Dental Braces 1925 – 1970
Whilst orthodontics in the USA developed early and treatment with fixed braces slowly started to spread, orthodontics in Germany fell by the wayside. Angle’s teaching and his fixed braces (edgewise-appliance) also became known in Germany through his pupils Körbitz, Grünberg and Oppenhaim. In Germany, skull X-rays were developed in 1931 as a result of the work of Hofrath, while virtually simultaneously in the USA Broadbent was also working on this important diagnostic tool.
Fixed braces dominated throughout the world until around 1930. In 1928, with the help of X-rays, Oppenheim discovered that fixed braces actually caused damage to the roots – so-called root resorption. At about the same time, removable braces such as the active plate were first suggested (Nord 1929) and subsequently developed by the Austrian A.M. Schwarz. To orthodontists in Germany and in some of its neighbouring European countries this seemed to be a milder, less risky treatment option so active plates and later various removable double-braces also became the norm here in Germany.
The Great Schism: Dentofacial Orthodpaedics versus Orthodontics
But it was Andresen’s introduction in 1936 of a removable double brace called an Activator that led to the momentous split of German orthodontics away from the development that was taking place in the USA. In a complete overestimation of his removable brace, Andresen claimed to have invented a completely new, ‘biological’ treatment method that was capable of influencing the development of both the skull and the face. He named his allegedly superior treatment method “functional orthodontics” and claimed to have eradicated purely mechanical orthodontics using fixed braces. As a result of this, the older term ‘orthodontics’ that was in use in most languages, was replaced in Germany by the new term ‘Kieferorthopädie’ (dentofacial orthopaedics). As a consequence of this, orthodontic treatment using fixed braces was no longer taught at German universities until 1970. Whilst orthodontic treatment in the USA was carried out exclusively using fixed braces, the removable brace dominated in Germany for decades. Scientifically, this was a pure mistake but at least it had the advantage that treatment with the cheaper removable brace became more affordable for many people, even if it could not produce results as good as the fixed brace and meant longer treatment times. Admittedly, German orthodontists did have to extract teeth during these times but avoided this wherever possible because, in most cases, the mechanical possibilities of the removable brace did not allow for very good space closure and sometimes just caused the teeth to tilt.
Extracting Teeth – the Turning Point in the USA
The more closely that Angle’s pupils followed his doctrine by not extracting any teeth for orthodontic reasons, the more that they started to notice that the patients’ teeth quadrants that had been so painstakingly enlarged, did not remain stable after treatment but often reverted back to their former position. One particular Angle pupil, Charles Tweed (1895-1970), was so frustrated by this that he considered giving up orthodontics altogether and re-training as a normal dentist. However, he subsequently changed his mind and actually treated many of his patients whose teeth had become crooked again years after treatment, a second time by extracting four of the premolar teeth (small back teeth). He established that not only did the results look better, but they also remained more stable after the treatment. Hayes Nance (1893 – 1964) went in a similar direction. Tweed and Nance’s articles from the late forties on the orthodontic extraction of teeth had a huge effect on American orthodontics and led to the abandonment of Angle’s doctrine of never extracting teeth. These brilliant articles, by the way, are still well worth reading after more than 60 years and should be recommended reading for all those orthodontists who feel that, yet again, they have to follow a doctrine of never extracting teeth. It should also be mentioned here that this led to an extraction mania, not only in the USA but also in other parts of the world because there were no clear, scientifically-based criteria as to when extracting teeth could be useful and when not (Favourite mottos in US orthodontics were ‘if in doubt, whip them out’ and ‘four on the floor’). However, since the 1970s the number of orthodontic treatments worldwide involving the extraction of teeth has again fallen. Now that so much is known about long-term stability, para dental health and facial aesthetics, an extraction rate of 20% of orthodontic treatments would appear to be the most reasonable compromise.
Development in Germany
Since 1970 there has been a gradual move back towards teaching students about fixed braces. This has seen an end to the big split with US orthodontics. However, the level of conservatism that still exists in some German colleges is illustrated by the number of articles that have been published since 2000 about orthodontic treatment just involving removable braces, which are essentially out-of-date, make no sense for the patients and, what is more, are simply uneconomic. And, in the case of established orthodontists in Germany, the situation looks even worse because the German fee reimbursement system actually rewards protracted, less efficient treatment better than short, intensive treatment. Furthermore, almost every German orthodontist has their own laboratory where they make removable braces. Orthodontists can charge twice as much for each individual treatment with a removable brace which means that in Germany an inefficient, outdated treatment regime for children and adolescents involving removable braces is becoming more commonplace.
Yet, from a scientific point of view, it is clear that the easiest, most effective and patient-friendly treatment is that involving a single, fixed brace. So in Germany we have the situation where, as a result of conservatism, bad training and an absurd reimbursement system, most treatment is still carried out using outdated, removable braces – much to the disadvantage of the patient!