This is important because there is little regulation of social media. As a result, there is a danger of claims being made for the benefits of treatment that cannot be realised. 

This interesting problem has been looked at by a team based in London and Dublin. The British Dental Journal Open published this paper. 

A qualitative exploration of orthodontists’ perceptions of social media marketing of orthodontics

Amardeep Dhadwal, 1Dominic Hurst 2and Padhraig S. Fleming

BDJ https://doi.org/10.1038/s41415-026-9795-3

What did they ask? 

They did this study too. 

“Explore orthodontist perceptions of social media marketing of orthodontics using qualitative methodology.” 

What did they do? 

They conducted a qualitative study using semi-structured one-to-one participant interviews conducted via video conferencing. The team invited members of the British Orthodontic Society to take part in the study. 

They used a pre-piloted topic guide to enable in-depth exploration during the interviews. They recorded and transcribed the interviews and analysed them using manual coding. Finally, they used an interpretive approach with thematic analysis. 

The team interviewed a sample of twelve orthodontists. Data saturation was reached after ten interviews. 

What did they find?

It is difficult to report in detail on a qualitative research paper; however, I am going to try to draw out the main points of their findings. 

Uneven playing field

The first theme they identified was an uneven playing field. The participants thought that social media marketing was dominated by companies who tended to advertise aligner-based products or direct-to-consumer orthodontics. This was also compounded by general dental practitioners advertising aligner-based orthodontics. They felt that these groups trivialised conventional orthodontic treatment modalities and incorrectly suggested the superiority of other treatments which lacked substance. 

Importantly, several of the participants felt that general dental practitioners face less scrutiny than non-specialists about the claims that they’re making. They also felt that social media marketing by orthodontists was rather sparse and that orthodontists did not necessarily share their opinions. 

Unsafe expectations and misinformation

This was the second theme. Participants expressed concern that social media marketing currently creates false expectations among patients and the public, while failing to reflect the true realities of orthodontics. Many also worried about the risks posed by misinformation. They believed that social media tends to sensationalise certain treatment options. Importantly, cases are often cherry-picked, showcasing only the most satisfied patients and the best outcomes in an overly idealised way. 

Importantly, they believed that the public was more vulnerable to harm from misinformation than clinicians and was less likely to critically evaluate marketing posts. This raised concerns about potential risks of harm.  

Universalising social media marketing.

Theme three focused on universalising social media marketing. They emphasized that self-regulation could be a solution and highlighted the importance of orthodontists embracing social media to enhance acceptance and effectively counteract misinformation. 

Finally, they advised that orthodontists should engage in self-regulation by sharing accurate, evidence-based content, being truthful, and addressing any concerns. 

What did I think?

This study employed standard qualitative methods, which enable researchers to capture the perceptions of participant groups. Although some might view this as ‘soft data,’ it remains a valuable and insightful source of information.

The findings are significant because they clearly show that social media is primarily dominated by companies that operate without regulation. In addition, general dentists, who may lack specialized knowledge, might not be able to critically evaluate some of the claims being made.

The main implication is that current orthodontic social media aimed at patients may present information that targets vulnerable individuals. This is an important issue that needs to be addressed.

It is also important to note that orthodontists can sometimes face the same criticism. We can see this by looking at the popular US-based social media accounts that focus on breathing.

Finally, I believe that specialist societies should take action by promoting self-regulation and, more importantly, by increasing their activity on social media to confront the widespread misinformation currently circulating. The British Orthodontic Society has done a great job in this area. They have released statements on breathing and orthotropics and have taken action against some fringe orthodontists. I’m not sure if other societies have been so proactive. Perhaps non UK orthodontists could comment on this?

      

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I thought this study was interesting because it evaluated a real-world clinical problem in a well-conducted small study. 

A team from India did this trial. The Angle Orthodontist published the paper. 

Clinical implications of recall visit ligature-tie activation on alignment efficiency in premolar extraction cases: a randomized controlled trial

Jayashree Karingha et al

Angle Orthodontist. Advance access: 

DOI: 10.2319/111425-942.1

What did they ask?

The aim of their study was to 

“Evaluate whether replacing stainless-steel ligature ties at each recall visit significantly enhances the efficiency of anterior de-crowding compared with maintaining the same ties throughout.” 

What did they do?

They conducted a prospective, single-blind, parallel-group randomised controlled trial. They registered the trial before the study began. 

The PICO was 

Participants:

Orthodontic patients aged 16 years or older, in good health, with moderate-to-severe anterior crowding who required premolar extractions. All received pre-adjusted edgewise braces. 

Intervention.

In this group, they did not replace the ligature ties at recall visits until they had resolved the anterior crowding. 

Comparator: 

In this group, they replaced the ties w at every 4-week recall visit. 

