300 Readers’ forum American Journal of Orthodontics and Dentofacial Orthopedics

March 2010

The inherent problem is not the value and relevance of Without laboratory research, the specialty would be re-
in-vitro research; it is the inappropriate interpretation of these stricted to clinical observational research without ever devel-
research findings into clinical practice. Clinicians who are oping a fundamental understanding of ‘‘why.’’
functioning as high-level ‘‘clinical scientists’’ will use the out- Hisham Badawi
come of fundamental research (biologic and engineering) to Paul Major
generate hypotheses that are then tested with well-designed Edmonton, Alberta, Canada
clinical studies. Am J Orthod Dentofacial Orthop 2010;137:299-300
Although we agree with the editor on the importance of 0889-5406/$36.00
Copyright Ó 2010 by the American Association of Orthodontists.
in-vivo studies, it is important to recognize that (just like
doi:10.1016/j.ajodo.2010.01.011
any other research method) clinical studies in orthodontics
have many limitations. The main attribute of clinical trials
is the control of bias through randomization and blinding.
Whereas randomization is possible in orthodontic research,
blinding is impossible. It is simply impossible to blind the cli- Editor’s response
nicians making the treatment decisions necessary to complete
the orthodontic treatment for a number of subjects with 2 types First, I want to thank Hisham Badawi and Paul Major for
of orthodontic brackets. Randomized clinical trials do not taking time to respond to my editorial (Turpin DL. In-vivo
provide all the answers, but they typically answer a specific studies offer best measure of self-ligation. Am J Orthod Den-
question quantitatively, and, when a study is looking at a qual- tofacialOrthop 2009;136:141-2). Their statements show a level
ity-of-care issue in which the criteria for success have not of professionalism that is not always easy to maintain when
been clearly established, a randomized clinical trial is one is teaching, conducting original research, and maintaining
inappropriate. a practice. Although I do some teaching, I am not running a re-
The use of ‘‘between method triangulation’’ has received search laboratory or a private practice—and I still find it diffi-
much attention in the medical literature; the idea is that, rather cult to satisfy the reasonable demands of our many readers for
than being opposites, the mixing of paradigms might comple- a new editorial each month, written with clarity and under-
ment each other. By combining multiple observers, theories, standing. I will try again to make myself understood regarding
methods, and empirical materials, researchers can hope to the issue of in-vitro and in-vivo studies.
overcome the weaknesses or intrinsic biases and the problems Drs Badawi and Major are correct in stating that their 3-di-
that come from single-method, single-observer, and single- mensional orthodontic force measurements should not be
theory studies. Therefore, we believe that clinical evidence compared with the in-vitro shear bond strength study of adhe-
does not eliminate the need or invalidate in-vitro evidence. sives; the AJO-DO quit accepting new in-vitro bonding studies
Most of the evidence base in orthodontics is the result of in- about a year ago, when we realized that the relationship of the
vitro research; the sum of in-vivo and in-vitro research studies findings to patient treatment was fleeting, at best. Since then,
is the evidence on which we should base our conclusions. we have tended to look more carefully at all in-vitro studies.
When we embarked on the task of developing a 3-dimen- Perhaps a better analogy would be the study of static friction
sional orthodontic force measurement device, we kept in mind done by pulling a straight wire through a series of brackets
that the orthodontic force system by nature is extremely in a typodont to determine which brackets provide the most re-
complicated, and measuring it is no easy task. Therefore, we sistance to tooth movement. These types of in-vitro studies
followed a systematic plan to build a device with rigid tooth teach us little about actually aligning teeth in the mouth and
connectors, and, without tooth-to-tooth contacts, we built the tend to have little value for clinicians.
device in a way that allows us to add more variables to our I share Drs Badawi and Major’s interest in obtaining
system as we go forward, such as periodontal ligament compli- a deeper understanding of the biologic principles of tooth
ance and tooth-to-tooth contacts. We are already working on movement resulting from complex force systems, with the
building those variables into our device to develop the system goal of transferring what is learned through in-vitro studies
1 step at a time; this helps to more closely simulate the oral en- to the clinical environment. It is challenging to weigh the ben-
vironment, although we will never be able to totally simulate it. efits of a 3-dimensional environment that is devoid of muscles,
Our data, for the first time in the history of our specialty, bone, and, most of all, a periodontal ligament. Perhaps their
show clinicians the actual forces applied on the teeth with the approach will shortcut the trial-and-error method of testing
straight-wire appliance. Using our data, we can plan clinical treatment modalities and biased ‘‘expert’’ opinions. They are
experiments to test specific hypotheses. We also can ‘‘engi- certainly correct in noting that ‘‘it is the inappropriate interpre-
neer’’ orthodontic force systems to deliver the desired force tation of these research findings into clinical practice’’ that
magnitudes. As we continue to refine our measurement of or- must be guarded against.
thodontic forces, we are using the finite element method to an- David L. Turpin
alyze the pressure per unit of area of projected root surfaces. Seattle, Wash
Am J Orthod Dentofacial Orthop 2010;137:300
This will move us closer to predicting the biologic effect of 0889-5406/$36.00
the complex force systems used in contemporary orthodontic Copyright Ó 2010 by the American Association of Orthodontists.
mechanics. doi:10.1016/j.ajodo.2010.01.007