JCO ROUNDTABLE The Future of Orthodontics

Diagnosis

MR. VOGELS What patient records do youcurrently take in digital form? Will digitalrecords completely replace paper records in thenear future?

DR. GLENN I currently take digital intraoraland facial photographs. I plan to change to digi-tal radiographs within the next two years, when Imove to a new office. Over time, I expect thatdigital records will replace paper and filmrecords.

DR. ALEXANDER The time for digital recordshas come. The technology is available. We cur-rently do our photography in digital form andplan to be “paperless” by the end of this year.

DR. MOSKOWITZ Intraoral and facial photo -graphs and cephalometric and panoramic radio -graphs are digital in our office. While we areexploring the desirability and feasibility of digi-tal casts, we still prefer (at this time) to have plas-ter dental study casts. In time, I imagine that allof our offices will be completely digital withrespect to patients’ physical records as well ascharting, etc. The future is in a paperless andplaster less orthodontic office.

DR. SANDLER The patient records that I cur-rently take in digital form are extraoral pho-tographs, intraoral photographs, cephalometricradiographs, panoramic radiographs, and intra -oral bitewing and periapical radiographs. I’mcurrently looking into changing to digital studymodels. Digital records will undoubtedly replacepaper records, but this change will probably takeanother 15 to 20 years in the U.K.

DR. CARRIERE Our patient records are all indigital form now. They are stored at the centralserver and connected to a fiberoptic intranet with30 points at the chairsides and in the offices.Only for x-rays and models do we like to keephard copies as well for backup.

DR. REDMOND All our diagnostic records arenow digital as well, including photographs, radio -graphs, cephalometric analysis, and study models.Many orthodontic offices have already progressedto completely paperless, which means that all

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The Future of OrthodonticsPart 1 Diagnosis and TreatmentDAVID S. VOGELS III, ModeratorR.G. “WICK” ALEXANDER, DDS, MSDLUIS CARRIERE, DDS, MSD, PHDGAYLE GLENN, DDS, MSDELLIOTT M. MOSKOWITZ, DDS, MSW. RONALD REDMOND, DDS, MSJONATHAN SANDLER, BDS, MSC, FDS RCPS, MOrth RCS

Mr. Vogels is Managing Editor of the Journal of Clinical Orthodontics,1828 Pearl St., Boulder, CO 80302. Dr. Alexander is a ContributingEditor of the Journal of Clinical Orthodontics, a Clinical Professor ofOrthodontics at Baylor College of Dentistry, Dallas, and in the privatepractice of orthodontics at 840 W. Mitchell, Arlington, TX 76013. Dr.Carrière is a Clinical Professor, Department of Orthodontics, Univer -sity of Ferrara, Italy, and in the private practice of orthodontics at Es -cue las Pias, 109, 08017 Barcelona, Spain. Dr. Glenn is the South westSociety of Orthodontists Trustee to the AAO Board of Trustees and inthe private practice of orthodontics at 7005 Pastor Bailey Drive, Suite101B, Dallas, TX 75237. Dr. Moskowitz is a Contributing Editor of theJournal of Clinical Orthodontics and a Clinical Professor, Depart mentof Orthodontics, NYU College of Dentistry; he is in the private practiceof orthodontics at 11 Fifth Ave., New York, NY 10003. Dr. Redmond isTechnology Edit or of the Journal of Clinical Orthodontics and in the pri-vate practice of orthodontics at 30111 Niguel Road #G, Laguna Niguel,CA 92677. Dr. Sandler is a Contributing Editor of the Journal of ClinicalOrthodontics and Consultant Orthodontist, Chester field RoyalHospital, Calow, Chesterfield, Derby shire S44 5BL, England.

©2007 JCO, Inc. May not be distributed without permission. www.jco-online.com

records, schedules, accounting, treatmentrecords, lab slips, prescriptions, health histories,and informed consents (with digital signatures)are now digital. It appears that filing cabinets arefollowing typewriters out of the modern office.

MR. VOGELS What experience have you hadwith the new three-dimensional or other imagingtechniques? Will these techniques replace two-dimensional imaging? What new kinds of analy-sis will have to be developed to make the best useof these techniques?

DR. CARRIERE I started working with 3D vir-tual imaging in 1993 in the “Softlander Project”,a 3D Stereoscopic Virtual Reality environmentwith a library of appliances and protocols,designed for orthodontic teaching.1 Since then Ihave been developing all my R&D orthodonticprojects with these platforms. I am a strong be -liever that these technologies are the future inorthodontics. In reference to the use of 3D imag-ing for diagnosis, it is interesting to note that themost frequently contemplated human facial pos-ture in real life is the frontal view. Therefore, 3Dimaging will give us the information we need notonly for hard tissues, but for facial esthetics. Inthe future, advances have to be made in standard-izing the morphometry of craniofacial structuresin 3D imaging, not only statically, but dynami-cally as well, correlating different technologies.

DR. MOSKOWITZ There have been a numberof recent articles in our orthodontic publicationson 3D imaging. Without question, 3D imagingwill replace the two-dimensional imaging that wehave been using since Broadbent (in the U.S.)and Hofrath (in Germany) introduced standard-ized lateral cephalometric radiographs in 1931.The ability to more accurately visualize ourpatients’ dentofacial structures and the relation-ships of hard and soft tissues to each other shouldhelp clinicians and researchers better and moreprofoundly understand the important qualitativeand quantitative factors in the treatment of mal-occlusions. Areas that will be significantlyimpacted include diagnosis, treatment planning,appliance selection, and treatment outcome sim-

ulations. Research efforts hold the promise ofconsequential enhancement with 3D imaging.Naturally, innovative and very different analyticalsystems with algorithms appropriate for 3Dimaging will need to be developed.

DR. REDMOND I have purchased two cone-beam scanners: the NewTom,* in 2003, and the i-CAT,** in 2005. The NewTom is in use at theUniversity of Southern California, and the i-CATis located at the University of the Pacific. USCand UOP have made tremendous strides in ana-lyzing CBCT (cone-beam computed tomogra-phy) images. One 3D scan yields all the radio -graphs that orthodontists need: panorex, lateraland frontal headfilms, TMJ tomograms, sinusfilms. In addition, stereolithography allows the3D images to be recreated in photosensitiveacryl ic. Imagine the maxillofacial surgeon’s de -light in predicting a surgery based on a life-size,3D acrylic model of the craniofacial complex.These models help the surgeons understand bonethickness and density before they reach for a sur-gical instrument in the operating room. Current -ly, 3D x-ray scans are being refined to producestudy models of sufficient quality to allowInvisalign*** appliances and Insignia****custom ap pliances to be fabricated without theuse of poly vinyl siloxane impressions. This is thenext step in the digital revolution, and an eagerlyawaited step. Orthodontists will have the abilityto take one CBCT scan, and from that tease out

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Mr. Vogels

all the diagnostic records, including the studymodels and working models.

DR. SANDLER I have had very little experi-ence with three-dimensional imaging techniques.Only two or three of my patients have had CTscans taken, and only one patient has had three-dimensional rendering of this DICOM† data,although with very impressive results (Fig. 1). Ithink once the equipment is in widespread useand the patient dose is down to acceptable levels,three-dimensional imaging with i-CATs or simi-lar machines will become standard practice. Ob -viously, new analyses will need to be developedto allow us to make the best use of this data.

MR. VOGELS Do you see any other new diag-nostic technologies on the horizon?

DR. REDMOND Several companies are devel -op ing intraoral scanners to produce 3D images andeliminate impressions for study models and work-ing models. The CBCT scans and the intraoralscanning devices are competing for market share.

DR. SANDLER Another diagnostic tool thatmay be of benefit would be to relate digital pho-tographs of study models to the patient’s digitalextraoral photographs, so that much of the infor-mation that is currently obtained from cephalo-metric radiographs may be possible to obtainfrom high-quality photographs of study modelssuperimposed accurately within lateral head pho-tographs (Fig. 2).

