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ON THE NATURE OF ORTHODONTICS
Mary Louise and Dr. George Boone


ON THE NATURE OF ORTHODONTICS
Dr. Robert E. Moyers D.D.S., Ph.D., D.Sc. (Hon.)
Lectures Dedicating
the Boone Chair in Orthodontics
at
The University of Southern California
School of Dentistry
November 8, 1984
Edited by
Julian Singer
Katherine Ribbens
Monograph 1
BOONE LECTURE SERIES
Published by
The University of Southern California
School of Dentistry
and
Center for Human Growth and Development
The University of Michigan
1985
Copyright © 1985
by the Center for Human Growth and Development
The University of Michigan
and
the School of Dentistry
University of Southern California
No part of this publication may be reproduced, stored in a re-
trieval system, or transmitted, in any form by any other means,
electronic, mechanical, photocopying, recording or otherwise, with-
out the prior written permission of the Center for Human Growth
and Development.
PREFACE
A university looks upon the endowed chair as one of its most prized
gifts. The University of Southern California inaugurated its first
chair in 1885. Since that time, a relatively small number of chairs
have been acquired; however, they have been noteworthy in bringing
distinguished scholars to our campus.
Today, we formally dedicate the George and Mary Lou Boone
Chair in Orthodontics. This unique gift is presented by two people
whose USC roots go very deep. Both received professional degrees
here. Mary Lou graduated in Dental Hygiene and George in Den-
tistry and Orthodontics. They obviously never forgot the education
and opportunities derived from their university.
In choosing the vehicle of the Chair to acknowledge their com-
mitment to USC, the Boones have touched the entire educational
process. For when a chair is created, the spinoff benefits are felt
far and wide. The Chair in Orthodontics is one of the first of its
kind in the world. It will bring added strength and recognition to a
department that already ranks among the very best. Furthermore,
the Boones share the notion that this gift can encourage giving in
Other parts of the dental school, and, on a larger scale, other schools
within the University.
We are delighted that at this initial activity of the Chair, we
have present Dr. Robert E. Moyers from The University of Michi-
gan. Dr. Moyers is a scholar and an individual who understands the
academic world. His achievements are legion, and I will not dwell
upon them. Needless to say, we could not have chosen a better
Qualified individual to help plan for the future of the Chair. Like
the Boones, Dr. Moyers can see the impact that this gift will have
throughout the educational community.
And, once again, we say, “thank you” George and Mary Lou
Boone.
Dr. William H. Crawford, Jr.
Dean, School of Dentistry
University of Southern California
November 8, 1984
V
TABLE OF CONTENTS
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
On the Nature of Orthodontics . . . . . . . . . . . . . . . . . . . . . 1
“Good” Orthodontics . . . . . . . . . . . . . . . . . . . . . . . . . . 15
On the Measurement of Facial Form and Growth . . . . . . . . . 31
Evolution of Concepts of the Face . . . . . . . . . . . . . . . . . . 59
Changing Role of the Professions in Society . . . . . . . . . . . . 69
Mainstreams in American Orthodontic Thought . . . . . . . . . 87
vii
FOREWORD
The invitation to be the first Boone Lecturer requested that I deliver
a week-long series of lectures to students, faculty, alumni, and oth-
ers to help dedicate and inaugurate Dr. George and Mary Louise
Boone's generous gift to their alma mater. I accepted, not only
because of the honor of such an invitation, but because of a long-
Standing relationship with the University of Southern California and
my firm friendship with the Boones.
Many years ago, when I was a very young Orthodontic teacher
and Spencer Atkinson still headed USC's Orthodontic Department,
I was asked to lecture in Los Angeles. A few years later, during
another visit, Cecil Steiner invited me to attend a meeting of his
Orthodontic study group in the basement of his home. There I first
met George.
My associations with orthodontics and orthodontists at USC
have been warm and meaningful to me in a personal way for many
years, so the privilege of being the Boone Lecturer provided a fine
chance to acknowledge how I have benefited through the years by
these associations.
This volume contains only those lectures given in November,
1984, which dealt with ideas, concepts and problems singular to
Orthodontics. Discussions of specific clinical treatments presented
at that time are not included. Two other unpublished papers have
been added which deal with “The Nature of Orthodontics”.
Robert E. Moyers
Center for Human Growth
and Development
The University of Michigan
Ann Arbor, Michigan
August, 1985
ix
ACKNOWLEDGMENTS
“On the Measurement of Facial Form and Growth” was prepared
as the inaugural T.C. White Memorial Lecture before the Royal
College of Physicians and Surgeons of Glasgow, October 24, 1984.
I am grateful to the College for permission to deliver it again and
include it in this collection.
“Evolution of Concepts of the Face” was given at a convoca-
tion at the Aristotelian University of Thessaloniki, Greece, May,
1980. It has been published, as given, under that title (HEEEAIEH
TQN IAEON TOY IIPOXXOTIOT). The Aristotelian University of
Thessaloniki graciously permitted its publication here in English.
“The Changing Role of the Professions in Society” was the topic
of the Gaver Lecture at the University of Maryland, Baltimore,
April, 1982, and was delivered in revised form at the University
of Southern California, with permission.
“Good’ Orthodontics” will also appear in “Orthodontics: State
of the Art, Essence of the Science”, Lee W. Graber, Ed., C.V. Mosby,
Co., St. Louis, 1986.
Twenty years ago on the balcony of my apartment in Athens,
Harvey Jenkins and I discussed the “Eras of Orthodontics”, “The
Extraction Era”, and “The Era of Cephalometrics”. I am certain
that “Mainstreams in American Orthodontic Thought” grew out of
that discussion, even though it deals with evolving new concepts of
Orthodontics.
Professor Rudolph Schmerl, an old friend, helped me prepare a
lecture some years ago on themes contained in “Good’ Orthodon-
tics”. Though this is a new essay, I acknowledge my debt to him for
any ideas that have continued in this essay.
All of the essays in this volume have been read by one or more of
the Craniofacial Group at the Center for Human Growth and Devel-
Opment at The University of Michigan. The group provides a stimu-
lating environment for work, and criticisms are freely given. Though
none of them are responsible for the words herein, I am especially
grateful for criticisms, ideas, and encouragement to Fred Bookstein,
David Carlson, Stanley Garn, Jim McNamara, and Mike Riolo.
xi
I am indebted to the Boone Chair Committee for their invitation
and for continuing opportunities to collaborate with them in their
exciting venture.
Andrea Johns has carefully prepared the manuscripts and Steve
McKelvey has added his usual meticulous and helpful technical
assistance.
R.E.M.
xii
ON THE NATURE OF ORTHODONTICS
Specialties in medical practice emerged when the fund of knowledge
in a clinical area became great enough to demand particular train-
ing to provide efficient treatment. Many medical clinical special-
ties are dependent on an underlying basic science: i.e., surgery—
anatomy, urology—renal physiology, neurology–brain Science, etc.
The dental specialties unfolded differently, for several of them di-
verged from one another simply because of the proliferation of com-
plicated restorative technics. Though complete denture prosthet-
ics, operative dentistry, fixed partial denture prosthetics and partial
denture prosthetics, are all specialties largely dealing with the rav-
ages of one disease, caries, they separated and became defined as
specialties by their dependence on distinctive technics.
Orthodontics is more like some of the specialties in medicine
than dentistry, since it is based on an underlying basic science: crani-
ofacial growth and development. It is not separated from the other
dental specialties by distinctive technics, but by the different bio-
logic, psychological, and even cultural needs of Orthodontic patients.
