clinical

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ORTHODONTICSand ‘THE PINOCCHIO FACTOR’
By Dr Robert Cerny, BDS, MDSc. Specialist Orthodontist
E-mail: rcerny48@gmail.com

Art Work by Peter Mark Lewis
E-mail: pmlewis1@optusnet.com.au

P

Dr Robert Cerny

inocchio tells the tale of a poor carpenter,Geppetto, who has no wife and no child. Hecarves himself a puppet boy out of wood andcalls him Pinocchio. Pinocchio (is granted life,with conditions, and), like other children, hasa lot of lessons to learn in life. When he disobeys his father and runs away, he has a series ofadventures which teach him these lessons, themost famous being that he shouldn’t tell lies.
When Pinocchio lies, his nose grows longer....’1
Applying the Pinocchio factor to orthodontics, how long would its nose be today?
Orthodontics became the first dental specialty in 1900 thanks to Dr EH Angle2. The‘laws of orthodontics’ were developed fromtrial and error assessments, opinions and anecdotal claims. Most of the laws have never being
scrutinised or validated scientifically.

Fig 1. Before treatment. After treatment.

The nose was one inch long to start with.
1. Orthodontics is evidence based (EB)............................................. add one inch
Approximately 33,500 papers havebeen published in the orthodontic
literature3 and of these, about 20
satisfy the evidence based requirements4, that is, 0.05%.
The new EB philosophy has yet
to address the value of the many
papers which don’t fulfil the strict
EB requirements but do have merit, especiallywhere many case reports etc come to similar
conclusions.

2. Orthodontics is not about aesthetics............................................. add one inch
The truth is, orthodontics has
always been about aesthetics byenhancing the beauty of the dentition and the face2People who have crooked teeth
are embarrassed by them. You can’thide a facial disfigurement easily
48 Australasian Dentist

unless you use a masking device like a fan – aswas done in the 1600’s. Ugly teeth are a social
handicap. Beautiful people have the benefitsof the “beauty bias”5 – they get more favours
and go places. They have many advantages
over the plain people throughout life. Figure 1
demonstrates what orthodontic treatment canachieve in enhancing the beauty of the face andconfidence of the smile.

3. Or thodontics is about function............................................. add one inch
The truth is, most orthodontic
treatments
don’t
noticeably
improve dentition function whenassessing mastication performance6 or alter speech7 or correction/prevention of temporomandibular joint dysfunction (TMD)8, 9.
As Shaw et al commented, ‘Even themost severe deformities of the jaws such as cleft
lip and palate, skeletal open bite and mandibular prognathism appear to be associated withsurprisingly little functional disability’.

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4. Orthodontics is about stabilising the dentition.............................................add one inch

9. Orthodontic research is unbiased................................................................. add 1 inch

Any dentist who has been in practice formore than five years will verify that relapse
occurs more often than most orthodontist’s
realise10.

All research has bias problems16. How
can a cash-strapped institution
run expensive prospective randomised controlled trials with
sufficient numbers of patientsover the two years and more thatis necessary to achieve a valid evidence based result? And how does one get‘Ethics Approval’ to conduct these trials on children?

5. Orthodontic treatment never dishes the face in..............................................................add one inch
Just ask anyone who is over 20 years old
and from a sophisticated society how
often they have seen or heard about thisproblem. The majority of orthodontic
patients, 55%, have a retrognathicmandible11, 12 and to achieve the obligatory ideal Class I occlusion outcome from‘camouflage orthodontic treatment’, the maxilla
is invariably retruded, that is, dished in, to fit onto the deficient mandible13.
Ah! But wait, these patients do have great lip posture.

6. Orthodontic/Orthopaedic treatments can makedeficient mandibles grow larger..
...................................add one inch
In 2007, ‘The Cochrane Collaboration’14
finally buried that BS claim.

7. Surgical orthodontic treatments with rigid
fixation correct skeletal discrepancies
permanently..............................................................add one inch
A recent long term, 12.5 years, review
study by Joss and Thuer15, presented
in 2005 and published in 2008, foundsuch surgery for Class III corrections
reverted, on average, by approximately 2% per annum and Class II
mandibular advancement corrections
reverted by approximately 5% per annum.
This is not a good outcome for the retrognathics.

