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

1. Paradigm shift in Orthodontics
Gabor Hermann DMD,
Orthodontist, Hungary
drhermann.g@gmail.com

2. We have been giving beautiful smiles to our
patients for many years

3. Our offices provide a workplace for many people
at chairside and in administration

4. Our offices are being served by orthodontic
laboratories…

5. …and by orthodontic companies

6. We are members of orthodontic study clubs…

7. …and associations nationally and internationally

8. We have orthodontic schools with a great
reputation

9. We study constantly on courses and at
conferences

10. We undertake researches and we publish the
results in the peer review literature

11. In conjunction with our employees, labs,
supporting companies, associations and schools
we form the orthodontic industry…

12. …the oldest specialty of dentistry

13. Based on this, one might think that this specialty
is very well organized, scientifically grounded and
operates smoothly…

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. However, if we scratch the surface, there are
really big changes happening

16. And, this is the real paradigm shift

Straight talk about
straight teeth

17. These big changes started in the early 2000’s

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. 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. However, if we focus on this change from
another perspective it is going to be even more
interesting

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. This competition has increased tremendously.
We accepted the rules of the game

37. But who will win in this competition?

Instant orthodontics

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. This issue leads us to the third problem

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. Namely, from the identity standpoint this
provokes 3 very important questions:

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. 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. Who are we?

Cosmetologist
or medical
doctor?

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. 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. 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. Best evidence in orthodontics?

How does it work?

Let us see a typical case

49. How would you treat this case?

Class II subdivision
non-growing
individual

Chief complaint:
sticking out upper
fronts

51. 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?

52. There are highly successful techniques with
a great reputation

Alexander, MBT, Bioprogressive, Andrews, Roth, Damon…

53. There are treatment modalities each with a
lengthy history of success

Distalization, extraction, surgery, Herbst, elastic pull…

54. 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?

55. 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?

56. 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

57. Is this all that we have?

How can I be evidence based when
planning the treatment for this particular
patient?

No answer

58. Sorry, but it can be even worse!

59. 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…

60. What does this sentence mean?

Are any of the above
mentioned treatment plans
better than the lack of
treatment from the
risk/benefit perspective?

61. 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?

62. 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

63. 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

64. 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

65. Can we make arbitrary borders in a complex
system?
The example of the specialist of the Sea of Japan

66. Can we make real assumptions in such an
artificial system?

67. Can we make a prognosis if we don’t see
the interdependence?

68. 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

69. 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

70. The new functional paradigm

Craniofacial

Interdisciplinary

Functional

Orthodontics

Craniofacial functional orthodontics, or
craniofacial functional medicine

71. We have to operate on an interdisciplinary
team

Occlusion

Swallow

Breath

Posture

Integrity of the fascia
and neuro reflexes
(osteopathy)

72. We need to work in a team which also
includes the patient

Interdisciplinary,
patient-centric

Not unidisciplinary,
structurally normcentric (symptomcentric)

73. We have been giving beautiful smiles to our patients for
many years –
And we are also responsible for their overall health

74. 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

75. 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

76. Thank you for your attention!

77. How we imagined our specialization…
“Give me the
teeth please”
“Sorry but
the jaw
goes with
it. May I
leave it as
it is?”