Treatment results — what’s ahead?

Dr. Jeffrey Miller reflects on CBCT and asks, “Do we really want to know what we are doing to our patients, or are we afraid to find out?

In 1959, Dr. Cecil C. Steiner in his classic article, “Cephalometric in Clinical Practice” asked, “Do you really want to know what you are doing to your patients, or are you afraid to find out?” This question reflects the resistance to cephalometric analysis 63 years ago. The same argument could be made today about the use of CBCT in clinical practice.

As orthodontic specialists, we should differentiate ourselves from the other orthodontic providers with our superior treatment outcomes. Using 1959 technology (cephalometrics) is inconsistent with this goal. For example, decrowding of dental arch via lateral expansion is not measurable using cephalometrics. It is almost as if we are playing the system by expanding the lower intercuspid width to decrowd while measuring changes with a pre- and posttreatment cephalometric radiograph, which mostly looks at the changes in the incisor position.

Modern-day technology allows us to visualize individual teeth and the supporting alveolar housings. This changes not only how we treatment plan our cases, but also how we evaluate our finished orthodontic results. Poor treatment results cannot be hidden by the wide focal trough of the cephalometric radiograph.

Think about the following scenario: A patient comes to your office with 12 mm of lower crowding. You want to extract, but the parent is against it. You tell the parent that you would be willing to level and align the arches and take a progress ceph to see if the treatment approach is acceptable. Eight months into treatment, you take your progress ceph. The progress ceph shows slight flaring of the lower incisors, perhaps 2-3 degrees. At this point, you tell the parent that you believe you can continue the nonextraction approach with some interproximal reduction. Unfortunately, the cephalometric radiograph cannot measure the “primary” mechanism for decrowding via lateral arch expansion. It is almost as if these broad-form or lateral development archwires “trick” the cephalometric analysis system.

Let’s take the same scenario, but instead of only an 8-month progress ceph, we take a progress CBCT. No doubt the CBCT will show significant root dehiscence, which was completely missed via ceph/pan analysis. Despite no shortage of rationalizations in the orthodontic community, attempting to explain away what we see on the CBCT is not what we see. Most orthodontists would not knowingly promote a treatment approach resulting in significant dehiscence. While minor root dehiscence may not be accurately diagnosed via CBCT, larger orthodontically induced dehiscence can be easily and accurately visualized.

Now let us jump to 2032. This same patient is at his/her general dentist for an annual checkup. I would predict that most all general dentists will be replacing panoramic X-rays with CBCT over the next 10 years. I believe it will be fairly easy to connect the dots once the general dentist looks over the CBCT scan and sees a generalized root dehiscence pattern, which could only be associated with orthodontic treatment. Imagine the phone call from the general dentist asking how he/she should deal with the significant root dehiscence now visible via CBCT.

As orthodontists, we get blamed for many things not associated with our treatments. Orthodontically induced root dehiscence is not only directly connected to orthodontic treatment, but also easily diagnosed with CBCT even in the absence of gingival tissue recession. To once again quote Dr. Steiner, “Do we really want to know what we are doing to our patients, or are we afraid to find out?”

For more info on CBCT, read “Using 3D CBCT imaging in orthodontics,” by Dr Jay Burton, and take the quiz to receive CE credits!

Jeffrey Miller, DDS, PA, graduated summa cum laude from Towson University in 1978 and earned his dental degree from the University of Maryland in 1982. He received his orthodontic certificate from SUNY at Buffalo in 1984. In 1991, Dr. Miller become a Board-certified orthodontist. He has specialized in orthodontics for over 35 years and is a regent for the AAO Foundation.

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