DR. CARRIERE I cannot think of possible fu -ture procedures, but conceptually speaking, theyshould be developed on a non-invasive basis forreasons of patient safety. They should be orient-

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Vogels, Alexander, Carrière, Glenn, Moskowitz, Redmond, and Sandler

*Trademark of AFP Imaging Corp., 250 Clearbrook Road, Elms -ford, NY 10523; www.aperioservices.com.

**Imaging Sciences International, 1910 N. Penn Road, Hatfield, PA19440; www.imagingsciences.com.

***Registered trademark of Align Technology, Inc., 881 MartinAve., Santa Clara, CA 95050; www.aligntech.com.

****Trademark of Ormco/“A” Company, 1717 W. Collins Ave.,Orange, CA 92867; www.ormco.com.

†Registered trademark of the National Electrical ManufacturersAssociation, 1300 N. 17th St., Suite 1752, Rosslyn, VA 22209;www.dicom.nema.org.

Fig. 1 Three-dimensional rendering of DICOM dataallows visualization of unerupted teeth (courtesyof Dr. James Mah, Craniofacial Virtual Reality Lab,California).

Fig. 2 Accurately locating study models withinfacial photograph would provide many useful mea-surements.

ed toward the variability of individuals, trying toidentify their different responses to our therapeu-tic action. Molecular biology can give us thecomplementary knowledge necessary to under-stand the reactions or the treatment possibilitieswith different technologies.

MR. VOGELS Will growth prediction becomemore reliable in the immediate future? What im -pact will technology have on growth prediction?

DR. ALEXANDER Technology will be critical.Someday, when we can do a saliva test (or someother test) and it tells us when a growth spurt isapproaching, it will revolutionize treatment tim-ing and enable the orthodontist to actually reducetotal patient treatment time.

DR. SANDLER I don’t see any great future ingrowth prediction with the tools we have current-ly available to us. Certainly the work done byBaum rind over 20 years ago showed that expertclinicians examining radiographs of patients per-formed no better than chance, when trying to pre-dict forward and backward rotators.2 Houston castserious doubt on growth prediction methods andsuggested that just by adding the average incre-mental growth to existing facial patterns, the erroris probably as good as computer-based meth ods.3Houston and colleagues also cast some doubt onthe use of hand-wrist radiographs to accuratelypredict the onset of the pubertal growth spurt.4Probably the best methods we have available arethe standing height measurement and the Tannerand Whitehouse growth charts.5

DR. MOSKOWITZ I hope that the extension of3D imaging into a more meaningful 4D type oftechnology at some point will indeed improveour ability to more accurately record growthchanges and quite possibly lead to substantialgrowth-prediction capabilities. As Dr. Carrièrepointed out, however, such technology is stilllimited by our current understanding of individ-ual variation in our offices. Let’s not make thesame overly optimistic mistakes with this newmultidimensional imaging that we did with tradi-tional two-dimensional cephalometrics. The abil-

ity to make consistently accurate growth prog-nostications in orthodontics will largely dependupon future developments in other areas. Thereare profound differences between the ability torecord growth changes (regardless of the dimen-sions included in such assessments) and accu-rately and consistently predicting such growthchanges in individuals. Until significant advancesare made in fields such as genetics, cellular biol-ogy, physiology, biochemistry, and endocrinolo-gy, to name just a few areas, it is unlikely thatmeaningful growth predictions will be availableto the orthodontic clinician.

MR. VOGELS Do you see an increasing multi-disciplinary involvement of referring dentists andother specialists in the diagnostic process? Howwill this affect the practice of orthodontics?

DR. REDMOND I have spent the last 10 yearspracticing in a multidisciplinary office in Seattle.The transfer of information between profession-als is extremely beneficial to the patient. Endo -dontics, crown lengthening, gingival grafts, im -plants, and preprosthetic and premaxillofacialsurgery all play into a multidisciplinary treatmentplan. The resultant treatment plan is certainlyworthy of the oft-quoted phrase: “The whole isgreater than the sum of the parts”. I do not be -lieve that multidisciplinary treatment will weak-en the orthodontic specialty; my experience hasbeen quite the contrary.


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DR. CARRIERE The more we know about thedifferent components in a case, the better thetreatment outcome, so multidisciplinary involve-ment is very important. At an institution with dif-ferent specialists, it is easy. In the case of profes-sionals located in different offices, this can beorganized via Internet. With special software,such as Glance†† and Skype,††† it can be donein real time.

DR. GLENN Digital records certainly make iteasier and more convenient to involve the refer-ring dentist and other specialists during the diag-nosis and treatment-planning phase of treatment.The digital records can be shared electronicallywith colleagues to gain multidisciplinary input ina timely manner, both prior to and during treat-ment.

DR. ALEXANDER Multidisciplinary treatmenthas been around for many years. It has been a resultof the increased popularity of adult treatment, asorthodontists realized their limitations with ortho-dontic treatment alone. It will continue to grow asmore GPs and non-orthodontists are educated torecognize problems and refer to specialists. Teamsof specialists working as one unit will becomemuch more prevalent, and exposure on TV “make-overs” can show the public what is possible.

DR. SANDLER There will almost certainly bea further increase in multidisciplinary treatment

of complex cases as the adult market for ortho-dontics increases. This will necessitate involve-ment of the referring general dental practitioners,as well as specialists in endodontics and crownand bridge. There will probably be a much great -er increase in preprosthetic orthodontics as thespecialists appreciate how the orthodontist cangreatly enhance the final results that they are ableto achieve just by moving the teeth into a morefavorable position.

MR. VOGELS Will patients and parents havemore say in treatment decision-making in thefuture? How will this affect treatment techniques,practice management, and internal marketing?

DR. MOSKOWITZ Patients and parents ofyoung patients already have a great impact uponthe treatment decisions that are made in modernclinical orthodontic practice. The use of informedconsent is not optional, but mandatory. And I sus-pect that this empowerment and more interactiverelationship will increase in the future. Thedemand for orthodontic services has never beengreater. No doubt, the near-invisible appliances(Invisalign, Essix,‡ and lingual appliances) areresponsible for this surge in the public’s demandfor orthodontic care. Orthodontists should realizethat their ultimate role should be as educators andnot necessarily as salespeople. Helping patientsselect appropriate and meaningful treatmentstrategies and appliances takes time, knowledgeof current treatment options, communicationskills, and integrity. Successful practices now andin the future must rely upon the ability of theorthodontist to maintain treatment expectationsthat coincide with patient and parent expecta-tions. Everything else is mere commentary.

DR. SANDLER Patients and parents will prob-ably have more input into the decision-makingprocess in the future. Certainly, over the last five

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Dr. Carrière

††Trademark of Glance Networks, Inc., 1167 Massachusetts Ave.,Arlington, MA 02476; www.glance.net.

†††Trademark of Skype Technologies, 2 Stephen St., London W1T1AN, England; www.skype.com.

‡Registered trademark of Raintree Essix, LLC, 4001 Division St.,Metairie, LA 70002; www.essix.com.

years in the U.K., they have been made central toall decisions about treatment. On the insistenceof Tony Blair’s government, the patient is nowgiven a choice not only of where treatment willbe provided, but of all the different alternativetreatments available. For fully informed consent,the advantages and disadvantages of all possibletreatment modalities are meant to be discussed indetail with patients and parents prior to any irre-versible decision being taken. This means that anincreasing number of compromise treatmentsmay end up being carried out in the future, as cer-tainly a proportion of patients in the U.K. merelywant their upper front teeth to be straight. If thepatients are the final arbiters of clinical treat-ment, this could mean shorter and less rewardingcourses of orthodontic treatment would be car-ried out in the future. Obviously, there wouldhave to be changes in the management of thepractice to accommodate increased numbers ofshorter treatments.

DR. ALEXANDER Patients and parents havealways had a role in the final treatment plan. Aslong as everyone understands the benefits andconsequences of their choices, compromise treat-ment may be considered. But it seems rather sadthat we are trained to “do it right”, then let thepatient control the treatment rather than the doc-tor. As university-trained specialists, our respon-sibility to our patients is to offer the best qualityof treatment we can give them.

