From a young orthodontist’s notebook

It was early 1990s. I was a 5-year-old boy when my mom brought the big box from her work to our studio apartment in Moscow. It was a humanitarian aid from the U.S. The Soviet Union had just collapsed and people were experiencing difficulties with consumer goods. But there was something in that cardboard box that excited me much more than American food and clothing. It was a brand-new baseball mitt and a ball.

The whole summer, my friend and I were throwing the ball to one another, pretending we were playing baseball. We knew no rules and had never watched a single game on TV. But we called ourselves baseball players.

At the very same time, post-Soviet dentists began to experiment with marvelous appliances that they had never seen before. Contemporary bracket systems just came to market. Soon after, these dentists started to call themselves orthodontists. They mistakenly named the new specialty “Orthodontiya”, throwing themselves back into the times of Edward H. Angle and stepping on the thorny path of trial and error…

I gained a degree in general dentistry from the Moscow Medical Academy in 2009. Couple of years later, I enrolled to a postgraduate program in orthodontiya at the Central Research Institute for Dental Surgery in Moscow. If you have never experienced the difference between ‘orthodontiya’ and ‘orthodontics’, there is no point in telling you about it: you won’t understand anyway. And for anyone who has, I do not even want to call it to mind.

I will state briefly: after two years practicing ‘orthodontiya’ in Moscow I felt deficiency in knowledge and need for additional learning. With this in mind I found myself on a plane travelling from Moscow to New York.


New York, New York 

– No really?! Are in the U.S. for the first time?

– Yes, I came here to shoot a documentary.

– That’s awesome! What is it about?

– Well, about orthodontics.

– Cool, I’m also going to start a video blog. Is your camera good for it?

– Actually, I’ve shot only one scene by now, a kind of introduction. You can find it on YouTube, just type in ‘Straightening the Way: Orthodontic Documentary’.

We arrive to the Grand Central Station from the JFK airport. My new friend shows me the way to the nearest Starbucks and wishes good luck. After getting a free portion of Wi-Fi and booking a hostel room at one of the countless Manhattan avenues, I take a long walk towards the park, from which – according to Holden Caulfield- ducks move away every winter. The island of nature enclosed by walls of skyscrapers. Thousands of runners are following their daily routes across the Central Park. My own pencil-traced-in-a-notebook-route is so illusive, that I am deciding to check if I have not mistaken with a continent:

– Hi, can I talk to Professor McNamara?

– Sure, how can I introduce you?

– Please tell him it’s Alex from Russia.

– Alright!

– Alex? – his voice sounds a bit cautious.

– Yes, it’s me, I’ve just arrived.

– Good, I’ve booked the library for videotaping. What’s your schedule?

– Tomorrow I’m filming the first interview, then going to Connecticut to Ravi Nanda, then going to you, then Kentucky, Jeffrey Okeson, next Rolf Behrents…

Buzz? He’s definitely a good choice for your film.

– Then Lawrence Andrews, Herbert Klontz and… a couple of others…

– Sounds good! So, I am waiting for your call from Ann Arbor. Take care!

In 1884, Moses Montefiore founded the Home for Chronic Invalids in Bronx. Today his project has become one of the largest medical centres in the city. Here I am going to record my first interview.

In recent years, there was a raise in speculations on the relationship between orthodontics and obstructive sleep apnea, but we still do not have detailed data on the issue.1,2 I decided to look at it from a standpoint of an ENT specialist. Dr Steven Park is a board-certified specialist in both otolaryngology and sleep medicine. During our interview, we discuss a range of topics in craniofacial growth and development. My overall conclusion from this is clear: the diagnosis of OSA should be done by otolaryngologists, not orthodontists. They definitely have more expertise in this.

After the interview, I jump on a train to Connecticut. I arrive to New Haven and then take a taxi to Farmington. The cabdriver, Mark, is excited by the fact that I came from the Former Soviet Union. The phenomenon of totalitarianism entertains him: he has been through all the books on Joseph Stalin.