Outcomes:

The primary outcome was reduction in anterior crowding using Little’s irregularity index. They measured this from study casts for the initial study models and at each follow-up visit.

They calculated that they needed 12 patients in each group, but I couldn’t find any information about the expected difference used to determine this number.

Patients were randomly assigned to each group with a 1:1 ratio using an online tool. They kept the allocation by placing it in sealed envelopes.

Both the participants and the clinicians knew which group the patients were in. The data on Little’s Irregularity Index was collected using digital vernier calipers. 

What did they find? 

They enrolled 24 patients into the study. They excluded one participant because of repeated failures. 

There were no differences between the groups at the start of the study. 

When they examined the mean duration required for complete alignment of the anterior teeth, it was 68.73 ± 29 days in group 1 (ligature ties not replaced) and 65.33 ± 24.85 days in group 2 (ties replaced at each visit). This difference was not statistically significant. 

Their most important conclusion was:

“Replacing stainless steel ligature ties at each recall visit does not result in a clinically significant acceleration of anterior alignment during the initial phase of orthodontic treatment. Scheduling recall visits every eight weeks may increase efficient time management during the alignment phase.” 

What did I think? 

I always enjoy reading clinically relevant studies. The team conducted this study well, and it met most of the criteria for a good randomised clinical trial. My only concern is familiar to regular readers: this was a single-centre study restricted to the initial alignment phase, with a relatively small sample size. The findings may also be relevant only to extraction cases. 

One piece of information missing from this study was any reporting of treatment side effects. For example, did patients who were not seen every 4 weeks have more problems with archwires poking through the molar tubes? 

Nevertheless, the findings are interesting and may reflect our regular clinical experience. They certainly provide reassurance that it is possible to leave our patients with fully tied-in ligatures for longer than four weeks. 

It is nice to return to studies about day-to-day orthodontic treatment, and this study is a small addition to our literature. 

       

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Bill Shaw changed the lives of thousands. His legacy continues to be felt by families across generations.

As some of you may know, Bill is currently in care with Alzheimer’s disease. He was diagnosed in 2018, and his health has deteriorated quickly. He is now bedridden and unable to talk, but occasionally will give us a smile.  It is heartbreaking to see him suffer like this.

On July 4th, Bill’s son, Stuart, is honouring his Dad in an extraordinary way.

Stuart is taking on the incredible challenge of cycling 600 kilometres in just 24 hours to raise vital funds for Alzheimer’s research—a disease that affects millions of families and continues to rob loved ones of their memories, independence, and dignity.

This challenge will demand immense physical and mental endurance, but it pales in comparison to the daily struggles faced by those living with Alzheimer’s and the families who care for them.

By supporting Stuart, you are helping to fund research that brings us closer to better treatments, improved care, and, one day, a cure.

Please give what you can, share Stuart’s story, and help turn every kilometre into hope.

Thank you for your generosity and support.

If you would like to donate, just follow this link.

Donate here

      

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The quackery checklist.

I would like to start with my impressions of how a fringe treatment can be developed. 

The first step is to develop a new disease that we can to treat. This can relate to any orthodontic problem or new treatment. They then invent a new diagnostic method that is difficult for people to understand. For example, a new or obscure cephalometric analysis.

It is then a good idea to devise a new name for the treatment. I recently came across the term orthopneumodynamics! The next step is to form a new club of special people to deliver this treatment. I recall that “Damon Doctors” were a clique that provided this special treatment.

The next tactic is to criticise others. For example, refer to other orthodontists as “conventional” or ask them to open their minds to the new way. The final step is to dismiss research evidence and offer to engage others in debate, where they download a massive reference dump of poor-quality research.

Waves of quackery.

Once a new form of treatment is developed, it tends to gain popularity, and we are swept up in a wave of enthusiasm. However, all waves subside, and after a few years of generating income, the treatment’s popularity declines.

I qualified as a specialist orthodontist in 1986, and these are the waves of orthodontic quackery I can still remember.

Orthodontic treatment for TMD and other “diseases”.

In the mid-1980s, the gurus promoted mounting study casts for every patient. This was part of their philosophy of treating patients towards what they felt was a perfect occlusion. They hope that this would prevent and cure all TMD disorders.

All my treatment is non-extraction.

The next wave occurred in the early 1990s. There was a movement to treat all our patients without extractions. We were then presented with multiple case reports and conference presentations showcasing heroic non-extraction treatments. Some of these patients looked excellent, with nice, wide smiles; others had rictus grins with overexpanded arches. This trend lasted for a few years and has recently been revitalised by the increasing use of all manner of expanders.

Self-ligation

This was the first tsunami from a supply company. These brackets became popular in 1996. The market leader was Ormco, which provided Damon brackets. They made several claims about these brackets. The most common “benefits” were reduced treatment time, arch development, and less pain than with conventional brackets. They ran a high-profile campaign, and many orthodontists became self-ligating providers. Unfortunately, the claims did not withstand scientific scrutiny, and several trials reported that they were no different from conventional appliances. They rapidly lost popularity.

