What price progress

For at least 2 centuries, orthodontic treatment planning and appliance fabrication have relied on creating an accurate facsimile of the teeth, by using various impression techniques and materials. In the early 20th century, attempts were made to orient the plaster casts of the teeth with a plaster facial moulage. These techniques were labor-intensive, time-consuming, and uncomfortable for the patient. With the advent of photography and the later introduction of radiographic cephalometrics, nearly the same goal could be accomplished rapidly and noninvasively, although the representation was 2 dimensional rather than 3 dimensional. For the last 50 years, alginate impressions, plaster casts, facial photographs, and radiographic cephalometrics have remained the standard orthodontic records. During this same period, there has been a slow evolution in the materials used for constructing removable orthodontic appliances. In the early 20th century, vulcanite and precious-metal wire appliances were supplanted by acrylic and stainless-steel wire appliances. Fifty years ago, the tooth positioner was introduced. It was created by carefully removing the individual plaster teeth from a model and setting them ideally in wax, similar to a denture setup. On these perfectly aligned and articulated models, a rubber removable appliance, similar in shape and size to an athletic sports guard, was fabricated. In the last 20 years, thin, clear thermoplastic materials have been used to vacuum-form retainers that are essentially invisible. These retainers can also be modified to effect limited tooth movement. With Cadcam techniques, computer technology can be used to create a sterolithographic model rather than 1 resulting from the old casting techniques. The advantage of this approach is that the teeth can be rearranged on the computer screen rather than having to cut the teeth off a plaster model and reset them in wax. These stereolithographic models can then be used to thermoform thin, clear, invisible, retainer-like trays that can be used for orthodontic tooth movement. Tooth-colored elements can be bonded to individual teeth to improve the biomechanical capabilities of these appliances. These devices now have limited capability and efficacy compared with fixed appliances; however, the promise of this technology is that ultimately the laser scan can be done directly in the mouth, and 3-dimensional images of the teeth can be integrated seamlessly with 3-dimensional photographs and radiographs. This will create a virtual patient’s face, teeth, and jaws. The articulator will be relegated to a historical curiosity! With such a computer model, all elements of the craniofacial dental complex can be analyzed in either static or animated format, and the clinician can manipulate them for diagnostic and treatment-planning purposes. This information can be transmitted via the Internet. The company that designed the technology would then fabricate the appliances that the orthodontist prescribed. Is this scenario science fiction? No, it merely requires a company with enough venture capital and commitment to the task. The danger behind this scheme is that if this company chooses to take its product directly to the public with an intensive advertising campaign, it could create a shift in the traditional mode of orthodontic patient referral (the tail wagging the dog, as it were). There would be nothing to prevent this company from launching its business scheme long before a single publication in the orthodontic literature about this method. How acceptable would it be if the clinical testing that led to the first legitimate article in an orthodontic journal was sponsored by the company, and the author, a university professor, acknowledged that he had a financial interest in the company? If the company then offered the product to general practitioners and advertised that its successful use requires no previous orthodontic experience, this would surely constitute fraud. But what could the recognized orthodontic specialty organization do if it had already accepted large donations from this company for various purposes? What a dilemma! On the 1 hand, there is such great promise that modern technology can accomplish the dream that orthodontists have had for nearly a century. On the other hand, becoming closely linked with a commercial enterprise whose only goal is profit is a dangerous precedent. The boundary between ours and the oldest profession of them all could become obscured. Am J Orthod Dentofacial Orthop 2002;121:243 Copyright © 2002 by the American Association of Orthodontists. 0889-5406/2002/$35.00 0 8/1/122830 doi:10.1067/mod.2002.122830