Infant tongue ties – should I have my baby’s tongue cut?

Tongue-tie, or ankyloglossia, is a condition whereby the lingual frenulum (stringy bit under your tongue) attaches near the tip of the tongue and may be short, tight and thick. It is potentially a concern if it limits the range of movement of the tongue, interfering with feeding or speech. Tongue-tie is present in ~4% to 11% of newborns and has been cited as a cause of poor breastfeeding and maternal nipple pain. Frenotomy (cutting/removal of the tongue tie) has been promoted to correct restriction of tongue movement and allow more effective breastfeeding with less maternal nipple pain. Recently there have been dramatic increases worldwide in performing this procedure. Canada has reported an 89% increase, the USA a 300% increase between 2006 – 2012 and in Australia a 420% increase has been reported. Frenotomy may seem like a logical solution but is it supported by evidence?

A Cochrane review based on older research found frenotomy reduced breastfeeding mothers' nipple pain in the short term but did not find a consistent positive effect on infant breastfeeding. However the evidence was based upon only a small number of studies with a small number of infants. More recent research in Australia has found an alarming increase in the number of frenotomies or tongue-tie releases being performed and in New Zealand it was found to be performed in 13% of newborn infants. With only 25-50% of babies with ankyloglossia having feeding problems, the target or suggested rate for tongue-tie release surgery is between 0.2-5%. This suggests many of these procedures are being performed without indication and potentially placing the child needlessly at risk of complications.

A recent study in Western Australia found instead of improving breastfeeding rates, the frenotomy was actually more likely to lead to early weaning! Their research revealed that the real problem in many cases was low milk production and not the baby’s tongue tie. Breastfeeding rates were NOT improving following surgery and some babies required hospitalisation for serious bleeding or infection. It therefore appears many may needlessly be receiving this procedure and being placed at harm. Frenotomy may seem like a ‘simple’ solution and for some it is appropriate but if you are unsure, then seek a second opinion from your Paediatrician.

Dr Peter Miles is the orthodontist at Newwave Orthodontics in Caloundra, Australia and has taught orthodontics part-time at the University of Queensland and Seton Hill University in the USA for over 10 years. Peter is one of the editors and authors of the orthodontic textbook, 'Evidence-Based Clinical Orthodontics'. Importantly, he has no financial interest in any products or techniques mentioned in these Blogs.

Vibration does not speed up extraction space closure

I have blogged previously on appliances claiming to accelerate tooth movement and shorten orthodontic treatment. One of these is micro-vibration and an appliance using this principal is AcceleDent. I have previously researched this topic during initial alignment and now Part 2 has been published on extraction space closure.


I strongly believe in an evidence-supported approach to clinical practice and this study (as with all my research) was conducted in my orthodontic practice to answer the clinical question of whether this was a worthwhile technique to consider implementing for my own patients. Forty Class II adolescent patients planned to have premolar extractions in the upper arch were randomly assigned to using either the AcceleDent appliance or no appliance. The extraction space closure was measured over time so a rate of movement in mm/month could be calculated. So what did I find? There was no clinically (0.05 mm per month) or statistically significant difference in the rate of space closure (P = 0.74). Compliance was found to reduce over time and this is the subject of another paper to be published in the Journal of Clinical Orthodontics. However, even when compliance was accounted for there was still no clinically meaningful difference in the rate of space closure.

This article appears in the American Journal of Orthodontics and Dentofacial Orthopedics and anyone clicking on this link before February 14, 2018 will be taken directly to the final version of my article on ScienceDirect. No sign up, registration or fees are required – you can simply click, read and hopefully enjoy.

https://authors.elsevier.com/a/1WHqw3AGXGWWNM

Digitally positioned brackets - are they any better?

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’.

Fast Orthodontics - In Search of the Holy Grail

I recently wrote a review article in the Australian Dental Journal supplemental issue on accelerated orthodontic treatment. In it I discuss the many claims by manufacturers of several appliances and proponents of various techniques that claim to accelerate treatment. This appeals to both the patient’s and the clinician’s desire to ‘speed’ up and shorten their treatment, however how strong is the evidence or is it just marketing hype? I am a little concerned as it would appear that in some respects, advertising claims in orthodontics are following down the path of the exercise fads claiming rapid results with little or no effort - I certainly find some effort and restraint is required :-). Mechanically and biologically, many of the claims of accelerating orthodontic treatment just do not make sense (such as with self-ligating brackets which I have written about before) or are quite invasive and/or expensive (some of the surgical techniques are ~$5000 and the effect lasts only ~3 months). This is discussed in more detail in the article.

