The real paradigm shift in orthodontics

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Orthodontic specialty got in a great crisis. The specialty loses patients every day, tries to compete with general dentist and uncontrolled commercial influence. We tend to blame GPs, the economic environment, but if we really want to help the specialty survive we must analyze what we as a specialty made wrong in recent years. The lecture tries to help in this analysis

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  • Dear Darin,
    Thanks a lot
    In fact the mainstream orthodontics has been sticked to orofacial structures. We move teeth, jaws to planes, angles of a 2D ceph and facial aesthetic parameters, instead of taking all the interdependence into account what has been already proven outside this specialty. AAGO, IFUNA and all the associations which collects those who have opened their eyes should form an alliance. We need a stronger voice of the functional paradigm
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  • ...oh yeah, AMAZING logo with the H.....love it.
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  • Awesome PPT. There IS a huge paradigm shift that NEEDS to happen. What about prevention? NOT early treatment, but prevention or maximization of the genetic potential for individuals? Its out there in the research and paradigms OUTSIDE of orthodontics.....and that is from where the impetus for change will come......I appreciate your PPT and you have inspired me to post mine.....stay tuned and THANK YOU again Dr. H. -Darin J. Ward, Orthodontist and Chief dishwasher at Okotoks Orthodontics. :)))
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The real paradigm shift in orthodontics

  1. 1. Paradigm shift in Orthodontics Gabor Hermann DMD, Orthodontist, Hungary drhermann.g@gmail.com
  2. 2. We have been giving beautiful smiles to our patients for many years
  3. 3. Our offices provide a workplace for many people at chairside and in administration
  4. 4. Our offices are being served by orthodontic laboratories…
  5. 5. …and by orthodontic companies
  6. 6. We are members of orthodontic study clubs…
  7. 7. …and associations nationally and internationally
  8. 8. We have orthodontic schools with a great reputation
  9. 9. We study constantly on courses and at conferences
  10. 10. We undertake researches and we publish the results in the peer review literature
  11. 11. In conjunction with our employees, labs, supporting companies, associations and schools we form the orthodontic industry…
  12. 12. …the oldest specialty of dentistry
  13. 13. Based on this, one might think that this specialty is very well organized, scientifically grounded and operates smoothly…
  14. 14. …And, also one might think that the only paradigm shift that I should talk about is that our specialty is entering the digital age
  15. 15. However, if we scratch the surface, there are really big changes happening
  16. 16. And, this is the real paradigm shift  Straight talk about straight teeth
  17. 17. These big changes started in the early 2000’s
  18. 18. Actually there were lots interesting changes in the specialty, that time, however here is something very important  David Sarver:  The new soft tissue based treatment planning paradigm  The importance of the soft tissues and the aesthetic parameters over the hard tissue parameters
  19. 19. This makes sense:  Contrasting the cephalometric analysis this paradigm suggested non extraction treatment many times (and mandibular advancement) which was more aesthetic for the patients  This language was a common language that was easily understood by the patient
  20. 20. However, if we focus on this change from another perspective it is going to be even more interesting
  21. 21. What else happened this time?  Publications on the role of occlusion in the development and treatment of TMD  Evidences on the role of the occlusion in the development of the periodontal problems  Challenges to find evidence from the functional perspective
  22. 22. How can we convince a patient to undergo an orthodontic treatment?  Occlusion/bite, vs. aesthetics?  Occlusional argument was weakly supported by the literature  On the contrary there already have been many publications on what a positive impact of straight teeth can make on the self-esteem  Aesthetics became a life preserver to the specialty
  23. 23. So our specialty adopted a new course  Taking the difficulty of proving the functional aspect of the orthodontic treatment into account we started to focus on promoting the aesthetic aspect of the treatment  This can be called:  The aesthetic paradigm
  24. 24. By now we have explored almost everything about how to achieve a nice smile and how big impact it makes on the self-esteem -  Growing number of researches on smile and self esteem  Growing number of publications on how to achieve a nice smile
  25. 25. It makes sense  If we know everything about what our patients want we can serve them on a higher level  From the business perspective we can gain more patients
  26. 26. So we entered the beauty industry  A relatively big slice from a small cake is smaller than a small slice from a very big cake
  27. 27. That time it seemed to be a very good way to position orthodontics  But in a relatively short period of time we have seen 3 major problems  In fact, by today it became clear that the aesthetic paradigm was not a good way of positioning our specialty  We pretend that everything is really all right, but the symptoms have been obvious
  28. 28. Problems of the aesthetic paradigm No.1: losing the market  2008 the bankruptcy of Lehman Brothers and the beginning of the Global Economic Crisis showed how vulnerable this concept was  People will postpone or cancel the orthodontic treatment in such a difficult time  Aesthetics can wait  In the beauty industry there is a huge amount of competition. It is really hard to compete with big companies and market players
  29. 29. The market is shrinking“We have to prepare for smaller offices”  The number of new case starts decreased significantly  Marketing coaches tries to address this situation
  30. 30. By the way! What do orthodontic companies do in such a situation?  They went to Asia  They started to sell braces to general dentists  Have you ever seen such a great number of orthodontic courses that are offered to GPs today?
