Dental Braces 1925 – 1970
Whilst orthodontics in the USA blossomed early and treatment with fixed braces slowly started to spread, orthodontics in Germany fell by the wayside. Angle’s teaching and his fixed braces (Edgewise appliance) also became known in Germany through his pupils Körbitz, Grünberg and Oppenheim. In Germany, skull X-rays were developed in 1931 as a result of the work of Hofrath, while virtually simultaneously in the USA Broadbent was also working on this important diagnostic tool.
Fixed braces dominated throughout the world until around 1930. In 1928, with the help of X-rays, Oppenheim discovered that fixed braces actually caused damage to the roots – so-called root resorption. At about the same time, removable braces such as the active plate were first suggested (Nord 1929) and subsequently developed by the Austrian A.M. Schwarz. To orthodontists in Germany and in some of its neighbouring European countries this seemed to be a milder, less risky treatment option. Most importantly, in the first half of the 20th century, removable braces were less expensive than fixed ones, so active plates and later the various removable double braces became the standard in Europe for a few decades.
The Great Schism: Dentofacial Orthodpaedics versus Orthodontics
But it was Andresen’s introduction in 1936 of a removable double brace called an Activator that led to the momentous split of German orthodontics away from the development that was taking place in the USA. In a complete overestimation of his removable brace, Andresen claimed to have invented a completely new, ‘biological’ treatment method that was capable of influencing the development of both the skull and the face.
He named his allegedly superior treatment method “functional orthodontics” and claimed to have eradicated purely mechanical orthodontics using fixed braces. As a result of this, the older term ‘orthodontics’ that was in use in most languages, was replaced in Germany by the new term ‘Kieferorthopädie’ (dentofacial orthopaedics). As a consequence of this, orthodontic treatment using fixed braces was no longer taught at German universities until 1970.
Whilst orthodontic treatment in the USA was carried out exclusively using fixed braces, the removable brace dominated in Germany for decades. Although this was scientifically and clinically an aberration, it at least had the advantage that treatments with the cheap removable braces became affordable for more people, even if the same good results could not be achieved as with fixed braces and the treatment times were very long.
Admittedly, German orthodontists did have to extract teeth during these times but avoided this wherever possible because, in most cases, the mechanical possibilities of the removable brace did not allow for very good space closure and sometimes just caused the teeth to tilt.
Extracting Teeth – the Turning Point in the USA
As much as Angle’s students followed his dogma of not pulling teeth for orthodontic reasons, they had to observe that the laboriously widened and enlarged dental arches of their patients did not remain stable after treatment, but reverted towards their former position. The almost complete recurrence after expansion of the dental arches was to be expected regularly.
One Angle student, Charles Tweed (1895-1970), was so frustrated by this that he considered giving up orthodontics altogether, preferring to return to dentures. However, he decided otherwise and treated many of his patients, who years after treatment had their teeth as crooked as before, a second time with the removal of four premolars (small molars). He found that the results not only looked better, but also showed better stability after treatment.
Hayes Nance (1893-1964) went in the same direction. Tweed and Nance’s articles on tooth extraction in orthodontics from the late 1940s made a powerful impact on orthodontics in the USA and led to the abandonment of the Angle dogma of never extracting teeth.
Incidentally, these brilliant articles are still worth reading after more than 60 years and should be recommended to all orthodontists who today again feel they must cultivate a dogma of never extracting teeth. However, it should not go unmentioned that in the USA, and subsequently in many other parts of the world, an extraction mania virtually developed (“if in doubt, whip them out” and “four on the floor” were mottos of US orthodontics),
However, since the 1970s the number of orthodontic treatments worldwide involving the extraction of teeth has again fallen. Now that so much is known about long-term stability, para dental health and facial aesthetics, an extraction rate of 20% of orthodontic treatments would appear to be the most reasonable compromise.
Development in Germany
Since 1970, classes with fixed braces were also gradually taught again at German universities. The great break with US orthodontics thus slowly came to an end. However, the strength of the conservatism of some German university teachers can be seen in articles published even after the year 2000 on orthodontic treatment exclusively with removable braces, which are fundamentally outdated, unreasonable for patients and, moreover, uneconomical.
The situation is even worse for orthodontists in private practice in Germany, because the German fee system rewards long, inefficient treatments more than short, intensive treatments. In addition, almost every German orthodontist runs his or her own dental laboratory where removable braces are manufactured. Treatment with removable braces is therefore rewarded twice as much, so that an inefficient, outdated method of treatment with removable braces is still widely used for children and adolescents in Germany.
The fact that orthodontists operate dental laboratories for the production of removable braces is unusual in the whole world and represents a unique feature of German orthodontics. It is obvious that something cannot be right here.
The state of science is clear that most treatments can be carried out most easily, most effectively and most patient-friendly with a single, fixed brace. So the situation in Germany is that, due to conservatism, poor training and a nonsensical fee system, a great deal is still being treated with the mostly outdated removable braces – to the detriment of the patients concerned.