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ABSTRACT
A A Background. This article J examines some of the data- driven advances in clinical A D A J orthodontics and how they might influence the N C U U IN D G E A decision-making process 1 RT ICLE in the specialty. N C Types of Studies Reviewed. G E D U A U I N Nearly 1 RT 100 years of orthodontic study has focused ICLE on two issues: one-phase versus two-phase treatment of Class II malocclusion and extraction versus nonextraction treatment of arch perimeter deficiencies. The author addresses these issues by presenting data from the first randomized clinical trial in orthodontics and from a survey of the current literature. Results. The clinical trial involved subjects who had Class II malocclusion. 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 percentages of the subjects with excellent and lessthan-optimal outcomes. Early treatment did not reduce the eventual need for orthognathic surgery. In a separate study, a researcher reported that the maxillary arch perimeter could be increased by 3 to 4 millimeters by using rapid palatal expansion, or RPE, providing space for incisor alignment to resolve crowding. The author concluded that any added benefit of RPE treatment in patients without a crossbite might be challenging to define. Clinical Implications. The challenge facing orthodontists in the 21st century is the need to integrate the accrued scientific evidence into clinical orthodontic practice.
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Evidence-based orthodontics for the 21st century


MARC ACKERMAN, D.M.D.

s dentistry in the 21st century struggles with the philosophical issue of evidence-based practice, the specialty of orthodontics, too, stands at a crossroads. Historically, orthodontics has uncomfortably straddled the fence separating oral health care and elective cosmetology. While societal and cultural mores increasingly have shifted toward facial and anterior tooth esthetics, dentists have continued to view the primary goal of orthodontics as correcting tooth alignment and occlusion. This article examines some of the data-driven advances in clinical orthodontics and The challenge how they might influence the decisionfacing making process in that specialty. orthodontists DEFINING AND REDEFINING in the 21st ORTHODONTICS century is the The American Association of Orthodonneed to tists defines orthodontics, or dentofacial integrate the orthopedics, as the area of dentistry accrued concerned with the supervision, guidance and correction of the growing and scientific mature dentofacial structures. This defevidence into inition includes conditions that require clinical movement of teeth or correction of malorthodontic relationships and malformations of practice. related structures by adjusting relationships between and among teeth and facial bones by applying forces or by stimulating and redirecting the functional forces within the craniofacial complex. Major responsibilities of orthodontic practice include the diagnosis, prevention, interception and treatment of all forms of malocclusion of the teeth and associated alterations in their surrounding structures; the design, application and control of functional and corrective appliances; and the guidance of the dentition and its supporting structures to attain

and maintain optimum relations in physiologic and esthetic harmony among facial and cranial structures.1 Although this definition addresses the occlusal, functional and esthetic components of malocclusion, there is no mention of the psychosocial aspect of malocclusion and the role of orthodontics in its treatment. Studies have

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demonstrated that well-aligned teeth and a pleasing smile afford positive social status, whereas irregular or protruding teeth are attached to negative status.2,3 A handicapping malocclusion not only implies a severe structural or functional deviation from the optimal state, but also underscores the psychosocial impact of the perceived dentofacial disharmony. According to data from the Third National Health and Nutrition Examination Survey, or NHANES III,4 which was conducted between 1989 and 1994, malocclusions falling into categories outside the limit of orthodontic correction alone (severe Skeletal Class II and III) occurred in about 4 percent of the population. By contrast, malocclusions related to severe or extreme incisor irregularity in adolescents and adults existed in about 15 percent of the surveyed population. Hence, it is exceedingly difficult to describe the prevalence of handicapping malocclusion owing to the many occlusal, skeletal, esthetic and psychosocial components involved. Another confounding variable is the disparity that exists between the lay publics view and the orthodontic specialtys view of what constitutes a malocclusion in need of treatment.
MYTHOLOGY REGARDING NEED FOR TREATMENT

chance of later periodontal manifestations. Some dentists have suggested that even minor deviations from a canine-protected occlusion will trigger parafunctional habits such as bruxism and clenching. If this indeed were the case, most peoples occlusion would need treatment to prevent symptomatology in the masticatory muscles. Data suggest that because a large portion of the population has moderate malocclusions (roughly 50-75 percent) and this number far exceeds the number of people in the population who have temporomandibular dysfunction (5-30 percent, depending on the symptoms examined), it seems unlikely that occlusal patterns alone are the cause of hyperactivity of the masticatory muscles associated with temporomandibular joint dysfunction.8
MYTHOLOGY REGARDING TREATMENT OUTCOME