Orthodontics is singular among the specialties of the health profes-
sions because of four combining distinctions: its underlying science,
the face itself, a special diagnostic method based on an individual-
ized rationale, and the goals and methods of treatment peculiar to
the field.
CRANIOFACIAL GROWTH AND DEVELOPMENT
There are many definitions of growth. Some biologists define
growth as all of the expected natural changes that take place be-
tween conception and death. To others, growth is size change
alone and is carefully separated from maturation, differentiation,
and translation, all of which are considered subsets of development.
Whatever the definition, the concepts associated with the study of
craniofacial growth and development are essential to understanding
the nature of orthodontics.
On The Nature of Orthodontics
Craniofacial Growth and Development, Its Basic Importance
The growth of the craniofacial complex is important since the
head and face are the site of so many vital functions respiration,
food ingestion, speech, vision, olfaction, hearing, mastication, facial
expression, and the brain itself. While certain craniofacial func-
tions are in place in the neonate-breathing, suckling, infant cry,
vision, hearing, smell, etc.—their natural maturation and all other
orofacial behavioral development is dependent on normal cranio-
facial growth. No other site in the body has such a concentration
of essential functions; therefore, several clinical fields are interested
in and contribute to craniofacial biology. None is more dependent
on the facts of craniofacial growth in practice than orthodontics,
nor has any clinical field contributed more to our current collective
knowledge of the developmental biology of this region.
Craniofacial Growth and Development, Its Relationships
With Orthodontics
Orthodontists use the accumulated knowledge of craniofacial
development within two logistic frameworks: understanding past
growth and anticipating future growth. Diagnosis studies what has
happened, but all treatments are in the future. -
Past Growth. A vast amount of data and related literature
exists describing the range, norms, and other statistics of cranio-
facial growth: biometric knowledge. Information and research has
accumulated on the origins of variability and specific malocclusions:
etiologic knowledge. Working hypotheses and theories have been
formulated on how the face develops: theoretical knowledge.
The Orthodontist, when confronting a clinical problem, com-
pares the patient to cephalometric and other standards (biometrics),
attempts to develop an etiologic history, and fits all of the features of
the patient’s morphology into a reasonable theoretical explanation
of past growth.
Future Growth. The clinician must attempt to estimate the
effects of future growth on any contemplated treatment and, ob-
versely, the effects of treatment on future growth (biometric know-
ledge). All orthodontists gain experiential knowledge, which some
of us choose to phrase as if it were theory. To “explain”, for exam-
ple, the effects of a particular appliance, is applied biometrics; i.e.,
mean responses, ranges, etc., unless one can account for individual
treatment responses in terms of meaningful differences in starting
form or condition. Experiential knowledge, at this time, is rooted
more strongly in intuition based on past treatments than in sound
theories or mathematical predictive models of future growth.
Recently, while thumbing through Strauss’ “Familiar Medical
Quotations” (Little, Brown & Co., 1968), I noticed something that
dramatized for me how very different the orthodontist’s involvement
with growth is from the physician's. To my surprise, in this book of
over 1,000 pages, there was not one single entry on “growth”. Just
preceding where growth would have appeared were twelve pages of
entries on the topic gout. Nor was there an entry on “develop-
ment”, for the editor skipped from dermatology to diabetes. A
new orthodontic text, “A Handbook of Orthodontics”, (R.E. Moy-
ers, Yearbook Medical Publishers, Chicago, 1986), in contrast, de-
votes six of eighteen chapters to growth and development. Although
it is, of course, only speculation, I would guess that if someone some
day were to compile a book on “Familiar Orthodontic Quotations”,
entries on growth and development would dominate the text, for
they are the raw material of orthodontic treatment.
Craniofacial Growth and Development, Its Complicated Biology
There are especially complicated problems in the development of
the head and face. Indeed, with the exception of the brain and cen-
tral nervous system, much of which is housed within the skull, facial
development seems more complicated than any other region. The
left and right sides must merge in early prenatal development and
function together in complicated synchrony throughout life. The
mandible, for example, has right, left and midline muscles attached
to it, the contraction of any one of which must occur in highly
coordinated concert with all others. Speech, mastication, facial ex-
pression, respiration, etc., use many of the same muscle groups and
neural pathways, so a constant determination of priority and syn-
chronization is imposed on the controlling centers in the brain. In
early embryogenesis, the primary facial processes must form and
fuse precisely within a critical time period of several hours or gross
craniofacial anomalies such as cleft palate will result. Bones are
On The Nature of Orthodontics
growing, teeth are erupting, and new muscle activities are being
learned simultaneously, while the vital functions of the region carry
on. The control mechanisms for these developmental activities are
Quite different; the eruption of teeth, the growth of facial and jaw
bones, the acquisition of speech, the learning of the muscle func-
tions needed for mastication and facial expression all occur on dif-
ferent schedules. These complicated and multiple developmental
processes are the source of much variability in skull morphology,
facial appearance, and malocclusion.
THE ROLE OF THE FACE IN SOCIAL INTERACTIONS
The face, each person's most distinguishing feature, plays a
unique role in all social interactions and in the establishment of self
image. It is the face that is photographed, it is facial features that
we remember or describe, it is the face we use to express ourselves
to others, and it is the face that most reveals all of our emotions. No
other part of the body laughs, cries, sings, speaks, sneers, or flirts.
It is no wonder that we often judge others and ourselves by facial
appearances or that we wish to improve undesirable facial features.
Variations in facial features and perceptions of such variations are
two of the reasons people seek Orthodontic treatment.
ORTHODONTIC DIAGNOSIS
The many problems, structural, functional, perceptual, etc., as-
sociated with variability in craniofacial growth and morphology are
the basis for the field of orthodontics. Variability itself is expected
in all aspects of developmental biology, but it must be dealt with dif-
ferently in orthodontics. In many diagnoses, it is sufficient to think
simply in terms of abnormal versus normal; a lesion, for example,
dental caries, is or is not present. In craniofacial development, how-
ever, variabilities become clinically important at different levels of
deviation from the norm depending upon the age, sex, self-image,
socioeconomic status, and even the cultural background of the pa-
tient and family. This fact requires a different diagnostic approach
by the orthodontist than is usual in medicine and dentistry, for facial
esthetics, self-image, and attitudes based on culture have nothing to
do with the science of craniofacial biology.
4
Diagnosis, strictly defined, is the determination of the presence
or absence of abnormality. Such a definition presumes a knowledge
of the normal. To the orthodontist that means normal craniofacial
growth and morphology, but to the patient it may mean “normal”
facial attractiveness. Diagnosis is the basis for determining clinical
action, usually in the face of incomplete evidence since one can never
know everything about the patient. Orthodontic diagnosis always
involves comparisons to population standards, to ideals and/or to
the clinician's past experience. Combined they comprise the basis
for what is sometimes called “clinical judgment”, but judging the
patient’s perceptions and self-image is a special problem.
Medical Versus Orthodontic Diagnoses
Much medical diagnosis depends on Koch’s postulates which
underlie the theory of disease. Such traditional medical thinking
tends to lead to all-or-none decisions in diagnosis. On the other
hand, the continuum that constitutes craniofacial variability usually
makes either/or orthodontic diagnoses impossible. Cleft palate, like
caries or a pericoronal abscess, is either present or absent, but such
common malocclusions as deep bite, Class II, or Class III constitute a
wide range of variabilities. However quantified, most malocclusions
have different effects in different heads and faces and are perceived
quite differently by different people. The least bit of incisal crowding
sends some to the Orthodontist, yet it remains unnoticed by others.
