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Don't Force It

In this issue of JCO is an article by Dr. Robert Cash about an apparatus developed several years ago by Dr. James Jasper of California. To my knowledge, this is the first article published in any journal on the Jasper Jumper, an innovative mechanism for applying Class II or Class III forces without relying on headgears, face-masks, or elastics. The article simply shows how the appliance was useful in successfully treating one adult patient. Nevertheless, it illustrates one more effort by orthodontists to overcome patients' reluctance to cooperate.

As I visit with orthodontists around the country, I find more and more interest in force systems that can be placed and kept in patients' mouths without relying on their compliance. Some of my older colleagues believe kids are less disciplined today than in the past. They swear that youngsters used to be more cooperative. I really don't know whether that impression is accurate, but there is no doubt that the orthodontic patient population has changed radically over the past 30 or 40 years.

Orthodontics is no longer limited to a small segment of the public. Third-party insurance programs, lower fees relative to average earnings, and an increased appreciation for the benefits of treatment have greatly enlarged and diversified our patient community.

No less a scientist than Sheldon Baumrind of the University of California tells us that children are entering adolescence earlier than ever before. Many of the youngsters we treat are entering puberty sooner and staying there longer. Our unenviable task is to treat them when surging new hormones are changing every physical and emotional feature they have.

We know from the work of Chase and Thomas (Know Your Child, Basic Books, New York, 1987) that many people are born with a low sensitivity threshold and remain supersensitive throughout their lives. When we put brackets, bands, and wires on the teeth of such patients, they will tug at, pull on, and generally abuse our appliances until they free their sore teeth from our intraoral traps. And if we submit their teeth to permissive, intermittent forces such as headgears and elastics, they aren't likely to wear them enough to implement our treatment plans. Intermittent forces are much more uncomfortable than steady, continuous ones; if given a chance, the sensitive patient will find frequent excuses for not enduring them. It is the equivalent of sending a strawman to put out a fire.

Curative chats with orthodontic miscreants have not been very productive for me, nor has the inclusion of the parents in these discussions. In fact, most parents start avoiding the office if they suspect they will have to endure one more lecture on the necessity for proper oral hygiene, the virtues of headgear wear, or the efficacy of elastics. It may be my lack of persuasive ability, but judging from the wide sample of transfer patients I have treated, most of us are experiencing the same problems in eliciting patient cooperation.

This is why I prefer force systems that are applied on a permanent basis, such as the cemented Herbst, the molar-distalizing Nance Arch Appliance, or the Jasper Jumper. These appliances don't confer automatic patient acceptance, because there isn't anything we put in the mouth that can't be broken if a patient is resourceful enough. But these permanent force systems are so much better tolerated that I can hardly ignore them.

Orthodontists certainly will not be satisfied with anecdotal evidence, and I'm hoping that some serious studies of the Jasper Jumper will be forthcoming, as they were with the Herbst and other functional appliances. The profession must have extensive and reliable information before any technique or instrument can be become a common part of our armamentarium. Nevertheless, the more clinicians who use these constant-force, non-permissive appliances, the more likely it is that we will refine them into streamlined, comfortable, reliable, and affordable systems that benefit everyone.

Pioneering has always been a risky business--those who charge ahead usually take many more arrows than later arrivals do. But orthodontic pioneers push the envelope of scientific knowledge and expand our professional universe. I'm grateful for people such as Emil Herbst and James Jasper, who combine their inquisitiveness with positive action on behalf of patients and colleagues.


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