Are We Adapting Technology to Treatment, or Treatment to Technology?

Sometimes technology is a better way to do the wrong thing. Be careful!

Dr. Bill Arnett | FABKnoweldge

With the recent growth and explosion of important technologies in 3D printing and scanning, we are also seeing a concomitant quantitative “explosion” of cases – mostly shared through social media – that are being treated through adapting these technologies to the manufacturing of customized appliances. This is an excellent and most welcome advancement for sure, yet it does seem – at least to me and a number of like-minded colleagues – that we are going through a period of initial hyper-excitement over the capabilities we have at hand at the moment, and that many seem to be using them practically on every patient they treat, simply because they can! The above quote from Dr. Bill Arnett is a real philosophical eye opener. Although he is an avid user of new technologies in the field of Orthodontics, he is very much aware of the potential pitfalls.

To give one obvious example; recent technological advancements that have allowed us to easily design and fabricate customized RME appliances in-house, along with the popularity of orthodontic mini-screws, seem to have got many people so excited that now almost every other patient starting treatment at their clinics gets a MARPE appliance to expand the maxilla! We are seeing regular social media posts, each with images of 6, 8, or 10 different 3D-printed maxillary models at a time – many of them often appear to be wide broad arches to begin with – that have nicely-designed, shiny MARPE appliances awaiting to be “screwed-in” to patients, many of them as young as 7 or 8 years old.

Of course, those of us who have many years of orthodontic practice under their belts know that there has always been a certain percentage of patients who require RME and the like, yet, with what we see today it seems that we have been mis-diagnosing most of our cases over the past couple of decades!

The question long on my mind is: Where did all these abnormally-large numbers of patients requiring rapid maxillary expansion treatment suddenly come from? … Does every young patient entering the clinic require a transverse skeletal modification? Do the majority of kids today suffer from obstructed airways? Are we going back to the days of – or schools of thought that encourage – indiscriminate skeletal expansion for every case without taking the time to do a proper diagnosis and evaluate our treatment choices?

The other question that comes to mind: If we have a choice between two, seemingly equivalent treatment modalities with marginal long-term advantages over one another, why wouldn’t we go for the obvious choice of the “less invasive” one? .. In other words; If RME is truly needed in all these patients, why aren’t “conventional” RME expanders used instead? or at least conventionally-bonded Expanders that have been designed and fabricated utilizing the same technology? They would certainly be simpler and much less invasive for an 8 year-old should they actually require that sort of treatment. This older, popular post discussed the notion of productive simplicity in Orthodontics.

Luckily, researchers are picking up on this and recent research is beginning to investigate this trend. One such recent RCT study published in the European Journal of Orthodontics by Bazargani et al in 2020, has evaluated such a question: its aim was to evaluate and compare the skeletal and dentoalveolar effects of tooth-borne (TB) and tooth-bone-borne (TBB) rapid maxillary expansion (RME). It showed that “.. in young preadolescents with constricted maxilla and no signs of upper airway obstruction, it seems that conventional TB RME achieves the same clinical results with good stability 1 year post-expansion at lower cost.” Despite some clinical limitations in the study design and double blinding of the operators, it is well worth the consideration.

Are we simply doing certain procedures because we can, or because they are actually needed?… food for thought…

To put things into proper perspective regarding our example of MARPE; unless there is an obvious and clearly-diagnosed airway obstruction in young pre-adolescents, it seems neither clinically significant nor fully justifiable to use the more invasive choice of palatal miniscrews for RME in those children, and even that point is not clearly universally agreed upon as an indication for RME treatment!

The same issue arises with the overuse of orthodontic mini-screws for extraction cases with minimal anchorage requirement, or Clear Aligner technology where the high learning curve of required software skills, technical knowledge and the overload of composite attachments required for even the most well-designed aligners to work in a reasonable fashion, far outweigh – in my humble opinion – any perceived benefits over the use of ceramic fixed appliances, which would provide – in most cases – faster, more efficient treatment with a similar – if not better – esthetic! Prof. Kevin O’Brien has talked about this on his blog. Of course, Patient preferences still have their place, but at least these options should be offered and explained.

All of this is not to say that we should abandon these technologies; far from it!.. It is only to turn the spotlight onto the ease with which we can unmindfully follow a trend without properly evaluating our available tools, or real patient needs and benefits, as well as not putting the simplicity and efficiency of the proposed solutions available to us into proper perspective. Balance is always the key.

Are we using technology, or is technology using us?.. A question that has been on my mind for some time now… you’re welcome to let us know your thoughts in the comments or through private messaging if you prefer…

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