" is, in practice, commensurate with education rather
than technical training. In this context, research has become a
"requirement" for graduation from almost all orthodontic pro-
grams in the United States. 63 If properly dispensed, this require-
ment would favor a trend toward scholarly education, because
it assumes and should provide an in-depth venture into an ar-
ray of scientific topics. The debate has inevitably encompassed
the definition of educational "models," specifically the "den-
tal" or "orthodontic" model versus the "medical" model. The
latter usually reflects learning through the interaction of resi-
dents with attending staff and other residents in a hospital set-
ting. In this environment, the scholarly acumen does not nec-
essarily prevail over the clinical competence; yet there is a ba-
sic assumption that biology is not disengaged from clinical ac-
tivity, even in the pure surgical model, which tends to be more
closely associated with the mechanically oriented dental model.
From a therapeutic point of view, the analogy is more appro-
priate between orthodontics and orthopedics. 63 Little attention,
however, is paid to tissue biomechanics.
In reality, the definition of education, in contrast with train-
ing, transcends the differentiation between models. The dif-
ference is in the quality and depth of study, which should
indeed involve treatment of a variety of malocclusions, but
not at the expense of comprehensive understanding and study
of the individual characteristics and needs of a patient, as well
as the underlying principles of biology and mechanics that
facilitate therapy. Many clinicians, including academicians,
view basic research as marginal, even irrelevant, to the edu-
cation of orthodontists, thus unwillingly but effectively di-
vorcing clinical action from biologic responseY This prob-
lem may be related to dentists in general, starting with train-
ing in dental schools.
The implication of comparing the educational models is
that the curriculum of specialty orthodontics must keep pace
with advances in biomedical science because specialty edu-
cation, rather than training, is the objective. Therefore the
emerging paradigm in education is the stated need to inte-
grate models for one goal: educate scholarly clinicians, profi-
cient in diagnosis and treatment, yet understanding and ap-
preciative of the scientific method of clinical investigation,
as well as the underlying biology of growth, tooth movement,
578 Guest editorial American Journal of Orthodontics and Dentofacial Orthopedics
May 1997
and related sciences. 63 To achieve this goal, a trend to longer
postdoctoral training in orthodontics has begun, with almost
a third requiring 3 years of study, given the skills and scope
of knowledge necessary for education and clinical compe-
tence, particularly when a Masters degree is sought in con-
junction with orthodontic certification.
The challenges that run counter to this goal are the in-
creasing difficulty to secure funding for research, high tu-
ition, and a decline in candidates for full-time academics,
or failure to retain them, in the face of an ever-increasing
demand for orthodontic education by high ranking dental
graduates. The major factors responsible for the loss or de-
cline in number of competent full-time academicians in-
clude debt from prior education; pressure to overproduce by
combining the requirements of (funded) research, peer re-
viewed publication, clinical and didactic teaching, and intra-
mural practice; politics, whose scope includes indictments of
entrenched self-protective leadership and expedient institu-
tional acceptance or protectionism. 63 These challenges help
to shift emphasis from education to training. Moreover,
when dental schools draw resources contributed by ortho-
dontic departments away from these divisions, they favor
the growth of competing institutions that offer reduced tu-
ition and/or stipends, including hospital training programs.
These institutions stand to attract the brightest crop of stu-
dents and, if a research environment is facilitated, most
productive teachers.
9. ORTHODONTI C SERVI CES/ OUTCOME MEASURE
Pressures to compromi se t reat ment results versus ideal
standards of care.
Three panels must be considered that relate to emerging
trends in orthodontic healthcare: the variable delivery sys-
tems, the doctor-patient relationship, and the implications of
outcome measures on individual treatment and public health
in general.
Orthodontic care. The state of orthodontic services was
best summed up in this statement at a conference that evalu-
ated contemporary trends in orthodontics~9: Cl i ni cal pract i ce
has become inundated in a worl d of [. . . ] managed care orga-
nizations, insurance reporting, peer review, mal pract i ce in-
surance, Occupat i onal Safety and Heal t h Ac t (OSHA) regu-
lations, guidelines f or Di sease Control (CDC), competition
f r om non-specialists in orthodontics, risk management and
changes in the pat i ent -doct or relationship. This listing may
seem overwhel mi ng and yet reflects the orbit of cont empo-
rary heaIthcare in general. Government regulators and in-
surance compani es all over the worl d determine more and
more and even dictate what, where and when, as wel l as how
medical and also dental and orthodontic t reat ment can and
should be provided.