Many orthodontic diagnoses are first begun by someone other
than the orthodontist: e.g., the patient, the patient's family, or the
family dentist. If the malocclusion doesn’t concern someone else
first, the orthodontist may not see it, and the diagnosis that might
have been made is moot and of little import. The identification
of malocclusion by a dentist is buffered by patients’ perceptions
of their face and how important the malocclusion is to their well-
being. No malocclusions are life threatening, and only a few are
physically disabling. Some do interfere with oral functions or oral
hygiene and thus impair mastication or speech or contribute to caries
and periodontal disease, and some malocclusions do impede social
acceptance. The treatment, which follows the diagnosis, is begun
not because of the classifying term applied to the malocclusion, but
because of how the patient feels the malocclusion affects his/her
well-being. The diagnosis and decision about treatment are not
On The Nature of Orthodontics
made by the doctor alone but by the patient and the doctor. Surely
no pathologist diagnoses cancer by whether or not the patient thinks
they have a cancer or how much they might be bothered by it!
All orthodontic diagnoses contain an element of prediction. The
Orthodontist analyzing craniofacial morphology must decide not
simply whether malocclusion is or is not present, but whether any
presently observed variation in morphology may develop into fu-
ture problems. Since malocclusions are rarely spontaneously self-
corrective, their early signs and symptoms, though subtle, are very
important, and become more evident with further growth. The di-
agnosis must also localize the site of the variability, and the clinician
must then determine whether or not the problem can be altered by
controlling growth or must be camouflaged by tooth movements.
Determining deviations from the normal, predicting the future de-
velopment, and planning treatment all must be based on knowledge
of craniofacial growth and variability and the potential for their
alteration.
TREATMENT
A number of verbs are commonly used to describe how doctors
deal with their patients’ problems: cure, heal, apply first aid, treat,
etc. In the usual connotations, these may mean to abolish the acute
stages of a disease or condition, to control the ravages of a disease,
or to assist the body's natural mechanisms of defense and repair.
But malocclusion has no inflammatory disease processes associated
with it; no unwanted infectious organisms are present as etiologic
factors; the immune system does not respond; leucocytes are not
marshalled into action. In fact, the body doesn’t systematically
recognize the presence of malocclusion. Orthodontists do not cure
disease as do physicians, nor deal with inflammation as do peri-
odontists, nor replace the irreversible destructions of disease as do
restorative dentists. Orthodontic therapy is not treatment in these
traditional senses, since orthodontists do not “heal” malocclusions.
What then do orthodontists do when they “treat” a malocclusion?
They deal with facial growth and form and their undesirable effects
on oral function and facial esthetics.
Misconceptions About Orthodontic Treatment
Dentists know that to treat may mean simply to deal with, and
it is thus proper to speak of treating rather than curing a malocclu-
sion; however, they may fail to appreciate the semantic difficulties
which arise because of patients' naivete about Orthodontics. Pa-
tients may assume that the Orthodontist uses his special techniques
to “fix” the malocclusion much as the family dentist replaces lost
tooth substance with an inlay or bridge.
General dentists, who have received several times as many lec-
tures in pathology, microbiology, therapeutics, and pharmacology
as in facial growth and whose clinical training was predominantly in
restorative and prosthetic dentistry, have been led by their instruc-
tion to an either/or approach to diagnosis and a “which technique
shall I use?” attitude about treatment planning. These ingrained
viewpoints leave them ill-prepared to cope with the variabilities, va-
garies, and changes in craniofacial growth when confronting a mal-
occlusion in a child entering pubescence. The point of view of most
recent dental graduates also leaves them especially vulnerable to
the enticing inducements of the advertising brochures, which clut-
ter every dentist’s daily mail, that promise so much from weekend
courses in orthodontics. Why shouldn’t the young dentist believe
that the solution to the problem of malocclusion is nothing more
than learning a new technic—wasn’t most of the time in dental
school spent learning technics? And didn’t much of that dreadful
undergraduate orthodontic course consist of wire bending? Gen-
eral dentists with a sincere interest in orthodontics can be forgiven
basic misconceptions about Orthodontic treatment that are but log-
ical inferences from a dental curriculum whose biologic courses are
slanted towards pathology and whose clinical practice instruction
overwhelmingly concentrates on restorative and prosthetic proce-
dures. Ironically, an important part of modern graduate residency
training in orthodontics is necessarily planned to undo attitudes in-
stilled in dental school, for the average undergraduate curriculum
prepares the dental graduate neither to understand the logic and
rationale of orthodontic treatment, nor to practice it satisfactorily.
On The Nature of Orthodontics
Characteristics of Orthodontic Treatment
Most Orthodontic treatments fall into one of two categories:
(1) control or modification of some aspect of growth or (2) move-
ment of parts to mask undesirable facial features. Altering growth
is only feasible while growth is sufficiently active to allow signifi-
cant improvement. Guiding occlusal development and the use of
extraoral traction and functional appliances are standard practice
examples of controlling or modifying growth. Such methods are the
basis for early treatment of malocclusion—eruption is controlled,
muscles are trained, and bone growth is modified. If treatment is
sought too late to utilize such procedures, then bracketed appliances
are used to produce tooth movements to obviate the unwanted as-
pects of the malocclusion. In gross dysmorphogenesis, the surgeon
repositions bony parts in conjunction with the Orthodontist’s move-
ment of teeth. In either of the two treatment categories, i.e., early
or late, the clinician’s work is based on quantified plans derived from
cephalometric evaluation of the morphology and growth of the facial
skeleton.
Usually the patient plays a passive role in treatment, depending
primarily on the skills of the doctor or therapist or the efficacy of
a drug; not so in orthodontics. Orthodontic treatments are more
like those of physical and rehabilitative medicine or speech therapy,
comprising repeated patient-doctor interactions, and the patient’s
interest and persistence are strong factors in success. The orthodon-
tist who is a master of appliance technics but who is unable to inspire
patient motivation will have difficulty reaching the best treatment
goals.
Though many treatments focus precisely (e.g., on a tumor, frac-
ture, lost tooth, or single dysfunction), there is much talk these days
about “holistic” medicine and dentistry. Orthodontics has always
involved treating the entire person from digestive function to self-
image. Orthodontists may persist in defining treatment goals in
terms of millimeters of overjet or degrees of some cephalometric an-
gle, but parents bring their children saying, “Johnny doesn’t want
to go to school because the kids tease him about his buck teeth and
call him Bugs Bunny.” Patients or their parents emphasize self-
image, facial esthetics, facial and oral functions and their effects on
success and happiness in our culture. What do orthodontists treat?
The answer must be that we treat far more than is often realized,
for we deal not only with the patient’s face and occlusion, but with
their psyche, ambitions, social life—their total well-being.