It would appear logical that malocclusion would have a causal relationship with both dental decay and periodontal disease. Theoretically, satisfactory oral hygiene for a maloccluded dentition would be more difficult to achieve than it would with a dentition that boasts an ideal occlusion. Recent data suggest that a persons willingness and motivation to maintain oral hygiene have a greater impact on the occurrence of dental disease than does tooth alignment.5 Two studies conducted in the late 1970s that examined a large number of orthodontically treated patients 10 to 20 years after treatment provide some insight on long-term relationships between malocclusion and oral health.6,7 In both studies, patients who underwent orthodontic treatment demonstrated a similar periodontal status to that of untreated subjects in the same age group, despite the better functional occlusions of the orthodontically treated group. There was no evidence of a beneficial effect of orthodontic treatment on future periodontal health. Conversely, these long-term studies gave no indication that orthodontic treatment increased the

Nearly 100 years of orthodontic study has focused on the issues of one-phase versus two-phase treatment of Class II malocclusion and extraction versus nonextraction treatment. With greater emphasis on data-driven dental treatment, there is good evidence in the orthodontic literature to put to rest these age-old debates. It would appear that some of the most strongly held orthodontic treatment strategies are severely flawed when viewed in light of efficiency and efficacy. Proffit9 stated:
All treatment needs to be evaluated from two perspectives. The first is its effectiveness, defined as how well it works, i.e., how successful it is in overcoming the patients problems. Since nothing works perfectly all the time and unlikely things occasionally succeed, effectiveness must be considered in terms of the average amount of improvement, or probably better in clinical studies, the proportions of patients with excellent, good, fair, and poor outcomes. Effective treatment produces large average improvement, and a high percentage of the patients have an excellent outcome. The second is efficiency, defined as how much benefit the patient receives relative to the costs and risks of treatment. In this sense, cost is broader than just money. There are also a host of factorstime in treatment, number of patient visits, discomfort or morbidity, emergency appointments to deal with problemsthat impact both the patient and the doctor. Efficient treatment produces large benefits with minimal cost (in both senses of the word) and minimal risk.

