Everything in life requires equilibrium. If we think about the functioning of our bodies, for example, we will realize that deviations for more or less in certain physiological variables may cause serious consequences for general health. If excessively low blood pressure is incompatible with life, due to the inability to boost blood to noble organs such as the brain and kidneys, the same can be affirmed in relation to abnormally high values of this variable. Heart attacks and strokes, to name only the main, are some conditions associated with hypertension and a higher risk of death.

Thus, attitudes such as balancing, evaluating, pondering and controlling normally constitute actions related to good results for the maintenance of body health. Extrapolating this physiological philosophy to our professional health, I believe that our decision making regarding the need for technical-scientific improvement should also be guided harmoniously.

That is, when you go to a very high-reputation Congress, such as the annual session of the American Academy of Orthodontists (AAO), I do not think it’s prudent to close your eyes to the countless technological advances available for the development and distribution of new orthodontic appliances, although most of these have not been judiciously tested with the scientific rigor required. On the other hand, embarking on the wave promoted by companies and marketing and technology gurus without proper care can bring you great disappointments.

These are my reflections coming from my participation in this year’s Congress. I attended several lectures carefully, seeking to collect useful and impartial information to share with my audience. After all, this is one of the missions of our blog, and I feel that it is quite urgent and necessary. The division (and even a certain friction) between the most conservative and the most modern speakers has been clear on several occasions. I will illustrate the difficulty we have in reconciling the activities based on marketing with those based on science, throughout some observations found in the three main themes of the event.

  1. AESTHETIC ALIGNERS

While the modern side-represented mainly by renowned specialists-exalted the possibility of obtaining qualified results using the appliances of the moment (clear aligners), the most conservative side-represented mainly by academic professors-emphasized the scarcity of scientific evidence on the aligners and pointed out the possible side effects arising from its misuse, such as inappropriate use of intermaxillary elastics, lack of vertical control and unfavorable changes in condylar position. The most enthusiastic defenders of the aligners highlighted that these devices constitute vehicles different from the usual. That is, if we compare a conventional fixed appliance to a car, the aligner would be a speedboat. Therefore, vehicle control requires very different knowledge and skills. In addition, the location indicated for each vehicle is also different. Thus, it is up to the pilot (orthodontist) to know the peculiarities of his car or speedboat in order to use it in the best possible way, and in the places (malocclusions) indicated. I liked the analogy, because I think it illustrates well the need of the professionals to know and understand the tools they are using, including its indications and limitations.

 Illustration inspired in the lecture “Customizing Aligners to Move Teeth Like Wires, by William Dayan”.

 

Another specialist in clear aligners also stressed the importance of the professional to be aware of the details that involve the sequential planning of orthodontic movements. According to him, the appliances are developed by advanced artificial intelligence systems, however the orthodontist must follow the plans for each case. On the other hand, a renowned international researcher began her lecture highlighting that there is practically no artificial intelligence behind the development of aligners. According to her, the use of technologies does not necessarily constitute artificial intelligence, after all this represents a highly complex field of study aimed at the use of mechanisms or softwares capable of performing intelligent actions similar to human beings. The teacher emphasized the importance of human knowledge in the development of qualified research in several areas of the specialty, including craniofacial growth, biology of tooth movement and imaging. She pointed out that orthodontics should be practiced whenever possible based on the solid and complex scientific fundamentals built (and still under construction) by the bases of the specialty.

In order to conclude this part about aligners, there was also divergence regarding the effects of these devices on mandibular advancement. According to the companies and key opinion leaders, these appliances are more effective than the other mandibular protractors for Class II correction, and they also have the ability to stimulate mandibular growth in selected cases. However, shortly after the presentation of a defender of this opinion, another researcher demonstrated that there is currently no scientific evidence to support these two statements.

  1. OBSTRUCTIVE SLEEP APNEA (OSA)

The high severity of this medical condition encouraged me to attend all possible lectures on the subject. I highlight the presentation of Professor Rolf Behrents, editor-in-chief of the American Journal of Orthodontics and Dentofacial Orthopedics, in which he synthesized the findings referring to a task force aimed at investigating the role of orthodontist in the OSA. I strongly recommend reading this full article published by the AAO, because in this post we have no space to address the topic with the deserved detailing.