Psychological Aspects of Orthodontic Treatment
There are many interesting implications and sequelae to the psy-
chological aspects of orthodontic therapy. While the orthodontist
is busy torquing incisors, establishing molar occlusion, improving
facial skeletal relationships, and judging success in the alteration
of such features, the young adolescent studies that same face in the
mirror each day asking the age-old questions, “Am I pretty?”, “Will
others like me better when treatment is over?”, and “How much time
and effort should one invest in one's face?” Adult patients are no
different, but the questions may also relate to success in business or
social image in a broader context. If the patient is happy with the
resultant treatment and other aspects of life thrive, the Orthodon-
tist often is credited with far more than the simple plan of tooth
movements undertaken in the first place. Every orthodontist enjoys
invitations to high school graduations and weddings, for they are
the natural result of the friendships established during a prolonged
period, the many conversations, questions, teasings, and shared mo-
ments together. A special intimacy arises between orthodontist and
patient, and surprisingly confidential questions are asked. The or-
thodontist may become a surrogate parent, confidant, or close friend
whose opinion or reaction can safely be sought since, unlike parents,
teachers, counselors, or psychiatrists, the orthodontist is in no po-
sition to use the shared information in any other way than as a
trusted listener. During one clinic session, which occurred just be-
fore these words were written, I was asked by a mother to discourage
her sixteen-year-old daughter’s recently acquired smoking habit; a
young male patient wondered if his appliances could be removed for
a “special date” on the following weekend; a 45-year-old man asked
the same question, but he wished to have them removed for only
three days during a trip to interview for a new job; a woman con-
fided that she had just become pregnant; a college student assured
me her new boyfriend didn’t mind her appliances and might begin
orthodontic treatment himself. That same afternoon at my prac-
tice, a 12-year-old son of an engineer observed how much technical
knowledge was involved in orthodontics and asked how many years
On The Nature of Orthodontics
of college were required to become an Orthodontist; the next patient,
a senior in high School, announced she was planning to become an
orthodontist after she finished a college degree in mathematics.
I do not suggest that Orthodontists should become amateur psy-
chologists or that courses in counseling be added to our training,
but I do insist that orthodontic “treatment” involves far more than
moving teeth and that our efforts have wide-ranging effects on our
patients’ lives.
How Orthodontic Appliances Work
There is a general belief among orthodontists that we know
exactly how orthodontic appliances work and that successful or-
thodontists routinely use such knowledge in practice. In the real
and practical sense, this simply is not true, for if it were, the know-
ledge could be taught more easily, unexpected difficulties in treat-
ment would not be encountered, and relapse would be infrequent.
Furthermore, there would have evolved a more universal agreement
about treatment methods and goals. The many diverse opinions
held by clinicians are testimony to our ignorance on this fundamen-
tal point. Differences of opinion cause more trouble than differences
of fact. If we knew the facts well, there would be more general agree-
ment about treatment, and treatment methods could be taught and
learned more easily.
Let us pursue this point by developing a simple statement: a
malocclusion to which treatment is applied should yield “success”;
that is, a known malocclusion plus a specific treatment should make
it possible for us to quantify “success”. However, the same kind of
malocclusion treated four different ways might yield success ratios
varying from unknown or questionable to success most of the time.
The complications become more apparent when considering the ef-
fects of three different appliances, e.g., hi-pull headgear, Activator,
and fully bracketed edgewise, on three different types of Class II.
One must assume that each appliance is used in a known, controlled
way each time, that the malocclusions in each category are approx-
imately alike, and that “successful” treatment can be represented
numerically in a manner agreeable and reproducible. Such impor-
tant matters as patient cooperation, sex, age, etc. are not included
in this simple outline, yet the analytical difficulties are obvious.
10
Clinical research in medicine is improving remarkably using
those concepts in quite sophisticated ways, but the methods of clin-
ical epidemiology have just begun to be considered by clinical re-
searchers in Orthodontics; hence the statement, “We don’t really
know in a practical way how orthodontic appliances work.”
As asserted earlier, many clinical fields in the health sciences
have a related basic science. Clinical practice is what we do; the as-
sociated basic science is what we study. The clinical field does not
necessarily relate totally to the associated basic science; nor does it
necessarily follow that study in the theoretical field has an immedi-
ate and direct application in practice. There are many interesting
examples of paradoxical relationships between what we do and what
we study or talk about. For example, aesthetics and painting: ex-
perts who study aesthetics are not necessarily good painters, and
good painters may know nothing about aesthetics, yet a relation-
ship exists between aesthetics and painting. Philosophers of science
are rarely scientists, and while many laboratory or clinical scientists
are avid readers in the philosophy of Science, only rarely is a scien-
tist also a philosopher. The exceptions are particularly noteworthy:
Huxley, Waddington, DuBos, Lord Kelvin, et al. The study of crani-
ofacial growth and morphology has interested Scientists from many
disciplines anatomy, embryology, anthropology, physiology, math-
ematical biology, biochemistry, etc.—as well as clinicians from or-
thodontics, Orthognathic and plastic Surgery, speech pathology, etc.
The basic scientist may study the field for its intellectual interest
alone; however, the clinician who studies craniofacial growth does
so not only for the intellectual excitement of the field, but also for
the hope of application. Craniofacial growth is the theory we study;
orthodontics is the practice.
The reader interested in learning more about the state of the art of clinical
research in orthodontics is referred to “Science and Clinical Judgment in
Orthodontics’. P. Vig, F.L. Bookstein and K.A. Ribbens, Eds., Monograph
18, Craniofacial Growth Monograph Series, Center for Human Growth and
Development, The University of Michigan, Ann Arbor, 1986.
11
On The Nature of Orthodontics
Research and Orthodontic Treatments
When one considers the hundreds of scientists and graduate stu-
dents intently involved in research on craniofacial growth, the mil-
lions of dollars expended to support them, and the obvious need for
information about facial growth and morphology, it may seem sur-
prising that all this effort and money has changed so little the prac-
tice of orthodontics. Are Orthodontic clinicians like clever painters
who work intuitively with little interest in the theory of aesthetics,
while scholars of beauty look over their shoulders and comment on
the painters’ efforts, but have little influence on their work? Or
are orthodontists who are also research scientists actually making
progress in bridging the gaps between theory and practice? A good
case can be made to show that research in certain areas, e.g., biome-
chanics and periodontal physiology, have brought significant changes
in Orthodontic practice. But it can also be argued that many clini-
cians have been slow to apply the significant advances in our under-
standing of how craniofacial growth and morphology can be modi-
fied. The reasons for these delays in application of research findings
are important and must be examined.
Sometimes in medicine the choice of treatments among several
alternatives involves no variation in technical skills—one drug is as
easy to administer as another. In internal medicine the best physi-
cians are all great diagnosticians, but surgery is dependent on both
diagnostic acumen and technical dexterity. Orthodontics is similar
to surgery since successful treatment depends as much on diagno-
sis as on technique. Therefore, it is easier to apply research find-
ings in some fields than others. No new skill is needed to provide
some new treatments, but some new knowledge defines treatment
strategies and tactics that we do not have and must develop. For
example, craniofacial growth research shows quite clearly the gains
to be had if we could modify facial growth in very young children,
as has been done in animals, but to apply such laboratory findings
involves the development of new modes and methods of treatment,
a far more complex task than simply administering a new drug.
Research findings sometimes threaten clinicians who are enamored
with and dependent on old familiar technics. It is taking time for
Some surgeons to abandon open knee surgery though the clear ad-
vantages of arthroscopic procedures for many problems have been
12
well established. And some orthodontists still treat most malocclu-
sions with full-banded appliances in the permanent dentition when
the benefits of facial Orthopedic therapy in the mixed dentition are
thoroughly documented.
Orthodontics, among the dental specialties, had a singular ori-
gin, for it deals neither with disease or trauma and was not created
because of the development of special and complicated techniques.
Its history is inextricably interwoven with human developmental
biology. Orthodontic treatments are not cures or restorations, for
there are no drugs and the raw material which we fashion is not gold
or plastic, but growing tissues which we change forever. Orthodon-
tics is a kind of biological sculpture, but the results of Orthodontic
treatment show as much in the patient’s self-image as in improved
oral function and facial aesthetics.
