Exaggerated actions to solve minimal problems. This may be an interpretation of the phrase that entitled our post, attributed to the Chinese philosopher Confucius. But what does it have to do with our profession?
I have decided to write about this topic because I am concerned about the current trend towards the search for fast, simplified and standardized orthodontic treatments. When during a congress, a key opinion leader suggests a sequence of wires, for example, one often notices a stirring of listeners, worried about not missing out on that important tip. However, this excessive preoccupation with fast and spaced visits may not effectively solve most of the orthodontic clinical cases. I am referring to the increasing number of adult patients in whom complicating factors such as multiple losses, asymmetries, and periodontal problems are often the rule, rather than the exception. That is, in patients in whom the influence of the craniofacial growth and development process is minimal, the influence of the professional becomes maximal. It is not enough to select our appliances based on two or three standardized prescriptions, and wait for a sequence of archwires and the use of intermaxillary elastics to solve complex problems.
First of all, we should be concerned with the diagnosis and planning of cases. In fact, these steps should not be underestimated even in seemingly simple cases. In all patients, the professional must be aware to the skeletal, dento-alveolar and muscular components of each malocclusion, as well as to the bone and periodontal limitations of each individual case. In addition, treatment goals should be well established from the outset, preferably on the three planes of space. These are the minimum reflections necessary for the professional to evaluate the need to apply a more customized mechanics, or to consider the possibility of a simpler and more conventional mechanics.
Even in simple cases, the professional should make an individualized treatment plan, so as not to run the risk of being part of the “Fast Food Orthodontics” network, in which a standardized sequence of archwires with a generally expansive and aligning purpose, usually ends with the exaggerated use of intermaxillary elastics and a questionable intercuspation. Unfortunately, this prescription has grown frighteningly in recent times, including with the participation of general practitioners who judge themselves able to practice orthodontics with great ease.
I finish the post with an extremely simple and very common case: a patient with a good posterior occlusion and a complaint of crowding in the dental arches. I chose the case because the patient’s posterior occlusion was similar to that considered ideal by Andrews (Image 1). However, mild crowding in the lower region made the patient very uncomfortable, reporting a rapid progression of the problem. In an inter-incisal view, we can see the interference of the lower crowding in the upper arch, which was also worsening according to the patient’s report (Image 2).
Photo 1: Posterior occlusion with conditions close to the ideals described by Andrews. Photo 2: Interference of lower crowding in the upper arch
The application of a “Fast Food Orthodontics” in this extremely simple case would be like using a cannon to kill a mosquito. The application of an expansive conventional mechanic in the upper and lower arches would resolve the slight crowding, at the expense of at least temporary changes in the posterior occlusion of the patient. In addition, the lack of a fundamental analysis (intra-arch dental discrepancy or Bolton’s analysis) could prevent obtaining adequate anterior functional guides.
In the present case, there was a slight excess of dental material in the antero-inferior region, which was resolved with a slight stripping. The partial appliance was installed in only eight lower teeth (passive bonding in premolars), so that a simple sequence of archwires (.013 CuNiTi, .014 SS, 16X16 CrCo and 17X25 SS with torque on 31) was able to solve the problem. in four months of treatment (Image 3).
Image 3: Basic treatment sequence included 1) stripping, 2) initial alignment with superelastic wires, 3) final individual torque with SS wire. 4) after treatment
No appiance was mounted on the upper arch, and note how the mild upper disalignment was solved only with the muscular forces of the lips (Photo 4).
Photo 4: Upper occlusal view of before and after treatment (the appliance was mounted only in the lower arch)
This case was solved with a minimally invasive orthodontics, without altering the teeth that were well positioned, without altering the posterior occlusion that was adequate and without altering the patient’s masticatory function. Well planned invisible aligners would also be an option for this simple case. The problem, therefore, lies in planning. Not planning properly, even in simple cases, can increase the firepower (damage) of our weapons (appliances). If this can happen in simple cases, imagine in more complex cases …