DR. CARRIERE I think patients and parentshave much to say. Actually, the degree of infor-mation that they have is very advanced, as wellas their expectations and objectives. Ortho -dontists have to discuss with patients the treat-ment project in a progressive scale of theirinvolvement in the process, explaining the differ-ent possibilities plus the quality of result they canachieve. The logic of the process has to be clear-ly explained, and once it is understood and

accepted by the patient, they will become posi-tively involved in the treatment.

DR. REDMOND The Internet has foreverchanged the way professionals conduct their prac-tices. We deal, on a daily basis, with patients andparents who are highly informed. Today’s chal-lenge for professionals is to help the public sepa-rate fact from the fiction that they have Googled.

Treatment

MR. VOGELS What “non-compliance” devicesdo you use? Will these eventually replace tradi-tional appliances such as headgear?

DR. ALEXANDER You are speaking to thegreatest fan of facebow-headgears! Researchshows the excellent long-term stability of head-gear treatment.6-10 Compared with the Herbst,‡‡it gives equal orthopedic and definitely more sta-ble orthodontic long-term results.11 Temporaryanchorage devices offer new approaches for non-compliance force application. Rapid palatalexpanders and tied-in lip bumpers can also beconsidered non-compliance appliances.

DR. GLENN As a student of Dr. Alexander’s, Ihave to agree that non-compliance applianceswill probably not replace headgear and other tra-ditional appliances in my practice. Temporaryanchorage devices or miniscrews show promisefor treatment of certain conditions and will likelybe used more routinely in the future.

DR. SANDLER The non-compliance devicesthat I have used besides headgear are the JasperJumper,‡‡‡ Jones Jig,‡‡‡ Distal Jet,‡‡‡ mid-palatal implants, and microscrews. If the reliabil-ity of micro screws can be demonstrated, thenthey theoretically could eventually replace head-gear. I have previously carried out a randomizedclinical trial investigating the use of palatalimplants and demonstrated that they work just aswell as headgear; this will be published in thenear future. Because of the not-insignificantamount of surgery required to place and removethe midpalatal implants, I would be surprised ifthey replace headgear in the foreseeable future.


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‡‡Registered trademark of Dentaurum, Inc., 10 Pheasant Run,New town, PA 18940; www.dentaurum.com.

‡‡‡American Orthodontics, 1714 Cambridge Ave., Sheboygan, WI;www.americanortho.com. Jasper Jumper and Jones Jig are trade-marks.

DR. CARRIERE Orthodontics proposes an ac -ceptance of a foreign mechanism into the mouth.This is in itself an act of compliance, with theexpectation of a result that compensates for it. If apatient accepts orthodontic treatment, it is in thehands of the orthodontist to convince him. He hasto develop the confidence that cooperation will berewarded with a good result, that it will be a gooddeal for him. The key to achieve this is to explainthe logic of the process. Once it is understood bythe patient, he is able to follow a protocol andbecome involved in a successful adventure. Theorthodontist has to take advantage of the initialexpectations that the patient has at the beginningof treatment. Surgical procedures and other alter-natives such as miniscrews are discussed with thepatient to evaluate the pros and cons.

MR. VOGELS In what types of cases do youprefer skeletal anchorage to traditional forms ofanchorage? Will miniscrews eventually become astandard form of treatment?

DR. SANDLER Skeletal anchorage is prefer-able to more traditional forms of anchorage inany situation where patient compliance is indoubt. Miniscrews will eventually become stan-dard practice if they can be demonstrated scien-tifically to be reliable. I am currently setting upanother randomized clinical trial on the use ofmicroscrews, and in five years’ time I will hope-

fully be able to give the answer on their effec-tiveness and reliability.

DR. CARRIERE Where traditional forms ofanchorage fail, especially in hyperdivergentcases, we like to propose miniscrews. Whenanchorage loss produces a forward movement ofthe lower incisors, skeletal anchorage can pre-serve the facial esthetics of the patient, preserv-ing the harmony in the curvature of the supra-mentalis sulcus.

DR. GLENN Miniscrews or TADs are showinga great deal of promise for cases that are difficultto treat with traditional mechanics. This is espe-cially true of cases with missing posterior teethand specific anchorage concerns.

DR. ALEXANDER Skeletal anchorage seems tobe best suited for non-growing patients withskeletal discrepancies who will not accept surgi-cal treatment. The future of miniscrews seemsbright. Types of cases where this technology willbe helpful include bimaxillary protrusions, muti-lated cases, and asymmetrical malocclusions.Con trolling and decreasing the vertical dimensionby molar intrusion has incredible possibilities.

DR. REDMOND TADs are already in use in alarge percentage of orthodontic practices. What isyet to be completely understood is the impact thatTADs will have on diagnosis and treatment plan-ning. Combining the knowledge gained fromCBCT scans and 3D growth prediction with TADs,the resulting treatment plans will dramatically alterorthodontic treatment as we know it today.

MR. VOGELS How do your average treatmenttimes today compare with 10 or 20 years ago?Will advances in technology, materials, ormechanics be able to shorten treatment timeseven further?

DR. CARRIERE Our average treatment timehas decreased from 24 to 18 months in extractioncases and to 12-15 months in nonextractioncases. Some of the last group can be reduced stillfurther, to nine or 10 months, in cases of goodcooperation and response. At present we are

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Dr. Glenn


working with passive self-ligating brackets, com-plemented by ultralight new-technology wires(Fig. 3). In the protocol developed in our Ortho -dontic Positioning Technique, the Carrière Dis -tal i zer§ is a complement of utmost importancefor nonextraction cases and for atypical extrac-tion cases.12-14 This opens the door to a more cre-ative approach for a new type of treatment basedon preservation of facial esthetics.

DR. GLENN I have seen decreased treatmenttimes due to improved wire technology and expe-rience in practice. I still find that the finishingphase relies on patient cooperation with elastics,which is often the limiting step.

DR. ALEXANDER Compared to 20 years ago,there have been amazing changes in how effi-ciently we can move teeth. In years past, I need-ed to see patients every three weeks with thestainless steel archwires. Today, because of theadvances in metallurgy, it is every six weeks. Theissue today is not “moving teeth”. This is the eas-iest and fastest part of treatment. But so manyother factors affect treatment time. The issue iscorrecting the skeletal deficiencies while havinga patient who never misses an appointment ornever has a loose bracket and follows your in -structions explicitly. I admire those who can rou-tinely treat a Class II nonextraction case in 12months. In our office, the treatment time dependson achieving correct skeletal relationships andfinal occlusion. This takes time (and growth) andcompliance! In summary, our total treatment timehas decreased by possibly three to six months,

depending on the case. Our chairtime has de -creased dramatically, without damaging the qual-ity of the finished result.

DR. SANDLER Average treatment times areprobably slightly shorter than they were 10-20years ago due to the advent of fully programmedappliances and nickel titanium archwires. Furtheradvances in bracket and archwire technologycould theoretically take another 10-20% off totaltreatment times, but if there is a major movementto private treatment in the U.K., this will hope-fully be offset by an increased amount of timespent in finishing.

MR. VOGELS How much do you use pread-justed appliances in your practice? Can these beeffective in most cases, and will they becomemore effective? Will new systems ever allowcomplete customization of appliances for indi-vidual patients at a reasonable cost?

DR. GLENN I use preadjusted appliances 100%of the time. I believe they are effective in mostcases and will become more effective over time.I routinely bend wire in the finishing stages toimprove final tooth positions when indicated.

DR. SANDLER We also use preadjusted appli-ances 100% of the time in our clinical practice, asthese are effective in every case where patientcooperation is forthcoming. Complete cus-tomization of appliances may eventually be pos-


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Fig. 3 Carrière Distalizer and Passive Self-Ligating Brackets.

§Trademark of ClassOne Orthodontics, Inc., 5064 50th St.,Lubbock, TX 79414; www.classoneortho.com.

sible, so that individual torque requirementscould be built in for particular aspects of the indi-vidual malocclusion.