One of the clinical trials I have been conducting in our office on vibration and accelerated treatment was also published recently in the American Journal of Orthodontics and Dentofacial Orthopedics and I was asked to produce a short video on that article which can be found here.

This was included in the review article I wrote also. More recently we have just analysed the data on the 2nd part of this ongoing RCT when closing extraction spaces and I also found that there was no clinically or statistically significant difference in the rate of space closure – in other words, vibration had no effect. This is important for patient’s to be aware of as they can be asked to spend $500 - $1000 for various appliances which may have minimal or no effect. The problem with emerging techniques and methodologies is that there may be no trials examining their performance so we must then rely on our knowledge of biology and mechanics on whether we consider it ‘may’ have a positive effect or not. However, if we are unsure, then patient’s should be informed of this until research exists. They can then decide if they will gamble on the appliance/technique possibly working or stay with the current approach. So the Holy Grail of accelerated orthodontic treatment seems elusive and the honest answer about the various options to patients is ”There are many techniques and appliances claiming to accelerate orthodontic treatment but the current evidence is poor and some have been shown to have no effect”.

DOES THE ACCELEDENT AURA APPLIANCE SPEED UP THE INITIAL ALIGNMENT OF TEETH WITH BRACES?

This summary of my recent clinical trial published in the American Journal of Orthodontics & Dentofacial Orthopedics demonstrated no effect of the AcceleDent Aura vibrational appliance during the initial alignment of teeth with fixed appliances.

ALLERGIES, HABITS AND MALOCCLUSION IN YOUNG CHILDREN - WHAT HAPPENS OVER TIME?

Some clinicians advocate very early treatment in the primary (~ages 3-5) dentition and recommend interventions claiming they will prevent future orthodontic problems. But what if we did nothing and observed them? This very interesting article from Sweden followed 277 children from age 3 to age 11.5 and evaluated the presence of malocclusion, sucking habits, breathing problems, allergies and trauma over time.

There was quite a high prevalence of malocclusion at age 3 of 71% and although this improved by age 7 to 56%, it worsened again to 71% by age 11.5. However ~45% of subjects were considered in severe or moderate 'need' of treatment so ~55% had minor or no need. Many advocates of early treatment suggest intervention for open bites but interestingly this was one of the malocclusions that tended to self-correct as found by previous authors. Conversely deep bites did tend to worsen. As with previous studies trauma to the top front teeth was ~2.2 times more likely with increased protrusion/overjet.

Another re-emerging (previously in 1930's then 1960-70's) claim in orthodontics is the influence of habits and allergies on malocclusion and that early intervention is required to prevent adverse growth effects. This long-term observational study found sucking habits had little or no association with anterior open bite or posterior crossbite in the permanent dentition. As I have discussed in a previous Blog, many children stop the habits themselves as they get older and an open bite can improve spontaneously so treatment may not be indicated except in those that persist longer term.

Similarly allergies at age 3 had NO association with any future malocclusion at age 11.5. There are many good reasons for allergy, tonsil and adenoid treatments but to prevent abnormal facial growth is not one of them. I have personally had an ENT tell my wife that our 9 y.o. daughter (who suffers from allergies) required a turbinectomy otherwise she will undergo abnormal jaw growth - you can probably guess my response to that! My daughter has normal horizontal and vertical facial growth with mild crowding and although she will require some orthodontic treatment once all adult teeth have erupted for the mild crowding, her growth is proceeding just fine without the surgery. I feel sorry for those parents that do not have the knowledge of normal facial growth that I do as they may be 'scared' into having procedures for their children that they may otherwise think twice about. This article helps contribute to that knowledge so thanks to this Swedish team for following this group and presenting their findings.

Dr Peter Miles is the orthodontist at Newwave Orthodontics in Caloundra, Australia and teaches orthodontics part-time at the University of Queensland and is a visiting lecturer at Seton Hill University in the USA. Peter is one of the editors and authors of the orthodontic textbook, 'Evidence-Based Clinical Orthodontics'. Importantly, he has no financial interest in any products mentioned in these Blogs.

THE CVM METHOD AND THE IDEAL TIME FOR ORTHODONTIC TREATMENT.

The timing of treatment of Class II (protrusive top teeth &/or retruding lowers) patients has been debated for many years in orthodontics with some claiming you need to treat early, even as young as 5-8 (discussed in a previous Blog) or 9-10 or wait until 12-13! Several indicators have been used to assess the ideal timing and a more recent one is the Cervical Vertebral Maturation method (CVM) which uses the maturational stages of the cervical vertebrae in the neck on a cephalogram x-ray.