  31. 31. This issue leads us to the second problem  Orthodontics is equal to giving smile to our patients (this is the core message)  Meaning, occlusion is not a primary goal - tooth alignment and creating nice smile are the primary objectives  Orthodontics is simple (look at the company flyers)  Anybody can do it…
  32. 32. Orthodontics is simple  “With SmartClip and Forsus orthodontic treatment is like a cookbook”  The key to your beautiful smile is putting Damon braces on: “ Ask for it by name”  “You will get the same bite in the mouth that you see on the set-up” (customized braces, like Incignito, Insignia)
  33. 33. Problems of the aesthetic paradigm No.2: losing the competition with general dentists  We accepted that aesthetics is the primary goal  We need patients for survival  So we want to serve them by giving them what they want  They want a nice smile  They prefer invisible treatments  They definitely want the fastest treatment possible
  34. 34. So orthodontics has been trying to do its best to reduce treatment time  …And get our patients back  Wilckodontics  Acceledent  Early elastics  Customized braces and pre-adjusted archwires from the very beginning  Advansync
  35. 35. But if the occlusion is the goal the treatment time will still be around 12 months  But who cares about Class 1?  “Patients are coming for a nice smile but not for a class I occlusion”  “If you can put on a rubber dam clasp on the upper second molar, you will be able to put braces onto the same teeth”  Six months braces  5 months smile  Inman aligner in 9-12 weeks
  36. 36. This competition has increased tremendously. We accepted the rules of the game
  37. 37. But who will win in this competition?  Instant orthodontics
  38. 38. If we compete with general dentists on a smile makeover course we haven’t got a chance  Especially due to the fact that we can only do orthodontics while they can also do cosmetic dentistry  AAO spends thousands of USD for consumer campaigns every year  but  What do we have that they don’t?  What do we do differently compared to how GPs do orthodontics?  We both can align teeth…
  39. 39. This issue leads us to the third problem
  40. 40. Problems of the aesthetic paradigm No.3: Losing the identity  If we accept that the nice smile is the primary goal…  Orthodontic treatment is purely alignment  In fact occlusion is not responsible for the development of TMD -  Occlusion is not responsible for the development of the periodontal problems -  So the role of occlusion as a functional parameter is not so important  This will not help us to built our self esteem -
  41. 41. Namely, from the identity standpoint this provokes 3 very important questions:
  42. 42. 1. Why should we treat our cases to Class1?  In what circumstances do we call an occlusion norm-occlusion and malocclusion if there is no evidence on functional relationships?  Class I is better just because it looks better?  A= Nice1  C=Less Nice II  D=The least Nice III  How can we defend the full mouth treatment concept?
  43. 43. 2. Why do we have 3 years of postgraduate study if we just align teeth as general dentists do?  What is the value added to our treatment compared to the treatment provided by GPs?  Will our treatments have more favourable results?  Will our treatment be more stable?  What do we learn during our ortho program that will make us different?
  44. 44. Who are we?  Cosmetologist or medical doctor?
  45. 45. These are very hard questions. However, in the meantime, in everyday practice we have been treating our patients based on what we find appropriate  Are these treatments experience based or evidence based?
  46. 46. 3. What do we call evidence based in contemporary orthodontics?  We have been using this term very often  Many times we use this in order to stigmatize those, whom we do not agree with
  47. 47. What is “evidence based medicine”?  “The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients."[1][2] Trisha Greenhalgh  Evidence based medicine is not "cookbook" medicine. Because it requires a bottom up approach that integrates the best external evidence with individual clinical expertise and patients' choice, it cannot result in slavish, cookbook approaches to individual patient care.  But still what would you expect from the expression “best evidence”?  Guidelines, standards, best practice
  48. 48. Best evidence in orthodontics?  How does it work?  Let us see a typical case
  49. 49. How would you treat this case?  Class II subdivision non-growing individual  Chief complaint: sticking out upper fronts
  50. 50. Everybody has his/her own concept, but where is the best evidence?  What is the best diagnosis?  What is the best treatment plan?  What is the best appliance?  What is the best treatment sequence?  What is the best timing?  What is the best retention protocol?