DR. MOSKOWITZ Preadjusted appliancesrank as one of the great advancements in ortho-dontics. Their use will continue to increase andbecome more sophisticated. Orthodontic manu-facturers realize this, and one company hasalready marketed customized brackets for eachpatient. Indeed, this is the future. The more cus-tomized these attachments become, coupled withmore precise methods of placing these sameattachments, orthodontists will be able to achievemore precise and better treatment outcomes.Naturally, we have to continually reevaluatethese technological advances to determine if themanufacturers’ promise of noticeably more pre-cise tooth movement actually does occur.

There are a few misconceptions about pread-justed appliances that we should dispel. Firstly,these “smart” appliances are only as smart as theorthodontists using them. Secondly, there is still aneed for postgraduate residents and orthodontiststo learn to routinely bend wire for intended move-ments that simply do not occur with preadjustedappliances for whatever reason. Thirdly, pread-justed appliance use must include special consid-erations as far as anchorage is concerned. Andfourthly, and perhaps most important, preadjustedappliances are just a way to efficiently move teeth.The manner in which we ultimately use these

appliances should stem from a thorough diagnosis,problem list, and establishment of orthodontical-ly sound treatment goals. “Any road will do, if youdon’t know where you want to go.”

DR. ALEXANDER Having created my ownpreadjusted appliance 25 years ago and continu-ally improving it over the years, I am exceeding-ly happy with the routine results it produces. Myexperience has been that my preadjusted appli-ance is very effective in virtually all cases. Toindividualize our system, we make bracket posi-tioning changes for certain malocclusions, arch-wire design changes involving curve of Spee, andindividualized changes in orthopedic forces andelastics. The quality of our finished result todayis better than ever.

DR. CARRIERE All of our treatments withfixed appliances are with preadjusted .022" ×.028" brackets of the passive self-ligating type.The system can be “activated”, whether withmetallic ligatures or a special program of wiresizes, to fulfill the individual needs of the case.More customization may be available in the nearfuture. Just as we all have photocopiers in ouroffices today, in the future we’ll have rapid 3Dprototyping available as a tool for research, todemonstrate with models, and to manufactureindi vidualized appliances on site, according tothe needs of the situation.

MR. VOGELS To what extent will stainlesssteel be superseded by space-age materials suchas ceramics and titanium? How will this affectorthodontic mechanics? Do you see any othernew materials entering the market?

DR. GLENN For brackets, I still prefer stainlesssteel over ceramic, unless the patient has a spe-cific esthetic concern. I find that the stainlesssteel brackets are easier to use and deliver a morepredictable result in my hands. Space-age wires,like nickel titanium, have been a wonderful addi-tion to our armamentarium. These flexible wireshave many uses during the course of treatment,but I still finish my cases in stainless steel wires.

DR. CARRIERE Stainless steel will continue



Dr. Moskowitz

to be a very good material for moving teeth, andin later stages of a treatment it is still indicated.New-technology wires delivering low force areof course the most promising materials at pre-sent, especially with self-ligating brackets. In thefuture, intelligent wires that deliver light forcesfor time intervals with precalculated interrup-tions could be developed. In terms of brackets,ceramics are still desired by many patients. Thefuture can bring us smaller sizes and bettermechanical features of ceramic brackets, withbetter control of movements and patient comfort.

DR. SANDLER If the price of ceramic bracketscan be brought down to a competitive level, thenI could see them ultimately challenging stainlesssteel as the material of choice for orthodonticbrackets. Obviously, if this occurs, then orthodon-tic treatment mechanics will have to be altered toa small degree, in that friction within the systemwill increase; therefore, orthodontists will have tostay in flexible wires for a slightly longer period,and space closure may be significantly slower.Nickel titanium wires have a very large share ofthe market, and I can see no reason why this willdecrease in the future. As the properties of nickeltitanium wires improve, there may ultimately beno need for stainless steel arch wires apart fromthe finishing stages of treatment.

DR. ALEXANDER Stainless steel still deliversthe most economical, safe, reliable bracket.Maybe titanium will offer an alternative—but isit worth the increased cost? “Clear” brackets arefor esthetics, and only for selected patients. Asfor archwires, do you want torque control early intreatment? I really sound like an old fogey, butthere is nothing in the world of orthodontics thatworks like a heat-treated rectangular stainlesssteel archwire filling the slot to level arches, con-trol torque, and position the roots. This is bestachieved with an .017" × .025" stainless steelarchwire in an .018" slot. Space-age materialswork great early in treatment, but may be tooslow for finishing.

DR. REDMOND I would only add that Ibelieve the next big push in orthodontics will

involve nanotechnology.

MR. VOGELS What are the best adhesives inuse today? How will bonding develop in thefuture?

DR. SANDLER I believe the best adhesiveavailable for bands is Band-Lok Blue,§§ and thebest adhesive available for brackets is 3M’sTrans bond.§§§ The consistency of the paste isunsurpassable, and there is minimal float of thebrackets once placed on the teeth. Light curingwill almost certainly take over completely fromchemical-cure cementing techniques, and indi-rect bonding may become a lot more popular asthe use of orthodontic therapy increases.

DR. MOSKOWITZ The best adhesives inorthodontics are the ones that provide adequatebonding strength and do not present too manyobstacles in their handling. There are many. Butthe real future of orthodontic bonding willrevolve around indirect bonding techniques.These techniques hold the promise of more accu-rate and precise placement of attachments andreduced chairtime. Orthodontic postgraduateprograms should devote more emphasis in thisarea than they do currently. Orthodontic attach-ments are now being manufactured with a greatersophistication than our ability to place theseattachments. The ability of the orthodontist totake full advantage of the prescriptions of these“smart” appliances will greatly depend upon thecapability of precision placement. Direct bond-ing techniques are generically unacceptable tothis end.

MR. VOGELS How much lingual treatment doyou perform? Does lingual orthodontics have afuture in the United States?

DR. REDMOND As a pioneer in lingual ortho-dontics, I found the experience interesting and, Ibelieve, contributory to my sore back. The appli-

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§§Registered trademark of Reliance Orthodontic Products, Inc.,P.O. Box 678, Itasca, IL 60143; www.relianceorthodontics.com.

§§§Trademark of 3M Unitek, 2724 S. Peck Road, Monrovia, CA91016; www.3Munitek.com.

ance has matured since the late ’80s, and hasfound a resurgence outside the U.S.

DR. GLENN I personally perform no lingualtreatment. Because of esthetic demands, espe-cially from adult patients, lingual treatment mayincrease in popularity. Time will tell.

DR. SANDLER I also perform almost no lingualtreatment. There is a small minority of practition-ers in the U.K. who provide lingual treatment. Ithink with the increasing popularity of techniquessuch as Invisalign and the increasing use of esthet-ic brackets, there will not be a burgeoning increasein demand for lingual techniques.

DR. ALEXANDER I had the opportunity tobecome involved in lingual treatment in 1980 andhave been doing it ever since, averaging 10-20cases per year. We now have over 25 active casesin treatment. It is interesting to look at theamount of lingual treatment in the U.S. today ascompared with Europe and Asia. It is much morepopular internationally than it is in America. Butthe future of lingual is great in the U.S.! Becauseof the increased exposure of adult orthodonticsresulting from advertising, patients come to theoffice hoping for Invisalign. Often their maloc-clusion is too severe, so the second option is lin-gual. Lingualcare§§§§ technology is amazing. Italmost makes it simple—but not easy. The brack-et design and preformed archwires are extremelyhigh-tech.

