Orthotown May 2022 - 12

second opinion
Notes on arch
development
Another key is that
there is no evidence and
no reason to believe
that these nonorthopedic
" arch development "
or tipping movements
are any better done for
the patient in Phase I
than they are if just done
in Phase II. At best, these
KOLs are doing something
early that should be done later.
At worst, this early treatment may
cloud our diagnosis at the beginning of
Phase II and cause us to incorrectly treat
some patients without extraction. I have
recently seen examples of this overdevelopment
or overtipping being done to patients
in a way that made me feel sick.
We are now at a point where partial
there are zero prospective randomized controlled
trials published in peer-reviewed
journals to justify this claim, so it must be
presumed false until proven otherwise.
What does this mean for this third condition
for Phase I treatments? This means
that when we " develop the arch " with braces,
wires, arch forms, removable appliances
or clear aligners, we are at best tipping the
crowns to the facial. Despite how pretty
the pictures look, we are not growing the
bony base and we aren't creating space.
However, these treatments are not necessarily
bad! Sometimes lingually inclined
posterior teeth need to be uprighted and
the arch " developed " within limits. However,
there is a limit to how much this can
be done and still keep the roots in the bone
without causing dehiscence or fenestration.
Among the shames of our profession
is that this sometimes acceptable limited
movement has been taken to extremes in
order to attempt non-extraction treatment
with patients.
12 MAY 2022 // orthotown.com
braces (2-by-4s), many appliances, and
clear aligners are seldom justifi ed to be
done because of this third condition.
However, we frequently see doctors
treating and posting Phase I aligner cases
where aligners are used in the mixed dentition
to bring teeth into the arch for no
other purpose than to relieve the current
crowding. Once admiration of the results
subsides, the postings and statements seem
to center around how much to charge, the
profi t per visit, and how this can sometimes
be timed so that both Phase I and Phase II
are within a single fi ve-year billing period.
Instead, the fi rst and main question we
need to ask ourselves is: Why this is even
being done in the fi rst place? Is it being
done because the patient is benefi tting, or
because a company and KOL are benefi tting?
All too frequently, I believe the answer
is the latter.
Demand evidence
Partial evidence for when we see this
is the actual lack of evidence or records.
While a KOL should be expected to have
thousands of fully completed cases to show,
rarely will we see complete records for any
time point, and possibly never for all time
points, pretreatment, post-Phase I, and
post-Phase II. If these KOLs are treating
thousands of these patients, why aren't they
presenting full records for all time points?
In answer, I'll share a phrase used by my
friend Dr. Mark Wertheimer: " selection for
projection. " That is, nearly any treatment
can be made to look appropriate or well
done if only selected records are presented.
I do believe that Phase I treatment is
sometimes very benefi cial. and sometimes
should not be done. Depending upon the
circumstances, this can be best done with
braces, appliances and clear aligners.
There are corporate interests at play
trying to guide us into doing these treatments
on patients when it is not appropriate.
We need to see this for what it is, resist
it and do what is right for our patients. Determining
the best treatment for patients is
something that should leave us constantly
questioning. Doing what we believe at the
time is best for our patients is something
that should never be questioned.
Dr. Robert Kazmierski graduated from
the University of Pittsburgh in 1983 with a
bachelor's degree in philosophy. Afterward, he
attended the University of Pittsburgh School of
Dental Medicine and graduated in 1987 with
a DMD degree and a certifi cate in anatomy. He
completed his orthodontic residency in 1989 at
Washington University in St. Louis. Kazmierski
has a special interest in treating orthognathic
surgery patients and open-bite patients. ■
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Orthotown May 2022

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