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'Does traditional orthodontics ruin faces?' – a debate

Abstract

In November 2005 a debate between John Mew and Simon Littlewood on the topic 'Traditional orthodontics ruins faces' was held in Leeds. Here Sarah Church gives an account of the session.

Main

On 3 November 2005, a debate entitled 'Traditional orthodontics ruins faces' was held at Elland Road, Leeds. This argument was proposed by John Mew and opposed by Simon Littlewood with Professor Bill Shaw as chairman.

John Mew's personal viewpoint regarding his treatment philosophy of orthotropics has been previously published in the BOS News in April 2005. In this he claimed that he had been excluded by the UK orthodontic establishment and rarely allowed to communicate with postgraduate orthodontic trainees. This debate provided John Mew with the opportunity to put forward his viewpoint against 'traditional' orthodontics, and for Simon Littlewood to defend it.

John Mew continued to question 'traditional' orthodontic practice with his thought provoking ideas. He stated 'you need to be strong and if you are in the right you must say so and act on it'. As a result he has ruffled some feathers in the past and has been seen as a controversial figure within the orthodontic community earning himself the title of 'maverick'. He argued that the undying dismissal of the orthodontic community was somewhat harsh.

Believing that orthodontic treatment has the potential to damage faces, he also passionately believes in the development and expansion of the maxilla whilst directing mandibular growth. He further stressed the importance of tongue posture. Unfortunately he failed to explain to the audience how this could be achieved with the use of orthotropics.

He alluded to his website (www.orthotropics.com) where he claims that natural growth guidance is the alternative to dental extractions and surgery. He remained very critical of what he described as 'traditional' orthodontic practice and specifically warns patients about the dangers of undergoing conventional orthodontic treatment. His website has a link to Orthodontic Outrage which is specifically vociferous against dental extractions as well as the use of fixed and functional appliances in the correction of malocclusions.

John Mew strongly believes that new treatment philosophies are needed to fuel advances in clinical practice. He argued his treatment philosophy on a number of case reports but his practice is based on personal opinion, the lowest form of evidence on the hierarchal scale. It seems rather unfortunate that John Mew, a very passionate orthodontist, having realised the need for evidence, has failed to produce evidence to convince his audience as well as the orthodontic establishment.

Simon Littlewood opened his defence by stating that he, like John Mew was passionate about what he believed in. He stressed that we needed to look beyond John Mew's spoken message and look at the evidence behind it.

The philosophy of orthotropics has been in existence for 47 years and although Simon Littlewood could not compete with this timeframe, he went on to succinctly discuss the consecutive class II cases he had completed within the last 47 days, using 'traditional' orthodontics. These included cases treated with functional appliances, cases that John Mew would have treated with orthotropics. All of these cases were well finished, and all showed a maintained or improved facial profile.

'...traditional' orthodontics might be more appropriately phrased 'contemporary' or 'evidence-based' orthodontics'.”

Simon Littlewood proposed that the term 'traditional' orthodontics might be more appropriately phrased 'contemporary' or 'evidence-based' orthodontics. In the current era most clinicians are constantly searching for their practice to be based on such research. Simon Littlewood then succinctly discussed the current evidence on functional appliances provided by randomised controlled clinical trials.

He went on to describe how in 1990 John Mew had stated in the BDJ1 his concerns regarding the insufficient clinical research which was being carried out, and how he had 'tried for 20 years to encourage prospective studies but without success'. However, on publication of the randomised controlled clinical trial by O'Brien et al. in 2003 showing the actual effects of twin block appliances,2 John Mew wrote to the AJODO in 2004 stating that 'we should remain highly suspicious of clinical papers, including randomized, controlled trials and base our treatment on the evidence of more basic science'.3 Simon Littlewood continued by describing how John Mew compared the O'Brien trial2 with the study by Voudouris et al.4 assessing the effect of the Herbst appliance in monkeys, John Mew questioning 'How different are humans to monkeys?'

Simon Littlewood then went on to describe in more detail the Biobloc system, which John Mew believes in. As part of this treatment philosophy John Mew claims that he can obtain stability of treated cases without retention. Simon Littlewood, with a particular interest in retention, looked into the evidence that John Mew has produced to support this statement. John Mew has published one case seven years out of retention.5 This case report was claimed to be stable seven years later, with no retention regime. However it was illustrated that the Biobloc regime actually includes a period of wearing an activator type appliance at night for a prolonged period, in this particular case, the activator was worn for two years. In addition, it was claimed there had been few changes post-treatment in the lower labial segment. However, photographs revealed marked crowding of the lower labial segment.

Simon Littlewood concluded his defence with a quote from Pierre-Charles-Alexandre Louis, a doctor from the 19th century. Louis stated that any therapy should be based on the results of collective clinical results and not on individual experience, tradition, theory and philosophy. The message was clear – in the 21st century we should still follow this aim, for the highest quality research to support our clinical practice.

John Mew had a fair chance to put his argument over. However Simon Littlewood left the audience in no doubt that John Mew could not produce substantial evidence to support his claims. The audience left reassured that traditional orthodontics does not ruin faces.

Editor's note

In the interests of fairness, both Simon Littlewood and John Mew were sent this report on the debate and asked if they wished to comment on it before publication. Simon declined, but John Mew's comments are printed below.

John Mew's comments:

I am glad to have the opportunity of commenting on this review by Sarah Church. The debate between Simon Littlewood and myself was originally entitled 'Traditional orthodontics ruins faces' but the authors have prefixed this with the word 'Does'. I would have been happier with the word 'Can'.

It is only natural that both the reviewer and Simon are anxious to dispel the thought that orthodontic treatment might damage faces. They criticise my supposed lack of scientific evidence but I doubt if they can quote one unflawed clinical paper that shows that any system of treatment is significantly better than any other, either in terms of long-term dental alignment or of facial change?

Not everyone would feel that it was fair of Simon to draw attention to the lower incisor relapse in a case that I had treated nearly 40 years ago, especially as the lower arch itself was 'untreated'. This paper was intended to show that Biobloc could achieve a 'permanent (seven years out of all retention) sagittal correction of about 6 mm' in 41 days. Does he know of other systems that can achieve this? It suggests to me that he was digging very deep to find evidence of my failures, and like everyone I am fallible.

The reviewer does not mention the real life story that I described where all the members of the British Orthodontic Society were shown the records of a boy 'Brian' with a 10 mm overjet. Ninety one percent suggested extractions although there was no crowding and 63% recommended retractive headgear although the mid-face was already flat.6 A panel of lay judges found that after this treatment the face looked noticeably worse.

'Basic evidence shows for certain that most orthodontic treatment lengthens faces and that longer faces are less attractive'.”

During the debate, I suggested that 20% of faces suffer damage of this type and would be happy to justify that on the basis of any consecutive series. I am not saying this to discredit orthodontists but to encourage more reasoned debate. I hear clinicians at meetings talking about how to avoid vertical growth but it is rarely mentioned to patients. 7 Basic evidence shows for certain that most orthodontic treatment lengthens faces and that longer faces are less attractive. Despite this Dr Church concludes that 'orthodontics does not ruin faces'. What, never?

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Church, S. 'Does traditional orthodontics ruin faces?' – a debate. Br Dent J 201, 243–244 (2006). https://doi.org/10.1038/sj.bdj.4813971

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