Another trend in the delivery of orthodontic care is the
increasing number of group practices relative to solo prac-
tices. This trend is primarily the result of large financial debts
young graduates face that steer them into association with
established practitioners. Group practice includes several ben-
efits: interaction with more experienced clinicians, guidance
in patient handling, and business organization. Commercial
undertones, however, are tangible. Not only is cost-effective-
ness promoted, but the focus on increasing the volume of pa-
tients carries the pressure of compromising treatment results
and/or lengthening treatment duration.
Doct or-pat i ent relationship. One of the outgrowths of the
commercial model is the shift in the doctor-patient relation-
ship, from the paternalistic "guild" model, to the interactive
format of a partnership, 64 albeit that this relationship becomes
increasingly impersonal with a larger volume of patients. In-
formed consent and risk management to avoid malpractice
claims are already an integral part of healthcare in general
and enforce a sense of responsibility for optimal treatment
planning and patient care also in orthodontics. At least two
consequences of this shift are noted: Compromised results
are presented as alternative approaches in contrast to the ideal
option, and general dentists who provide orthodontic treat-
men t and are conscious of potential malpractice litigation, tend
to delegate such treatment to orthodontists associated with
their practice on a part-time basis.
Out come measures. Initial data from measures of treat-
ment outcome indicate that orthodontists expect more con-
sumer inconvenience and greater esthetic benefits than the
consumers themselvesY In fact, it may be argued that from
the point of view of patients, limited treatment yields ac-
ceptable results faster, while orthodontists would rate these
results as inadequate. If these observations are borne through
more definitive research, the question would arise whether
"compromised" treatment results, short of the "ideal" neu-
troclusion with appropriate inclinations of teeth, should rep-
resent an acceptable goal. In view of the decrease in third-
party payment for orthognathic surgery, the financial pres-
sures also direct toward acceptance of compromised treat-
ment by established orthodontists, notwithstanding the fact
that this option should be recognized as only less than ideal
during specialty education. In this instance, nonorthodontists
may venture again in rendering orthodontic treatment, re-
versing the apparent present trend of delegating the treat-
ment to specialists.
The previous panels point to a potential conflict in the
development of orthodontic care. The standard of care has
been improved in the last 30 years, owing to an explosion of
information through research, surgical advancement, and prod-
uct development. 63Yet the quality of care varies (and is not
carefully monitored), because of financial and commercial
pressures, compounded with outcome measures that may pro-
mote expediency at the expense of optimal occlusion, an in-
creasingly impersonal relationship between health provider
and patient, and possibly the failure of clinicians to constantly
update their method with current concepts and new materials.
The emerging trend in this contradictory environment is
the realization that the solution to the conflicting realities is
not a uniform program for cook book treatment, but universal
standards of care, ethics, and education that are beyond any
reproach, and that can only be elevated by the level of com-
mitment to these values in daily endeavors. 63 Countries and
geographic entities are institutionalizing such standards and
American J ournal of Orthodontics and Dentofacial Orthopedics Guest editorial 5 7 9
Volume 111, No. 5
organizing in corresponding Boards (European, Australian).
The idea of a global World Board of Orthodontics 66 is now a
realistic project already under intense debate. However, the
open question in this paradigm is the definition of an indi-
vidual standard, in that the concept of an individual norm for
each patient must be explored. Furthermore, ideal standards
can be applied to people with financial means, while compro-
mised when financial resources are not available. This devel-
opment, in turn, will affect the patterns of education, depend-
ing on whether and what percentage of patients seeking treat-
ment in orthodontic departments opt for compromised therapy.
Compromised results, i f not regarded as only a secondary
option, may become institutionalized and accepted. The dan-
ger lies in adopting such results at the expense of recognized
optimal standards of care that are fitted to the functional and
esthetic needs of the individual patient, particularly by ortho-
dontists who ignore these standards or compromise them af-
ter Board certification.
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AAO
1998
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MEET I NG C A L E N D A R
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