Orthodontic vibration and magic lights.

I have grouped these together because they were promoted at the same time in 2009. The KOLs and companies claimed that these devices reduced treatment time, but there was no evidence to support this. It was, therefore, no surprise that people stopped using them a few years later.

Trauma

This is more recent. The theory behind this treatment was that trauma induced Regional Acceleratory Phenomenon. A team from NYU published a paper in the AJO. I wrote a blog post about this, which generated a lot of discussion. After several other studies and systematic reviews showed that this technique did not yield a meaningful reduction in overall treatment time, the treatment wave declined.

Airway

This is our latest wave.  There is currently a heated debate about the airway and orthodontics. Airway orthodontists seem to be increasing in number, and treatment is being promoted. History may be repeating itself.  We will know more in two years or so. 

I suspect that by then someone will have developed a new treatment. Which has been adopted by the non-critical or gullible members of our specialty. However, most orthodontists will ride this wave and continue to practise ethically. Perhaps I should not worry.

In the words of Jimi Hendrix, “And so castles made of sand fall in the sea eventually”.

       

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Should we practice evidence-based orthodontics?

The easy answer here is yes! It goes without saying that we should use the highest level of expertise when discussing treatment with our patients. Aside from the obvious issues with informed consent, we should not charge additional fees for unproven treatments. If we do, we are entering the realms of “quackery”, and it is unethical.

Nevertheless, we are all aware that science does not underpin everything we do. Importantly, many treatments are based on years of clinical experience. For example, clinical experience suggests that the most severe cases of crowding should be treated with extractions.

Looking back?

At this point, I feel it is useful to look back over the development of evidence-based orthodontics. We, as a speciality when compared to other health care fields, “discovered” randomised trials rather late. This may have occurred because we had stores of study models and radiographs that we could analyse using retrospective methods to obtain results quickly and cheaply. It was not until the mid-1980s that we realised these methods were biased and that trials were necessary in some areas of orthodontics.

At that time, I placed great emphasis in writing and presentations that promoted the value of trials. Looking back, I think I failed to consider that evidence-based care is grounded in a combination of research evidence, patient opinion, and clinical knowledge and expertise. 

This does not mean that these three components are equal. The extent to which each component influences a final clinical decision depends on its relative weight. For example, if good scientific evidence is available, it should outweigh clinical experience. In fact, we are not practising ethically if we do not explain to our patients whether high-level research findings on our treatments are not available.

So where are we now?

Over the past few years, I have been depressed about the direction we were going. This was because we were subject to multiple waves of orthodontic quackery, underpinned by low-level evidence disseminated via social media and low-quality “journals”. In addition, recent conferences seemed to be dominated by “show and tell” lectures based on case reports.

In retrospect, I wonder whether I was too concerned about this situation. For example, while I accept that the current debate about breathing and orthodontics is getting out of hand, I thought it was incredibly reassuring to see Dr Ben Pliska give a great lecture on “OSA and orthodontics: Can common sense save us from ourselves”? If we combine this approach with the recent AAO White Paper, perhaps we have nothing to worry about, and this current wave will disappear in a sea of sense. Or am I being strangely optimistic?

A word of caution?

Nevertheless, I am aware that I may need to be cautious and not let myself be carried away by a single excellent conference. Disappointingly, I have logged on to social media this morning to see that the orthodontic fringe are still posting extreme claims and misinterpreting the literature to suit their aims.

I hope that the other conference organisers break the mould and, along with journal editors and societies, follow this conference’s lead in promoting more research evidence and get our specialty back on track.

       

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This interesting new paper provides us with initial information on the environmental impact of fixed appliances and aligners. This is particularly relevant because the increasing use of plastics and the release of greenhouse gases are of concern.

A team from Nijmegen, Holland, did the study, and the European Journal of Orthodontics published the paper.

Environmental impact of orthodontic treatment: a simplified fast-track comparative life-cycle impact assessment of self-ligating metal brackets and clear aligners.

Maria Johanna Jacoba Heezen et al

EJO advance access. https://doi.org/10.1093/ejo/cjag025

What did they ask?

The aim of this study was to

“Develop an estimate overview of the environmental impact of self-ligating metal brackets treatment compared with clear aligner treatment”

What did they do?

They carried out an analysis based on the treatment of four cases: two were non-extraction and two involved extractions. Each case was treated with either clear aligners or fixed appliances. The team obtained these cases from an experienced orthodontist in both fixed appliance and aligner care.