– And then his mother asked him: «Whom have you become, Joseph?» And he was like: «Sort of a tsar» And guess what she replied?

– You’d better become a priest! – we chant out simultaneously. 

Farmington, Connecticut

 – Good morning Alex, my name is Shelly! Professor is waiting for you, – Shelly, a program coordinator, guides me through labyrinths of the UConn School of Medicine.

Professor Ravindra Nanda is a head of the Department of Craniofacial Sciences and  a chair of the Division of orthodontics. Great place to learn about the educational process in the U.S.

“Our program is not technique orientated. We feel that, if you teach orthodontics based on a technique, then personalities are coming to picture, then someone might start saying «I do Ricketts» or «I do Roth». This is the wrong way. There are good things with all the techniques, there are bad things with different techniques. So, we do our own system which is biomechanics-based edgewise orthodontic practice”, says Nanda.

After the interview, I am exploring the graduate clinic followed by residents. They have the great team of international students here. The department has been created by Charles J. Burstone and his passion for turning orthodontics into evidence-based discipline is deeply rooted in the study process. Meanwhile, is everything enough evident in contemporary orthodontics?

“I think, there is a lot of abuse in the system by treating children too early”, says Nanda. “I really don’t believe in early treatment, unless there are growth issues such as cross bites or class III problems”, he continues.

Early treatment has been and for many remains the apple of discord. But only a few have studied this topic as profound as professor James A. McNamara.

Ann Arbor, Michigan

We sit in a cozy café at a university campus. Professor McNamara has ordered tuna sandwiches. I am telling him that the idea of my journey first came to me when I discovered his series of interviews from 1980s on YouTube. “Interestingly, the videos that we did at that time have had far more impact in the last five years than they ever had before that, as soon as the interviews were placed on the Internet”, says McNamara.

We start the interview with the professor’s mentors. We are travelling from the University of California, Berkeley where he first met Egil Harvold down through the Iron Curtain to German Democratic Republic where visited Rolf Fränkel in Zwickau. Next, we go into various details in early treatment. I shoot the longest interview of the whole project. About two hours of video. As a last question, I am asking him, what piece of advice would he give to young orthodontists?

McNamara elegantly splits his answer into three parts:

“First, you need mentors at every stage of your carrier”, he begins. “You need those ten years from now, twenty years from now, thirty years from now… The mentors could be a professor or an older friend, but they just as easily could be a patient or a technician. And it doesn’t make any difference whether they are famous or not. There is always something that you can learn. On the other side of that, you will be a mentor to hundreds, maybe thousands of people. And I am not talking about patient care. I am really talking about just interactions. I think, that we all have to recognize that it is a two-way street: on one hand, you need mentors, on the other hand, you need to be a mentor”.

“The second thing is that you need to bring something to the table”, he continues. “When I came to Michigan, I walked in a wonderful situation, where I had the opportunity to work with many famous people, but I also had the opportunity of doing a thesis project that was as timely as anything, because I started in the early 1970s dealing with functional appliance therapy. By the time I got finished with my thesis and especially a few years later, I had something, that most orthodontists wanted to hear. I think, it is very important for a young person to develop some expertise in something, that is of interest to other people.

And the third issue is to follow your curiosity. I have been very fortunate in my career to be able, more so than most, to conduct studies, to interact with other people, to look for questions that arise. For example, how to expand in the mixed dentition? Essentially, that has been a carrier, even though there have been a lot of other things that have been involved. After all, you are never going to know everything. I’ve been in orthodontics fifty years. I’ve made a lot friends. I’ve published a lot of papers, and I am always still looking!” 

Lexington, Kentucky

The disadvantage with “Greyhound” buses is long night transfers. Just as this one in Cincinnati, Ohio. The advantage with interviewing Jeffery Okeson is that he does not need an interviewer to perform a great interview. Yes, I am a bit sleepy coming to the Kentucky Clinic.

