Interview “Der Spiegel” No. 18, 2018

“Just Have a Look at This Nonsense”

The orthodontist Henning Madsen (aged 56) from Mannheim talks about needless orthodontic appliances and profit-driven colleagues.

Spiegel: The Federal Audit Office criticizes your over-zealous colleagues. Has this institution the right to judge about the sense of medical treatments?

Dr. Madsen: Not with regards to a final judgement, but the Federal Audit Office is right with respect to the subject-matter. In our country, two thirds of girls and boys get orthodontic treatment. That’s why we have achieved a lonesome leadership in orthodontic care in the world. Only in the Netherlands and the United States of America this seems to be similar. In Scandinavia – countries with a highly developed dentistry – the rate of children in orthodontic treatment is round about half of that. In Germany, something is getting out of control.

Spiegel: What is it exactly?

Dr. Madsen: German orthodontists overdo the treatments – so that the public health insurance has to pay over one billion euros each year. Moreover, the orthodontists make a lot of mistakes. Just have a look at this nonsense about the removable appliances. It has already been proved that they are less effective than fixed appliances. Nevertheless, in Germany, they are prescribed en masse – and only here. Why? These appliances are cash cows! Fiexed appliances bring only half of the profit.

Spiegel: Do orthodontists talk parents into inappropriate treatments?

Dr. Madsen: In my opinion, this is a drastic formulation. But the demand for orthodontic treatment is often triggered by orthodontists making use of inappropriate arguments. Many of them advertise with the fact that straight teeth can prevent tooth decay, periodontitis and head- or backpain. But there’s no proof for this at all.

Spiegel: Do your colleagues act wrong even in other ways?

Dr. Madsen: Internationally, orthodontics starts at the age of 11 – 12, when the permanent dentition has developed. In contrast, in Germany most of the orthodontic treatments start at the age of eight or nine. That’s the reason why treatment duration is quite long: up to four years. My colleagues in Scandinavia can’t believe it. They ask me: “What are you doing for such a long time?”

Spiegel: Are you an outsider among the orthodontists with a radically different way of thinking?

Dr. Madsen: The accusation of being uncooperative is nothing new to me. But everything that I’m complaining about has been known since 2001 and has been criticized severely and repeatedly in expert reports. There’s a need of action – but nothing happens. In my opinion, the lethargy shown by the health policy is incredible. ME

The Statement on the Federal Audit Office Issued by the DGKFO is Dishonest and Scientifically Intolerable

After, the Federal Audit Office in its annual report had criticized missing care research and proof of benefit for orthodontic treatment in Germany, this caused enormous excitement. The German Society for Orthodontics (DGKFO), the scientific organization of German orthodontists, presented a press release on this issue on  April 26, 2018 in which the DGKFO declared to support “the enhancement of studies regarding the benefits and effectiveness of orthodontic treatment of children, teens and adults – a high quality care research is included.” Moreover, the DGKFO appreciated, “that the Federal Audit Office asked the Federal Ministry of Health to initiate care research in orthodontics”.

These statements seem less than credible because in 2001 the Council of Experts in health care had already mentioned in its report that despite an exorbitantly high supply level and high annual costs, “epidemiology and health economics had treated orthodontics in comparison to other parts of health care quite stepmotherly”.[1] Care research deals with investigations concerning health care of the population. It investigates how health care services are distributed and who receives them. Moreover, the benefits of these services are monitored. Finally, recommendations can arise from care research, how health care resources can be used targetedly and beneficially. Nor in 2001 neither in 2008, the German orthodontics could answer questions about orthodontic care in Germany. In 2008 the HTA report from DIMDI “Oral health after orthodontic treatment with fixed appliances” was published. Among others, it criticized that there was no proof of health benefit through orthodontic treatment. [2] While the statement of the Council of Experts was ignored by the DGKFO in 2001 a statement was given in 2008: The executive board announced, “that within the next meeting at the end of May the members would discuss the coordination and financing of a multicenter EBM-based scientific study regarding oral health and orthodontics. The project would soon be initiated“. [3]

Even 10 years later, nothing has been published yet. Nonetheless, there’s the urgent question to be answered, why the orthodontic supply rate is at 60 % concerning the public health insurance, whereas the privately insured might even increase the supply rate to two thirds per birth year. This is an exorbitant supply rate and it exceeds twice the rate of Scandinavia – highly developed countries with high quality dentistry. The reason for this development in Germany might be that there are many minor orthodontic findings which are treated neither with a positive effect on health nor improving the quality of life. Furthermore, the question why half of the treatment duration is performed with removable appliances has to be answered [4], although fixed appliances produce better and faster results. In 2001, the Council of Experts had already mentioned these facts without having any influence on the orthodontic supply rate. An answer to the question should be found why in Germany orthodontic treatment duration lasts three to four years which is twice as much as in similarly developed countries. Moreover, it should be explained why Germany has an orthodontist-to-population-ratio from 1:20000, Scandinavia 1:30000 and Great Britain 1:47000.