They obtained information on all environmental aspects of providing this treatment, and from this they constructed environmental indicators. These were

• Carbon footprint, expressed per kilogram of carbon dioxide equivalent. 
• Cumulative Energy Demand. This measures the total energy consumption throughout the life cycle of a treatment.
• ReCiPe 2016. This is a widely used method for evaluating the environmental impact of processes.

The data they used were provided by the manufacturers of the fixed appliances (Damon) and the clear aligners (Spark). They then combined this with data from the individual treated cases. This included the amount of materials, the materials’ life cycle, the impact of transport, and, most importantly, the multiple stages of clear aligner treatment.

What did they find?

They produced a large volume of complex data. I do not have the space to cover all of this in this post. However, the key findings were;

1. The carbon footprint for clear aligner treatment ranged from 20.6 to 24.7 kg of CO₂, while fixed appliance treatment was 0.22 kg CO₂.
2. The CED was in favour of fixed appliance treatment and showed greater energy waste with aligner treatment.
3. Fixed appliances created a lower environmental burden.

Their overall conclusions were:

“Within the limitations of a small sample size and simplified model, fixed appliance treatment showed a lower environmental impact than clear aligners.”

What did I think?

This was a very interesting yet complex paper to interpret. Importantly, the authors noted that the results are exploratory and that more research is certainly needed.

Nevertheless, the findings were logical. For example, there are many stages to aligner treatment. These include: 

• multiple 3D printed models
• thermoforming
• trimming and polishing
• the individual plastic wrapping and 
• international shipping

This is compounded by discarding the aligner after a week or two of wear. This process is repeated 30 to 40 times per patient. It was interesting to note that the author estimated that aligner therapy up to 2020 had already generated approximately 1,875 tonnes of plastic waste. This is certainly concerning.

In contrast, fixed appliances use comparatively small quantities of material and generate far less waste.

The authors made several suggestions to change this situation: 

• The use of recyclable polymers
• Biodegradable materials
• Direct 3D printing aligners
• An improved disposal programme

Final thoughts?

This paper addresses a very serious question that is relevant to us all. While the authors have made several assumptions that may overestimate the impact of aligners, there is a degree of logic to their conclusions. This area requires considerably more detailed investigation. I hope to see this team and others continue working on this over the next few years. We need to become more environmentally aware.

Until then, perhaps we need to consider the environment and sustainability when prescribing different types of treatment. This may influence our and our patients’ treatment choices.

       

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The study was done by a team based in Erciyes University, Turkey. The European Journal of Orthodontics published the paper. 

The impact of different rapid palatal expansion appliances on sleep, nasal airway resistance, and dentoskeletal/dentoalveolar characteristics: a prospective, randomized controlled trial.

Sertan Soylu et al

EJO On line. https://doi.org/10.1093/ejo/cjag030

What did they ask?

They did this study to 

“Evaluate and compare the effects of different RPE appliance designs on sleep-related breathing, nasal airway resistance, and dental-skeletal outcomes in post-pubertal adolescents with maxillary constriction.”

What did they do?

They carried out a randomised controlled trial with 3 arms with a 1:1:1 allocation.  The PICO was

Participants

Orthodontic patients aged 14 to 17 years in the post-pubertal growth stage. They had mouth breathing, which was confirmed through a comprehensive ENT examination. They had skeletal maxillary constriction of between 4 and 10 mm transverse deficiency with unilateral or bilateral posterior crossbites. 

Intervention one. 

This was a full-coverage RPE appliance which covered all the buccal, palatal, and occlusal surfaces of the maxillary teeth. (FCRPE)

Intervention two.

A similar RPE appliance , however, the upper incisors and canines were not included in the appliance. (MMRPE)

Intervention three.

A MARPE appliance fixed with two palatally placed mini screws. (MARPE).

Outcomes

These included;

• Respiratory polygraphy
• Rhinomanometry
• Sleep questionnaires
• PA radiographs
• Digital models

They took measurements before treatment and approximately three months after treatment.

They used a pre-prepared randomisation scheme and conducted an adequate sample size calculation. I was unclear about their method of concealment. 

They carried out a relevant univariate statistical analysis.

They compared the active treatment groups with an untreated control group. This group comprised healthy people from the same age group who attended the department. However, little additional detail about this group was provided.

What did they find?

45 patients entered the study. At the end of treatment, forty-three completed the study. Fifteen participants were enrolled in the control group, and all 15 had data collected at the second data collection.

They produced a large amount of data, and I’m going to focus on AHI, oxygen desaturation and sleepiness scale.

There were no differences between the groups at the start of treatment. Importantly, the control group had lower AHI and fewer oxygen desaturations.

I have tried to interpret the large amount of data they included by focusing on the end-of-treatment values. This is a simple yet relevant method for analysing large data sets in a study such as this. I have included data on AHI, De SPO2 and the Epworth Sleepiness Scale (ESS).

