MOVING TEETH & RAISING EYEBROWS: UNORTHODOX TREATMENT Saint Paul Pioneer Press (c) 1996 St Paul Pioneer Press. All rts. reserv. 02660489 MOVING TEETH & RAISING EYEBROWS: UNORTHODOX TREATMENT DIVIDES DENTAL COMMUNITY St. Paul Pioneer Press Dispatch (ST) - SATURDAY September 24, 1988 By: Nancy Livingston, Staff Writer Edition: AM Metro Final Section: Fitness and Health Page: 1B Word Count: 1,734 TEXT: Eric Galler's orthodontic future was unalterably changed eight years ago in the lobby of a Stillwater church. As Eric's mother waited to get her picture taken for the church directory, a dental supply salesman overheard her say that Eric, who had braces on his teeth, would not be going on a sailing trip because he was scheduled for jaw surgery to correct his bite. "Please don't think I am too forward," the salesman told her, "but after you have your picture taken, could I talk to you about Eric's surgery?" When she returned to the church lobby, the salesman passed along the name of Dr. John Witzig of Golden Valley, a tall, gentle dentist and former professional wrestler who is shaking up the well-ordered world of American orthodontics. Since he returned from studying at the universities of Bonn and Vienna in 1972, Witzig has been moving teeth by using "functional appliances" instead of traditional brackets and wires. But he has also been raising eyebrows in the orthodontic community - a place where unorthodox treatment is not always welcome. The removable appliances originated in Europe and are made of acrylic and wire. Similar in appearance to dental retainers, many of the appliances are imbedded with screws and can be adjusted to give a specific correction. "There are dentists in flames" over this issue, says Dr. Terrence Spahl, a St. Paul dentist and co-author of a textbook with Witzig. The book, written for dental clinicians and entitled "The Clinical Management of Basic Maxillofacial Orthopedic Appliances," has sold 6,000 copies at $95 a piece since publication in 1986. A second textbook by the pair will be published in December and a third book is also planned. Spahl and Witzig's approach cuts to the root of orthodontic theory. In traditional orthodontic treatment, the patient with crowded teeth and a bad bite usually has two to four bicuspid teeth extracted to create space. Then brackets and wires are put on to close the gaps and bring the upper teeth back to meet the lower ones. The functional appliances, says Spahl, work differently. Instead of bringing the top teeth back, the whole lower jaw and sometimes the upper jaw are brought forward to correct the bite. The appliances redirect bone growth, retrain facial muscles and enlarge the jaw to accommodate more teeth and give patients a fuller face and wider smile. After 14 to 18 months of wearing the appliances 18 hours a day, patients may still need some teeth straightened. In such cases, they may wear brackets and wires for six months or so beyond their functional appliance treatment. The cost of functional orthodontics treatment is about the same as the traditional method - $2,000 to $3,000 for the average case. And because they are removable, functional appliances require a high degree of patient motivation. They won't do any good sitting by the bathroom sink. But Witzig says his patients have been faithful about wearing their mouthpieces. Designed to be unobtrusive, the appliances do not interfere with talking, eating or brushing the teeth. Usually a single wire across the front teeth is the only evidence of the device. Witzig adds that because his appliance brings the lower jaw forward, it may also help prevent TMJ syndrome - a disorder of the temporomandibular jaw joint characterized by headaches and jaw, neck and ear pain. "Pull-'em-back orthodontics," says Witzig, can actually contribute to TMJ syndrome. Taking out the bicuspids and pulling the top teeth back to meet a receding lower jaw, he contends, puts more pressure on the TMJ. But the pro-braces camp says studies show the incidence of TMJ syndrome among people who have had braces is the same as among those who have not had orthodontic treatment. Dr. T. Michael Speidel, head of the orthodontics department at the University of Minnesota, says the university has been using functional appliances for 20 years. "Orthodontic appliances," he says, "are simply tools - a way to grab onto teeth. In themselves, they have no intrinsic value - like a hammer hanging on the wall in a hardware store. It's the skill of the operator (that counts)." And, he adds: "Whatever claims he (Witzig) makes, I cannot judge them because he has never presented them, never published them (in the American Journal of Orthodontics) and never done studies to support them." At 6-foot-4, Spahl is the John Wayne of dentists. He carved his dental office out of a former Maryland Avenue grocery store and did most of the construction himself. Eschewing the usual dental decor, Spahl has surrounded himself with early American furniture and an enthusiastic display of cowboy art. He owns a piece of a Montana cattle business; a history of the flintlock rifle stands on the bookshelf next to dental research journals. When he talks, Spahl bares his teeth like a pitbull to describe a normal bite and juts his jaw in and out to demonstrate overbites and underbites. One of his scientific heroes is Dr. Ignaz Semmelweis, who was practically laughed