The only argument given by the DGKFO regarding the health benefit of orthodontic treatment is the risk reduction of front teeth traumata caused by large overbites which were responsible for ”200 millions of traumata per year and their follow-up costs”. No doubt, there is a correlation between large overbites and upper front teeth traumata which could be proved in several studies. [5] But it seems to be risky announcing it as an urgent indication of treatment. Authors of a randomized controlled study concerning early treatment of Angle Class II with large overbite found that patients undergoing later treatment showed a higher number of front teeth traumata but without any clinical significance. Moreover, the authors of this study found that this early treatment followed by a second treatment phase caused a high increase in costs, whereas there were mostly minor front teeth traumata which could be treated easily and cost-effective. This is the reason why the authors didn’t recommend early treatment of a large overbite, particularly as it would have to be started at the age of 6 to 7 being an inappropriate phase anyway [6]. Furthermore, a systematic review showed that ten kids would have to be treated early in order to prevent one from having a new front teeth trauma [7]. In terms of health economy an early orthodontic treatment in order to reduce a large overbite doesn’t seem to be indicated.

The statement on the Federal Audit Office issued by the DGKFO is deeply dishonest and scientifically intolerable. It’s you, professors, who have circumvented the question of orthodontic supply levels for decades. In 2001 the Council of Experts had suggested to define criteria for minimizing orthodontic treatments and to rearrange fees in favor of the efficient but poorly rewarded fixed appliances. In order to reduce the supply-side induction of demand the Council of Experts recommended “a modest reduction of training capacities” and to make use of the free capacities “in order to improve research and teaching” [8]. The Council of Experts is absolutely right but the DGKFO doesn’t seem to have this on its agenda. This might be up to the DGKFO’s self-image. Regarding the statements of Prof. Hirschfelder, former president of DGKFO, “a beneficial cooperation between the scientific society and association of orthodontists” (BDK, the professional lobby organization of German orthodontists) was favored by the DGKFO. Then, the president-elect (and current  president) Lisson announced, “the coordination between science and professional policies is important – tasks of the latter shouldn’t be part of the DGKFO’s work” [9]. Nevertheless, the BDK asks for a high supply level and the inappropriate but profitable treatment with removable appliances. So it seems that the DGKFO doesn’t want to play the spoiling role!

References:

  1. Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen. Über-, Unter- und Fehlversorgung in der Kieferorthopädie. In: Gutachten 2000/2001, Band III. 14. Zahn-, Mund und Kieferkrankheiten. Bonn 2001. https://www.svr-gesundheit.de/index.php?id=337
  2. Frank, W., K. Pfaller, and B. Konta, Mundgesundheit nach kieferorthopädischer Behandlung mit festsitzenden Apparaten. HTA-Bericht 66, Deutsches Instituit für medizinische Information und Dokumentation (DIMDI), Köln 2008. https://portal.dimdi.de/de/hta/hta_berichte/hta205_bericht_de.pdf
  3. Deutsche Gesellschaft für Kieferorthopädie. Stellungnahme der DGKFO zu dem  von  der  Deutschen  Agentur  für  HTA  (Health  Technology  Assessment) des   Deutschen   Instituts   für  Medizinische  Dokumentation  und   Information (DIMDI)    in    2008    veröffentlichten    Bericht    über Mundgesundheit    nach kieferorthopädischer Behandlung mit festsitzenden Apparaturen von W. Frank, K. Pfaller und B. Konta. 2008. https://www.dgkfo-vorstand.de/fileadmin/redaktion/veroeffentlichungen/DZWHTA050508.pdf
  4. Krey, K.F. and C. Hirsch, Frequency of orthodontic treatment in German children and adolescents: influence of age, gender, and socio-economic status. Eur J Orthod, 2012. 34: S. 152-7.
  5. Shulman, J.D. and J. Peterson, The association between incisor trauma and occlusal characteristics in individuals 8-50 years of age. Dent Traumatol, 2004. 20: S. 67-74.
  6. Koroluk, L.D., J.F. Tulloch, and C. Phillips, Incisor trauma and early treatment for Class II Division 1 malocclusion. Am J Orthod Dentofacial Orthop, 2003. 123: S. 117-25.
  7. Thiruvenkatachari, B., et al., Early orthodontic treatment for Class II malocclusion reduces the chance of incisal trauma: Results of a Cochrane systematic review. Am J Orthod Dentofacial Orthop, 2015. 148: S. 47-59.
  8. Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen. Fazit und Empfehlungen des Rates. In: Gutachten 2000/2001, Band III. 14. Zahn-, Mund und Kieferkrankheiten. Bonn 2001. https://www.svr-gesundheit.de/index.php?id=338
  9. Deutsche Gesellschaft für Kieferorthopädie. DGKFO Mitgliederversammlung: Prof. Dr. Jörg Lisson einstimmig zum Präsident Elect gewählt. Presseerklärung vom 13.10.2016. https://www.dgkfo-vorstand.de/service/news/details/dgkfo-mitgliederversammlung-prof-dr-joerg-lisson-einstimmig-zum-praesident-elect-gewaehlt-5.html