The statistical analysis revealed the following:

• The control group had significantly lower AHI values and De SP02 index.
• When they looked at the data for the RPE groups, they showed decreases in AHI and De SPO2 across all groups. Importantly, there was no change in the control group.
• Although AHI values decreased in the MMRPE group, the effect was not as pronounced as in the MARPE group.
• There were no significant differences in EES scores between the groups.

Their overall conclusion was

“RPE decreases AHI. This approaches the values of individuals in the control group.”

What did I think?

This was another small-scale randomised controlled trial exploring an important question. The authors noted that since the participants were post-pubertal, facial growth likely had minimal impact. Therefore, any observed changes could probably be attributed to the expansion itself. However, factors like BMI and hormonal changes during late puberty might influence tissue remodelling around the airway. This highlights the need for an untreated control group to draw more definitive conclusions. Additionally, the follow-up period was quite short.

It’s worth mentioning that the AHI values in this study for all the groups suggest mild obstructive sleep apnea, and the EES scores indicate normal levels.

We should also remember that polysomnography is considered the gold standard for sleep assessment. In this case, the authors used respiratory polygraphy, which is more practical but generally less sensitive than PSG. Still, it offers reasonable validity for measuring AHI, though it’s a bit of a compromise.

The study also found that MARPE was the most effective method of expansion, adding to the evidence supporting the use of miniscrews in expansion devices.

It was encouraging to see that the authors avoided making exaggerated claims about expansion treatment. Overall, this study is much better than the retrospective, convenience-based studies often promoted by some “airway” orthodontists.

We’re gradually making progress in exploring this important area of research.

       

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Before I continue with my discussion of this paper, I would like to point out that I did not post over the last two weeks because I was on a fantastic holiday in the Isle of Skye in Scotland. In addition to giving me a break, the internet access was rather poor where we were staying, in a remote part of the island. 

The authors of this paper noted that digital dentistry is significantly affecting our treatment methods. When these are combined with Artificial Intelligence, there are enormous opportunities to deliver our care. 

A team from China and Malaysia did this study. The journal PLOS ONE published the paper. 

Randomized controlled trial comparing AI assisted digital and conventional orthodontics: Superior PAR reduction and occlusal outcomes

Xie Xiaoting et al

PLOS One. https://doi.org/10.1371/journal.pone.0347499

What did they ask? 

They wanted to

“Compare AI-assisted digital orthodontics with conventional fixed appliance therapy using percentage reduction in the PASS score as a primary endpoint.” 

What did they do? 

They conducted a single-centre, parallel-group, randomised controlled trial. The PICO was 

Participants 

140 orthodontic patients with class I malocclusion 

Intervention. 

This was an AI-assisted digital workflow. It comprised a suite of AI-assisted tools embedded within 3D planning software and the Dental Monitoring platform. These tools use machine learning algorithms to automate tooth segmentation, landmark identification, arch form estimation, and preliminary tooth movement simulations. The outputs were then used to inform treatment planning. However, all final diagnostic interpretations and movement prescriptions were determined by the treating orthodontists. 

They manufactured custom brackets chair-side using 3D printing. 

When treating patients, remote monitoring with Dental Monitoring was used. This detected issues such as bracket failure, wire displacement, plaque accumulation, or soft tissue irritation. If threshold-based alerts were triggered, clinicians reviewed the images and arranged earlier clinical visits where necessary. 

Control 

This group of patients was treated with conventional orthodontics. Panoramic radiographs and lateral cephalograms were used for diagnosis and treatment planning, and all patients were treated with 0.022-inch-slot pre-adjusted edgewise appliances. Follow-up appointments were scheduled at four-week intervals. 

A team of board-certified orthodontists, each with at least five years of clinical experience, carried out the treatment. 

Outcome 

The primary outcome was the percentage reduction in the Peer Assessment Rating (PAR) from baseline to treatment completion. 

They conducted a clear sample size calculation, which indicated that 140 participants were needed to take part in the study. 

They used a pre-prepared randomisation sequence with block randomisation and concealed the allocation using sequentially numbered, sealed envelopes. These were prepared by a research assistant not involved in participant recruitment or assessment. The envelopes were opened by a treating clinician only after all baseline measurements had been completed. It was not possible to blind patients or operators to the group allocation, but data were analysed blind. 

Finally, they carried out appropriate univariate and multivariate analyses. 

What did they find? 

140 patients were randomised in a one-to-one ratio to the interventions. All participants received their allocated intervention and completed treatment. 

At the start of treatment, there were no major differences between the two groups. 

When PAR scores were examined, they decreased in both groups, with a lower post-treatment score in the digital and AI group. The mean final PAR score for the AI group was 4.88 points, with a standard deviation of 4.45. For the conventional group, the mean was 7.81, with a standard deviation of 0.7. This resulted in a mean difference of -2.93 (95 CI -3.13 to -2.73). These differences were statistically significant. 

