SPECIAL ARTICLE
Orthodontic learning curve: A journey we
all make
Miguel Hirschhauta and Carlos Flores-Mirb
Caracas, Venezuela, and Edmonton, Canada
T
his reflection commentary is aimed to be an aide-
memoire about our clinical journey and the
vicissitudes that we all go through, the Dunning-
Kruger Effect.1
After 25 years as orthodontists, we should have
become more analytical earlier during the journey.
The (never-ending) story usually goes like this: first
few years out of the orthodontic residency, and we
think we have the perfect treatment plan for every
malocclusion we face. After a little while, we start
seeing inconvenient situations that we put ourselves
into, complications (both generated by us or not fore-
seen), and clinical relapses. Then we start questioning
our clinical capability. Everyone around seems to treat
patients better than us. You go to conferences, and
most of the patients are beautifully finished. Eventu-
ally, we come to the realization that we all have pa-
tients that worked exceptionally well and a bunch of
those that we do not want to show to anyone (hidden
in that famous basement drawer!). Let us go through
some examples.
Condylar resorptions develop in some of our active
patients. Initially, we do not assess the temporoman-
dibular joint in detail or simply do not foresee the pos-
sibility of future joint problems. Treated patients with
Class II malocclusion come back with an apparent
relapse of some of the achieved correction, and then
the story goes on. Scenarios like this make us (hope-
fully) stop for a moment and think deeply. We dig in
with a clever set of eyes, and we start seeing that these
patients usually fall into the teenage or young adult
a
b
Private practice, Caracas, Venezuela.
Private practice, and Division of Orthodontics, Department of Dentistry, Univer-
sity of Alberta, Edmonton, Alberta, Canada.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Carlos Flores-Mir, Division of Orthodontics, Depart-
ment of Dentistry, University of Alberta, 5-528 Edmonton Clinic Health Acad-
emy, 11405, 87 Ave NW, Edmonton, Alberta T6G 1C9, Canada; e-mail, cf1@
ualberta.ca or carlosflores@shaw.ca.
Submitted, July 2020; revised and accepted, September 2020.
0889-5406/$36.00
Ó 2021 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2020.09.025
female group.2 We begin to add things up, understand-
ing that they belong to the risk group for posttreatment
condylar changes. That is where that old boring resi-
dency lecture now makes sense. You see where we are
going. Then we also start being puzzled by the tempo-
romandibular joint adaption capabilities and why some
of your patients look better after 15 or 20 years. But
others do not adapt so well, and they have relapses in
different areas.
Another example is patients that we treated with
nonextraction. They sometimes become extraction pa-
tients the second time around, and they come back to
us for retreatment. With time we start understanding
better the biological limits (they were covered during
residency!). The so call envelope of the discrepancy.3,4
Can we expect lifelong fixed retention? Is fixed retention
a panacea for moving teeth outside of their set biological
limits?5
Every health professional goes through a lifelong
learning journey. So, our specialty should not be
different. The clinical environment can humble us
down. That journey is not the same for everyone. The
slope of the learning curve and the endpoint varies indi-
vidually. Background educational level, different stan-
dards of care, different adherence levels to those
standards, willingness to improve our professional skills,
and financial realities all become intertwined.
Another aspect that we learn with time is to become
more pragmatic and less heroic. Professional mishaps
make you wiser. The more you learn, the more you
realize that you cannot know everything. In addition,
the definition of success or failure is not transparent. It
depends on several factors. The variability of treating
human beings by other human beings, all with their
microcosmos, makes it challenging to have a clear set
of success criteria.
To learn from our successes and failures, we need to
assess critically how our patients fare after decades, not
months. It is hard to call those patients back, but is the
potential learning experience not worth the effort?
Some conventional orthodontic x-rays may be advis-
able so that we can not only visually assess what we
413
414 Hirschhaut and Flores-Mir

100
Orthodontic learning journey

I can solve every orthodontic case. Don’t require any advice

I am improving my orthodontic skills and learning as much as i can

So many complications can happen Orthodontics is more complicated than you think
Confidence

I can’t possible prepare myself for every orthodontic complication or relapse

0
Novic Orthodontic knowledge Expert

Fig. Adaptation of figure from Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in
recognizing one’s own incompetence lead to inflated self-assessments. J Pers Soc Psych 1999;77:
1121-34.

think happened but quantify it. Is an added set of ra-
diographs an ethical crime?6,7 Is the learning of what
happened over the years not something that will
benefit other patients in a multiplying curve? The
ALARA (as low as reasonably achievable) rule should
be carefully considered but learning from failures to
provide better treatment to the next set of patients is
also a consideration.
So, having the Dunning-Kruger Effect curve visible
may be a wise thing to have, in our opinion. Maybe it
should be on the desk of every practicing orthodontist.
An adaption to our specialty is attached (Fig). Because
even a seasoned orthodontist will have patients that if
he or she looked back at them again after treatment
completion, we would have approached them differ-
ently. We must accept this fact and not be worried
about acknowledging it. We are not perfect, but we
try the best for our patients! Let's share our journeys
with others for the greater good. We suggest it is
time to open our conferences and interactions to pa-
tients that did not work and, ideally, what we could
have done to avoid the problem to develop. We all
have those patients!
AUTHOR CREDIT STATEMENT
Miguel Hirschhaut and Carlos Flores-Mir: conceptu-
alization; writing – original and final draft.
REFERENCES
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recognizing one’s own incompetence lead to inflated self-assess-
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3. Proffit WR, Ackerman JL. Diagnosis and treatment planning. In:
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6. Rule JT, Veatch RM. Ethical questions in dentistry. In: Bywaters L,
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Publishing; 2004. p. 71.
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April 2021  Vol 159  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics