70 Australian Dental Journal, February, 1968

The changing face of orthodontics in Australia”

John F. Reading, B.D.S. (Syd.), F.D.S.R.C.S. (Eng.), D.Orth., R.C.S. (Eng.) t

In the period 1956-66 the orthodontic situa- tion in Australia changed considerably, not only in the increasing availability of orthodontic services but also in the methods of treatment and in the standards of the results.

Australian Society of Orthodontists

These changes were associated with the pro- gress of the Australian Society of Orthodontists which has conducted three national congresses in the last six years. While mainly enabling members to meet and discuss the more detailed advances i n materials and techniques, these independent orthodontic congresses were invalu- able in bringing to Australia international orthodontists of renown. The flrst Australian Orthodontic Congress in Sydney in 1961 had Dr. P. R. Begg of Adelaide as its main speaker. In Perth in 1964, Professor C. F. Ballard of the University of London conducted three lecture-discussions, and Dr. Robert Ricketts from the U.S.A. also lectured for three sessions.

At the third congress, held a t Surfers’ Para- dise, Queensland, in 1966, Dr. Harold Perry of Chicago and Northwestern University was the main speaker with six lecture sessions.

Orthodontic Foundation

These events were highly signiflcant and the influence of these lecturers has been responsible for some of the general changes in the ortho- dontic scene in the period under review. While the A.S.O. itself sponsored some of these visits, the leading influence was undoubtedly the Australian Society of Orthodontists’ Foun- dation for Research and Education. Through the foresight and generosity of Dr. W. Stanley

* Presented at the 18th Australian Dental Con-

t Part-time Senior Tutor in Orthodontics, Univer- gress, Melbourne, February-March, 1967.

sity of Sydney.

Wilkinson, this Foundation waa inaugurated in 1961, and with the support of the full-time specialists enabled Dr. Ricketts to tour Australia in 1964.

In 1967 the Foundation arranged for Dr. Alton Moore of the University of Washington to visit the various capital cities of Australia and lecture on the latest developments in cephalometrics.

Graduate courses

Another major influence was the course in the Begg lightwire technique, sponsored by the A.S.O. and the University of Adelaide in May 1963. A second course was held in 1965 in Adelaide. Over sixty orthodontists attended these courses in Australia. In 1968 the A.S.O. is to conduct a course in Melbourne in the edgewise technique.

Graduate training in orthodontics has resulted in the award of the flrst two M.D.Sc. degrees of the University of Sydney, marking the completion of two years’ full time graduate training, the. presentation of a research thesis, and the successful conclusion of the examina- tions.(*) It is signiflcant that four graduate students completed their training at the end of 1967 and that another eight students completed half of their two years’ training in this period. There is a waiting list for future courses. Previously, dental graduates gained experience in orthodontics as pre- ceptors to established specialists. The only other method available for Australian dental graduates to gain specialist status was to obtain such training and higher qualiflcations in the U.K. or the U.S.A.

(1) Alumni Faculty Day 1966, Dental Alumni Society, University of Sydney - Apollonia, 4 : 1. 8-11, 1967.

Australian Dental Journal, February, I968

SRecialirt registration

Regulations for specialist recognition differ in each State. of Australia, with speciflc condi- tions applying in Queensland and New South Wales. As orthodontics is a specialty requiring a minimum period of formal training (at least two years full-time), the need for uniform registration in all States of the Commonwealth was recognized by the A.S.O. After six years’ investigation the Society adopted the recom- mendations of a standing committee and inaugurated the Australian Orthodontic Board in May 1966.

With these advances in orthodontic services, specialized instructional courses and increasing opportunities for critical evaluation of treat- ment results at national congresses and other meetings, i t is understandable that more ambitious results of individual treatment pro- cedures are being achieved. This fact is demon- strated by the voluntary acceptance of case reporting by members of the Australian Society of Orthodontists for presentation at orthodontic congresses and the various study groups. Requirements for case reporting a re of inter- national standards and uniform; before and after records permit quicker understanding and comparison. These records, which most specialists regard as essential for case. analysis and diagnosis, include record models, facial photographs, and tracings of cephalometric roentgenograms, which enable conditions before and after treatment to be compared.

71

Orthodontic materials Also of great signiflcance in the Australian

scene is the increasing availability of ortho- dontic materials and equipment. Such items as preformed bands with prewelded attachments, heat treated arch-wires, extra-oral appliances, new prosthetic materials, and tooth positioners, are flnding a n increasing application in Aus- tralia. The trend is to bulk ordering of pre- welded attachments on preformed bands. There is no doubt that this saves chairside time, but the careful adaptation of individually fashioned bands could offer better protection from decalci- fication, especially of anterior teeth.

There is a constant introduction of new technical advances, such as the interchangeable plastic bracket and the “snap-it-on” archwire attachments.