The past has shown orthodontic progress to have been heavily
dependent on research, and it would seem likely that future or-
thodontic progress may proceed in a similar fashion since we have
much to learn about facial development, its clinical alteration, and
more efficient ways to extend quality orthodontic service to all who
need it.
13
“GOOD" ORTHODONTICS
The term good has as many meanings as the word is: it is
used to describe substances, e.g., divinity and intelligence
are good; qualities, e.g., the virtues are good; quantities,
e.g., the proper amount is good; relatedness, e.g., the useful
is good; time, e.g., the right moment is good; place, e.g., a
place to live is good; and so forth. It is clear, therefore, that
the good cannot be something universal, common to all
cases, and single; for if it were, it would not be applicable
in all categories, but only in one.
Aristotle, Nicomachean Ethics, 1.6
Most orthodontic papers are based on some kind of facts, clinical or
scientific, related to the field of orthodontics. This paper is based
on facts too, but some of the facts come from outside of our field.
It is also based on one orthodontist’s interpretation of current so-
cial trends, changing lay attitudes, altering relationships within the
branches of dentistry and new pressures on the speciality of or-
thodontics. It is not a paper to describe how a given case might
be treated; it is not an attempt to sell or promote any ideas about
treatment; it is not an exhortation to action. Rather, it is a look
at the speciality of orthodontics in the later part of the twentieth
century: a look illuminated by four questions.
—Who has an interest in good orthodontics?
—Where do they get their ideas about good orthodontics?
—What is good orthodontics?
—Who determines good orthodontics?
WHO HAS AN INTEREST IN GOOD ORTHODONTICS2
Orthodontists
Orthodontists have an interest in good orthodontics, not only
because of our ethical responsibilities to patients, but because we
are the only ones dedicating our lives to orthodontics and risking our
total professional reputation on the quality of orthodontic services
provided.
15
Good Orthodontics
The Patient
The patient’s point of view about good orthodontics is relatively
simple: good orthodontics is orthodontics that produces the desired
result at the lowest possible cost in the least amount of time. How-
ever, the patient’s desired result may be an impossible fantasy and
quite a different thing than the orthodontist has in mind. No pa-
tient has ever come to me and said, “Dr. Moyers, please move the
maxillary first permanent molar distally until the mesio-buccal cusp
occludes correctly with the buccal groove of the mandibular first
permanent molar.” Patients have an interest in good Orthodontics
because treatment involves their mouths and their faces, but their
definition of good orthodontics may be quite different than that of
the orthodontist; it is usually based on esthetics and self-image, cost,
and time and not on occlusal relationships or cephalometric values.
Other Dentists
Other dentists have an interest in good orthodontics because we
all belong to the same profession and good or bad results reflect di-
rectly or indirectly on all. Further, dentists refer their patients to us
and expect the best of services. In recent years, some general prac-
titioners and pedodontists have been treating many more Orthodon-
tic patients than previously. Surely they have the same professional
ethical interest in “good orthodontics” for their patients as does the
orthodontist. The periodontist, oral surgeon, and restorative dentist
who join with us in collaborative treatment have a special interest
in the quality of the orthodontic part of the cooperative effort.
The Public
The public has had no point of view at all in the past, because
the public is only a convenient symbol invoked by speakers who
wants us to believe that they know what the public wants and are
about to let us in on the secret. Recent governmental action remov-
ing restraints on advertising by professions has resulted in a glut
of television commercials and newspaper advertisements hawking
legal services, medical laboratory tests, and orthodontic treatment
interspersed with the usual extravagant claims for dog food, deodor-
ants, and automobiles. It is too soon to discern the effects of this
16
daily source of “information” on the public's point of view of or-
thodontics, but I have never heard anyone claim that commercial
advertising was the best way to educate all in a fair, dispassionate
IIla, Ill]6. I’.
There is no public as an entity with a coherent single point of
view about anything, let alone a single spokesperson. There are,
however, a number of publics with points of view that often conflict
dramatically. Good orthodontics for the rich is one thing, for the
poor quite another. The kind of good Orthodontics migrant workers
in Michigan's cherry country seek for their children may be quite
different from that sought by parents in a wealthy Detroit suburb.
The labor union and the employer providing health benefits for
workers may have different concepts from each other about good
orthodontics. When they speak of “cost containment”, the words
are understood by all. But unions, employers, and insurance com-
panies may embody in the phrase “quality control” quite different
concepts of good orthodontics than does the orthodontist, the fam-
ily dentist, or the patient. To date, third party administrators and
those who fund orthodontic care have shown proper interest in the
cost of services, but they must soon face the issue of quality con-
trol. It is a very difficult and important matter logistically, legally,
and professionally. There will always be someone or some way to
contain costs, but it must not be at the cost of poor orthodontics
for employees or their children. Employers, unions, and insurance
companies have as much at stake in quality control as the dental
profession, but quality of orthodontic treatment is difficult to define
and quantify. On this point they need help, for there is no sure
procedure yet in place to guarantee the quality of the service they
buy.
So there are many publics interested in good orthodontics, some
represented better in national and state capitals than others. Those
best represented seem to be the ones politicians like to think and
talk of as “mainstream Americans”. Politicians—who always claim
to represent the public—have a point of view, too: the country needs
more service at lower cost. Therefore, their emphasis is on numbers
of practitioners and dollars. Dentists may think that quality of
orthodontic service is too technical a matter for discussion by any
of these publics, but the public discussion of good orthodontics goes
OIl.
17
Good Orthodontics
The Universities
As orthodontics exists within the profession of dentistry, so den-
tistry itself exists within the double framework of the university and
the government. Dentists are university graduates who have had to
demonstrate to the satisfaction of their professors that they have
acquired the minimum knowledge and skills regarded as requisite
for the D.D.S. degree. Universities have an interest in the quality
of service rendered by their dental school graduates. Such inter-
est should be reflected in changes in the dental school curriculum
to provide for the current greatest needs of the public which funds
the universities. If this is true, the university should also have an
interest and a responsibility in the increasing numbers of patients
receiving orthodontic service from university graduates who were
given very little orthodontic training in dental school and who have
gotten their ideas about “good orthodontics” from short courses
taught outside the university by dentists who are neither professors
nor orthodontists.
The Government
Behind the university is the government, for without federal and
state support for dental education, research and facilities, the profes-
sion would collapse quickly. On the one hand, government support
maintains things as they are, assuring a continuing flow of dentists
emerging as replicas of their instructors. On the other hand, federal
support of research and surveillance of dental school expenditures
tend to emphasize change and improved dentistry. Despite tension
between attempts to maintain the status quo and forces of change in
practice, a balance existed for some time. Within the last decade,
however, government interpretation of antitrust concepts combined
with a strong national interest in “consumerism” has changed radi-
cally the orderly progress of the profession and the way services are
delivered to the public.
The government that once felt it was in the public’s interest
to license professionals and charge them with regulating themselves
has decided it was all a mistake. Both government action and public
attitudes have blurred the distinction between the professions and
business enterprises. Surely the health professions must have higher
ethical standards and nobler and more stringent obligations to serve
18
the public’s need. But these standards and obligations have been
eroded, first by government actions and public acquiescence and
then by some in the profession.
