Will Implantology Set Us Free?
In an earlier career as a sports writer, I came in contact with a large number of players and coaches. I often recall the lament of one major college coach that his livelihood and the well-being of his family depended on the efforts of a bunch of 18- and 19-year-old kids. Orthodontists are in the same boat. The success of our treatment, and to some extent our family's standard of living, depends on the efforts of pre-teen kids in many instances and on the extent of patient cooperation at all ages.
Being able to recognize uncooperative patients in advance is a will-o'-the-wisp that orthodontists have pursued for a long time. Claims have been made that this or that instrument or personality evaluation was effective in weeding out uncooperative prospective patients. However, to my knowledge, the instrument or technique that can accomplish this consistently and effectively has yet to be devised.
In my experience, if a prospective patient is obstinate in refusing treatment, it is prudent to pay attention. Not all of them mean it, but it is only possible to separate those who do from those who don't after their treatment has started. In the current state of orthodontic practice, with few having the luxury of waiting lists, orthodontists lean toward accepting patients whenever they can. Still, it would be advisable to accept them only on a tentative basis, with adequate escape routes.
It may be unreasonable to expect that any young child can be so future-focused as to sustain a high level of cooperation for treatment that may take 18 to 24 months or longer. Longer, certainly, if you include retention. Considering the checkered experience of orthodontists as behavior modifiers, when treatment works it almost seems as if we are the happy recipients of favorable growth, or that our patients are better cooperators than we sometimes give them credit for.
With the deck apparently stacked against us, the results that orthodontists have been able to achieve are remarkable, especially since we have a long history of presenting orthodontics as a cooperative effort. Most orthodontists have been brought up to think of orthodontic outcomes as patient-achieved, with some help and guidance from the orthodontist. The typical orthodontist says to the patient, "The quality of your treatment results rests with you and your cooperation. The better you cooperate, the faster and better your treatment result will be. I can tell you what needs to be done, but you need to do it. I don't achieve the necessary correction, you do. I don't perform this treatment for you. It is something we do together."
Now there seems to be a growing tendency for orthodontists to diminish the need for patient cooperation and actually accept the responsibility for the orthodontic correction almost exclusively--actually performing the treatment for the patient, not with the patient. In the past, many cases of poor cooperation were treated with the removal of upper bicuspids, followed by the retraction of the upper anterior segment. Recently, we have seen the introduction of a number of appliances aimed at reducing the need for patient cooperation--the Jones Jig, Jasper Jumper, and Herbst appliance, to name a few.
Eliminating the need for patient cooperation can result in more controlled tooth movement and shorten treatment time. The danger in the indiscriminate use of these appliances lies in their own limitations. For the most part, they should be looked upon as ways out of unproductive treatment of uncooperative patients. They may be handy extra arrows to have in the quiver, but they should not be used without careful diagnosis and awareness of what they can and cannot do. Frequently, they may involve compromises that one would not accept if one could be assured of a cooperative patient working assiduously on an ideal treatment plan.
In the April 1983 issue of JCO, Drs. Creekmore and Eklund published an article entitled "The Possibility of Skeletal Anchorage". They presented a case in which Dr. Eklund, an oral surgeon, inserted a screw in the upper anterior midline, following which Dr. Creekmore used the screw as anchorage to open a severely closed anterior bite. The treatment appeared to have no adverse effects, and the authors stated that their purpose in presenting the case was "to pose the question--'Might skeletal anchorage be applied to orthodontic tooth movement and orthopedic jaw movement?'--and to stimulate an appropriate in-depth investigation in the hope that skeletal anchorage might be validated as a safe and effective procedure in orthodontics."
Since 1983, there has been considerable research and clinical investigation of endosseous implants and, recently, a few published articles from Dr. Roberts of Indiana University on the use of endosseous implants as anchorage for orthodontic tooth movement. We are fortunate to have in this issue of JCO a clinical article by Dr. Roberts and associates on the use of an endosseous implant as anchorage to close a mandibular first molar extraction site. More experience with this technique is needed, but it does show promise of offering orthodontists another way of controlling orthodontic tooth movement without the need for patient cooperation.