DR. MOSKOWITZ We are doing more lingualorthodontics and suspect that this technology willonly increase in the future. The new lingualappliances are more clinician- and patient-friend-ly, and there is definitely a need for such estheticappliances that are more clinician-directed thansome of the removable clear aligners. The entiresubject of decreased visibility of appliances hasshown all of us that adult patient motivation toseek treatment will in large measure depend upontheir perceptions of the visibility of the appli-ances that we use. The orthodontic manufacturershave realized this and have expended a tremen-dous effort in this direction. The genie is out ofthe bottle, so to speak. It is not a question of

whether the orthodontic specialty will be movingto appliances with decreased visibility (such asInvisalign and lingual orthodontics), but ratherhow quickly these appliances can be refined tothe point where they are delivering clinical out-comes similar to what we know we can obtainwith traditional labial appliances.

DR. CARRIERE Lingual orthodontics has aplace in orthodontic therapy, although the degreeof comfort to the patient is not too high. The onlyway to promote it is by improving the design oflingual brackets. Lingual self-ligating bracketswill be the next step in providing more comfortfor the patient with low forces; for the orthodon-tist, the ligation of wires on the lingual side willbe eliminated, which is a great advantage initself. The new Carrière Lingual Self-LigatingBrackets§ are the most recent devices we havedeveloped (Fig. 4).

MR. VOGELS In what kinds of cases do you useInvisalign appliances? Will these and similar com-puter-designed removable appliances eventuallybecome more common than fixed appliances?

DR. MOSKOWITZ The use of Invisalign hasdramatically increased in our office, and I sus-pect that Invisalign will continue to be used by



Fig. 4 Carrière Lingual Self-Ligating Bracket.

§§§§Trademark of Lingualcare, Inc., 5304 Beltline Road, Dallas,TX 75254; www.lingualcare.com.

§Trademark of ClassOne Orthodontics, Inc., 5064 50th St.,Lubbock, TX 79414; www.classoneortho.com.

both the orthodontist and generalist in the UnitedStates. In fact, Align Technologies has donesomething unprecedented in orthodontics: theyhave been significantly successful in direct mar-keting to the public. Of course, pharmaceuticalcompanies have done this for years. But the pub-lic is demanding Invisalign, and individual adultpatients are calling offices inquiring aboutInvisalign use or going directly to the Invisalignwebsite to find more information, or even to findclinicians using this appliance in their areas. Ifyou want to see just how successful Invisalignhas been, their stock prices, quarterly earnings,and number of cases submitted to Align Tech -nology are all a matter of record. They have alsoexpended great efforts in educating cliniciansand appear to remain sensitive to clinicians’needs, assisting them with internal and externalmarketing strategies. While Invisalign will not

replace traditional orthodontic appliances in thenear future, it is highly likely that the range ofcases that might be treated with the Invisalignsystem will be broadened. No orthodontic clini-cian should ignore the dramatic and sustained in -crease in the number of Invisalign cases underprogress today.

DR. CARRIERE Evidently there is a place forInvisalign appliances, and the more experienceprofessionals gain with “invisible” appliances, themore complicated cases they treat. The de mandfrom patients also has a big influence on appli-ance selection, provided it is adequate for the mal-occlusion they present. I would like to point out anew strategy that opens up a broader use ofInvisalign in cases in which there is a Class IIdentoalveolar relationship. In this group of cases,in a first stage, the Carrière Distalizers are placed

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Fig. 5 Distalizer complementing Invisalign in Class II treatment.

and the maxillary posterior segments moved in ablock to a “Class I Plat form” between canines andmolars. This stage can last from three to fivemonths. Once the Class II is corrected, theDistalizers are removed, and the case can be fin-ished using Invisalign to close the diastemasbetween the maxillary in cisors and canines creat-ed in the first stage (Fig. 5).

DR. ALEXANDER Invisalign can be very ef -fective in correcting mildly rotated teeth. We usethem as “glorified retainers”. In other hands, theymay be used more effectively, but I have neverbeen a big fan of using removable appliances tocorrect major problems.

DR. GLENN My use of Invisalign has beenvery limited. I have used removable aligners suc-cessfully on adult patients with mild crowding orspacing and a good Class I occlusion.

DR. SANDLER I use Invisalign applianceswhere no major contraindications exist—that is,where extractions are not required, where nomajor tooth movements are required, where nointermaxillary retraction is required, and largelyin non-growing patients. From the aforemen-tioned criteria, you can understand that this pre-cludes Invisalign treatment in about 95% ofpatients I am currently providing treatment for. Ifind it very hard to believe that computer-designed removable appliances will ever becomemore common than fixed appliances; however,time will tell.

MR. VOGELS Will nonextraction treatmentcontinue to predominate over extraction treat-ment in orthodontics?

DR. ALEXANDER Yes! The larger question is,“Where should the teeth be at the end of treat-ment?” With anchorage control using Class IIIelastics or temporary anchorage devices, gainingarch length by posterior expansion and interprox-imal enamel reduction, probably 80-90% of ourpatients should be treated nonextraction andachieve stable results. The sad reality is thatmany cases that should have extractions are treat-ed nonextraction. Why? Is it because nonextrac-

tion treatment is easier or the extraction mechan-ics are too difficult?

DR. GLENN Yes, nonextraction treatment willpredominate, because the practitioners and thepublic prefer the broader smiles. However, I feelthat extraction treatment will continue to be usedin cases with severe tooth-size-arch-length dis-crepancies and bimaxillary protrusive profiles. Asa more ethnically diverse patient population seeksorthodontic care, the use of extraction treat mentmay increase in some regions of the country.

DR. REDMOND As more orthodontists give uptheir closely held beliefs regarding the relation-ship between extraction and stability, I believeeven more nonextraction treatment will beattempted.

DR. SANDLER Nonextraction treatment willcontinue to predominate over extraction treat-ment for the foreseeable future. The pendulum isswinging quite a long way in the nonextractiondirection, particularly when used in associationwith self-ligating brackets.

DR. CARRIERE I agree, especially concerningthe increasing use of low-friction self-ligatingbrackets, together with new-technology wires.

DR. MOSKOWITZ Regrettably, nonextractiontreatment will seem to dominate orthodontics inthe future. And the reasons for this are not neces-sarily good. The emphasis on nonextraction treat-



Dr. Redmond

ment has little to do with new techniques orappliances that facilitate such a strategy, butrather a good deal of dogma, practice manage-ment convenience during initial consultations,and our specialty turning not one, but two blindeyes toward the evidence-based information onthe benefits of extraction strategies in selectcases. Additionally, extraction cases are generi-cally more difficult to manage and finish, asnumerous biomechanical concerns have to beconsidered as part of the overall treatment effort.Incisor position, torque, root parallelism, andother considerations place increased technicaldemands upon the orthodontic clinician. We haveto keep the extraction/nonextraction decision as apotential strategy in our treatment protocols andnot as a “goal” of treatment in itself. The vastmajority of quality investigations support theempirical perspective that extraction therapies

indeed have a legitimate place in modern ortho-dontic practice. Gross expansion of cases toresolve severe dental arch-length issues and sig-nificant intercanine width increases have beenshown to be ill-advised for long-term stability.

MR. VOGELS What will be the role of unusu-al extractions such as single incisors?

DR. SANDLER There is going to be an in -creasing use of unusual extractions, such as sin-gle lower incisors and upper canines, as thesedefinitely have a place in adult orthodontics or inany other cases where a compromise treatmentplan is considered appropriate.

DR. CARRIERE Unusual extractions are goingto increase in cases in which facial esthetics canbe damaged with the extraction of the upper bi -cuspids. We take advantage of the different histo-

Fig. 6 Pre- and post-treatment photos of single-lower-incisor extraction patient.

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logical conditions of the maxilla and mandible.Maxillary bone, with a better response, permits anesthetically protective approach. Using the Dis -talizer, we recover the lost and hidden space in themaxillary arch. With it, we can correct a Class IIwithout extraction of premolars, as well as caseswith crowding of maxillary anterior teeth withoutprotruding them. Upper canine distalization givesus the possibility of treating the case with theextraction of only one or two bicuspids in thelower arch; this is a creative approach to reduceextractions and preserve the facial profile. Withlower incisors, we limit it to one ex traction in caseof a Bolton tooth-size discrepancy.