Once professional ethics, the basis of quality control, was con-
trolled by the profession. When the government equated profes-
sions with businesses, it altered the character of professions and
diminished their ability to discipline their members. The new in-
terpretation of the concept of “restraint of trade” resulted in more
varied ways of delivering dental services but with less protection
of the public. Federal governmental intrusion greatly reduced local
quality control by the profession and did not replace it. It may be-
come necessary for insurance companies, unions, and employees to
guarantee the quality of orthodontics. With so much orthodontic
treatment being provided by dentists who are not qualified to be-
long to the American Association of Orthodontists, that association
has no power to control quality. The American Dental Association
and state boards of dentistry are dominated by general dentists who
profit from this state of affairs and thus have no inclination to in-
terfere. Third party payment plans are usually required to pay the
same fee irrespective of the quality of service. Safety of the seas is
not guaranteed by international treaties made by governments, it is
assured by Lloyds of London and other maritime insurance compa-
nies who simply will not cover unfit vessels. Perhaps the day is near
when health insurers, in order to protect the employees whom they
cover, must devise a plan to guarantee quality Orthodontics.
The public cannot have it both ways. If they are to be protected
and quality of services assured, someone must be responsible. Some-
body must be in control. If not insurance companies, is it to be a
government agency, court interpretations, Ralph Nader, the forces
of the market place, or the professions? It seems obvious that the
factors which determine cost of health services are not necessarily
the factors which regulate quality and protect the public.
There are many significant after-effects of this change in the
government’s attitude towards the professions: display, radio, and
television advertising by dentists; a rash of malpractice suits; fran-
chised dental clinics; difficulties in peer review; and, perhaps most
important of all, dramatic decreases in the number of applicants
to medical and dental schools. In the past there were many good
reasons for a young person to become a physician or dentist, in-
cluding the satisfaction that comes from providing a needed service,
19
Good Orthodontics
social respect and status, and a better than average income. Some
of these reasons seem no longer to exist, for the high quality young
people most often attracted to the professions in the past seem less
interested in them now.
All of these problems involve politics, not only the kind that is
endemic in Washington regardless of who is in office, but the politics
of dental schools and our profession as well. The point here is that
government, through its selection of what to support in universities,
whom to license and with its concept of a profession, becomes a
part of the dental profession. To deduce perspective from behavior,
the government’s point of view about good orthodontics is, at best,
Schizophrenic.
So, ºthere are many points of view about good orthodontics,
because many have an interest or claim to have an interest in the
treatment of malocclusion. Before we can decide about what consti-
tutes good orthodontics, and thus determine the merits of differing
points of view, it may be useful to probe further into the sources of
the concepts of good orthodontics held by each of these groups—
the orthodontist, the patient, other dentists, the public, universities,
and the government.
WHERE DO THEY GET THEIR IDEAS
ABOUT GOOD ORTHODONTICS2
Orthodontists
We got most of our basic concepts about good orthodontics
during graduate training, later adding ideas gained from journals
and orthodontic meetings. The American Board of Orthodontics
has assumed a special role in the maintenance of quality, but when
we “put the plaster on the table” before them for their judgment
of our abilities, we are aware that there are many aspects of good
orthodontics that cannot be tested under the circumstances of the
Board examination.
How does an Orthodontist determine whether an orthodontist
is good or not?—by his/her training, university, mentor, the ap-
pliances used, Sub-Society or orthodontic sect, income, appearance,
personality, etc.? A good test comes when we must choose an or-
thodontist for a transfer case. At that time we often rely on the
20
factors listed, but there are other goodnesses about which we would
like to know, and there is difficulty in learning about these.
The Patient
In the past, before the advent of dental advertising, patients’
knowledge of orthodontics was often trivial, consisting of impres-
sions gained from other lay persons about such factors as the fees,
length of treatment time, discomfort, etc. Even our most satisfied
patients usually judge us by a completely different set of facts than
fellow orthodontists would use—the patient has little knowledge
about good Orthodontics, only hearsay.
Other Dentists
General Dentists. I invited a small group of general dentists to
a discussion of “What is good orthodontics?” The group included
Several whose general practices consist of a high percentage of or-
thodontic patients. I do not suggest that the group is representative;
they were chosen because they were individuals I knew would talk
freely. They were not told why I sought the information nor how I
would use it, though I promised not to reveal their names.
In answer to the question, “What are some of the problems
of good orthodontics?” they agreed that getting the orthodontist
to undertake early treatment was a major problem and that the
more severe the malocclusion, the more difficult it was to get early
treatment. Also mentioned were adult cases involving periodontal
therapy and restorative dentistry combined with orthodontics. One
dentist said it was apparent to him that none of the orthodontists
he knew had had any formal training in adult orthodontics. They
also said that selecting the cases they could treat themselves had
been a problem before they took courses from Dr. X.
The question, “How do you expect a case to look after treatment
by an orthodontist?” elicited explicit details of occlusion, parallelism
of roots, absence of temporomandibular disturbance, etc. But the
next question, “Can you do this well on all the cases you treat
yourself?” produced a different set of responses. Rationalizations
were made about their poor undergraduate training in Orthodontics,
the fact that they used “functional appliances” and did not extract,
which somehow absolved them of the criticisms they had earlier
made of “regular orthodontists” using fixed appliances. Their lower
21
Good Orthodontics
fees also excused them, they felt, from the necessity to reach such
standards.
It seemed clear, in that Small group at least, that “good or-
thodontics” by the general dentist was judged by a different standard
than “good orthodontics” delivered by the orthodontist.
The Pedodontist. A similar meeting was held with a small group
of pedodontists after I had addressed a pedodontic society. They
too emphasized the need for early treatment, treatment without
extraction, service to all patients, and the need for more Orthodontic
training for pedodontists. Their attitude almost seemed to revolve
around the idea that Orthodontics was a sub-speciality of Dentistry
for Children which existed to provide treatment of difficult cases for
which they, unfortunately, had received no training. When I made
such a comment to them, they said I was too cynical, but inquiry
about the precise extent of their formal orthodontic training quickly
revealed that no one in the group felt he had received adequate
training in Orthodontics. However, only one person conceded he felt
himself unqualified to attempt treatment of all malocclusions which
came his way.
Pedodontists’ and family dentists’ concepts of good orthodon-
tics are different than the orthodontist and neither group is inclined
these days to accept automatically the orthodontist’s views. Both
the family dentist and pedodontist seem to have derived their work-
ing ideas of good orthodontics less from their formal training than
from the exigencies of practice and proprietary short courses mostly
taught by dentists who are not orthodontists.
The Public
In this context, the public is little different than the individual
patient, since the public has little real knowledge about orthodon-
tics, a fact which does not trouble them until a malocclusion appears
in the family. There are few studies to show why the public seeks or-
thodontic treatment. Do they seek what we want to deliver? Should
we give them what they want, or should we insist on providing what
we think is best for them? These are not easy questions, and any
answers that dentists alone provide are suspect. We must remem-
ber that our knowledge about malocclusion and its treatment is a
mixture of scientific facts, clinical assumptions, and opinion. But
22
the answers to these questions are likely to revolve as much around
the public's concept of good orthodontics as around ours.
The Universities
The dental faculties’ ideas about orthodontics are derived from
their own training, or lack of training, in orthodontics, plus their
interactions with their colleagues in orthodontics. The importance
dental faculties place on the treatment of malocclusion or the role
of orthodontics in the dental profession is easily gauged by study of
undergraduate curricula. In the average dental school, the great pre-
ponderance of students’ time is spent in learning technical details of
restorative dentistry, the repair of the ravages of caries. This is true
even in dental schools in cities where the communal water supply has
been fluoridated for forty years as it has been in Ann Arbor, Michi-
gan. Periodontists have been more successful in expanding their
subject in the undergraduate clinical curriculum, but periodontics
can be taught well in less time. The intransigence of the faculty
to accept any reduction in the teaching time assigned to restorative
dentistry does not leave enough time to teach well the details of
facial growth, the complications of Orthodontic techniques, and the
duration of treatment, all of which are overwhelmingly important
factors in teaching good orthodontics to the undergraduate student.
