Editorial: Dental Hypotheses: Has Do-It-Yourself Alignment for Malocclusion Doomed the Orthodontic Specialty?

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Has Do-It-Yourself Alignment for Malocclusion Doomed the Orthodontic Specialty?

TECHNOLOGY AND DO-IT-YOURSELF ORTHODONTICS IN THE 21ST CENTURY

Orthodontics is the dental specialty that diagnoses and corrects malocclusion of teeth during and after eruption. Treatment involves the use of forces on teeth to shift their position. Traditionally the magnitude and direction of these forces are determined by the orthodontist and appliances fabricated for the application of these forces.

Several years ago, digital technology was developed specifically for orthodontic treatment. By using computer guided design and manufacturing, appliances were fabricated that when used correctly move teeth in a controlled manner.

This technology, together with artificial intelligence (AI) has spawned a wave of do-it-yourself orthodontic treatments. In fact in 2016, an enterprising college student printed his braces in order to perform orthodontic treatment on himself.[1] Also, a BU faculty using AI has developed DIY ortho treatment.[2]

These changes suggest a threat to the orthodontist scope of practice: namely that orthodontists will have to change to provide other activities. One activity for orthodontics is preeruption orthodontics.

THE SURVIVAL OF ORTHODONTICS REQUIRES SHIFTING FROM POST-ERUPTION TO PRE-ERUPTION TREATMENTS

The steady march of technology will improve DIY orthodontics increasing the pressure on the traditional orthodontist to find a solution to survive. History suggests that attempting to stop the advance of this new technology will not be successful. The solution is not to try to stop the march, but for the orthodontic specialty to acquire methods and procedures for treating malocclusion before eruption occurs.

While it is not clear what interventions will be developed to control odontogenic alignment for pre-eruptive teeth, what is needed is a new theory to encourage orthodontists to devise methods to move teeth in utero. Just as Miller’s theory guided clinical dentistry, dental research, and dental education, in the 20th century this new theory will guide clinical orthodontics, orthodontic research and orthodontic education.

A THEORY FOR MALOCCLUSION

In 1899 when Edward Angle devised his classification for malocclusion little was known about the odontogenesis.[3] As a result, Angle was not intellectually prepared to understand the process at the cellular or molecular level. In contrast when Miller examined a patient’s decayed tooth, he did so with a mind prepared by years of working with the foremost microbiologists of the time and with the knowledge of the role played by microbes in the disease process.[4] As noted by Pasteur, “Chance favors the prepared mind”, [5] and because little was known about odontogenesis, Angle was not prepared intellectually to see a relationship between malocclusion and the underlying odontogenesis.

All this changed in the 1940s when the development of human teeth was described.[6]By 1959, when I was in dental school, an important part of the histology curriculum was to learn the cap stage and bell stage of tooth development. In looking back, however, I cannot recall tooth development being linked to malocclusion in any of my histology lectures. Almost forty years later, when I began to lecture about tooth development, I included discussion of the relationship between the positioning of the embryonic tooth bud and adult malocclusion. In 2011, I published a paper that introduced the term ectopic odontogenesis for malocclusion.[7]

THE ECTOPIC ODONTOGENIC THEORY FOR MALOCCLUSION

In 2020 when dentists look intraorally and sees an Angle Class 1 occlusion, they have the histological and cellular background to visualize the odontogenesis that occurred during embryogenesis. Today we know that the odontogenic process begins with a coordinated cascade of gene expressions in both epithelial and mesenchymal cells of the presumptive alveolar ridge.[6] For a normal Class 1 occlusion, the odontogenic event must occur at specific locations on the ridge. Should these events occur at incorrect sites, malocclusion results.

MOLECULAR ORTHODONTIC TREATMENT IN UTERO?
One attribute of a good theory is it suggests treatments and can be tested. For example, Miller’s theory of the role of microbes in dental decay inspired G.V. Black to propose extension for prevention, a treatment he reasoned would limit sites for bacterial colonization thereby reducing the caries incidence. It is hoped that by proposing the EC theory, 21st century orthodontists will begin to formulate new treatments to prevent malocclusion that are molecular and cellular.

Molecular and cellular interventions would require procedures performed on the embryo − i.e. in utero. Editorial © 2020 Dental Hypotheses | Published by Wolters Kluwer – Medknow 95 [Downloaded free from http://www.dentalhypotheses.com on Friday, January 1, 2021, IP: 241.187.251.232] Would this be possible? Tooth formation begins at day 11 of gestation. This is preceded however at day 9 with genes (transcription factors) expressed in neural crest ectomesenchyme of oral part of first brachial arch.