The CVM method was first developed by Don Lamparski along with Maria O'Reilly at the University of Pittsburgh where I trained and was later modified. However to be useful a method needs to be reliable and valid. One article demonstrated <50% intra-rater agreement (in other words less than half the time you agree with your own assessment). Another demonstrated that the CVM method offered no advantage over chronological age. Two recent papers concluded "CVM method could not accurately identify themandibular growth peak" or "...cannot predict craniofacial growth in girls with Class II malocclusion.". But let's say you do identify the ideal timing of treatment using the CVM method with the Herbst the study found ~1.9mm of advancement of Pogonion. However another study in adults (who are not growing) found they could still gain 1.3mm of advancement of Pogonion  so the ideal timing was only 0.6mm better and that is also assuming the change holds up long term which we know from other trials it doesn't.

The timing of orthodontic treatment is an interesting topic and really revolves around the issue of whether we can ‘modify growth’ of the mandible or not. Based upon the available quality scientific evidence it seems we can temporarily accelerate mandibular growth (Lysle Johnston’s ‘mortgage on growth’) but not achieve a significant long-term change and so the final outcome is mostly dento-alveolar/tooth movement. Studies supporting a change are retrospective in nature and/or use a historical control which is ~60 years old and not valid for comparison as trials using historical controls show larger treatment effects. In contrast the prospective RCT’s (UK, UNC, Florida) show no difference between treating early or in adolescence and this is supported by the Cochrane Review on the topic. The long-term ‘amount’ of change is similar regardless of the timing of treatment so it is more the ‘efficiency’ of the change/how quickly that is achieved that is affected by timing. Therefore the importance of determining the ideal timing of treatment with any method seems of minimal significance to the final outcome.

Finally I would like to thank Maria and all my other instructors at the Univ of Pittsburgh. I was so incredibly fortunate to have such wonderful mentors and friends.



Dr Peter Miles is the orthodontist at Newwave Orthodontics in Caloundra, Australia and was a part-time lecturer at the University of Queensland for 11 years and is a visiting lecturer at Seton Hill University in the USA. Peter is one of the editors and authors of the orthodontic textbook, 'Evidence-Based Clinical Orthodontics'.

PASSIVE SELF-LIGATING BRACKETS ARE BETTER - IT'S OBVIOUS?

This Blog topic was prompted by comments in Kevin O'Brien's excellent Blog regarding 'thinking about orthodontics'. Kevin was discussing evidence-based care and what we know versus what we don't know and how to apply our knowledge, skill and experience as clinicians in the treatment of our patients. Many suggestions were made about what we do and don't know but two comments in particular claimed that Passive Self-ligating (PSL) brackets were superior to conventional brackets during initial alignment in non-extraction treatment. I have also seen other claims in Facebook study clubs where the clinician states that in their experience, PSL brackets are superior for space closure in extraction cases (a future Blog topic). So is this evidence or their opinion and what is the evidence if any?

In 2006 I conducted the first prospective study comparing PSL brackets with conventional brackets in the lower arch in non-extraction cases. This was published in The Angle Orthodontist and I found that the PSL bracket was no better during initial alignment than a conventional bracket. Another non-extraction study published in the American Journal of Orthodontics in 2010 found there was no difference between PSL or Active SL brackets. Based upon this evidence in clinical trials this refutes the claim that PSL brackets are more effective in non-extraction cases during initial alignment. If we then include the evidence from extraction cases as well, this was summarised very nicely in another article in the American Journal of Orthodontics in 2014 where the data was plotted graphically (shown below) in a meta-analysis. The vertical line at zero ('0') represents no difference between brackets and the purple squares are the individual studies. What we are most interested in are the large green diamonds which represent the results combined together and as they overlap the zero line, this indicates there was no difference between any of the bracket types tested across the various studies during initial alignment. It seems the evidence is quite compelling that there is no advantage in PSL or ASL brackets over conventional brackets during initial alignment.

As the evidence clearly shows there is no difference between brackets, the choice of bracket then comes down to the personal preference of the clinician. BTW if you are interested in evidence-based orthodontics then I highly recommend subscribing to Kevin's Blog at http://kevinobrienorthoblog.com/

Dr Peter Miles is the orthodontist at Newwave Orthodontics in Caloundra, Australia and was a part-time lecturer at the University of Queensland for 11 years and is a visiting lecturer at Seton Hill University in the USA. Peter is one of the editors and authors of the orthodontic textbook, 'Evidence-Based Clinical Orthodontics'.