Professor Jeffery P. Okeson is a head of the Orofacial Pain Center and widely known by numerous publications and lectures on the subject of TMD. My main goal is to clarify, does the subject have something to do with orthodontic treatment?

I start the interview with the Brimm’s case. The landmark legal process, which resulted in a million-dollar judgement against a Michigan orthodontist for allegedly causing TMD in a 16-year-old girl.

“What you have to understand is that courtrooms are not scientifically based”, Okeson begins.

“After that case, the orthodontic community was forced to get together and ask, if there is really a relationship between occlusion and TMD? At that time, there was a lot of speculation and not a lot of good data. In the 1990s, we started to get together on data, looking is TMD a risk factor for orthodontics? And most of the data that came out suggested – not really a risk factor. I look at that favorably. But for us to assume that orthodontist could not cause problems is pretty naive. For example, if orthodontist builds an occlusion in some very orthopedically unstable position, I think, that this patient has a greater risk factor to develop some temporomandibular disorder.

 All the studies that were done, were pretty much done in very controlled orthodontic settings – dental schools, orthodontic graduate programs. And I think, that literature suggests that when we train our orthodontists to do things well, there is not a risk factor. But if you are not a formally trained orthodontist, not thinking about joint position, you can in fact leave somebody with occlusion that might be esthetically pleasing, but has risk factors to cause TMD in the future”.

So, what if not orthodontics?

“There are five major etiological factors that relate to TMD.  Occlusion can be one. Trauma is one. A singe episode of trauma can lead to a clicking painful joint. Emotional stress is definitely another factor. There are also deep sources of pain. People can have cervical pain and their masticatory muscles start to become involved and cause TMD. And then we have parafunction – bruxing, clinching.

So, there are five ethological factors that we can scientifically relate to TMD. One of them is occlusion. But I always tell orthodontists that it is better not to do orthodontics on patients with TMD, unless you can identify that orthopedic instability is part of the problem. Because if patients have emotional stress – it doesn’t work, if they have other sources of pain – it doesn’t work, if they are bruxing their teeth – it doesn’t work. So, you have to understand where orthodontics fits into the big picture of temporomandibular disorders.”

After the interview, Okeson invites me to his lecture, which ends with the slide saying, “The best tool to fix TMD is your brain”

Saint Louis, Missouri 

– Excuse me, do you know where the Olivia Building is?

I am hanging around the Saint Louis University campus for a couple of hours asking people this question. I am looking for the birthplace of orthodontics. Landscape design of the campus is amazing and the graduate orthodontics clinic looks like a hockey arena with dental chairs scattered all over.

Only two days later, I will find a small red-brick building downtown. Looks like nobody, except Professor Rolf G. Behrents, knows the exact address of the Olivia Building. My interview with him is scheduled on Monday. So, I spend my weekend enjoying sights of the city and Mississippi river.

1023 North Grand Boulevard, St. Louis, MO is the official birthplace of orthodontics. Here the specialty was conceived, nurtured and prepared for its endless world tour by Edward Hartley Angle.

“He was the leader. One of the things that you have to have for establishing a new specialty is some charismatic person. And he was very determined to make orthodontics successful. He didn’t necessarily think that it needed to be attached to regular dental school, so he started his own”, Rolf Behrents provides me with some Angle’s biographical facts, while we are driving to the former Angle’s office.

Of course, talking with the editor-in-chief of the oldest orthodontic journal, you can’t skip a question about the history of the journal. I am asking Dr Behrents, if he sees a controversy in the fact, that the journal has on its cover names of two disciplines simultaneously?

“We are arguing the titles, the categories – one phase vs two phases, early treatment vs later treatment, but it really doesn’t depend upon your categories, it depends upon what the problem is with your patient. For example, for cleft palate patients it could be nine or ten different phases,” he replies.

Talking about his own background Behrents notes his enthusiasm with functional appliances in the beginning of his career. But “over time everything finds its balance”, he sums it up.

How important is to know the history for young orthodontists?