In the 1990s, the first randomized clinical trial in orthodontics studied preadolescents with Class
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II malocclusion versus Class II treatment in adoessary to gain the needed arch perimeter to lescents.10 The central question was whether avoid extractions? If yes, then is maxillary arch early orthodontic treatment of a patient with a perimeter the primary determinant in the Class II malocclusion was sufficiently more effecdecision-making process about whether to tive than later treatment to justify the longer extract? He stated that the maxillary arch time in treatment and the greater economic cost. perimeter can be increased by 3 to 4 millimeters, In the clinical trial, which was conducted at the providing space for incisor alignment. Since this University of North Carolina at Chapel Hill, has a negligible effect on the perimeter of the researchers carried out Phase 2 treatment (commandibular arch, some type of space-gaining prehensive orthodontic treatment) for untreated procedure must be initiated to prevent Brodie control subjects and for subjects who had comsyndrome (maxillary transverse excess and pleted Phase 1 treatment.10 The result was no difconcomitant buccal crossbite) and to resolve ference in the quality of dental occlusion between mandibular arch perimeter deficiency when the children who underwent early treatment and needed. It should be pointed out, though, that those who did not, as judged by both the Peer data indicate that the transverse expansion of Assessment Rating index11 and the percentages of the mandibular arch in selected areas is the groups with excellent and unstable.13 less-than-optimal outcomes. Brennan and Gianelly14 recomIn the past two Another finding in the clinical mended an alternative approach to decades, the trial was that early treatment did resolving crowding by simply mainnot reduce the number of children orthodontic pendulum taining arch length during the tranwho needed premolar extraction in sitional period of dentitional develhas swung toward Phase 2 treatment. The extraction opment. When they preserved the treatment strategies percentages during Phase 2 treatE space (the discrepancy between aimed at avoiding the ment were almost identical the widths of the primary second extraction of between the groups, regardless of molar and the permanent second permanent teeth in whether they had had Phase 1 premolar) in a sample of patients treatment. Early treatment did not with an average of 4 to 5 mm the case of arch reduce the eventual need for incisor crowding, they found that perimeter orthognathic surgery. The Phase 1 68 percent of the patients had adedeficiencies. treatment generally reduced the quate space for alignment, and length of Phase 2 treatment by another 19 percent had adequate roughly 25 percent, although there was great space with only marginal arch length increase (up variability. The two phases of treatment took to 1 mm per side).14 In such patients, Brennan 9 longer than one phase in almost all cases. Proffit and Gianelly found that the maxillary arch could concluded that preadolescent treatment for most be properly positioned over the mandibular arch children with Class II malocclusion is no more without the use of RPE. Gianelly12 concluded that effective than later treatment, and it is less effiany added benefit of RPE treatment in patients cient. without a crossbite might be challenging to Rapid palatal expansion. In the past two define. Overall, the decision between extraction decades, the orthodontic pendulum has swung and nonextraction for any given patient is multitoward treatment strategies aimed at avoiding factorial. The clinician should view arch the extraction of permanent teeth in the case of perimeter deficiency from the standpoint of a arch perimeter deficiencies. One of the most vispatients well-being in functional, esthetic and ible mechanotherapies has been the use of rapid psychosocial areas. palatal expansion, or RPE, in the absence of posCOMMUNICATION: PARAMOUNT IN terior crossbites, to gain arch perimeter and avoid ORTHODONTIC CARE extractions. This treatment, which often is initiated in the mixed dentition, raises some questions A shift that has occurred in the last 15 years of related to efficiency and efficacy. dental practice is the evolution of patient Gianelly,12 in a recent article, raised and autonomy and informed consent and the departure answered two important questions. First, with from paternalism in the decision-making process. the absence of a posterior crossbite, is RPE necA conflict for todays orthodontist is, on the one
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hand, to adhere to the obligation set forth in the American Dental Association Principles of Ethics and Code of Professional Conduct15 to perform the highest quality service within his or her power to perform, yet, on the other hand, to observe the patients right to decide on which treatment alternative is best suited to his or her needs. The alternative of no treatment always is an option as long as the risks are explained to the patient. To satisfy the doctrine of informed consent, Chiccone16 recommended discussing the following points with the patient: da diagnosis, presented in language the patient can understand; da comprehensive treatment plan, explaining what procedures are recommended and how they will be Figure 1. The decision-making process in clinical orthodontics. Interacperformed; tive discussion between the patient and orthodontist will help elucidan overview of reasonable alternative date the patients esthetic, functional and psychosocial needs. Ultimately, the orthodontist will describe the risks of treatment and the treatments that are available regardpatient will be able to make an informed decision regarding less of who is the clinician who pertreatment. forms them; dthe probable sequelae of electing not to have treatmentas a mode of promoting a patients treatment; well-being and enhancing quality of lifeis a dthe potential risks, consequences and likelimatter of individual judgment. The orthodontist / hood of secondary treatment (typically, it is the dentist must share this judgment with the complication not discussed with the patient that patient by providing adequate information triggers a liability claim); regarding the risks involved in treatment. Thus, dthe predicted outcome of treatment including when a patient or a parent asks the dentist how the patient will benefit and the probability of whether he or she or his or her child needs success. Realistic goal setting should always braces, the dentist must in turn frame the quessupersede optimism. tion in a wider context. Essentially, the question He added that three caveats must be heeded in becomes one of whether some form of orthodontic implementing the doctrine of informed consent: treatment will improve the patients overall welldthe greater the potential injuryeven if the being and quality of life in the functional, esthetic risk is minimalthe greater the obligation to or psychosocial area (Figure 1). inform the patient (such as the risk of death It has been argued that the orthodontic speresulting from anesthesia); cialty evolved from a guild model in the early dthe greater the chance of complications occur20th century to a commercial model in the second ringeven if the injury would be minimalthe half of the century.17 In the 21st century, greater the obligation to inform the patient (such orthodontics needs to move to an interactive as the risk of root resorption); model, fulfilling the patients esthetic, functional and psychosocial needs by providing treatment dthe more elective the proposed treatment, the that is clinically effective and efficient and that more invasive the bodily intrusion will be considpreserves the patients autonomy by virtue of the ered in the event of an injurythus, again, the doctrine of informed consent. If dentistry in gengreater the obligation to inform the patient (for eral and orthodontics in particular do not initiate example, orthognathic surgery performed for this change, then it most likely will come from the esthetic reasons). legal profession. In the absence of objective criteria, orthodontic
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Figure 2. The scope of contemporary orthodontics.

THE SCOPE OF CONTEMPORARY ORTHODONTICS

Contemporary orthodontic practice can be summarized as interactive problem-oriented diagnosis and treatment planning between clinician and patient, with the goal of defining mutually desirable treatment objectives coupled with the selection of the most appropriate mechanotherapy to achieve these ultimate goals (Figure 2). The first key to a successful outcome in orthodontic therapy is to follow a systematized method of clinical examination and data collection, which should aid in eliciting the patients chief concerns and dentofacial presentation in the four dimensions of the sagittal aspect, the vertical aspect, the transverse aspect and time. Computer imaging has become a tremendously useful communication tool for both the patient and orthodontist in describing dentofacial discrepancies. Once a diagnostic problem list has been determined, the clinician and the patient should rank each problem in terms of its therapeutic modifiability and its importance to the patients esthetic,
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functional and psychosocial needs. The term therapeutic modifiability18 refers to the clinicians ability to predict the achievable Dr. Ackerman is in the optimum for a given private practice of patient when orthodontics at 931 Haverford Road, Bryn attempting to satisfy Mawr, Pa. 19010, treatment objectives e-mail Ackersmile@ aol.com. Address with a given treatment reprint requests to modality. The greater Dr. Ackerman. the effort needed to produce a small improvement in a malocclusion, the lesser the therapeutic modifiability, and vice versa. The clinician and patient must weigh each problem against its therapeutic modifiability so that the clinician can synthesize and initiate a final treatment plan. At the completion of orthodontic treatment, the clinician removes the orthodontic appliances and the retention phase begins. Traditionally, the orthodontist has served in a supervisory role during this phase; today, however, the orthodontist should take more of an advisory role. If the orthodontist clearly explained the potential risks of relapse before the initiation of treatment, then the onus of following the prescribed retention at the completion of treatment should come as no surprise to the patient. The orthodontist should reiterate the potential manifestations of orthodontic relapse and provide anticipatory guidance in how to prevent them. Lastly, adolescent patients should be advised as to the status of their third molars at the completion of treatment, and the appropriate recommendations should be made in concert with their general dentist.
CONCLUSION: THE FUTURE