Because there are three axes for development − anterior/ posterior (front to back), labial/lingual (outside to inside) and oral/aboral (top to bottom) − the location for the initial odontogenic event must be specified in three dimensions. The tooth forms on the labial and oral sides of the ridge[6] however, so it might only be necessary to specify the anterior posterior dimension.

With knowledge that molecular signals control the location of the tooth germ, one possibility for controlling location is the application in utero of the signal to specific locations on the mesenchymal ridge using microbeads soaked in a chemical signal of the orthodontists choice. The problem is to arrange the signals along the ridge to ensure proper spacing of deciduous. As the position of permanent teeth is determined by the deciduous tooth, the positioning of the deciduous teeth is all that is necessary.

What is needed is a spotting system like the type used in bowling alleys to replace the ten pins in precisely the correct locations. If a spotter could be developed the orthodontist would be able to initiate tooth development in the correct spot for all teeth at the same time with the correct spacing.

CAN THE EC SAVE ORTHODONTISTS FROM EXTINCTION?

It appears the orthodontic community has a choice between two alternatives: do nothing and stay the course or pursue a program of change with the expectation that new research will lead to innovations in orthodontic treatment. There are risks with pursuing either program. Staying the course could prove catastrophic especially if the technology improves and if the acceptance by the public increases. Of course, the entire DIY effort could fade especially if news reports like the one on NBC continue. This report was extremely critical.[8] However, Smile direct has filed a lawsuit in Tennessee court against NBC lawsuits like the one filed in NY against Smile Direct.[9]

Should the second alternative (pursuing a program of change) be adopted what would the program for change look like? Since there is no theory for the origin of malocclusion the first step in developing a program would be to advance a theory of malocclusion. This theory will guide the research and educational programs to implement the change. I suggest as a starting point the ectopic odontogenesis theory of malocclusion be seriously considered. While it is true that at the present time the idea of preventing malocclusion by intervention in utero is outside what is feasible or even imaginable, this theory provides a direction for both an aggressive goal for an aggressive research program.

While it not clear if in utero orthodontics will save the orthodontic profession, if orthodontists do nothing their future is in jeopardy.

Financial support and sponsorship
Nil.

Conflicts of interest
There are no conflicts of interest.

Edward F. Rossomando

Emeritus University of Connecticut, School of Dental Medicine, USA

Address for correspondence: Edward F. Rossomando, DDS, PhD, Professor
Emeritus University of Connecticut, School of Dental Medicine, 12 West Fairway Ave,
Westerly RI 02891, USA.
E-mail: efr360@gmail.com

Received: 30 May 2020 Revised: 2 June 2020
Accepted: 23 June 2020 Published: 18 November 2020

REFERENCES
1. Padmanabhan S. Do it yourself orthodontics: Alarmist or real? J Indian Orthod Soc 2016;50:137-8. 2. Brace Yourselves, AI Is Coming to the Orthodontist’s Office | The Brink | Boston University. http://www.bu.edu/articles/2019/brace-yourselves-ai-iscoming-to-the-orthodontists-office/. [Accessed on September 24, 2020]. 3. Malocclusion – Wikipedia. https://en.wikipedia.org/wiki/Malocclusion. [Accessed on September 24, 2020]. 4. Miller WD. The human mouth as a focus of infection. Dent Cosmos 1890;33:689-706. 5. Louis Pasteur – Wikiquote. https://en.wikiquote.org/wiki/ Louis_Pasteur. [Accessed on September 24, 2020]. 6. Ten Cate’s Oral Histology, Nanci, Elsevier, 2013, pages 70-94 7. Rossomando EF. Ectopic odontogenesis: A hypothesis for malocclusion to guide future research and treatment. Dent Hypotheses 2012;3:53-4. 8. “Things didn’t feel right”: Some SmileDirectClub customers report problems. https://www.nbcnews.com/health/health-news/things-didn-tfeel-right-some-smiledirectclub-customers-report-problems-n1134056. [Accessed on September 24, 2020]. 9. SmileDirectClub Sues NBC Over News Report, Seeking dollar 2.85 Billion – WSJ. https://www.wsj.com/articles/smiledirectclub-sues-nbcover-news-report-seeking-2-85-billion-11589832227. [Accessed on September 24, 2020]. This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. Access this article online Quick Response Code: Website: www.dentalhypotheses.com DOI: 10.4103/denthyp.denthyp_67_20 How to cite this article: Rossomando EF. Has Do-It-Yourself Alignment for Malocclusion Doomed the Orthodontic Specialty?. Dent Hypotheses 2020;11:95-6. © 2020 Dental Hypotheses | Published by Wolters Kluwer – Medknow Rossomando: Aligners doom orthodontics 96 Dental Hypotheses ¦ Volume 11 ¦ Issue 4 ¦ October-December 2020