Article
I genuinely believe that orthodontics is relatively straightforward. A standard course of treatment should take 2 years, give or take, providing that it is started at the appropriate time and the rate limiting steps are identified every visit.
Admittedly, I had the benefit of a traditional orthodontic education at the Eastman Dental Institute, followed by a lively 5 years as a Senior Registrar at the Royal London Dental Hospital and Southend Hospital, working with some of the best clinicians in the land. During my training, I was taught to thoroughly assess a case, carry out a cephalometric appraisal and a space analysis to allow the problems to be quantified, write a problem list in order of importance and come up with a plan to address each and every problem in the correct order.
During treatment, I learned to reassess the case at every visit, specifically to identify the feature of the malocclusion that was furthest from the finishing line (the rate limiters) and to address that specific issue, if nothing else. I understood that unless that ‘limiter’ was explicitly addressed, then irrespective of whatever else was dealt with during the visit, the patient would be no nearer their debond appointment. Don't talk to me about the centrelines (a complete obsession of a number of dental schools) when the patient is only halfway through space closure and when there are still so many much more important aspects of the malocclusion to address.
I hear stories of audits of average orthodontic treatment times coming in at over 4 or 5 years, which I find unfathomable… until you hear how the patients were ‘cared for’. Years perhaps, using removable appliances as a precursor or alongside fixed appliances. Why would you, I ask myself? Or cases referred to orthodontic therapists with the prescription ‘straighten the teeth’ with little further input on a regular basis from the supervising practitioner. I hear of cases ‘shared’ in practice, where whichever clinician is free will take over the next patient waiting, and no named clinician is responsible for the overall care. All of these approaches are, in my opinion, doomed to take ages to complete and could be considered failures if an efficient and effective course of appliance therapy is your measure of success.
Also, this new trend to aligners first is another travesty in my view, just lengthening the time patients have to wear braces. The thought of burdening some poor child who is at a completely normal stage of dental development (learn the eruption times, order of teeth emergence and normal physiological changes – and educate the parents accordingly) and persuading them and their parents of the ‘advantages’ of a course of invisible braces during the mixed dentition is, how can I put this nicely… oh, I cant! Obviously, there are benefits… But, sadly none of these go in the patient's direction. It is unnecessary at best and achieves very little for the patients. They will still require a definitive 2-year course of orthodontic treatment when in the permanent dentition, if indeed orthodontics was indicated at all.
We owe it to all of our trainees first and foremost how to spot which aspect of the malocclusion is determining the overall treatment time, and to teach them well how to fix this. Approaching training in this fashion, we can show them how to finish even a moderately difficult malocclusion within the 2-year mark.