Trying to teach quality undergraduate orthodontics in an unfriendly
environment and with limited time is a task few orthodontic teachers
relish. .
Most dentists still practice in isolated individual offices or in
small groups. After dental school there are no rigorous universal
requirements or means to force us to reevaluate our own treatment
standards or concepts of good orthodontics and compare them to
new ideas or faddish concepts being presented. In recent years,
dentists have gotten more and more new knowledge from short
courses. Each mail brings me promotional brochures promising glo-
rious changes in my practice if I would but spend two days listening
to Dr. X. In the past, the itinerant medicine man went from town
to town in a horse-drawn wagon selling nostrums and magic cures.
His modern counterpart flies on the weekends to airport motels to
peddle his wares. His short course topics are not necessarily what
is needed but what will gain a crowd, for he wishes to be paid for
his trouble. Such short courses provide a quick way for new ideas to
23
Good Orthodontics
be transmitted and they make up for certain shortcomings of dental
training and dental society meetings. University sponsored short
courses may be better suited to advancing the common cause of
good Orthodontics, but, unfortunately, most continuing education
departments also must turn a profit, a fact which determines too
the choice of short course topics. Courses on the construction and
manipulation of appliances always draw more registrants than those
on growth and development or diagnosis, though the latter are as
necessary and practical.
Large numbers of dentists who are not orthodontists have in re-
cent years increased significantly the number of malocclusions they
treat. Most of their training has come from short, very short, tech-
nical courses taught by enthusiastic dedicated dentists who also are
not orthodontists. No short course can include the treatment of or-
thodontic patients. Emphasis is placed on “functional appliances”
which are promoted as European, new, and completely outside the
realm of the organized orthodontic speciality. As one who has taught
functional appliances at both the graduate and undergraduate level
for more than thirty years, I take particular resentment in such false
promotion. An unfortunate result of this new teaching is the arrival
of new one-appliance sects. Often the members of these appliance-
oriented groups equate good Orthodontics more with what their ap-
pliance is alleged to do than with the needs of the individual patient
or the community at large.
Dentistry, like a river, rises no higher than its source—the dental
School. Until Orthodontics has an accepted, appreciated, and proper
role in undergraduate dental education, the conflicts among the dif-
ferent branches of dentistry about good orthodontics will continue,
and it will continue to be difficult to maintain orthodontic ideals in
dental schools and the profession.
The Government
Ultimately, it may be the government that determines what is
or is not possible, not only because the government allocates or does
not allocate much of the money for dental education, but also be-
cause it puts strings on the money it provides. A few years ago our
dental schools were in disrepair and there was said to be a paucity of
dentists. The government responded by funding many new dental
school buildings and insisting on increased enrollments. Medicine
24
was wiser, for though it readily accepted the government’s largesse,
enrollments in medical schools were more controlled. Now there is
a surfeit of dentists and many have difficulty meeting payments on
equipment and student loans, let alone achieving the standard of
living they had planned. (The government has responded in typi-
cal fashion by curtailing funds to dental schools and necessitating
severe reductions in enrollment.) The new graduates, young people
with ethical standards as high as those of any other professionals,
are particularly vulnerable to the suggestion that the inclusion of
orthodontic treatment in their practices will solve many of their pro-
fessional and financial problems. Their inadequate undergraduate
preparation in Orthodontics is a factor in their vulnerability for it
leaves them fair game for the short course orthodontic entrepreneur,
however sincere the motives of the person offering the course. Thus,
in a strange, indirect way, even the government vis-a-vis its poli-
cies towards dental education plays a role in deciding what is good
orthodontics.
WHAT IS GOOD ORTHODONTICS2
The Aristotelian quotation which prefaces this essay makes clear
that “the good cannot be something universal”. Is there more than
one definition of good orthodontics? Do they all have validity? Do
concepts of goodness outside of dentistry affect our work, our future,
our ability to serve the public? I would like now to introduce some
other elements of goodness which are not always discussed, yet which
Seem important.
Goodness Related to Failure to Use More Than One
Available Method
Some orthodontic training programs concentrate on one spe-
cific method of using one appliance, claiming it is better to mas-
ter one approach than to be less skilled in several. The result is
that some orthodontists are well trained in one way of doing a few
things. Most orthodontic graduates are highly skilled in treating
adolescents with precision appliances but much less skilled in early
treatment of malocclusion, the treatment of adult malocclusions
combined with periodontal disease and loss of teeth, or combined
orthodontic-orthognathic surgical problems. A person so trained
25
Good Orthodontics
may have difficulty keeping up with changes in practice and the lat-
est research findings and in being flexible and adaptive in meeting
the needs of their community and the family dentists they serve. It
has been suggested that one reason family dentists and pedodon-
tists enroll in so many orthodontic short courses is their emphasis
on early treatment which is disdained by some orthodontists. Over-
emphasis on adolescent orthodontics invites other dentists to provide
the services orthodontists neglect to deliver.
Goodness Related to Narrowness of Clinical Goals
Some clinicians seek a reliable quantitative method of assessing
good clinical results; they often resort to using a few clinical cephalo-
metric measures, which can result in treating all patients to a single
goal. Morphologic variability creates malocclusion, and, therefore,
it seems naive to assume that every patient can be treated alike. I
read one time that five percent of us think, fifteen per cent think we
think, and the other eighty per cent are looking for rules so we won’t
have to think. Still, we persist inflexibly in a zeal to achieve a com-
mon ideal. The result is selection of patients which fit our concepts,
our training, our appliances, etc. There seems to be a common fail-
ure to understand sexual, racial, psychological, and cultural, as well
as morphologic differences in the needs of the individual patient.
Goodness Related to the Timing of Treatment
Most malocclusions can be recognized and diagnosed long before
the average onset of treatment. There are several reasons for this
unfortunate state of affairs. Primary or mixed dentition treatment
is more difficult to integrate into the office routine, and it is more
difficult to assess fees for this type of treatment, particularly if third-
party payment schemes are involved. Patients are often referred
well after the ideal time for beginning treatment. Many orthodon-
tists were not trained in early or diphasic treatment. Also, many
patients complain about prolonged treatment, confusing calendar
time with office time. Finally, the problem of timing of orthodon-
tic treatment is even related to our basic definition of orthodon-
tics. Recently, I saw a short course advertised on “Preorthodontic
Guidance”—as if the guidance of occlusal development was not re-
ally orthodontics but the later placement of brackets on all teeth
was. Such misconceptions about goodness related to the timing of
26
treatment are rooted in the nature of our training and our concepts
about treatment. As long as treatment is perceived as the insertion
of an appliance rather than the correction of a patient’s occlusal,
morphologic, and facial esthetic problems, such illogic will persist.
Goodness Related to One Practitioner's Responsibilities
Each dentist feels his primary obligation is to those patients
who seek his services. But what about our responsibility towards
other children in the community needful of orthodontics? Whose re-
sponsibility are they?—the dental societies, the dental schools, the
state boards, public health agencies, employers, unions, or the gov-
ernment? We dentists did not make such an assumption about the
fluoridation of communal water supplies. One of the most glorious
pages in the history of American Public Health was the energetic,
almost missionary, efforts of dentists to persuade municipal officials
to include fluoride in communal water supplies. Few professions
have demonstrated so well their sense of social responsibility. Per-
haps because there is no foreseeable easy solution to malocclusion,
we have not assumed responsibilities beyond those we hold towards
Our Own patients.