“People that don’t know history are destined to repeat part of it. And they might repeat the part that is good or they might make the same mistakes that we made in the past. Some people might think that they have a good idea and then find out later that some German a hundred years ago had a better idea. New appliances often look a little borrowed from other places. So, you have to know a little bit of a history for not wasting your time and effort.”

San Diego, California 

Efforts of Dr Lawrence F. Andrews in teaching us about sound occlusion could not be overestimated. His concept of six keys of optimal occlusion led to the invention of fully programmed straight-wire appliance in the 1970s. And now he states that he has found optimal parameters not only for position of teeth, but for facial esthetics as well.

I meet him at his private practice based at a calm district in San Diego. We record our interview in the room full of dental casts. They are everywhere here – on the table, in boxes on the floor, mounted in articulators on shelves. Lawrence Andrews is very passionate about his new 6 elements of orofacial harmony concept. Answering any of my questions he ends up with ‘6 elements’. Potentially, having “uniquely correct parameters for each patient” can improve results of orthodontic treatment and enhance examination procedures, such as board certification. But it is quite hard to predict the future…

Tucson, Arizona

 “With the way, it is going now – large practices and untrained orthodontists straightening teeth – if it doesn’t change, the orthodontic profession may be in the future will die. And general dentists with their helpers will be doing the straightening of the teeth to whatever degree they can. And there will be all kinds of results. We start to see some of that right now…” 

I lost my tripod a day before at Las Vegas airport, so my new close-up shots make Herbert Klontz’s message even more dramatic. Dr Herbert A. Klontz is a co-director of The Charles H. Tweed International Foundation. The study course is in full swing. The office is filled with students from around the world practicing wire bending. Dr Klontz and I are sitting outside in a nice backyard. I am trying to formulate a question which would develop the topic further:

–  Tweed once said that Hell is going to be full of orthodontists who are carrying five to six hundred active patients in their practice, how many patients should have an orthodontist if he doesn’t want to find himself in Hell one day?

“Well, the problem is the size of the practice… Many offices in the United States have as many as 10 to 15 young ladies doing work that the orthodontist could do a lot better. So, they are treating many more cases and often relying on non-extraction treatment…

 The real recovery is what Dr Tweed said many years ago – a small practice where you do work yourself with moderate amount of work being done by assistances, of course. But if you start letting somebody do all the work, you lose your profession”.

The Tweed Foundation has known for its strong principles. In 1929, Tweed himself travelled about 5,000 miles across the state of Arizona to establish the specialty law or, in other words, to prohibit for general dentists to provide orthodontic treatment3. Today, according to Klontz, orthodontists are facing the crisis of identity again. “I hope we could go back to some basic fundamentals”, he states. In his opinion, economic issues are the main handicap for young orthodontists: the costs of education and overwhelming market often turn practices into a mass production.

“You can make a wonderful living being an orthodontist, but you can not make that amount of money that somebody in the factories can make… I don’t have the answers for the future, as long as I am living, I want to help these young people teaching them fundamentals. And really it is for this younger generation to try to solve some of the problems. I can’t solve it for them…”, Klontz concludes. 

Moscow, FSU

I land at the Moscow Sheremetyevo Airport on the 12th of April 2016. The previous three weeks gave me incredible and priceless experiences. I have a sand of Arizona on my shoes and gigabytes of wisdom on my SD cards.

And I am not going to quit…

1. Nelly T. Huynh et al., Orthodontics treatments for managing obstructive sleep apnea syndrome in children: A systematic review and meta-analysis, Sleep Medicine Reviews, vol. 25, February 2016, pp 84–94.

2. Larsen A.J. et al. J Clin Sleep Med, Evidence Supports No Relationship between Obstructive Sleep Apnea and Premolar Extraction: An Electronic Health Records Review, 2015 Dec 15;11(12):1443–8.

3. James L. Vaden, Charles H. Tweed, 1895-1970, AJO-DO, vol. 147, 2015 May, Issue 5, Supplement, pp 171-179

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