Eleven-year-old female, just entering peak of her circumpubertal growth spurt, can be seen with her initial smile (left). The patient post-treatment (right). Increased upper lip support and smile visibility.

Eleven-year-old female, just entering peak of her circumpubertal growth spurt, can be seen with her initial smile (left). The patient post-treatment (right). Increased upper lip support and smile visibility.

Approximately 20 years ago, in an article for The Angle Orthodontist, I wrote, “Orthodontics stands at its crossroads. We either accept change and new technology, or we cease to exist as a profession.”

Now after 39 years in practice, I find myself reflecting on the many important protocols I was taught and how my own practice has evolved. Every change in protocol was met with my own skepticism as to its potential success. Through evaluation, consultations with colleagues, and relevant CE courses, I was better able to understand how such a change would affect my practice, especially in a profession that is constantly evolving and comes with multiple complexities.

Today, I suggest one protocol change that I believe can assist us in moving forward as a profession: Continuous diagnosis and flexibility throughout treatment.

Why change how we have all performed for so many years?

We were instructed to perform a thorough initial clinical exam, take appropriate radiographs, models, and photographs, and come to a conclusion about a patient’s orthodontic treatment. Next, we were required to present the treatment, including the time required, and fees to the family. I am not suggesting we change these steps.

Next we schedule the patient for an appointment to complete the diagnostic records. In the interim, we trace the lateral cephalometric image, as well as analyze the models and photographs. If the patient is nearing or in their circumpubertal growth spurt, we would take and analyze a wrist radiograph, or analyze the vertebral development, to determine when the patient’s growth spurt is occurring. Again, I am not suggesting we change these steps.

We record the entire diagnosis, the components and the sequence of treatment required, and the total fees in our computers. Then, we bring patients and parents in for a consultation to present our findings and recommended treatment. No change is suggested here.

But where I am suggesting a change…

A major reason for proposing continual flexibility in orthodontic treatment plans is the changing amount of growth and development in a significant number of our patients. Depending on the DNA of both parents, each patient will grow into a unique individual. We all know this intellectually. However, no matter how long you have been an orthodontist, we commit ourselves to an initial, fixed treatment plan, based solely on our initial diagnosis.

Why have we committed ourselves to a fixed treatment plan when we know each child will grow in a unique manner? Because this is the way we were taught, and many of us have always followed this protocol.

I realize suggesting change of a well-established protocol/technique will be met with criticism and rebuttal. But why not update our approach?

What if, at the initial diagnostic consultation, we say, “This diagnosis was made from a very careful analysis of all the information I have gathered. And, yes, I am suggesting a treatment plan, following the standard of care. However, I do want you to understand that each child I treat is a unique individual with unique DNA, inherited from each parent’s family facial characteristics. Therefore, I am suggesting that either you can restrict me to my initial diagnosis and treatment plan, or you can consent to give me the freedom to RE-DIAGNOSE/EVALUATE YOUR CHILD throughout treatment.”

I am proposing we consider reanalyzing a patient’s facial growth and development during treatment, utilizing the initial diagnosis and treatment plan as a guideline. Once per year, I reevaluate a patient’s amount and directions of growth, asymmetries, and unique changes by updating the lateral cephalometric and panoramic radiographs. This allows me to see where treatment is proceeding as I expected, or where the facial growth pattern has changed or evolved. This new information permits me to (only where required) make mid-course changes. My goal is to adapt and refine my treatment to the patient’s specific facial growth and development.

Naturally, I inform the parents and patients that should any significant treatment changes occur, I will call them all in for a consultation. At that time, I repeat the initial consultation findings and treatment plans, and inform them of why any treatment changes are required. I add, “In this manner, I can continue to offer your child the best treatment results.”

Not sure about making this change? Consider the medical field. In medicine, continual diagnostic flexibility has proven effective. Physicians realize that nearly all treatment may require modifications, additional procedures, adjustments, or refinements as the patient heals and ages.

Think about your last visit to a physician; he or she may have prescribed a medication for a condition you have, like high blood pressure. What would happen if the physician did not check or reevaluate how the medicine was affecting you, or whether your blood pressure was getting better? Wouldn’t you be concerned, especially if you were experiencing side effects? Shouldn’t these same principles apply to orthodontics?

If we suddenly notice a distinct asymmetry in the maxillary and mandibular arches halfway through treatment, and the treatment plan does not include flexibility, how do you justify your planned changes?

 

The maxillary arch before treatment (left) and during the retention phase (right). Rapid palatal bite plane expansion was used during treatment, followed by bonded/banded brackets.