Manual Structural Analysis (MSA) According to Bumann

The Manual Structural Analysis (MSA) according to Bumann comprises a series of manual techniques for the examination of the jaw (temporomandibular) joints (TMJs). Manual techniques (examinations performed with the hands) were developed in the USA, the Netherlands and many other locations of the world. That’s why a variety of manual techniques for the examination of the TMJs  and masticatory muscles is spread all over the world. Mr. Bumann has summed up a series of manual techniques resulting in a systematic and extensive examination which is called Manual Structural Analysis. Many dentists and several universities have made use of MSA for years.

Unfortunately, some of the manual examination techniques aren’t supported efficiently by scientific evidence. Others show a lack of proof about what is examined exactly (lack of specificity). So it’s doubtful which validity should result from the nine directions of TMJ compression which are described in the MSA. The four different types of TMJ clicking mentioned in the MSA are also viewed critically. Moreover, the theory of “occlusal vectors” which considers faulty dental contacts responsible for TMJ disorders is just a hypothesis. In fact, the findings in recent decades have shown that tooth contacts and jaw position play only a minor role in the symptom development of TMJ or chewing muscles. It cannot be excluded that MSA diagnostics might turn a healthy patient into a sick one.

Even though three quarters of the temporomandibular disorders (TMDs) are based on muscular problems the MSA concentrates on diagnostics of TMJ disorders. In the MSA, the palpation of muscles is only treated superficially. The survey of psychological stress factors which is important in pain diagnostics isn’t part of the MSA. Therefore, the Manual Structural Analysis is to be regarded as a uniaxial, somatic diagnostic method focusing on TMJ diagnostics.

As Mr. Bumann was one of the first in Germany who systematized manual examination techniques and conducted a lot of courses, MSA is widely known in Germany. Unfortunately, many of the practitioners are not aware of the fact that only some of the described techniques are validated. Despite of being an extensive and systematic analysis the MSA should be viewed critically regarding scientific and validated diagnostics of the Craniomandibular Dysfunction (CMD).

In contrast, the RDC/TMD (Research Diagnostic Criteria for TMD) or DC/TMD are scientifically validated methods which make use of less diagnostic steps enabling a diagnostic conclusion. The RDC/TMD is a biaxial diagnostic method which takes somatic and psychological findings into account.

Functional Orthodontics

Functional Orthodontics describes the treatment with Activator-like appliances. It was originally introduced by Viggo Andresen in 1935. Since then, a perplexing number of activator-clones have appeared including the Bionator, the Bite-Former, the Kinetor and the Functional Regulator, amongst others. Apart from Andresen the Austrian Karl Häupl was very much engaged in Functional Orthodontics. Both authors created the Andresen-Häupl-Hypothesis which has been dominating orthodontics in Germany and some other European countries for decades.