DR. MOSKOWITZ I foresee the use of moreatypical extractions (including lower incisorextractions) as a reasonable compromise in somecases, as the more esthetic appliances (lingualappliances and Invisalign) should advance theirtechnologies shortly to accommodate these typesof cases. We must maintain caveats such asesthetics, function, and stability as guiding forcesin our treatment decisions. If we do just that, wewill find that the extraction strategies have greatbenefits to our patients. I hope that the future oforthodontics will include a critical reexaminationof this entire subject with a little more scienceand a lot less emotionalism and dogma.

DR. ALEXANDER Unusual extractions willalways be an option in selected cases, usually inadults. Extracting a single mandibular incisorcould be recommended when the patient has agood Class I molar occlusion and small maxillarylaterals (Fig. 6).

MR. VOGELS What methods of palatal expan-sion do you use? What devices or techniqueshold promise for the future, in either growing ornon-growing patients?

DR. GLENN I usually use a banded fixedpalatal expander, either Haas or Hyrax‡‡ design.

DR. CARRIERE We use palatal expansion plates

in early mixed dentition cases with crossbite. Incleft-palate cases, we use fixed palatal expanders.

DR. ALEXANDER An all-metal rapid palatalexpander with bands on the bicuspids and molarsworks best for us. This unique design includes aHyrax screw parallel to the first molars, 3mmfrom the palatal tissue and angulated 20° to alloweasier engagement of the key before activation,and an .030" stainless steel wire soldered to thebicuspid and molar bands (Fig. 7). These are verysuccessful in both children and adults.15-17

DR. SANDLER The method of palatal expan-sion that we use in Chesterfield is rapid maxillaryexpansion with or without surgical assistance.The Hyrax appliance, banded to the first premo-lars and first molars, is the most popular tech-nique, and this can be used in growing and non-growing patients. We tend to use surgical assis-tance where the patient is older and has a need fora large amount of maxillary expansion, and wetherefore feel there is a possibility of the mid-palatal suture having ossified.

MR. VOGELS Is growth modification feasible?Will biochemical engineering lead to new pos si -bilities? Will orthopedic therapy continue to beappliance-based, or will other techniques emerge?

DR. SANDLER There is no clinical evidence to‡‡Trademark of Dentaurum, Inc., 10 Pheasant Run, Newtown, PA18940; www.dentaurum.com.

Fig. 7 Rapid palatal expander designed by Dr.Alexander.



date that growth modification can be carried outto a large degree. The randomized clinical trialsorganized over the last 10 years by KevinO’Brien, based in Manchester, have shown that asmall but worthwhile amount of growth modifi-cation is achievable with the use of both twinblocks and the Herbst appliances. It is difficult topredict how biochemical engineering may lead tonew possibilities with growth modification;orthopedic therapy will for the time being con -tinue to be appliance-based.

DR. REDMOND A recent study was done todetermine the possibility of using a naturallyoccurring hormone, relaxin, to determine itseffect on the speed of tooth movement. Althoughthe animal studies were encouraging, but thehuman clinical trial proved disappointing, I viewthis study as a trend in orthodontics directed bythe pharmaceutical companies. Imagine a trans-mucosal medication lining the Invisalign alignersthat promotes rapid tooth movement. Now thatwould be something you could market.

DR. ALEXANDER This is really space-age!When we see such incredible advances in alltypes of technology in the 21st century, we mustsay that it may be feasible. During my lifetime,however, I believe that orthodontics will be appli-ance-based. A quote from my first book, writtenover 20 years ago: “The basic concept of arch-wires placed in brackets to move teeth will, byand large, continue to be the most efficientmethod.” To date, this is still true.

MR. VOGELS What do you see as your role inTMJ and myofunctional treatment? Will ortho-dontists become more or less involved in thesetherapies?

DR. GLENN I feel that it is my role to recog-nize these problems and refer when appropriate.

DR. ALEXANDER The initial exam shouldfocus on TMJ health. If it is a big TMJ problem,we refer. In addition, we routinely teach our“squeezing” and tongue exercises to addressmyofunctional problems.18

DR. SANDLER As there has been no scientific

evidence whatsoever for a very convincing rela-tionship between malocclusion and temporo-mandibular joint dysfunction, I see no major rolefor the orthodontist in the treatment of thesecases. As future scientific studies will reiteratethis lack of relationship, I suspect orthodontistswill eventually become involved in fewer andfewer therapies for this unique group of patients.

MR. VOGELS What do you see as your role intreating patients who need oral and maxillofacialsurgery? How will this multidisciplinary fielddevelop in the future?

DR. CARRIERE The role of the orthodontist isto program correct functional and esthetic dentalarches, to be built on adequate skeletal bases, orcorrected to a Class I by the surgeon in case thisis needed. Surgical procedures are invasive andextensive, for which reason they should be pro-posed only to correct severe skeletal problems.Refined orthodontic techniques permit us to treatmany borderline skeletal problems in a moreorthodontic-oriented approach. Sometimes re -stricted procedures can include minimal estheticsurgery of the soft tissues, such as chin implants,lip remodeling, etc. The patient has the finalword in this election, since surgery is usually per-formed in adulthood.

DR. MOSKOWITZ There is no question thatorthognathic surgery is a procedure that should

Dr. Sandler

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be recommended in a modern orthodontic prac-tice when indicated. The manner in which theorthodontist and oral and maxillofacial surgeoninteract is critical to both facial and dental out-comes. We work closely with oral surgeons andtake a more active role than merely referring thepatient. We also receive referrals from oral andmaxillofacial surgeons, as it is clearly recognizedtoday by the surgeon how important the ortho-dontist’s contribution can be to the overall surgi-cal effort. Details as to the specific requirementsof both the orthodontist and oral surgeon shouldbe discussed prior to beginning treatment. Whatsurgical procedures are contemplated and thecritical presurgical orthodontic decompensationsand other movements that need to be performedare important aspects of successful treatment.The only limiting factor in the future might be thereluctance of insurance companies to actuallycover the surgeon’s fee and hospital costs.

DR. SANDLER I suspect that in the futurethere will be increasing demand for this type oftreatment, and as surgical techniques improve, itwill probably be provided for less severe maloc-clusions, providing the high-standard result canbe almost guaranteed. I think caring for jointorthognathic cases will become a larger part ofthe orthodontic training in the future.

DR. ALEXANDER We have been blessed withincredible maxillofacial surgeons very close toour office and have worked successfully withthem over the years. I agree that this kind of com -bined treatment should get even more popular inthe future as the public becomes more educatedregarding its possibilities.

MR. VOGELS What do you see as your role intreating patients who need prosthetic replace-ments or cosmetic enhancements? How will thesemultidisciplinary fields develop in the future?

DR. GLENN I feel that my role is to work withthe restorative dentist to align the teeth in theoptimal position to make the prosthetic replace-ment or enhancement easier and more successful.Communication between the orthodontist and the

restorative dentist is very important in thesecases. This is an area where digital records havegreatly enhanced our communications.

DR. SANDLER As the adult market increasesin the U.K., there is going to be an increasing roleof the orthodontist in treatment of patients whorequire prosthetic replacement of teeth or cos-metic enhancements of the existing teeth. It isquite possible that orthodontists in the future maysubspecialize as there becomes an increasingneed for this kind of work.

DR. MOSKOWITZ I also believe the orthodon-tist’s role in multidisciplinary treatment willincrease in the future. The orthodontic specialtyis far less insular than it was 30 years ago. Post -graduate training and continuing educationcourses stress our role as legitimate stakeholdersin the overall esthetic effort of improving dentaland facial esthetics in complex adult cases.Ortho dontic education supports this view, as res-idents have a much keener sense of the periodon-tal, restorative, implant, and prosthodontic needsof our patients. My sense is that this en lightenedpath will continue, as we have earned the respectof dental colleagues due to our ability to see thebig picture, as well as to expertly move teeth asmight be required in complex dental rehabilita-tion treatment.