It is conceivable in 2004 that if a patient seeks orthodontic opinions from 10 orthodontists, he or she may receive 10 different treatment plans. It also is conceivable that all 10 treatment plans could achieve satisfactory results. However, when viewed in light of the principles of effectiveness and efficiency, there might be only one or two treatment alternatives that best satisfy the patients esthetic, functional and psychosocial needs. The challenge facing orthodontists in

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the 21st century is the need to integrate the accrued scientific evidence into clinical orthodontic practice. Until this occurs, orthodontists will not be able to present a forthright and accurate cost / benefit analysis to the patient and, therefore, not obtain truly informed consent. s
1. American Association of Orthodontists. Glossary of dentofacial orthopedic terms. St. Louis: American Association of Orthodontists; 1996. 2. Shaw WC. The influence of childrens dentofacial appearance on their social attractiveness as judged by peers and lay adults. Am J Orthod 1981;79:399-415. 3. Shaw WC, Rees G, Dawe M, Charles CR. The influence of dentofacial appearance on the social attractiveness of young adults. Am J Orthod 1985;87:21-6. 4. Proffit WR, Fields HW, Moray LJ. Prevalence of malocclusion and orthodontic treatment need in the United States: estimates from the NHANES III survey. Int J Adult Orthodon Orthognath Surg 1998;13:97-106. 5. Helm S, Petersen PE. Causal relation between malocclusion and caries. Acta Odontol Scand 1989;47:217-21. 6. Sadowsky C, BeGole EA. Long-term effects of orthodontic treatment on periodontal health. Am J Orthod 1981;80:156-72. 7. Polson AM, Subtelny JD, Meitner SW, et al. Long-term periodontal status after orthodontic treatment. Am J Orthod Dentofac Orthop 1988;93(1):51-8. 8. Greene CS. Etiology of temporomandibular disorders. Semin Orthod 1995;1:222-8.

9. Proffit WR. Treatment timing: effectiveness and efficiency. In: 28th Annual Moyers Symposium, Vol. 39 (monograph). Ann Arbor, Mich.: The University of Michigan Department of Orthodontics; 2002:13-24. 10. Tulloch JF, Phillips C, Proffit WR. Benefit of early Class II treatment: progress report of a two-phase randomized clinical trial. Am J Orthod Dentofacial Orthop 1998;113:62-72. 11. Richmond S, Shaw WC, Roberts CT, Andrews M. The PAR Index (Peer Assessment Rating): methods to determine outcome of orthodontic treatment in terms of improvement and standards. Eur J Orthod 1992;14(3):180-7. 12. Gianelly AA. Rapid palatal expansion in the absence of crossbites: added value? Am J Orthod Dentofacial Orthop 2003;124:362-5. 13. Burke SP, Silveira AM, Goldsmith LJ, Yancey JM, Van Stewart A, Scarfe WC. A meta-analysis of mandibular intercanine width in treatment and postretention. Angle Orthod 1998;68:53-60. 14. Brennan M, Gianelly AA. The use of the lingual arch in the mixed dentition to resolve incisor crowding. Am J Orthod Dentofacial Orthop 2000;117:81-5. 15. American Dental Association. ADA principles of ethics and code of professional conduct. Chicago: American Dental Association; 2003. Available at: www.ada.org/prof/prac/law/code/index.asp. Accessed Nov. 26, 2003. 16. Chiccone MU. Informed consent: in perspective. The Dental Rx (publication of the Mid-Atlantic Medical Insurance Company) 1990;3(2). 17. Ackerman JL. Ethics and risk management in orthodontics. In: Ghafari JG, Moorrees CF, eds. Orthodontics at crossroads: Trends in contemporary orthodontics. Boston: Harvard Society for the Advancement of Orthodontics; 1993:49-60. 18. Moorrees CF, Gron AM. Principles of orthodontic diagnosis. Angle Orthod 1966;36:258-62.

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