The fervent advocates of Functional Orthodontics believed that they had discovered a new, “biological” and “causal effective” working principle in orthodontics which they contrasted to the mechanical principle of traditional appliances. They believed that large-volume twin appliances like the Activator could influence the chewing muscle function as well as the mimic muscles. The improved muscle function would lead to the correction of tooth or jaw misalignments in a “natural” way. First of all,  this was only a non-proved scientific hypothesis.

It is not by chance that in the 1930s Functional Orthodontics prevailed over the traditional orthodontics in Germany.  The National Socialists wanted to create a “New German Medicine” based on the principles of alternative medicine and some scientific set pieces. Functional Orthodontics fitted well into this concept: it prevailed over the traditional orthodontics with its mechanical principle and promised the awakening of holistic ideas. In the language of this time, the inventor of the Activator, Viggo Andresen, called for the extermination of traditional “orthodontics”.

The Triumphant Progress of  Functional Orthodontics in Germany

His claim was successful: In the following years, lectures about efficient fixed appliances receded at German universities. In the 1940s at the University of Frankfurt, all active appliances were forbidden ­- even Coffin springs for jaw expansion – because they believed that the Activator and some magical forces would lead to excellent orthodontic results. German orthodontists must have been absolutely desolated: they weren’t able to treat the tiniest misalignments properly. In Nazi-Germany orthodontics had got on a sectarian and unworldly track and stayed so for decades after. It is even worse that all the myths of Functional Orthodontics continued to have an effect until the 1970s or partly until now. There’s no doubt that functional appliances like the Activator can have treatment effects under optimal circumstances, though most of them are of low impact. Functional orthodontics as a dogmatic system of theories seems to line up with the Lyssenkoism in Soviet Russia and the “Deutsche Physik” (German Physics) in Germany during National Socialism. Therefore, Functional Orthodontics is a politically controlled wrong route to take.

The Facts

Orthodontic treatment is based on correcting tooth and jaw misalignments by using orthodontic appliances which exert forces and moments to teeth. They are more or less efficient. Primarily, the tooth itself is affected and moved through the jaw bone. Nowadays, the Functional Orthodontic hypothesis to correct tooth and jaw misalignments indirectly by influencing the muscle function can be recognized as absurd. Moreover, it’s the same misbelief that removable appliances, made of a lump of plastic, could correct teeth in a biological and holistic way, different from fixed appliances.

Early in the 1950s, the best minds among the European orthodontists didn’t support this idea. In 1960, the Danish expert Arne Björk had already published an article giving a well reflected and rejecting statement about Functional Orthodontics. Nowadays, it has been scientifically established that Functional Orthodontics is neither able to influence muscle function nor cranial or jaw growth significantly.

Therefor, the term Functional Orthodontics has become insubstantial and shouldn’t be used anymore.

Why is it Called Dentofacial Orthopedics?

Up to the 1930s, our specialty was called orthodontics (the correction of tooth misalignment) in most languages. But in Germany during the 1930s, those who supported Functional Orthodontics replaced it by the term “Dentofacial Orthopedics” (Kieferorthopädie). Back then, those orthodontists believed that their appliances, made of rubber, could influence the cranial and facial growth significantly.

At the beginning of the 1970s, Tom Graber, editor of the American Journal of Orthodontics (AJO) was persuaded to rename the journal into American Journal of Orthodontics and Dentofacial Orthopedics (AJODO). In the light of the present state of knowledge, this false and misleading titling should be changed back. We aren’t dentofacial orthopedists, only humble orthodontists. If dentofacial orthopedists would be able to correct tooth misalignments they would do the public a bigger service than with unsubstantial higher claims.

Early Orthodontic Treatment – a Huge Swindle

According to the international gold standard it’s common to start orthodontic treatment when the patients’ early permanent dentition is present. The young patients are at the age of 11 to 12 then and all permanent teeth have erupted. At this time most of the patients can be treated with a single fixed appliance in about 18 months. If you start earlier the dentition is partly primary and partly permanent. Moreover, some of the permanent teeth haven’t erupted yet. Regarding the latter: you can’t move teeth which haven’t emerged from the bone.  That’s the reason why it’s questionable to start an early orthodontic treatment in the mixed dentition. Furthermore, orthodontics at the age of 11 to 12 is absolutely favorable because the adolescent growth spurt approaches and during this phase of rapid growth you can reduce the treatment duration in contrast to orthodontics for younger children.