DR. ALEXANDER As orthodontics moves to ahigher level, so do the other dental specialists. Welove working with Pankey-educated prostheticdentists. They can teach us many things. Often,our role is to be the quarterback in coordinatingtreatment plans and sequences, as well as educat-ing other specialists so they can recognize poten-tial future cases.

MR. VOGELS What percentage of your prac-tice is devoted to adult care? Will more adultsseek orthodontic treatment in the next decade,and if so, why? How will emerging technologiesand treatment methods affect this trend?

DR. GLENN Only about 12% of my practice isadult, as my top referrers are the pediatric den-tists in my area.



DR. SANDLER About 10-20% of my practiceis devoted to adult care in the hospital in which Iwork. Many more adults are going to seek ortho-dontic treatment over the next 10 years as we inthe U.K. slowly but surely follow the trends in theUnited States. Today, it is felt that the adult mar-ket is probably less than 5% of the total ortho-dontics practiced, whereas in the United States, Ibelieve it is over 25%. Therefore, there is poten-tially an enormous increase in adult orthodonticsover the next decade or so in the U.K., with theincreasing availability and popularity of Invis -align techniques and ceramic brackets.

DR. CARRIERE Adult care occupies approxi-mately 25% of our practice. The most frequentreasons for their seeking care are improvedesthetics of the smile, a better facial profile, anda desire to have long-lasting masticatory func-tion. In the next decade, new technologies thatare biologically friendly and less conspicuous,and that shorten treatment time with ultralightforces, will promote even more demand in theadult population.

DR. ALEXANDER We have approximately30% adult patients. We have always encouragedadult treatment and will continue to do so. Thepercentage may even increase in the future asolder adults continue to take better care of them-selves and want to look better as they age.Invisalign, lingual, and clear brackets will helpmake treatment more palatable. When dealingwith extraction and mutilated adult cases, tempo-rary anchorage devices will allow the orthodon-tist to produce much better results.

DR. REDMOND My Seattle practice is 98%adults. Many have been treated as teen-agers andrelapsed, and I am retreating them with Invis align.They are knowledgeable and unusually mo ti -vated, and most important, realize the ab solutenecessity of “lifetime” retention.

MR. VOGELS What other demographic changesdo you see in orthodontic practices over the nextdecade?

DR. MOSKOWITZ Without question, the in -

crease in adult patients will continue. In manyorthodontic practices, this increase has alreadyoccurred due to many factors, including a sub-stantially more robust predoctoral orthodonticcurriculum that stresses the inclusion rather thanexclusion of orthodontic services for adults. Butthe explosion of technology with “invisible” ap -pliances probably will account for a continuedincentive for adult patients to seek orthodontictreatment.

DR. GLENN I feel that a more ethnically di -verse patient population will seek orthodonticcare. We will need to be more aware of ethnic andcultural norms and preferences.

DR. ALEXANDER In our practice, we contin-ue to see more home-schooled and private-schooled children. The advantage of having beenin practice for over 40 years is that our No. 1referral source is probably second- and third-gen-eration patients. Since we have kept our patientrecords, this is also a great opportunity to studylong-term stability.

Retention

MR. VOGELS How do you see the long-termstability of cutting-edge techniques such as thosewe’ve discussed?

DR. REDMOND Long-term stability is a myth!

DR. SANDLER The quest for the “holy grail”of orthodontics—the “stable position of the lowerlabial segment”—is probably going to be a fruit-less search. Certainly as the pendulum swingstoward more and more nonextraction treatment,the amount of “orthodontic relapse” seen over thenext decade is going to increase. With the in -creased use of self-ligating systems and Invis -align, I suspect there are going to be a lot of disappointed patients in the future unless theyare willing to wear their removable retainersindefinitely.

DR. ALEXANDER If I have a particular ex -pertise, it may be my studies on long-term stabil-ity.6-9,15,19,20 I believe that long-term stability is not

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a myth! There are specific, evidence-based goals,which, if reached, will place the teeth in positionsthat can have long-term stability. Cutting-edgetechniques can be stable if the orthodontistachieves these goals. The problem is that some ofthese techniques could be moving teeth in thewrong direction when the clinician ignores thesegoals. The bracket does not change biology.

DR. CARRIERE As in conventional orthodon-tic procedures, stability is more related to theindividual characteristics of the treated malocclu-sion. Relapse is multifactorial, and it should betaken into consideration in the diagnostic andtreatment-planning process.

DR. GLENN It is my feeling that, regardless ofthe technique used, expansion of mandibularintercanine width is not stable long-term.6 Long-term retention is especially critical in cases thatviolate this principle.

MR. VOGELS What is your usual retentionregimen? What new retention devices or tech-niques hold promise?

DR. MOSKOWITZ Admittedly, retention is amajor problem in orthodontics. You would thinkthat it would be addressed a bit more seriouslyand less casually than it tends to be in both privatepractice and orthodontic residency programs. Ourusual retention regimen begins with a reexamina-tion of the pretreatment malocclusion. It is obvi-ous that if you had severe mandibular incisorcrowding, this particular area is going to needsome special considerations. For whatever rea-sons, stability in this area is most problematic. Weuse a lot of lower lingual canine-to-canine bond-ed retainers. The overall benefits of such retention(at least in our opinion) greatly outweigh the dis-advantages. Some of these disadvantages includethe ethical responsibility of following post-ortho-dontic patients more formally and for longer peri-ods of time. This might represent a managementissue in some practices. We discuss this aspect oforthodontic treatment up front, and we chargefees (although nominal) for retention visits.Naturally, oral hygiene considerations might rep-

resent another potential disadvantage.Adult treatment should routinely and critically

evaluate the level of supporting alveolar bone.Such cases will frequently demonstrate relapse.Pretreatment severely rotated anterior teeth also rep-resent some special problems in post-treatmentretention. While fiberotomies have been shown tobe helpful for this particular problem, I wonder howmany of us actually prescribe such procedurestoday, and if so, how many patients accept this soft-tissue surgical procedure.

DR. SANDLER My usual retention regimenis removable, thin, clear vacuum-formed Essixretainers worn on a night-time only basis for thefirst 12 months and for alternate nights the sec-ond 12 months, and then reducing to one night aweek over the third 12-month period. At the endof three years of retention, I ask the patient tocontinue wearing the appliances one night aweek if they wish their teeth to remain straight.As the patients get into their late teens and early20s, they have more important things in lifegoing on than the continued long-term wearingof removable retainers; therefore, during their20s a certain amount of tooth movement willalmost certainly occur.

DR. REDMOND Lifetime retention is my usualroutine. I use both fixed and removable appliances.

DR. GLENN For the maxillary arch, I usuallyuse a removable wraparound retainer. For themandibular arch, I use either a fixed canine-to-canine retainer or a removable Hawley retainer.For removable retainers, I recommend full-timewear for the first year, then night-time wear afterthat. I like for the teeth to occlude during reten-tion to allow the teeth to settle into a final occlu-sion after debonding.

DR. ALEXANDER We feel very comfortablewith our present regimen. A maxillary wrap-around circumferential retainer is worn at nightonly from the beginning—every night for oneyear, then as needed. There are no wires crossingthe occlusal surfaces; therefore, the posteriorteeth can continue to have “vertical driftodon-tics” and improve the occlusion. Bonding the



upper 2-2 works well in some cases, rather thanremovable retainers.

In the mandibular arch, an .0215" multi-stranded wire is bonded on the lingual of the sixanterior teeth. This is worn until the wisdom teethare “resolved” (extracted or erupted) and all growthis completed. When the 3-3 retainer is removed,interproximal enamel reduction is performed. If themandibular incisor roots are spread, IMPA hasbeen controlled, and the cuspids have not beenexpanded excessively, the chances for long-termstability are good.

DR. CARRIERE After treatment, our cases areput on “activable retention”. We use a maxillaryupper plate with passive adapted lingual springs,which can be activated, in the anterior segment.In the mandible, we use a hybrid of a Crozat ap -pliance with acrylic buttons on the molars to sup-port the wires; it is passive, but it can be activat-ed if needed.