Evaluation of a new technique When a new technique is described in a

scientific publication there follows a period

of testing and critical appraisal. In clinical orthodontics, the testing period must be pro- longed as the actual treatment time i s seldom less than twelve months and, frequently, active treatment must extend to dghteen months or, more rarely, to twenty-four months. Removal of appliances is not the end of the clinician’s responsibility, as the patient must be seen through the retention and observation period. This could mean at least another twenty-four months. It seems, then, that a minimum period of four years would be necessary to assess the earliest results of the flrst cases treated by a new technique. As many complex factors lead to apparently similar cases of malocclusion, i t is essential to evaluate the new technique on a group of cases and to compare it with existing techniques for similar cases under treatment. This must extend the time. of personal evaluation of the new technique, and this period of individual assessment is essential in such a fleld as clinical orthodontics despite the evidence already available of the results achieved by the advocates of the new technique.

Figure 1 shows the results of four different methods of treatment. Note the parallel roots on either side of the extraction spaces which were closed during treatment. In Fig. la no root torque was attempted and no lower premolars were extracted. The results can be contrasted with the later methods.

The Begg technique

It is, perhaps, not generally known to the general dental practitioner in Australia the world-wide influence that Raymond Begg of Adelaide, South Australia, has on orthodontics. Shortly after graduating from Melbourne University over thirty years ago, he gained his orthodontic training in America under Angle. His anthropological studies resulted i n the publication in 1954 of “Stone Age Man’s dentition”.(2) Brief mention was made in that article of the use of light round arch wire and differential force for more rapid tooth movement. This description of what is now generally known as the Begg technique. was published in America in 1956.‘’) Since then he

(2) Begg, P. R.-Stone Age Man’s dentition with reference to anatomically correct occlusion, the etiology of malocclusion, and a technique for i ts treatment. Am. J. Orthodont., 40: 4, 298- 312 (Apr.); 5, 373-383 ( M a y ) . 6, 462-475 ( J u n e ) , 7, 517-531 (JUIY) 1956.

(8) Begg, P. R.-Differential force in orthodontic treatment. Am. J. Orthodont., 42: 7, 481-510 ( Ju ly) 1956.

Australian Dental Journal, February, I968

Fig. 1.-Results of orthodontic treatment: (a) 10 years ago; extraction of upper flrst premolars and fully banded technique. (b) Four years ago; extraction of all four flrst premolars and round arch and edgewise brackets technique. (c) Speed of tooth movement with Begg technique (reduction of overjet and overbite in six months' treatment. space closure and root paralleling still to follow). (d ) Two years ago; ext'raction of all four

flrst premolars and Begg treatment.

Fig. 2.-Proflle obtained af ter flxed appliance therapy using the Begg technique: (a) Before flxed appliance therapy but af ter six years' serial extraction culminating in removal of al l four flrst premolar teeth. (b) After Begg technique treatment. (c) Stage I11 of Begg technique showing uprighting springs for canines and second premolars and auxiliary archwire to torque roots of maxillary centrals and laterals

palatally. (d) Occlusion, two years out of retention.

Aust ra l ian Denta l Journal, February , I968 73

Fig. 3.-Profile ohtained a f t e r Axed appl iance therapy with round archwires and edgewlse bracke ts fol lowing extract ion of all f o u r second premolar teeth. Both maxil lary la te ra l incisors were inlocked: ( c ) Shows initial 0.016” archwires with bands cemented to the four anterior teeth, first premolar and Arst molar teeth. ( d ) Progress six weeks later, with initial archwires in place, showing improvement in position of lateral incisors. (e ) Archwire change with hand placement on remaining teeth, apar t from partially erupteil upper left ranine. ( f ) , ( g ) All teeth handed 0.020”, finishing

arches for f ina l nlignment Xnte final ~inaitinn of lower right lateral incisor.

F

74 Australian Dental Journal, February, I968

has conducted courses and has lectured exten- sively in this technique in the United States and in Australia, although the first course in Adelaide was not held until 1963.

In the U.S.A. a Begg Society was formed and a new publication known as the Begg Journal of Orthodontic Theorv and Treatment was commenced. In 1965 the text book, “Begg orthodontic theory and technique”,(4’ was pub- lished in the U.S.A. In the foreword H. D.

well be the most precise and exacting of all techniques yet developed”.

Implicit in this technique and aided by the increasing availability of preformed bands and prewelded attachments together with the obvious advantages of bulk buying of appliance materials, i t is clear that many practices may soon become tied to this technique exclusively or, for that matter, to another technique such as the edgewise technique.

Fig. 4.-Profile after non-extraction fixed appliance technique: (a) Profile after treatment. (b) Before and after record models. ( c ) Facial contours after treatment. ( d ) Treatment opened space for right maxillary canine

by distal movement of the buccal segments.