There are hardly good reasons for starting with orthodontics when the children are of primary school age. Unfortunately, in Germany early treatment is of common use contrary to the current state of science: a great number of early treatments are started during primary school phase when children, aged 6 to 10 years, still have a lot of baby teeth. It’s even worse because most of the early treatments are conducted with outdated removable appliances. Most of the times, removable appliances can’t be worn efficiently so that 30 to 50 percent of treatments end up in failure. Even if there are any treatment results they are negligible and so poor that treatment has to be continued with fixed appliances.

It’s interesting that in most other developed countries early treatment with removable appliances isn’t of common use any more. This also applies to most of the removable appliances which aren’t used any more in other countries. Moreover, it’s a special German feature that orthodontists  run their own in-office-laboratory where removable appliances are produced. In-office-labs aren’t common in other countries – no wonder, as foreign orthodontists don’t need such a huge amount of removable appliances. Patients and parents have to pay dearly for early treatment with removable appliances regarding overlong treatment duration, many failures and discontinuation of treatments, and last but not least the unnecessary high costs. This is exactly the reason why the German orthodontists continue this outdated way of treatment. The German reimbursement system for dental care pays nearly twice as much for the treatment with removable appliances than for those with fixed ones.

Treatment with removable appliances asks for such a little knowledge, expertise and effort that it is close to the old human dream of earning an income without having to work. No wonder why German orthodontists want children to start with treatments at the age of six. ”The earlier the better” is the common motto and “starting early would make later treatment easier”. There will be a few years of early and afterwards a few years of comprehensive treatment. It would be easier to wait and see and perform a singlestage  treatment, don’t you think? These statements show that these orthodontists haven’t got on their minds to improve your individual treatment but to follow their own economic interests.

Exceptions are a retruded mandible with extreme incisor overjet or a narrow maxilla with a total lateral crossbite. In these cases and some other rare findings early treatment can be reasonable. Not more than only one child out of twenty should be affected – moreover, orthodontics should be performed with fixed appliances which lead to a safe, fast and successful result.

Criticism of German Orthodontics on NDR

On January 16, 2018 the TV program “Visite” on NDR (a regional TV channel) reported critically on German orthodontics. Dr. Madsen was available as interview partner and had contacted a patient beforehand who had been treated in a questionable way. Maybe, this kind of report might lead to the future avoidance of senseless early orthodontic treatment and the usage of outdated removable appliances.

Video

Fastbraces – the Next Flop in Orthodontics

In orthodontics it seems to be a fashion that some manufacturers of brackets give unrealistic promises in sales promotion. It’s particular popular to claim that in comparison to other brackets bracket X called for a shorter treatment duration, less appointments, more comfort, minor root resorption and less wires.

Fastbraces was developed around 1995 by Anthony Viazis, an American orthodontist. This bracket is supposed to have those wonderous characteristics. They are described in detail on the website https://fastbraces.com/. The following statements are mentioned: Whereas orthodontic treatment with “normal” brackets was supposed to take several years the treatment duration with Fastbraces was just six months. While using common brackets, wires had to be changed regularly. Fastbraces worked with only a single wire. Naturally, patients had less pain, discomfort and root resorption than with “normal” brackets. It’s really funny that Mr. Viazis claims, Fastbraces provoked root movement right from the start whereas the commonly used brackets only moved the tooth crown. There’s another wonderous characteristic which must not be missing: If Fastbraces was used, patients would virtually never have tooth extractions.

It doesn’t have to be mentioned that these advantages of Fastbraces aren’t proven by scientific studies but are based on casual statements. If you are an orthodontist with years of experience who has worked with different bracket types you’ll come to the conclusion that differences between bracket types are minor and are mainly focused on a better manageability. Even Fastbraces’ original triangular bracket shape wouldn’t be a sufficient reason why this product should have a superior effectiveness. Against the background, orthodontists who are engaged in scientific research wouldn’t be persuaded to start a comparative study between Fastbraces and “normal” ones. There have been a lot of studies with numerous bracket types without finding any significant clinical differences between them. During the past 20 years while Fastbraces has been available on the market, the inventor Viazis didn’t take the trouble to prove his claims conducting a high-quality study. So we can draw the conclusion that Fastbraces doesn’t differ a lot from “normal” ones and is marketed in a dishonest and quite unfair way.