8. Orthodontic education is up to date andeffective..............................................................add one inch
Most university orthodontist training schools suffer from academic
stress; they have serious cash andstaff shortages due to their poor
financial circumstances. Theirresearch projects are handicapped
for the same reasons.
Students are encouraged to challenge their lecturers on orthodontic theory and techniques,
if they don’t mind repeating the year.
Some orthodontic conferences have taken on a policy of‘No question time’ after presentations. It’s like being backin undergrad classes. So, how dumb is the audience? Don’t
they have the ability to contribute valuable and objective
information indirectly? Often the best information obtained
from a lecture is during question time and if that facility isremoved, why bother attending?

10. The Orthodontic press is up to date and unbiased................................................................. add 1 inch
If a research paper agrees with thestatus quo, chances are, it will‘get published within 30
months of presentation ata conference’16, if not, takea number and wait (up to 4years, if at all).
A computer that is more than threeyears old is a ‘dinosaur’ but orthodontic research that gets
published after three years is ‘cutting edge stuff’.
Any would-be contributor to a journal should expect
their paper to be peer reviewed, scrutinised, sanitised andoften emasculated before being published. Any statisticalanalysis is usually designed so that only ‘the initiated few’can understand it, for example ∑ = √p/x armstron/pascal/hertz°. And always remember, the higher the P value, themore insignificant the result is.
References sometimes can’t include research presented
at a conference or seminar etc. unless it has been publishedin an acceptable journal, eg, Professor R Little’s17 summaryof findings from the Seattle Studies presented at the AAO
Annual Conference in Orlando USA, 2004. For most journals, references that are not published didn’t happen. And if
it’s off the web, should we really be very afraid?
Idle chit-chat conversations with the ‘Brains trusts’ atconferences have mentioned that there are over 200 formsof scientific bias including editor biases. The readers can’t
be considered to be intelligent enough to separate fact fromfiction -hence, if the reviewer(s) and/or editors don’t like apaper, in the bin it goes. As an example which would probably apply to most journals, in 2007, the ADJ reviewed 155
papers from 25 countries and of these 26% were published18.
Most of the rest (74%) we will never know about. How sadis this for the rejected researchers and science? Couldn’t
these papers be been published as abstracts with web links
to access the full text? Reviewers could add their concerns-with references, and couldn’t we, the readers, be humoured
enough to make judgements on the validity of these papers
for ourselves?

11. Patients and parents opinions from theirexperiences in orthodontics are sought after andrespected................................................................. add 1 inch
Does it matter what they think?
We are the experts so what
we say goes! A searchof the literature willshow how few studies there are in thisregard.

Australasian Dentist 49

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12. Governments see to it that the public are looked
after................................................................ Hold 1 inch
Adding a touch of sarcasm,
there are no struggling
faculties or students
in Australian Universities, apart fromthe post grad research
students who are provided with just enough money
to keep them below the poverty line. Here in Australia,
Kevin has promised to fix education; no comments areneeded at this time.

13. But wait, there’s more, there’s the biggest lie of
all and that is ‘The essential need for orthodontic
treatment to establish an ideal Class I occlusion’.
Where is the evidence? 19----- then again, I think Ortho Pinocchio has had enough.
The orthodontic Pinocchio face has an advance escortof conservative archaic doctrine and non-questioning blinkered troopers wherever it goes so that the nose doesn’t get
knocked around. Ah! But it does have really good lip service,uerr, posture.

REFERENCES

ses in orthodontics. Am J Orthod Dentofacial Orthop. 2007;131:58999.
5.

Berry B. Beauty Bias. 1’st ed. Westport,CT 06881 USA.: Greenwood
Publishing Group, Inc. 2007.

6.

Shaw WC, Addy M, Ray C. Dental and social effects of malocclusionand effectiveness of orthodontic treatment: a review. Community
Dent Oral Epidemiol. 1980;8:36-45.

7.

