In
orthodontics, the current trend is to find ways to accelerate treatment with
many appliances making these claims, even in the naming of their appliance or
technique (Fast, Quick, Rapid, Speed, 6-month, etc.). There is substantial
evidence now to demonstrate that simply changing to a different type of bracket
makes no difference – it is the skill of the operator that is most important,
otherwise the patient may be accepting a compromise. For example; if treating
only in round wires then the roots are not rotated, tipped or especially torqued
into their best and most stable positions or the occlusion or overjet not
addressed.
To overcome
this, some companies have suggested that digitally positioned brackets are the
answer as they reduce variability and take into account a lot of the skill and
variation of the operator. Systems such as Insignia, SureSmile and even
Invisalign are examples of these in orthodontics. However, there is a lot of
biological variation with individual patients varying in response as well as appliances
do not deliver 100% of what is built into them which is why detailing/finishing
is required (the fiddly part of orthodontics). Previous retrospective studies
have suggested that digitally customised appliances did deliver faster
treatment but these had the same flaws as the self-ligating bracket and
vibration appliance studies in that there is a high risk of bias and potential
confounding variables that can influence the result beyond just the appliance (the
later RCTs found no difference). This is why blinded, RCT’s are considered the
gold standard – but also take more time and cost to conduct. However, an RCT was
just published online in the Journal of Dental Research (considered the top
journal in dentistry in terms of the quality of the articles) and this paper looked at the Insignia system of digitally positioned brackets
compared with conventional placement. The results were interesting!
There were
180 patients in this RCT and when completed, they analysed 85 patients in the
customized group and 89 in the non-customized group. The authors found no
difference in treatment duration (digital = 1.3 years vs. conventional = 1.2
years) or quality of outcome as measured by the PAR (Peer Assessment Rating) index.
Most importantly, the Orthodontist did have a significant effect on
treatment duration, quality of treatment outcome, and number of visits (P <
0.05) - not the appliance used. Interestingly, the customized orthodontic group
also had more loose brackets, a longer planning time, and more complaints (P
< 0.05).
In the rush
(pardon the pun) for faster treatment and to seem to be on the cutting edge, we
can leap into new technologies. Sometimes they deliver what they claim while at
other times they do not. Such systems usually involve additional cost with an
expectation by the patient of faster treatment but in this case, it wasn’t delivering
what it claimed. Some practitioners may prefer these systems and that is a personal
choice just as some prefer one bracket type over another, but when claims are
made of a faster or better outcome (and often at added cost)… proof rather than
opinion is required. As Carl Sagan (Astrophysicist) famously stated; ‘Extraordinary
claims require extraordinary evidence’.