This even provoked criticism from the British regulatory organization Advertising Standards Authority (ASA). On 23 April 2016 they stopped a British orthodontic practice giving advertising statements about Fastbraces. ASA criticized numerous rule violations within the Fastbrace advertising: e.g. misleading, exaggeration and incorrect comparison to competing products. The owners of the practice were told to stop claiming that treatment duration with Fastbraces was shorter, patients suffered less pain and there was less root resorption than with “normal” brackets as long as they couldn’t prove it. You can learn more about the decision of the ASA under https://www.asa.org.uk/rulings/igdp-ltd-a16-348854.html.

The right time for starting orthodontic treatment

Orthodontists often provide their young patients and parents with confusing informations about the right time for starting orthodontics. Some colleagues recommend to start with orthodontics when the kids are at preschool age or at primary school – referring to a developmental stage when kids have their primary dentition.

Basically, it’s very simple: The permanent dentition should be treated orthodontically, whereas the primary teeth fall out anyway and therefore their orthodontic treatment is generally questionable. This is the reason why almost all over the world it’s of common use to start orthodontic treatment when the patients’ permanent dentition is present. This is generally the case when kids are 11 – 12 years old. Orthodontists who want to treat their patients in an honest and modest way start treatment at that age.

Beside the logical conclusion of avoiding any efforts of treatment on the primary dentiition, there’s even another reason why you should start with orthodontics in the early permanent dentition. All of the tooth movements benefit from the adolescent growth spurt – you can handle them in a quick and elegant manner. It’s another hint for avoiding orthodontic treatment before the age of 10 and wait patiently until kids are 11 – 12 years old. This patience is the basis for a huge profit: The young patients and their parents are rewarded with short and smooth treatments and finally with a reduction of costs.

In Germany early orthodontic treatment predominates

It’s interesting to recognize that in a wealthy industrial country like Germany breaking the simple rules for an ideal start of orthodontic treatment is taken as a matter of course. German orthodontists mainly stick to the outdated model of early treatment. Most of the colleagues try to recrute young patients favourably as soon as they enter their practice. This nonsense is justified on the basis of two pretexts: On the one hand treatment would be easier because of its early start on the other hand malocclusions would be getting worse without any orthodontic intervention for primary school children. This could only be avoided by an early treatment. Propaganda for early treatment is summarized in the slogan “the earlier the better“. Well, why don’t we start their orthodontic treatment in utero – in their mother’s womb? Even less effort would be required then, right? In contrary, scientific data prove: The earlier you start with orthodontics the longer is the treatment duration and the higher are the costs. Furthermore it’s proven that childrens’ malocclusions when they are at the age of 6 – 12 don’t change significantly. This is further aggravated by a high probability of new diagnostics and therapy planning during treatment leading to higher costs and a greater burden on patients caused by an early treatment – all given facts contradict the early orthodontic treatment.

In general, starting orthodontic treatment in the early permanent dentition when kids are aged 11 – 12 is the scientifically proven gold standard. The true mystery why Germany of all countries is a stronghold for early orthodontics, can be revealed easily. In Germany there’re no fixed prices for orthodontics but services are paid individually. Those orthodontists who perform the longest and most complex treatments seem to act wisely when it comes to business. Therefore it’s none of a surprise that in other countries orthodontic treatment duration takes 1 – 2 years whereas in Germany it takes 3 – 4 years. This is further aggravated by using outdated removable braces during most of the early treatments – these are hardly in use internationally, they are neither scientifically investigated nor continually developed, because fixed appliances are more efficient, profitable and patient-friendly. Despite their inferior quality removable appliances are the gold-dropping donkeys of German orthodontists, because there’s no other dental technique which offers such high profits than these simple and easy-to-handle removable appliances. When your orthodontist tells your parents about starting orthodontics “the earlier the better“ he hasn’t got on his mind to improve your individual treatment but to follow his own economic interests.

A tip for parents: The later orthodontic treatment starts, the better for your children

Parents can only be advised to resist the hinting whispers of starting early treatment of their primary school children – although they seem to appear quite plausible. More than ninety percent of the children with orthodontic treatment indications are best served when orthodontics starts at the age of 11 – 12. Exceptions are crossbites of front teeth, total lateral crossbites with lateral displacement of the lower jaw and some other rare findings. All the other medical indications don’t benefit from an early orthodontic treatment, but have to pay the price later. The simple but efficient rule is to wait until the early permanent dentition is established before orthodontics gets started.

