I find it disingenuous that the February JADA article, "Evidence-Based Orthodontics for the 21st Century," by Dr. Marc Ackerman, was given cover-story status. Data from the first randomized clinical trial in orthodontics and selected literature review are popping up in the media and dental journals. The apparent intent is to gather support for maintaining conventional delivery systems of orthodontic care.
The poster child for this onslaught has become one-phase versus two-phase treatment, or simply early versus late treatment of Class II malocclusions, as evidenced by the University of North Carolina randomized trial funded by the National Institutes of Health.1
The researchers who conducted the trial found no difference in the quality of the dental occlusion between the children who had early treatment and those who did not, as judged by both an occlusal index (peer assessment rating scores) and the percentage of the subjects with excellent and less-than-optimal outcomes.
It is suspicious that a preliminary report of this trial, "When It Comes To Kids Getting Braces, Earlier Is Not Always Better," found its way into the Sept. 29, 2000, Wall Street Journal,2 with the aftershock of confusing parents looking for orthodontic care for their children. Also, when was the last time a feature opinion article on orthodontics was found on the cover of JADA? Is this another ploy by a protective guild to influence the gatekeepers of orthodontic care?
The nature of this controversy can never be resolved philosophically because of the variability between patients, and the uncertainty about growth and treatment response. It remains a personal preference. A fairer approach to this issue would be to put unbiased, fully documented, unconventional early treatment as presently practiced versus conventional late treatment on the same playing field, and allow the practitioner/consumer to judge without bias.
What about skeletal relationship correction? A large percentage of late treatment Class II outcomes, as evidenced in the literature and private practice, show dentoalveolar Class I correction, but a remaining Class II skeletal relationship with a retrognathic mandible or retrognathic maxilla and mandible.
Let me offer a common pediatric case in point that challenges Dr. Ackerman’s treatise. A 3-year-old child initially presents with a posterior crossbite, a multifactorial malocclusion. Correction is recommended, but the parent refuses. The parental decision may have been influenced by the media reports, or by a consulting dentist who uses the so-called evidence referenced by Dr. Ackerman.
On recall, this same child may present with a Class II Division 1 type malocclusion. The occlusion accommodated for the constricted upper arch by posturing the mandible into a retrognathic position, so that the lower teeth occlude with the wider part of the constricted upper arch without the cross-bite. The child transitions through growth and development with a deficient arch perimeter, causing continual crowding, and progressing into a full Class II molar relationship.
The orthodontic gold standard for treating this Class II patient in late mixed dentition or early permanent dentition, as reported by Dr. Ackerman, is distalization-retraction mechanics of the upper arch to a Class I dental relationship. This conventional protocol frequently results in dentoalveolar correction with a locked mandible.
Wouldn’t common sense dictate that at a younger age the maxillary arch form should be developed, so that the mandible has the opportunity to come forward in a normal growth pattern? Does not distalization mechanics at adolescence put the patient at risk of developing retrognathic facial and jaw position, with greater potential for relapse because the mandible, in its natural attempt to posture forward posttreatment, becomes restricted by the coupling of the upper and lower incisors? This orthodontically produced therapeutic matrix causes a lingualization and breaking of contact points of lower anterior teeth with resultant relapse. Could not all of these issues be prevented with proper early treatment objectives: proper overbite, overjet, molar relationship, jaw relationship, serial guidance and lip seal?
To a certain degree, of course, this is a moot question, since most orthodontists rarely get the opportunity to see the child in the primary dentition phase, when the true etiology of the Class II problem evidences.
A major ethical issue related to this controversy is that a good number of practitioners place only acrylic appliances or headgear (Phase I) in the patient as the engagement ring, at considerable cost, until it’s comfortable to consummate the marriage at a later date (Phase II comprehensive orthodontic treatment).
All forms of orthodontic care would benefit from scientific research that determines what works, and what doesn’t. However, early treatment strategies—not necessarily the ones reported in the University of North Carolina trial—are expected to meet a higher standard of validation than conventional orthodontic care simply because the conventional is more customary, even when the conventional may contain more risk.
The challenge facing orthodontics in the 21st century is the need to integrate early treatment education and strategies into the undergraduate programs, so that 90 percent of common-type malocclusions can be treated by the general and pediatric dentists, and the 10 percent of complex orthodontic cases can be identified for treatment by the true specialist.
This is the only way that 70 percent of the total population with orthodontic needs can be serviced effectively and efficiently. This resistance—obstruction to change—prevents a needed health service to the pediatric population.
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