  51. 51. There are highly successful techniques with a great reputation  Alexander, MBT, Bioprogressive, Andrews, Roth, Damon…
  52. 52. There are treatment modalities each with a lengthy history of success  Distalization, extraction, surgery, Herbst, elastic pull…
  53. 53. But what is the best treatment for this particular patient?  There can be around 20 different treatment plans for this individual  What are the similarities in these treatment approaches?  Class I cuspid  But where this occlusion should be in this patient’s head from the health persective?  Are the results the same by aesthetics and function?  Where are the standards, guidelines?
  54. 54. What does the newest book say?  The introduction verifies that we should make our decisions based on evidence based guidelines  There is no chapter called diagnostic procedures  The book concludes that lifelong retention is necessary, so there is no guarantee for the stability at all  And how about the treatment of Class IIs?
  55. 55. What does the newest book say about evidence based Class II treatment?  En-masse space closure is better over two-step procedure  NiTi springs are better in space closure for appointment purposes  Appointment scheduling efficiency can be improved by using appropriate material selection  Early Class II correction is not proven to be stable
  56. 56. Is this all that we have?  How can I be evidence based when planning the treatment for this particular patient?  No answer
  57. 57. Sorry, but it can be even worse!
  58. 58. How about this sentence?  “EBM seeks to assess the strength of the evidence of risks and benefits of treatments (including lack of treatment) and diagnostic tests.This helps clinicians predict whether a treatment will do more good than harm”  This makes sense…
  59. 59. What does this sentence mean?  Are any of the above mentioned treatment plans better than the lack of treatment from the risk/benefit perspective?
  60. 60. If the patient is symptom free at the moment, how can the potential side effects of the treatment be measured?  How about the risk/benefit ration?  Can we guarantee that there will not be gum recess, bone loss,TMJ problem, root resorption as a result of the treatment?  Can we guarantee that the result will be stable?  But more importantly…  Will the intensive full mouth treatment be worth it if aesthetics will be the only benefit?  Should we convince the patient to undergo the treatment?
  61. 61. Conclusions:  We have to be cautious when using the term “evidence based” in contemporary orthodontics  We need to reevaluate how successful the current paradigm is   In finding the answer to stability   In finding evidences In finding what is the best for a particular patient from the health perspective We need a change, we have to admit that the structural thinking has not been able to provide the answers
  62. 62. The change starts with the clear and honest investigation of the problem  We are fully aware of the fact that the human body is a complex system  We call it multifactorial (this is the term what we use in explaining the etiology of all the problems what we are encountered to)  After all we insist on     limiting our activity to the orofacial area limiting our activity to unidisciplinary orthodontontics limiting our activity to structural changes Altogether:   we make changes on the human body without knowing what consequences we produce we use very high forces without knowing what consequences we produce
  63. 63. The current orthodontic paradigm  Orofacial Structural Orthodontics  more precisely…  Unidisciplinary Orofacial Structural Orthodontics  Regardless, if we measure soft tissues or hard tissues, soft tissue paradigm did not change the overall structural focus
  64. 64. Can we make arbitrary borders in a complex system? The example of the specialist of the Sea of Japan
  65. 65. Can we make real assumptions in such an artificial system?
  66. 66. Can we make a prognosis if we don’t see the interdependence?
  67. 67. It is evident that we need a change to ensure the future of our specialty  We need another mindset  We need a new paradigm, that takes the complexity of the problems into account  We need to look at our patients from another perspective
  68. 68. What do we need to do to understand and treat the complex system?  Enlarge the focus to the whole body  Cooperate with other specialties, working in an interdisciplinary TEAM  Accept and reinvestigate the functional aspects of the occlusion
  69. 69. The new functional paradigm  Craniofacial  Interdisciplinary  Functional  Orthodontics  Craniofacial functional orthodontics, or craniofacial functional medicine
  70. 70. We have to operate on an interdisciplinary team  Occlusion  Swallow  Breath  Posture  Integrity of the fascia and neuro reflexes (osteopathy)
  71. 71. We need to work in a team which also includes the patient  Interdisciplinary, patient-centric  Not unidisciplinary, structurally normcentric (symptomcentric)
  72. 72. We have been giving beautiful smiles to our patients for many years – And we are also responsible for their overall health
  73. 73. We are a part of the oldest specialty of dentistry – We are also responsible for the future of this specialty  This is the time for significant changes  We need a new mindset  The new Functional Paradigm can bring us a new perspective
  74. 74. IFUNA can play a vital role in the future of orthodontics  We have to work together to develop the new protocols  It is not going to be easy  But we don’t have an alternative
  75. 75. Thank you for your attention!
  76. 76. How we imagined our specialization… “Give me the teeth please” “Sorry but the jaw goes with it. May I leave it as it is?”

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