Parents, please pay attention: Removable appliances are obsolete, inefficient and uneconomic

All over the world orthodontics with fixed appliances is considered to be the gold standard. Only in Germany about fifty percent of treatment duration concerning adolescents is performed with removable appliances. However, removables aren’t a full-value alternative to fixed ones: Many tooth movements like the rotation of lateral teeth and lengthening or shortening of teeth aren’t possible with removable appliances. Generally, one can only tilt teeth with these primitive appliances; as physical movements and control of the tooth axis are required, removables are only suitable for simple and limited treatment. Furthermore most of the removables are associated with severe speech impediments. Studies concerning the analysis of wear-time have shown that this is the reason why young patients wear their removable appliances for a median of ten hours a day, whereas 12 – 16 hours are recommended. – Under these circumstances orthodontic treatments with removables can’t possibly succeed.

In this context it’s no wonder that improvement of dental position with fixed appliances is much more effective than with removables. Comparative studies have shown that fixed appliances are highly efficient. As British scientists have recovered the probability of worsening the malocclusion rises when using removable appliances. Moreover, thirty to sixty percent of orthodontic treatments with removables are cancelled unsuccessfully, because young patients don’t accept to wear these plastic blocks. They resist in their own ways by not wearing these troublemakers. Finally, other studies have proven that treatment with removables isn’t only less promising, but even more expensive. Removables are simply uneconomic, as it has been proven, whereas fixed appliances offer a real value for your investment.

The mystery why removable appliances, despite their disadvantages, are favoured by German orthodontists can be easily revealed. Actually there’s no dental procedure right up to dental implants which proves so highly profitable with least efforts like working with removables. They’re made by dental technicians and can be distributed to patients with little know-how, skills and effort. With 6 to 8 short checkups per year a considerable profit can be generated, without any special know-how and without lifting a finger at all. In the German system of reimbursement for dentists orthondontics with removables is too close to one of the oldest dreams of mankind of earning an income without having to work. Therefore it’s hardly surprising that it is favoured by an entire group of  healthcare professionals. It is only fitting that young orthodontists who establish their practice set up a dental laboratory immediately and engage a dental technician who produces removable appliances. Whereas this is considered normal in Germany foreign orthodontists are rubbing their eyes in amazement: they don’t need a considerable amount of removables. Moreover, dental laboratories belonging to the practice are almost unknown in other countries.

It can be summarised that in Germany removable appliances are still used against better knowledge, despite their proven unsuitability, their high failure rate and inefficiency, because a small professional group makes a profit at the expense of patients. Parents can only be advised to reject any orthodontic treatment with removables and ask for fixed appliances. There’s one exception: The treatment of a mandibular retrognathism with a single double appliance – using these appliances in a sequence seems absurd and must be rejected.

Removable retainers aren’t often worn efficiently and are unreliable

After an orthodontic treatment the dentition would always be prone to relapse if the outcome wasn’t stabilized properly. The stabilization of orthodontic treatment outcomes is possible with the help of removable and fixed appliances.

For common plates, favourably used in Germany for retention, the prescribed wear-time is eight to sixteen hours a day. In a recent study scientists from the University of Tübingen could prove that patients’ compliance isn’t appropriate. One hundred patients were treated with orthodontic retainers into which microsensors were incorporated in order to estimate the daily wear-time. The collected data was read off by computers. The actual median wear-time was seven hours a day being far below the required level prescribed by the orthodontists. Moreover the scientists found out that the young patients showed a heterogeneous daily wear-time behavior. This is probably the reason why removable appliances often fail because during the first months after active treatment just a few days without optimal retention can be enough to force front teeth to relapse.

There’s of course the fixed retainer, a thin wire which is positioned on the backside of the front dentition without being seen – a reliable, economic and comfortable solution. Unfortunately retention with removable appliances is still of common use in Germany. The reason for this is of economic nature because German orthodontists earn double income with removables in comparison to fixed appliances – it’s obvious that this mistake resulting from the German system of reimbursement for dentists will not remain without consequences. Therefore it’s recommended to patients and parents to ask for fixed retainers just before the end of active treatment.

Reference:
Schott TC, Schlipf C, Glasl B, Schwarzer CL, Weber J, Ludwig B. Quantification of patient compliance with Hawley retainers and removable functional appliances during the retention phase. Am J Orthod Dentofacial Orthop. 2013 Oct;144(4):533-40. doi: 10.1016/j.ajodo.2013.04.020. PubMed PMID: 24075661