The maxillary arch before treatment (left) and during the retention phase (right). Rapid palatal bite plane expansion was used during treatment, followed by bonded/banded brackets.

To illustrate my point, here is a case study where I presented a treatment plan with flexibility.

Initial Diagnosis: Eleven-year-old female, just entering peak of her circumpubertal growth spurt. Cephalometric: Skeletal Class I, hypodivergent, could strongly grow Class III. Marked facial (maxillary/mandibular) asymmetry, mid-face deficiency, deficient functional tongue room, and maxillary/mandibular width deficiency.

Dental Class I, multiple cross-bites, and crowding. Pre-existing TMJ symptoms. Impacted/transposed maxillary cuspids. Multiple fragile, limited gingival areas.

Mandibular arch pre-treatment (left) and during retention phase (right). A fixated RPEBP was used as “disposable” anchorage (with elastics attached to lingual mandibular buttons) to upright the mandibular buccal segments.

Mandibular arch pre-treatment (left) and during retention phase (right). A fixated RPEBP was used as “disposable” anchorage (with elastics attached to lingual mandibular buttons) to upright the mandibular buccal segments.

Treatment Goals: Increase maxillary and mandibular width, and functional tongue room with expansion. Maxillary protraction, simultaneous with maxillary expansion. Attempt to minimize skeletal, dental, and facial asymmetry. Improve facial aesthetics (full smile) and strive for facial (nose to chin convexity). TMJ improvement; occlusal functional vertical contacts.

Anterior view before treatment (top). Note crossbites and deficient functional tongue room. Anterior view after treatment with no extractions (bottom).

Anterior view before treatment (top). Note crossbites and deficient functional tongue room. Anterior view after treatment with no extractions (bottom).

Initial Treatment Plan: Due to presenting with multiple complex skeletal (jaws) and teeth malformations and asymmetries, strongly suggest flexibility in treatment plan, including trial non-extraction approach. (Completed in 2.5 years.)

Alpern_Flexibility_5Alpern_Flexibility_6

Initial panoramic image (top). Note both condyles have apparent bone-to-bone contact, especially left. Also, maxillary cuspids impacted and transposed. Justified trial non-extraction treatment, while maintaining flexibility due to severe crowding. Continued non-extraction plan (center). Image taken during retention phase (bottom). Note both maxillary cuspids are aligned. Mandibular left cuspid needs mesial root tip.

Initial panoramic image (top). Note both condyles have apparent bone-to-bone contact, especially left. Also, maxillary cuspids impacted and transposed. Justified trial non-extraction treatment, while maintaining flexibility due to severe crowding. Continued non-extraction plan (center). Image taken during retention phase (bottom). Note both maxillary cuspids are aligned. Mandibular left cuspid needs mesial root tip.

Treatment: Began with bonded rapid palatal expansion bite plane (RPEBP) appliance with thin bite planes, Class III protraction hooks (with simultaneous helmet protraction during activation of expansion screw) for a total 8 weeks (16 hours/day), plus 2 to 4 weeks after expansion screw deactivation. Then, an additional 8 weeks, worn during sleeping. RPEBP also includes buccal cross-bite hooks in molar area. Additionally, mandibular full bonded self-ligating buccal brackets and lingual buttons on mandibular first molars. After expansion, began crossbite elastics from bonded buttons on lingual of mandibular first molars to cross-bite hooks on expander, and maintain RPEBP and elastics (as needed) for 4 more months. Thus, the fixated RPEBP becomes disposable anchorage.

Treatment, Continued: Remove RPEBP, immediately band maxillary first molars, full direct bond all maxillary teeth, and place Cetlin palatal bar. Open spaces for maxillary cuspids. Maxillary left cuspid required surgical exposure and traction to place.

Constant Reevaluation Procedures: Constant periodontal monitoring of all teeth. May need periodontal grafting. It was at this midpoint in treatment, I decided that no extractions were required. Also, decided, sequential square and then rectangular archwires to finish. Third molars were to be removed later.

Retention: Maxillary removable retainer (full time, 1 year; then nights), and mandibular bonded lingual braided steel wire. OP

Michael_Alpern_2Michael C. Alpern, DDS, MS, completed his dental training at Ohio State University before going on to serve in the United States Air Force. He later returned to Ohio State University where he earned his orthodontic certificate and a Master of Science in Orthodontics. Alpern is a Diplomate of the American Board of Orthodontics and a member of the Edward H. Angle Society. In addition to authoring and coauthoring a number of journal articles, he is the author of the textbook, The OrthoEvolution: The Science and Principles Behind Fixed/Functional/Splint Orthodontics. He recently retired from private practice, but continues research, development, and teaching.