Great Expectations
Sir Isaac Newton is supposed to have said, "If I have seen further, it is by standing on the shoulders of giants." One of the contributing authors to this issue of JCO, Dr. Jim Hilgers, describes a similar experience when he outlines the development and use of a new palatal expander for treatment of Class II malocclusions.
Hilgers generously borrows from and, just as generously, acknowledges his indebtedness to such orthodontic pioneers as Hays Nance, Robert Ricketts, and Andy Haas in the evolution of this truly helpful appliance. He has perceived--correctly, I think--that many Class II malocclusions are thinly disguised posterior crossbites, and that if the upper posterior teeth don't expand adequately, a crossbite will develop as the posterior occlusion approaches Class I. More often than not, such patients display narrow, tapering upper jaws with high palatal vaults. If one moves the models into or near a Class I occlusion, the posterior crossbite becomes apparent. Many of these cases need distalization of the upper molars and subsequent retraction of the upper anterior teeth, but the distalization carries with it the threat of crossbite if the upper arch isn't simultaneously expanded.
I imagine most orthodontists who move upper molars distally have experienced this type of iatrogenic crossbite. In my practice, it seems to happen most often when I use compressed coil springs against the upper first molars. Headgears and most functional appliances, on the other hand, have a built-in capacity to encourage expansion. Unfortunately, they also require cooperation from the patient.
Some orthodontists apparently have mesmerizing motivational skills that can easily bring reluctant patients into compliance. I refer to these people as orthodontic Lindberghs, because the practice of orthodontics fits so well with their personalities that if the specialty hadn't existed, they would have invented it. But in talking to people from all over the world, I have found that such persuasive skills are exceptional.
Charles Lindbergh could fly by the seat of his pants with almost unfailing intuition. Most pilots, however, need all the training, charts, and guidance they can get. It's a good thing that airlines don't rely on pilots' intuition to get us from one destination to another; rather, they use dependable and relatively simple systems that work reliably with ordinary pilots.
The same is true of orthodontists. We need more reliable systems that help us move patients predictably from malocclusion to health--without their cooperation, if need be.
A pathologist friend told me recently that a new survey of cancer patients showed no more than 30 percent compliance with the prescribed therapies. If 70 percent of this patient population is unwilling to cooperate in battling a life-threatening disease, perhaps we shouldn't be too surprised to find our patients reluctant to hurt themselves with rubber bands, headgears, and other intermittent, patient-controlled devices that we routinely prescribe.
Even parents nowadays seem to expect us to achieve success without their children's participation. When confronted with my pleas for more help from home, many parents give me the feeling that they don't want to be bothered, as if to say, "Isn't that what we're paying you for?"
Jim Hilgers admits that patient compliance often fails to match what successful orthodontic therapy requires. So out of either inspiration or frustration, he has developed an appliance that needs no extraordinary effort from the patient. It has a simple design, is cemented in place, and effects substantial improvement where needed. I think it may be as important as the headgears, Class II elastics, and various bite jumpers we have come to rely upon.
Whether we like it or not, patients and parents today tend to believe that doctors and their modern technologies should deliver successful results regardless of patient behavior. The Hilgers Palatal Expander is one more useful instrument that will help us meet those great expectations.