Another way to interpret PAR scores is to consider a 70% reduction a “great change” in score. The proportion of participants achieving this was 82.9% in the AI group and 50% in the conventional group. 

The final step in the statistical analysis was a regression analysis aimed at identifying independent predictors of improvement in PAR scores. The most significant factor was treatment modality, followed by patient age and baseline PAS scores. 

Their overall conclusions were 

“The AI-assisted digital orthodontic workflow produced statistically significant and clinically interpretable short-term improvements in PAR scores compared with fixed appliances. These benefits likely reflect the combined influence of high-precision imaging, customised appliance fabrication, and AI-supported monitoring. They cannot be attributed to AI alone.”

The authors made an important point. The intervention was not limited to AI. In fact, they tested improved imaging, appliance customisation, remote monitoring and workflow integration simultaneously. 

What did I think? 

It is not often that I come across a very well executed and well written publication. This was the case with this study, which was published in a very good open access journal. The study team followed a standardised and clear randomised trial methodology, and the trial was carried out very well. 

Their findings were interesting, showing a difference between the two interventions. As usual, we need to consider whether these are clinically significant. When I looked at the raw PAR scores and the differences in finish between the two groups, the differences were only in the region of 2-3 PAR points. These are not clinically significant, even though they were statistically significant. 

However, it was interesting to see that a much greater proportion of cases treated with AI-assisted mechanics were classified as greatly improved. As a result, their conclusions are fairly robust. 

The study team highlighted some shortcomings in their study. Firstly, they noted that the treatment was assessed at the end of active treatment. I thought this was entirely reasonable and reflected common practice in occlusal index studies. They also noted that it was a single-centre study. While this may reduce generalisability, it still provides us with very useful information. 

When I consider the findings of this study, however, I cannot help but feel that I would have liked to see some information on the overall duration of treatment. As I am sure this would influence the final treatment outcomes. It would also provide us with very useful information on whether AI-assisted treatment was of shorter duration. The study team pointed this out and suggested that larger-scale studies be conducted. This study is an excellent starting point for planning future studies.

I think that we should all look forward to further studies in this interesting area, as it is very likely to influence the future of orthodontic treatment. 

       

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A team from South Africa, the USA and South Korea wrote the paper. The AJO-DDO published the paper.

Orthodontic perspective on treatment recommendations for missing maxillary incisors: A contemporary guideline

Mark Wertheimer, Lauren Kim, Jae Park

Am J Orthod Dentofacial Orthop 2026;169:559-67 https://doi.org/10.1016/j.ajodo.2025.12.003

What did they ask?

They wrote this paper to provide information on 

“The treatment considerations for treatment selection, complications and evidence-based guidelines for the management of missing anterior teeth”.

What did they do?

They condensed the available evidence on options for replacing missing maxillary incisors.  Importantly, this was a “traditional” non-systematic review.

What did they find?

Firstly, they suggested that the options for this problem were canine substitution to close the space, bridges, autotransplantation and implants. They then discussed these options in more detail, with an emphasis on how facial growth affects treatment success.

Growth and implants 

We all know that we are experts in facial growth. However, we need to remember that facial growth doesn’t simply cease in the late teens. It continues at a much slower rate throughout adulthood. As a result, compared with an ankylosed implant, the vertical and horizontal movement of the teeth and the alveolus increases the risk of implant submergence. This is referred to as implant infraposition and is a considerable problem because its correction can be difficult. 

Some may argue that growth potential can be determined using hand-wrist radiographs and cervical vertebral maturation; however, these methods have been shown to be comparatively inaccurate for the individual patient. As a result, no definitive criteria or diagnostic methods exist to indicate when dental alveolar changes have ceased. 

The authors of this paper noted that systematic reviews have shown that nearly half of patients with implants develop an infraposition. As a result, we should carefully consider the appropriate timing for implant placement or look for alternatives.

Alternative Treatment Options 

One of these is of bridges. There is, of course, reluctance to prepare unblemished teeth as abutments for a fixed bridge. As a result, this form of treatment is not popular. 

The other alternative is, of course, orthodontic space closure. They pointed out that we have to consider the whole malocclusion when planning this treatment, but importantly, the use of temporary anchorage devices may make this an option in many cases. 

It goes without saying that one consequence of replacing a missing lateral incisor with a canine is that treatment is necessary to ensure the canine resembles the lateral incisor. This may be rather complex, but it should be within the skill set of most dentists and certainly of specialists.  

This also depends on the canines’ morphology, size, and colour. Another concept to consider is whether group function, rather than canine guidance, is acceptable. Importantly, there is no evidence supporting a preference for either option. 

There are, of course, other issues, such as symmetry, when one lateral incisor is missing. Finally, we need to consider whether there is an age at which we can safely placed an implant in the anterior region without adverse effects. I felt that they suggested there was no definitive answer to this question because the craniofacial complex continues to adapt. 

