Marc Ackerman & Ben Burris

We were discussing orthodontic theory and practice from an historical point of view today and remembering that 1) Transverse First was a big deal in the 1990’s and early 2000’s (Vanarsdall) and 2) “Airway orthodontics” was very popular in the 1930’s and 1940’s made us stop and think about all the drivers in orthodontics today. Here is the list we came up with – we don’t claim it to be all inclusive but it sure is interesting. Many of these approaches are sold to patients as the latest and best. It’s even more interesting that some of these approaches are used simultaneously/competitively in any given office which can make for some interesting results.

1. Failure driven orthodontics – Probably the second most popular of those listed here. This model uses braces and/or aligners to straighten the teeth. When things go well the braces come off in the estimated treatment time. When things don’t go well, devotees keep the braces on as long as possible until the patient demands a debond or they finally realize that ideal is unattainable for this patient. It can take years beyond the estimated treatment time for debond to finally occur and the failure is usually chalked up to “bad growers” and “non-compliance” as it cannot possibly be our fault. This model is often accompanied by an orthodontic schedule that is out of control where patients come in droves before and after school making it impossible render excellent treatment.
2. Financially driven orthodontics – Keep the braces on until they finish paying. This use of “financial wires” is very popular though ethically questionable at best.
3. Patient driven orthodontics – In this paradigm the orthodontist actually listens to the patient, figures out what the patient wants to accomplish, determines if they can make the patient happy or not (this takes experience), treats patient to the best of their ability to help them achieve the patient’s goals as well as the traditional orthodontic ideal and removes the braces when the patient says they are happy regardless of financial obligations or distance from ideal.
4. Sagittal first orthodontics – Purveyors of class II devices and CE courses want to make sure they get paid first so they have constructed this treatment modality to insure class II correction precedes braces or aligners. Highly paid KOLs play a big role in making this model popular.
5. Airway orthodontics – Purveyors of CE and devices that “improve the airway” as well as cone beam CT salesmen want to make sure they get paid first so they have convinced orthodontists that orthodontists are the gatekeepers and the hub of the wheel when it comes to treating sleep/airway issues just because they have taken a weekend course. Highly paid KOLs play a big role in making this popular.
6. Faith based orthodontics – This modus operandi is at least third on the list and possibly the second most popular of these paradigms where adherents blindly follow what has always been done, zealously defend ideas that were randomly chosen over a century ago and refuse to change what they do for any reason. This model is prevalent in older orthodontists as you’d suspect but it’s also surprisingly popular among young orthodontists and residents. We assume this is due to the vast majority of full-time faculty being “Faithers”.
7. Consultant driven orthodontics – There are hundreds of orthodontic consultants who want to get paid and then rehired for some after work. There is nothing wrong with this in and of itself but it’s important for the orthodontist to remember that consultants’ main focus is making the orthodontist happy so that they get rehired. They will rarely criticize. They will rarely give an orthodontist geographic exclusivity and will use current clients to get new ones in the same area. They will talk in terms of average and industry standards instead of excellence and prosperity. They have zero compunction about making major changes to your practice that will benefit them and the way you perceive them short term even though it can be costly both in terms of your budget and long term practice growth. Residents and younger doctors are particularly susceptible to consultants looking for an easy mark.
8. Aligner driven orthodontics – Purveyors of aligners want to get paid first so they make it clear that every case in every situation can and should be treated with aligners. The most interesting recent development in this area is the prevalence of vertical attachments on ALL THE UPPER ANTERIOR TEETH which kind of defeats the purpose of doing aligners. Another recent trend is the so called attachmentless aligner – we find this ironic given that one of the biggest “negatives” of DTC Aligner therapy is the lack of attachments according to orthodontists.
9. Passive self-ligation driven orthodontics – The purveyors of PSL brackets and accessories want to get paid first so they constructed this treatment modality to insure the use of PSL brackets. Magical things happen during their “arch development” particularly with posterior crossbites. Highly paid KOLs play a big role in making this popular.
10. Evidence based orthodontics – These bibliophiles, mostly academics, claim that there is a best way of doing anything in orthodontics and that can be found in the literature despite the multitude of treatment modalities and variance among practitioners. The truth is that there is very little real science in orthodontics and those sitting in ivory towers who haven’t touched a patient in decades don’t know the first thing about effective, efficient treatment since it is almost entirely experience based. Furthermore this erudite group couldn’t care less about patient comfort or happiness. Those in practice had better care because the stakes and the risk are much higher.
11. Appliance driven orthodontics – Sagittal, Airway, PSL and Aligner driven models are examples of the larger category of Appliance driven orthodontics but there are so many relatively small market share appliances out there that groups of orthodontists swear by, defend and tout as the best that we needed to mention this model. Tweed, tip edge, Crozats, Mara, Herbst, lingual appliances, etc. are other, smaller examples of this model. Each has their own mythology of why their appliance is singular and the best way to treat patients. The resulting groups can be quite Procrustean and even cultish in the fulfilment and distribution of their mantra. Their “second tier KOLs” are not as well paid but no less vital to the spread of any given treatment modality utilizing their appliance.
12. Orthodontist driven orthodontics – This is the most popular driver in orthodontic practices hands down and can be good or bad depending on the orthodontist in question. In this model, everything in the practice is infused with the orthodontist’s attitude and mindset. The best practitioners who often run the biggest practices are almost always excellent examples of the positive side of an orthodontist driven practice. As are some of the worst, most backwards practices that we’ve ever seen or heard of. Of course every practice will be orthodontist driven to some extent and that’s fine. The key is for the orthodontist to recognize what they are good at and avoid the things they struggle with (hire good people to help but have checks in place to evaluate them). Also, the best practices are both patient centered and orthodontist driven meaning that they focus on patient comfort, patient happiness, access to care and great outcomes delivered in a reasonable amount of time.
13. Omnidirectional orthodontics (also known as Pragmatic orthodontics) – Instead of artificially segmenting orthodontic treatment in arbitrary ways, the pragmatist seeks to correct everything they can as quickly as they can. For example, there are cases where an orthodontist would commit sacrilege and run power chain or elastics in an 0.014 or even 0.012 Niti wire (a chief complaint of a diastema between upper 1s and high canines are examples of each). Another aspect of Omnidirectional orthodontics is the idea that one should advance treatment maximally at each and every appointment rather than just changing ties. To do this one must have mastery of their orthodontic schedule and see an even load of patients all day long. If an orthodontist does this then that also allows them to finish cases early in general and thus increase patient happiness and capacity while attracting new patients based on their reputation and results.

We are not judging – well, we kind of are judging the treatment modalities that have serious, obvious issues – but the point of this blog is not which model you use. The important takeaway here is that orthodontists recognize why they do what they do. Orthodontists should know the real reason they use that model/appliance (science? the cool kids? results? they just like it?) so that they can constantly evaluate what they do and be open to better ideas that make their lives easier and patients happier. Orthodontics is almost totally experience based and all about patient happiness after all. One day the profession will realize this – we only hope it happens before orthodontics follows prosthodontics and periodontics onto the ash heap of history.