DR. MOSKOWITZ I began answering thisquestion with the statement that our retentionprotocol begins with a reexamination of the orig-inal malocclusion. To amplify this point a bit fur-ther, let me say that retention considerations real-ly begin (or at least should begin) at the time thatthe orthodontist is developing a diagnosis andtreatment plan. Most experienced orthodontistsshould be able to anticipate most retention issuesprior to the actual orthodontic treatment.

I see the problem of retention remaining withus for quite some time, and I do not see any newtypes of retention devices on the horizon that holdany promise for any one of us. As someone oncesaid, “Retention is more than just a problem inorthodontics, it is the problem in orthodontics”.When we finally learn where teeth are best suitedto be repositioned in our individual patients, we willthen first begin to resolve the problem of retention.Until then, our retention devices are like the littleboy with his finger in the dike: trying to prevent theinevitable.

MR. VOGELS What do you see as the future oflong-term patient management?

DR. CARRIERE Body structures and the stom-atognathic system, treated orthodontically or not,undergo changes throughout life. The fact is thatlife expectancy has increased in the present gen-eration. The attitude of patients has to change interms of developing the maintenance habits topromote good health for a longer time. This alsoapplies to teeth. We propose to our patients tocontinue with the maintenance of orthodonticresults after the retention period with the “acti -vable retention”. After two years of wearing re -tainers, we request them to wear the retainersonce a week, to check for any changes. This islong-term patient management, but this mainte-nance can detect any influence of deleterioushabits or a relapse tendency when it is still possi-ble to recover.

DR. GLENN I think that long-term retentionwill continue to be important for successfulorthodontic results. Patients need to be educatedto the fact that teeth may shift throughout theirlife, whether they have had orthodontic treatmentor not.21 Retainers are the key to keeping post-treatment changes to a minimum.

DR. ALEXANDER “Lifetime retention” is apopular phrase today in orthodontics. If anterior“expansion” continues to be in style, there will bemany opportunities for lifetime retention orretreatment of former patients in the future. Theunanswered question is the long-term periodontalhealth in the area where teeth have been pro-clined, expanded excessively, and held in thatposition over a long period of time. If we focuson achieving certain guidelines for stability dur-ing treatment, then stability should not be a majorissue in most cases. Of the 15,000 patients we’vetreated over the years in our office, less than adozen still return for long-term retainer checks,and these are former adult patients.

DR. SANDLER The future of long-term patientmanagement will be getting the patients used to theidea that their teeth will be straight at the end oftreatment and as long as they are willing to weartheir retainers on a part-time basis. The idea of asecond and even third course of treatment during a

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lifetime should be discussed with them before theinitial course of treatment is undertaken.

DR. MOSKOWITZ In addition, the future oflong-term patient management will rely upon atremendous shift in orthodontic philosophy astaught in our residency programs, practiced in ouroffices, and espoused by the practice-manage-ment gurus. It will ultimately depend upon thedegree that we, as health-care practitioners, arewilling to educate our patients, so that realisticpatient expectations are established early in ortho-dontic treatment and extend throughout the reten-tion phase. It is also related to both clinician andpatient accountability as well as more completediscussions of the risks, benefits, and limitationsof orthodontic treatment. Orthodontists tend toperform their consultations in “poetry” and thentreat in “prose”. Perhaps a little less preoccupa-tion with the glitz of marketing and more of anemphasis on patient education as to the truenature of our services would serve as useful goalsif we are going to establish longstanding relation-ships with our patients—the very same patientsthat will refer other patients to our practices.

Patients should understand that undergoingorthodontic treatment is a long-term commitment,not unlike other forms of cosmetic services thatrequire maintenance and/or revisions from time totime. Appropriate and justifiable fees for follow-up radiographs and maintenance of our treatmentoutcomes should be established for this long-term(and in many cases, life-long) service called ortho-dontics. Orthodontists who continue to compete onfee alone have probably done themselves, theirpatients, and the orthodontic specialty a tremendousdisservice. Retention, in my opinion, and long-termmanagement of our patients are the “forgottenphase” of orthodontic treatment. My views on thissubject, I hope, will not be perceived as elitist, butrather as more of an ethical imperative for all of us.

REFERENCES

1. Carrière, J. and Carrière, L.: Softlanding Treatment throughInverse Anchorage and virtual reality, J. Clin. Orthod. 29:479-486, 1995.

2. Baumrind, S.; Korn, E.L.; and West, E.E.: Prediction ofmandibular growth rotation: An empirical test of clinician per-formance, Am. J. Orthod. 86:371-386, 1984.

3. Houston, W.J.B.: The current status of facial growth prediction:A review, Br. J. Orthod. 6:11-17, 1979.

4. Houston, W.J.B.; Miller, J.C.; and Tanner, J.M.: Prediction ofthe timing of the adolescent growth spurt from ossificationevents in hand-wrist films, Br. J. Orthod. 6:145-152, 1979.

5. Tanner, J.M.; Whitehouse, R.H.; and Takaishi, M.: Standardsfrom birth to maturity for height, weight, height velocity, andweight velocity: British children, 1965, Arch. Dis. Child.41:454-471, 1966.

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8. Elms, T.N.; Buschang, P.H.; and Alexander, R.G.: Long-termstability of Class II Division 1 non-extraction cervical facebowtherapy: I. Model analysis, Am. J. Orthod. 109:271-276, 1996.

9. Elms, T.N.; Buschang, P.H.; and Alexander, R.G.: Long-termstability of Class II Division 1 non-extraction cervical facebowtherapy: II. Cephalometric analysis, Am. J. Orthod. 109:386-392, 1996.

10. Sproul, P.W.; English, J.; Corbett, J.A.; Gallerano, R.L.; andMinkoff, R.: A cephalometric comparison of cervical headgeartreatment in maxillary protrusive versus mandibular retrusiveClass II patients, thesis, University of Texas Dental School,Houston, 2000.

11. Hansen, K.: Treatment and posttreatment effects of the Herbstappliance on the dental arches and arch relationships, Semin.Orthod. 9:67-73, 2003.

12. Carrière, L.: A new Class II distalizer, J. Clin. Orthod. 38:224-231, 2004.

13. Pardo, B.; De Carlos, F.; and Cobo, J.: Distalizer treatment ofan adult Class II, division 2 malocclusion, J. Clin. Orthod.40:561-565, 2005.

14. Banach, T.; Wnuk, P.C.; and Pasin, E.: Klinische Anwendungdes Carrière Distalizer, Kieferorthop. 20:105-110, 2006.

15. Ferris, T.; Alexander, R.G.; Boley, J.; and Buschang, P.: Long-term stability of combined rapid palatal expansion-lip bumpertherapy followed by full fixed appliances, Am. J. Orthod.128:310-325, 2005.

16. Alexander, R.G.: Adult rapid palatal expansion, World J.Orthod. 1:157-163, 2000.

17. Buschang, P.H.; Horton-Reuland, S.J.; Legler, L.; and Nevant,C.: Nonextraction approach to tooth size archlength discrepan-cies with the Alexander Discipline, Semin. Orthod. 7:117-131,2001.

18. Parks, L.R.; Buschang, P.H.; Alexander, R.A.; Dechow, P.; andRossouw, P.E.: Masticatory exercise as an adjunctive treatmentfor hyperdivergent patients, Angle Orthod. 77:457-462, 2007.

19. Carcara, S.; Preston, C.B.; and Jureyda, O.: The relationshipbetween the curve of Spee, relapse, and the Alexander disci-pline, Semin. Orthod. 7:90-99, 2001.

20. Bernstein, R.I.; Preston, C.B.; and Lampasso, J.: Leveling thecurve of Spee with a continuous archwire technique—A long-term cephalometric study, Am. J. Orthod. 131:363-371, 2007.

21. Sinclair, P.M. and Little, R.M.: Maturation of untreated normalocclusions, Am. J. Orthod. 83:114-123, 1983.



JCO ROUNDTABLE The Future of Orthodontics

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