Kesling stated : “Correctly applied the light arch wire technique can produce universal tooth movements with light optimum forces, least discomfort to patients, minimum loosening of teeth, and least injury to tooth-investing structures. These light forces move teeth most rapidly and are the most easily controlled forces . . . furthermore, his technique is capable of handling efficiently all classes of orthodontic cases - non extraction, extraction, discrepancy cases and even severely mutilated cases.”

A final paragraph, however, warns that “the light wire differential force treatment may

(4 ) Begg, P. R.-Begg orthodontic theory and tech- nique. Phil. and London, W. B. Saunders Co.. 1965.

While either of these techniques is capable of providing universal tooth movements it follows that either can be used exclusively in practice, but there are many advantages for the patient in being able to select the type of appliance and technique for the specific require- ments of the individual malformation.

For gross skeletal deficiencies, problems of increased anterior overbite, bimaxillary pro- trusions, bimaxillary imbrications, elevation of surgically exposed teeth and associated tooth movements, the Begg technique is the method of choice if all four first premolar teeth are to be removed as part of the treatment plan (Fig. 2 ) .

Australian Dental Journal, February, I 968 7 5

Alternative fixed appliance techniques

Where the problem is more that of dento- alveolar disharmony on a mild skeletal pattern, where the apices of the upper incisors are approximately in the correct position at the s tar t of treatment, and where there. is a need to remove all four second premolars as part of the case analysis, it would be easier and just as effective to use light round wire and multi- looped arches or compressed coil springs for

Careful case selection is therefore a s essential as ever,@) even though the Begg technique’s innovation in the. period under discussion has revolutionized fixed appliance therapy.

Profile changes

The extreme limits of tooth movement achieved with the Begg technique are respon- sible for greater changes than were. possible with other techniques, changes not only in the

Fig. 5.-Profile changes followina extraction of first Dermanent molar< fixed appliance technique: cay, ( b ) Appearance- is s’eneraiiy-enhan<&j

i f first and second premolars a re present. (c), (d) Where there is a n extensive display of teeth in smiling i t is desirable to limit the extractions where essential to the more distal posterior teeth. In this

picture maxillary canines were still erupting.

the active tooth movements with edgewise brackets.* The subsequent final stages of treat- ment could be completed with heavy arch wires without the complex stage I11 mechanics of the Begg technique. For these types of cases it is possible to complete treatment with less chairside time and less tooth movement than with the Begg technique (Fig. 3) .

The author prefers the so-called “ripple” brackets. These are pressed out of thick stainless steel tape and when welded to the band provide a rectangular central section 0.028’’ wide and two enclosed horizontal sections to hold the ligature wire. They are less bulky than milled brackets.

teeth in occlusion but also in the facial contours. It is likely that greater changes in the general appearance of orthodontic patients in Australia may be in evidence as gross skeletal cases are treated to a greater degree of success with this new technique.

Certainly there is no doubt that a better aesthetic result is obtainable if no permanent teeth have to be removed before commencing treatment (Fig. 4 ) , and that facial aesthetics

(j) Reading, J. F.-A guide to orthodontic diagnosis and treatment planning. Austral. D. J., 5 : 6 , 349-355 (Dec.) 1960 .

76 Australian Dental Journal, February, I968

is better served if teeth further to the distal of the mandible and this is where, theoretically, of the dental arch are removed as part of the the Andresen appliance is most helpful. This treatment plan (Fig. 5 ) . Although i n the appliance has been successfully used in the majority of cases requiring extractions the first deciduous, mixed and permanent dentition. premolar will be the tooth of choice, the removal of second premolars will often provide a better result as fa r as facial esthetics is Ten years ago in Australia the use of cervical concerned. traction appliances as direct appliances or as

Protrusion

Fig. 6.-Profile changes with Andresen therapy: (a) Commencing models and appliance. (b) Facial contours after treatment. ( c ) Result of 11 months’ treatment. ( d ) Cephalometric tracings showing mandibular advancement and

retroclination of maxillary incisors.

Mandibular post-normality

Ten years ago the use of the Andresen appliance was controversial in Australia. Slightly earlier than this, the “Norsk technique” was extensively debated.

Korkhaus i n “Vistas in orthodontics”‘a) again demonstrated the use of this appliance. As far as aesthetics is concerned, there is no doubt if the Andresen appliance can be used success- fully i t can produce a solution to the problem that can be obtained in no other way (Fig. 6 ) . Many case analyses suggest the post-normality

( 0 ) Korkhaus. G.-German methodoloaies in maxil- lary orthopedics. In Vistas in- orthodontics, Kraus, R. S., and Riedel, R. A. (Eds.). Phila- delphia, Lea and Febiger, 1962 (pp. 2 5 9 - 2 8 6 ) .

supplements to anchorage systems was increas- ing. The Begg technique has no need of cervical traction or Andresen therapy. Yet in certain carefully selected cases,(7) it is possible to modify facial aesthetics and entirely avoid full fixed appliance therapy by means of simple traction from an elastic neck strap through a face bow to bands cemented on the maxillary permanent molars (Fig. 7 ) . As growth is the active force in cervical traction cases, diag- nostic data could to advantage include a skeletal age assessment, in addition to cephalometric analysis.