Key takeaways

At the end of their discussions, they identified several key takeaways for us to bear in mind. 

“Growth and development will continue well into the third decade, and there are no reliable methods to determine when dental alveolar development ceases. Importantly, the reported incidence of IIP is between 50% and 75%, and it is very prevalent when implants are placed during the second and third decades. As a result, treatment methods that promote stable and aesthetic outcomes should be recommended”. 

What did I think?

This was an interesting overview of a relatively complex clinical problem. They wrote a clear paper and outlined several concepts very well. I think it is still important to point out that these guidelines are not necessarily based on high levels of evidence. We also need to remember that guidelines are not mandatory.

However, in the absence of high-level research, when we consider the concept of evidence-based care, this information is, arguably, useful. This paper achieves its aim of encouraging discussion.

Some may feel the content of this review is rather obvious, and we are well aware of the decisions we need to take and the factors that influence them. Nevertheless, I can’t help feeling that if these concepts are obvious, why do so many patients end up with implant infraposition in the anterior maxillary arch? 

My only concern with this paper is that I wish the authors had been a little more definitive in their conclusions and had made a recommendation on which option was best: space opening or space closure. After reading this paper several times, I felt that the decision still remained mine. This may have been their intention, but it does nothing to diminish my poor tolerance of uncertainty.

Now that you have read this blog post.

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Comments

• A decision should be made after consulting the orthodontist, ... by Medhat ALY
• Great insights on improving oral health with orthodontic care. ... by Bettagere Orthodontics
• Just my personal opinion, canine substitution might be a long ... by Jason Chua
• I think Ross and Jack sum it up best, depends on many factors ... by Anand Srinivasa
• I didn't see much discussion on what the molar relationship ... by Ronald Eugene Austin
• Plus 2 more...

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In this study, they examined the effect of sequencing slow rapid maxillary expansion (SRME) and adenotonsillectomy (TA) in paediatric obstructive sleep apnoea. A team from Australia and Hungary conducted the study. The Journal of Clinical Medicine published the paper.

Maxillary Arch Expansion and Adenotonsillectomy in Prepubertal Children Diagnosed with Paediatric Obstructive Sleep Apnoea: An Interventional Study

Derek Mahony Niroj Bhattarai and Peter Petocz

Journal of Clinical Medicine. On line https://doi.org/10.3390/jcm15082981

The paper is open access so anyone can read it.  The Journal of Clinical Medicine is listed as a predatory journal on the Predatory Journals website. 

What did they ask?

They did this study to ask the following question. 

” What are the combined effects of adenotonsillectomy and maxillary arch expansion in pre-pubertal children with OSA, and is there an effect of the sequence of treatment? 

What did they do? 

This was a retrospective cohort study using a subsample of patients from a larger cohort that I have previously posted about. 

They selected 80 sets of patient records from an original sample of 3,671 children aged 7-9 years who underwent polysomnography at their first orthodontic consultation, representing 2% of the original sample.

The main inclusion criteria were the availability of complete PSG records at three times:

• Baseline (pre-treatment)
• After the first intervention
• After both interventions

They had to complete slow rapid maxillary expansion and adenotonsillectomy, regardless of the sequence. 

They had no history of prior orthodontic treatment or diagnosed sleep disordered breathing at baseline. 

Exclusion criteria were incomplete records and the absence of level one hospital-based PSGs. 

They then divided this sub-sample into two groups. This was “based on a treatment sequence that was determined by the patient and parental preference and logistical factors rather than randomisation”. As a result, they suggested this reflected the “real world” of decision making.

Group one was designated TA first, comprising patients who underwent tonsillectomy as the initial intervention, followed by SRME. 

The second group had SRME as the initial intervention. This was due to delays in accessing publicly funded ENT appointments or waiting periods for private insurance cover. 

They collected demographic details, cephalometric classifications, and BEARS questionnaire scores greater than 5, indicating an SDB risk. 

Accredited sleep laboraties did the polysomnography measurements.

The primary outcome for this study was the respiratory disturbance index (RDI). This is the average number of apnoeas, hypopnoeas, and respiratory effort-related arousals per hour of sleep. 

Statistical analysis was based on a repeated-measures analysis of variance over time. The authors did explain the method clearly, and I couldn’t really work out the statistical plan.

What did they find? 

The mean age of the participants was 8.3 years, and 43% were male. At the start of treatment, the mean RDI was 18.99, indicating moderate severity.

At the start of treatment, there were no differences between the groups in most measured variables; however, there was a marked difference in BMI. The TA first group had 87% of the sample classified as overweight or obese, whereas the SRME group had 45% of participants in this classification. This is important because it represents a marked imbalance between the groups. 