Johnson NCL, Sandy JR. Tooth position and speech – is there a relationship? Angle Orthod. 1999;69(4):306-10.

8.

Hendrikson T, Nilner M. Temporomandibular disorders, occlusion
and orthodontic treatment. J Orthod. 2003;30:129-137.

9.

Greene CS. Etiology of temporomandibular disorders: implications
for treatment. J Orofacial Pain. 2001;15:93-105.

10. Little RM. Stability and relapse: Early treatment of arch length deficiency. Am J Orthod Dentofacial Orthop. 2002;121(6):578-81.
11. Pinskaya YB, HsiehT-J, Roberts WE, Hartsfield J K Jr. Comprehensive
clinical evaluation as an outcome assessment for a graduate orthodontic program. Am J Orthod Dentofacial Orthop. 2004;126(5):53343.
12. McNamara JA Jr, Brudon W. Orthodontic and Orthopedic treatmentin the mixed dentition. 6th ed: Needham Press Inc.; 1994: Cpt 5;95116.
13. Pfeiffer JP, Grobety D. The Class II malocclusion: differential diagnosis and clinical application of activators, extraoral traction, and fixedappliances. Am J Orthod. 1975;68(5):499-544.
14. Turpin DL. The long-awaited Cochrane review of 2-phase treatment.
Am J Orthod Dentofacial Orthop. 2007;132:423-24.
15. Joss CU, Thuer UW. Stability of the hard and soft tissue profile after
mandibular advancement in sagittal split osteotomies: a longitudinaland long-term follow-up study. Euro J Orthod. 2008;30:16-23.
16. Scholey JM, Harrison JE. Publication bias: raising awareness of apotential problem in dental research. Br Dent J. 2003;194(5):235-7.

1.

Penguin Young Readers Factsheets, Pearson Education Limited 2000.
www.penguinreaders.com

17. Little RM, Presenter. Treatment outcomes/ complications. Lecture,
AAO 104th Annual Session; 2004; Orlando, Florida. AAO.Audio-tape
19/2004;29A.

2.

Graber TM. Orthodontics – Principles and Practice – Development ofa concept. 3rd ed. Philadelphia: WB Saunders Co.; 1972.

18. Bartold PM. Editorial. BEGINNING OF A NEW ERA. Aust Dent J
2007;52: p263.

3.

Keim RG. The Editor’s Corner – The Power of the Pyramid. JCO.
2007;10:587-8.

4.

Papadopoulos MA, Gkiaouris I. A critical evaluation of meta-analy-

19. Ackerman JL, Martin RK, Ackerman MB. A Philadelphia Fable: How
Ideal Occlusion Became the Philosopher’s Stone of Orthodontics.
Angle Orthod. 2007;77(1):192-94.

QUESTIONS
1.
a.
c.

How many forms of Research Bias are there?
50b. 100
150
d. >200.

6.

2.

The Orthodontic literature contains approximately whatpercentage of valid ‘Evidence Based’ research papers?
50%
b. 20%
5%
d. 0.05%

7.

The surgical correction of mandibular retrognathia using
rigid fixation may revert over the following 12 years byapproximately how much?
60%
b. 40%
20%
d. 10%

8.

a.
c.
3.

a.
c.
4.

a.

The opinions of patients and parents on their orthodontic
experiences are keenly sought after and reported in theliterature.
True.
b. False.

5. 	Approximately what percentage of orthodontic patientshas a retrognathic mandible?
a. 75%
b. 55%
c. 35%
d. 25%

50 Australasian Dentist

a.

a.
c.

a.
9.

a.

Orthodontic treatments often provide functional benefits
for the patient’s dentition.
True.
b. False.
Papers submitted for publication in leading dental
journals are usually published within:
6 monthsb. 12 months
24 months
d. 30 months
Orthopeadic/orthodontic treatments do not make themandible grow larger.
True
b. False
The statistical analysis presented in orthodontic journals
is usually straight forward and easy for most readers tounderstand.
Trueb. False

10. 	Acceptable ‘Evidence Based’ research in orthodontics
usually requires which of the following
a. A lot of cash
b. More than 2 years
c. Ethics approvald. Dedicated researchers