out of the profession in 1848 when he first theorized that invisible germs cause infection. Witzig is as subdued as Spahl is dramatic. Calm and fatherly, he seems an unlikely choice to lead a revolt against the entrenched scientific establishment. He argues that his theories have been adequately proved in studies, some published in the American Journal of Orthodontics. Witzig says he has spent most of his career practicing and teaching. "The great advances in orthodontics," he says, "have been made by clinicians out there treating patients every day." Dr. Ira Yerkes has been watching this scuffle for years. A Boston orthodontist who taught in the orthodontics department of Tufts University for 10 years, Yerkes says, "I have been in orthodontics for 22 years. Back when I started, we were led to believe certain things that are not so anymore. This is where the battle rages." In the case of patient Eric Galler, Witzig told the family that Eric should have his braces removed. He could have his bite corrected and his teeth straightened by wearing a functional appliance. Jaw surgery would not be necessary, he advised. Witzig fitted Eric with an appliance, which he wore for nine months during his senior year of high school. By the end of that time, Eric's overbite was gone and his teeth were straight. The treatment cost about $900. The Gallers figure three years of braces and jaw surgery for her son would have cost 10 times that. The U of M's Speidel says testimonials such as the Gallers' prove nothing. Deciding on a course of treatment on the basis of testimonial, he says, is "not any more scientific than a person who says 'my soap flakes get clothes whiter than anyone else's.' They (the advertisers) know no housewife is going to set up a test laboratory in her home." If functional appliances are used in the university clinic, Speidel says he stresses "realistic expectations" on the part of the patient. The goal, he says, is to find the most cost-effective method of treatment for each patient. Fixed appliances (braces) can often produce the most correction in the most mechanically efficient manner, he says. Many of the claims by practitioners who use functional appliances almost exclusively in their practices cannot be substantiated by scientific data, Speidel says. For example, he says that while functional appliances are designed to influence bone growth, studies show that "none (of the appliances) give you enough bone growth to get an orthopedic correction." He also says it is useless to put appliances on "non-growing patients" (adults). Speidel is unimpressed that Witzig draws more than 500 dentists and orthodontists every year to a Minneapolis hotel for a three-day, $650-per-person seminar on functional orthodontics. The department chairman says he will not be attending Witzig's next symposium Oct. 20-22 at the Hyatt Regency Hotel. "It's not that I am closed-minded," he says. "If I went (to a seminar) it wouldn't be because I was looking for the Holy Grail. I know what you can do and what you can't do. People have been looking for it (the Holy Grail) for years." Dr. Lloyd Truax won't call functional appliances the Holy Grail, but the Rochester orthodontist sees them as a "very useful adjunct." A graduate of the University of Minnesota dental school with an advanced degree in orthodontics, Truax was on the staff of the Mayo Clinic for several years before starting a large private orthodontic practice in Rochester. "If I had to continue my practice in orthodontics without functional appliances, I know I could not treat my patients as well," Truax says. "I would be throwing away a very useful adjunct... With functional appliances, you can make changes you cannot make with fixed (traditional braces)." Truax says he has gone from putting braces on almost all of his patients to using functional appliances on 80 to 90 percent of them. "I do the jaw changes first," he says. "Then I do the fixed to rotate teeth and do the detailing." In the midst of all this ferment are orthodontists like Gary Lunstad of Roseville who have not aligned themselves with either side of the functional appliance debate. Trained in the orthodontics department at the University of Minnesota and certified by the American Board of Orthodontics, Lunstad says it is important for orthodontists to return to school and learn new techniques and ideas. He periodically closes his single-practice office for weeks at a time to attend seminars around the country. He has attended Witzig's seminar and uses functional appliances on about 20 percent of his patients to correct jaw problems. But he also uses headgear - a common tool of the traditional orthodontist. And he finishes almost all his cases with braces. CAPTION: 5 Photos 1) Dr. Terrence Spahl, left, and Dr. John Witzig move their patients' teeth by means of functional, or movable, applinaces. 2,3) BEFORE Eric Galler had a classic overbite. Two orthodontists said he could either wear braces for six years,or have braces for two to three years followed by jaw surgery. Cost would be at least $10,000. 4,5) AFTER Eric wore braces for two years, then decided against surgery. Instead, he wore a functional appliance for nine months. The device trained his lower jawbone, muscles and teeth to advance and meet his upper jaw. The appliance therapy cost $900. Copyright 1988 The St. Paul Pioneer Press Dispatch