I have extracted some of the data into this table. This illustrates the RDI for the combined BMI groups. I also calculated the 95% confidence intervals for this data.

When you look at the 95% confidence intervals, you can see that they overlap for the interventions’ effects. This means that the effects may not be statistically significant. Furthermore, they do not overlap at the start of treatment.

I looked closely at their statistical analysis, and the tables outlining it were rather brief, which made it difficult to interpret the findings.

They also presented a table showing RDI reduction. However, I felt we could be more focused in this blog post by simply comparing the values between the two groups.

The conclusions were 

“Both TA and SRMA significantly improved the RDI in pre-pubertal children with OSA and maxillary constriction. The greatest benefit was seen when these were combined. The SRMA first, followed by TA, was somewhat more effective by about 1.5 events per hour overall.” 

What did I think?

This study used the Respiratory Distress Index (RDI). I was unfamiliar with the RDI and sought further information on this measure. The RDI is similar to the Apnoea-Hypoxia Index (AHI) but includes Respiratory Effort-Related Arousals (RERAs). This makes it useful for assessing milder forms of sleep-disordered breathing. It is highly sensitive to treatment and, importantly, more sensitive than the AHI.

The RDI values can be classified as

• Normal: RDI < 1 event per hour.
• Mild OSA: RDI between 1 and 5 events per hour.
• Moderate OSA: RDI between 5 and 10 events per hour.
• Severe OSA: RDI > 10 events per hour. 

Problems with the study

Importantly, we may need to consider the accuracy of diagnosing sleep disorders from a single night’s readings. A systematic review has examined this and concluded that this variation may lead to misdiagnosis in single-night studies. We need to consider this when we interpret the results of this study, which used a single-night recording.

Bias

There is also considerable risk of further selection bias in the study, given that the authors analysed only 80 sets of records from a total sample of 3971 (2%). This risk is further compounded by the inclusion criteria, which require completion of treatment and full records. As a result, the study is at risk of being biased towards favourable outcomes.

When I looked at the data they presented, it was clear that the groups were unbalanced for BMI at the start of treatment. It appears that the clinicians had a preference for TA in obese children, which could lead to selection bias in the study. Furthermore, the treatment allocation order was determined by delays in access to ENT care. It appears that if a patient’s ENT treatment was delayed, they received SRME. This design is subject to systematic confounding, and we must account for differences between the groups. For example, they may be children from low socioeconomic groups.

Control group and effect size

In addition, there was no untreated control group. This is crucial for this form of study because the CHAT study estimated that 50% of 5- to 9-year-old children with OSA who were randomised to watchful waiting achieved OSA remission, as defined by PSG findings, after 7 months.

When we look at a paper, it is important to consider the differences in effect sizes. Even a cursory examination shows that there is limited difference between the two intervention sequences. I also could not really understand the statistics they used because of a lack of data, particularly the p-values. They also presented the percentage change in RDI as an outcome. It is more important to look at the group differences.

It is also relevant to point out that they did the in 9 private orthodontic practices with an interest in airway treatment. As a result, the findings may not be relevant to the general population.

We must also consider whether Dr Mahoney has an undeclared conflict of interest, given that he is the CEO of a company that operates several orthodontic practices specialising in “airway-focused” care.

Final comments

I may be criticised for being so blunt about a study. However, I felt it was necessary to point out the deficiencies in this paper.  This study provides very low-level evidence. However, its data may be used for planning randomised trials in this important area.

Now that you have read this blog post.

Last year, I requested donations to support my blog, and thankfully, I received an overwhelming response. With your help, I was able to raise sufficient funds to keep my blog going for another year. 

Now, I’m seeking your support again to help me cover the blog’s running expenses for the upcoming year. The funds will cover web hosting, software upgrades, email lists and general running costs. 

I believe that if every reader contributes a small amount, I can cover the yearly running costs. Your help will be much appreciated.

To make a donation, just use the form below. You can use the set-amount buttons or the free-field button to enter other amounts.

Then the easiest way to pay is to tap the Apple Pay button. If you want to use another payment method, click the “next” button and enter your details. This will take you to credit cards, PayPal, and other payment methods.

       

Comments

• In reply to Prof Dave Singh. Craniofacial orthodontists are ... by Rany Bous
• Prof, Thanks for your erudite analysis which is so valuable to ... by Geoffrey Wexler
• There is a small randomized clinical trial conducted to address ... by Steve Marshall
• I was surprised to read that you were “unfamiliar with the ... by Prof Dave Singh
• In reply to Trevor Baret. I wonder if I did not make myself ... by Kevin O'Brien
• i have never before seen a study being accused of bias because ... by Trevor Baret

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• New evidence from a trial of Orthodontic Expansion and Sleep Apnoea in Teenagers.
• An orthodontic perspective on replacing missing maxillary incisors.
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