(’) Reading, J. F.-Interception and correction of a Class 11, Division I malocclusion in the mixed dentition. Austral. D. J., 6 : 4 , 215-218 (Aug.) 1961 .

Australian Dental Journal, February, I968 7 7

Sucking behaviour patterns Thumb and digit sucking problems have pro-

duced no new solutions. More data have been published but the clinician is still as depen- dent as ever on intuition. Many methods of control will prove useless and may even

Pig. 'i.-ProAle changes with cervical traction : ( a ) Facial contours after treatment; note flat- ness of upper lip region. ( b ) Cephalometric tracings showing retardation of maxillary growth and reduction of overjet by mandibular

growth.

prejudice the. success of the final, inevitable fixed appliance. therapy. While it is often diffi- cult to advise parents to ignore the behaviour pattern until some useful tooth movements are possible and the child is understanding enough

to accept the discipline of orthodontic treat- ment, i t is generally the fairest decision to make. Clinical judgement again must be used to institute treatment in other cases where the end result of delay and extraction and fixed appliance therapy will yield a less satisfac- tory result than years of treatment in the mixed dentition stage.

In one patient ten years of treatment and observation were necessary to produce a reason- able occlusion (Fig. 8 ) . In this time, Andresen appliances, removable maxillary appliances, cer- vical traction appliances, and finally full fixed appliances, were progressively used. I t can be stated that the end result here is superior to that which could have been achieved by delaying treatment and subsequently extracting premolar teeth. Other questions naturally fol- low as to the overall treatment time, cost and inconvenience to the patient of such a treat- ment regime. These factors, however, are there to be overcome by understanding parents, latently cooperative patients and orthodontists of goodwill.

Modified fixed and removable appliances

These are general observations about the progress of orthodontics in Australia, in a very restricted sense limited mostly to what can be achieved in a specialist practice using full fixed appliance techniques. There are many problems indeed of an orthodontic nature that can be treated more simply using modified fixed appliances or removable appliances of the plastic base and finger spring variety.'") Whether the tooth movement is undertaken by the specialist or the general practitioner depends on the latter's experience and ability. I t is reason- able to perform a variety of limited tooth movements with removable appliances prior to a fully banded technique, or to attempt the movement of individual teeth with simple appliances if the means to follow on to a fixed appliance technique are readily available. Con- sequently, the specialist may still use the same appliance as would the general practitioner for a similar tooth movement as par t of a treat- ment plan.

This article is concerned more with the total result of orthodontic treatment and its effect on the dentition and on the patient's profile.

(') 1:eading. J. F.-The place of the removable appliance in orthodontic treatment. Austral. D. J., 4 : ti, 363-372 (Dec.) 1959.

78 Australian Dental Journal, February, 1968

Fig. %-Extreme skeletal disharmony and tooth proclination associated with prolonged thumb sucking: (a) Models before treatment. (b) Final appliances in place. No teeth were removed as part of the treatment plan.

The results of treatment

The Begg technique. has demonstrated clearly as no other technique has done before it, a step-by-step procedure to attain an ideal occlu- sion which, if the treatment involves ext'rac- tions, will achie.ve (after settling) :

( a ) overjet of 0-2 mm. ( b ) overbite of 0-2 mm. (c ) inter-incisal angulation of 130"-140". ( d ) extraction spaces closed. ( e ) teeth roots parallel on either side of

This technique requires extensive movement of teeth to achieve these ends together with appliances to upright tipped teeth, and to torque palatally the roots of the maxillary anterior teeth.

As this technique is used more extensively in Australia these results will become more

extraction spaces.

widely appreciated by the general practitioner, and consequently results achieved by other techniques will have to meet with the same criterion of achievement.

This means that more frequently treatment may be delayed and full fixed appliance tech- niques, with extractions, will be used more than removable appliances.

The precision of these fixed appliance tech- niques enables the correct placement of teeth and supporting structures in relation to skeletal and facial anatomy, thereby fulfilling the requirements of case analysis and leading to more satisfactory and stable results. As more and more cases treated in this way come to the attention of the profession and the public, the less acceptable will be the results of former methods of treatment.

187 Macquarie Street, Sydney, N.S.W. 2000.

Ineficiency It is a significant commentary on the world food problem that rice, the largest crop on our planet, is still harvested by hand, stalk by stalk, in most of the countries around the world.-Clarence 2'. Kelly, Scientijic American, August, 1967.