In the mentioned article, you will have the opportunity to better understand the concepts and prevalence of this condition in both children and adults. You will also understand the main causes, consequences, risk factors, methods of diagnosis and treatment of this important disease.

Briefly, the authors conclude that orthodontists cannot prevent, cause or cure apnea. Our main goal is to carefully examine the patient in search of signs and symptoms of this condition, preferably using valid tools for this purpose, so that patients can be properly referred for medical treatment when needed. Finally, we should participate with the appropriate orthodontic/surgical treatment when applicable, always in consent with the physician responsible for the case.

Despite this task force well organized from the technical and scientific point of view, in the Congress I was surprised by several companies and colleagues promoting themselves as practitioners of the airway friendly orthodontics, a concept highly questionable and well discussed by Professor Kevin O’Brien’s blog (suggested reading n.6).

  1. SKELETAL ANCHORAGE

I finalize this post highlighting the continuous and growing search for more practical and efficient methods of skeletal anchorage. The lectures on the theme were the most sought during the Congress. In the presentation of Professor Chris Chang, for example, there was no place to sit on the floor! As usual, Dr. Chris gave a show of didactics and charisma in his lecture on gingival smile treatment with mini-implants. In its basic protocol, he recommends the use of extra-alveolar screws, installed in the infrazygomatic crest, associated with anterior mini-implants to obtain the maxillary intrusion/distalization. The teacher provided important tips on the knowledge and management of the biological space of the anterior region, so that excellent aesthetic results are achieved, and ended by highlighting in a tone of play the utmost ease with which the screws allow the solution of complex cases. In his words: “It is SOOOO EASY!”.

Joking aside, I emphasize the care we should have in promptly following tips from more experienced professionals. In the case of mini-implants installed in the infrazygomatic crest, for example, you should be very careful if you choose to use it. At this point, we have noticed a clear divergence with a more scientific-based recommendation. According to Professor Sebastian Baumgaertel, in his very useful presentation about sites for the installation of mini-implants, the insertion in the infrazygomatic area is not an excellent and easy option, since the maximum bone depth in areas outside the reach of the roots is almost always smaller than the mini-implants of more than 6 mm! This means that the chance of you perforating the maxillary sinus is almost 100%! In fact, the incidence of maxillary sinus perforation with this type of screw is about 80%. Although small perforations do not imply the failure of the installation in most cases, there is a greater risk to the development of sinusitis in these situations. Therefore, a judicious analysis of the region before the installation of the mini-implant is highly indicated.

 

 

 

CBCT showing maxillary sinus perforation (reference n.4)

 

 

In conclusion, I believe we should follow in search of technological advances and protocols that can effectively optimize our clinical results. To do so, we cannot lose the equilibrium by leaving the balance overly focused on marketing-based actions. All of us, teachers, researchers, students and patients deserve a more balanced, prosperous and healthy future. Let’s do our part.

Recommended reading:

1- The AAO white paper about the role of orthodontist in OSA.

2- Baumgaertel S, Hans MG. Assessment of infrazygomatic bone depth for mini-screw insertion. Clin Oral Implants Res. 2009 Jun;20(6):638-42.

3- Baumgaertel S. Hard and soft tissue considerations at mini-implant insertion sites. J Orthod. 2014 Sep;41 Suppl 1:S3-7.

4- Jia X, Chen X, Huang X. Influence of orthodontic mini-implant penetration of the maxillary sinus in the infrazygomatic crest region. Am J Orthod Dentofacial Orthop. 2018 May;153(5):656-661.

5- Motoyoshi M, Sanuki-Suzuki R, Uchida Y, Saiki A, Shimizu N. Maxillary sinus perforation by orthodontic anchor screws. J Oral Sci. 2015 Jun;57(2):95-100.

6- Posts about breathing, from Professor Kevin O’Brien’s blog.