Other Goodnesses
It is easy to think of other attributes of good orthodontics, for
example, goodness related to speed of treatment. Surely, the less
time spent in treatment the better; however, we encounter the prob-
lem of how to measure time. Patients consider the calendar, but we
must consider office time.
Then there is goodness related to the amount and method of
assessing fees. Others may sell goods, equipment, or products, but
the professional person only makes available his skills and experi-
ence; therefore, our patients really buy our time. However, fees are
sometimes presented to the patient as if we were but middle-men for
the dental supply house. It may be difficult to achieve this goodness
in practice, but surely there are some methods of assessing, present-
ing, and collecting fees that are more appropriate for the professional
than others and are better from the patient’s perspective, too.
Then there is goodness related to the public’s needs. I have
alluded to this earlier, but I speak of it now in a different context.
Most orthodontists render their services on an individual basis, but
27
Good Orthodontics
we are judged collectively. It is difficult for the American Asso-
ciation of Orthodontists to speak for us all and contrive ways of
responding quickly to the public's real or imagined needs. Nei-
ther the American Association of Orthodontists nor the American
Dental Association speaks for all dentists doing orthodontics, for a
significant number of dentists are not members of either organiza-
tion. Countries adopt national health schemes on the assumption
that the public’s needs can be determined and met better by gov-
ernmental control of the profession. In my opinion, there is little
evidence that any such plan serves the public’s needs any better
than the private practice variations we have known in America in
the past. But we should ask the question, generally speaking, are
we now on a progressive or a distractive course? Nostalgia for the
traditional good old days of dental practice does not mean that we
cannot serve the public’s needs better, and surely to do so would be
good orthodontics.
WHO DETERMINES GOOD ORTHODONTICS2
Who determines good orthodontics? Specifically, the dentist
delivering the service to the individual patient. However, no one
determines good orthodontics for the profession at large, and it is
obvious from the argument thus far that many groups and social
forces interact in erratic ways to influence the quality of orthodon-
tic services available to the public today. Responsibilities for the
quality of care delivered, which the dental profession and its or-
thodontic speciality once thought were solely their own, are now as-
sumed or presumed by others. Companies that provide monies for
orthodontic treatment for their employees and their families have
an interest in the quality of those services. But good mechanisms
for monitoring those services and maintaining their quality are not
yet in place and will be difficult to institute. This is so not only
because of the different perceptions of good orthodontics by dif-
ferent groups and people, but also because of such factors as the
laws regulating dental practice, the power of state licensing bod-
ies, and the conflicts among those branches of the dental profession
which wish to treat malocclusions. Who is to tell a licensed gen-
eral practitioner that he cannot treat certain malocclusions when
he has a legal right to do so? How can a labor union insist that
28
the orthodontic services provided their members’ children be of the
highest quality? How can an insurance company be allowed to dis-
criminate against licensed dentists that do not “participate” with
the company’s programs, thus diminishing the patient’s free choice
of dentists? How can an insurance company, acting as a so-called
third party in behalf of management and employees whose dollars
they administer, refuse to reimburse a dentist for an improper or
inadequate orthodontic treatment? Such important questions point
up the complications involved in determining and guaranteeing good
orthodontics, irrespective of definition, within our rapidly changing
social structure.
Those of us in Orthodontics, and especially those in Orthodontic
education, have a singular responsibility in this regard, not only be-
cause we are the most experienced and best trained in orthodontics,
but because we teach all other dentists about orthodontics. And,
perhaps most important of all, we are the only group in Society
solely dedicated to the provision of orthodontic services. Our insis-
tence on the maintenance of the highest standards of orthodontics,
by all these definitions, is the price we pay and the obligation we
have simply because we bear the title orthodontist. Efforts on our
part to maintain or elevate standards of Orthodontic goodness may
be suspect simply because they will be seen as self-serving—and so
they may be—but such efforts also serve and protect the patient’s
needs, which are far more important.
Dentists, physicians, and other professionals are examined and
licensed by the government to protect the public and to guarantee
the quality of service provided to citizens. Orthodontists have a
special obligation in the treatment of malocclusion and facial de-
formity. The fact that government and industrial agencies have
difficulty wrestling with this problem does not absolve the dental
profession of its duty. Because orthodontists and other dentists do
not always agree is no excuse for orthodontists not doing that which
is correct.
Who determines good orthodontics? Many feel they must play
a role, but none can succeed without full knowledge of facial growth
and the logistics and economics of orthodontic services. In these
areas, our knowledge is more complete, our experience is greater and
our obligations are heavier than all others, including other dentists.
Despite the natural and proper interest of many in good or-
thodontics, the obligations involved belong more to orthodontists
29
Good Orthodontics
than anyone else. Determining and providing good Orthodontics is
a challenge we cannot ignore, a burden we cannot avoid. Such so-
cial responsibilities define the differences between a profession and
a business enterprise. The public, which created us legally, under-
wrote our education, and licensed us, has a right to hold us ac-
countable for the quality of the services it receives. And we have
the duty to insist that the dental profession provide the best possible
orthodontic service for all.
30
ON MEASUREMENT OF
FACIAL FORM AND GROWTH
SOME COMMENTS ON THE HISTORY
OF FACIAL MEASUREMEMT
Measuring the head and face was not begun, as we might suppose, by
anatomists or anthropologists but by philosophers and artists. The
Greeks wrote extensively about facial beauty, which seemed easy to
define since beauty to them was a matter of balance and proportion.
Plato devised the “golden section”, a way of subdividing an object
So that proportionally the smaller part is to the greater the same
as the greater is to the whole (Fig. 1). In perfectly beautiful faces,
according to this formula, about a third of the way along the profile
a natural division occurs. By medieval times artists, intrigued by the
number seven, felt that faces could be divided neatly into sevenths.
In Botticelli’s Venus, for example, the head occupied the top seventh
of the body, the forehead two-sevenths of the head, the nose another
two-sevenths, etc. (Fig. 2). While the Greeks felt that the width
of the face should be about two-thirds its height, a medieval rule
decreed that facial width should be twice the length of the nose.
Artists of the eighteenth century such as Sir Joshua Reynolds were
convinced that beauty was a simple matter of physical proportions.
Hogarth was a bit more sophisticated, for though he believed that
there was a simple overriding principle, he found it in “the wavy line
of beauty”, declaring that “the greatest, indeed the indispensable
element of all beautiful things is the smooth serpentine line.” Many
later artists agreed with the Greeks that the beautiful face was one
that had perfect symmetry, yet Francis Bacon found symmetric faces
boring. “There is no excellent beauty,” he declared, “which hath
not strangeness in the proportion.” Periodically, the search for the
magical proportions is revived, as evidenced by an article by an
American colleague which emphasized the “truth” of the Fibonacci
series in assessing facial beauty (Ricketts, 1957). Humans persist in
their search for a magic mathematical formula of facial beauty.
31
On Measurement of Facial Form and Growth
Figure 1. The head of Apollo.
32

\
Figure 2. Botticelli’s Venus.
33

On Measurement of Facial Form and Growth
Perhaps the first real cephalometrists were the 16th century
artists Albrecht Dürer and Leonardo da Vinci, both of whom left
sketches showing the use of planes and angles of the face to depict
not beauty but variability (Fig. 3). Indeed, Albrecht Dürer's volume
“On Measurement” is, to this day, the classic in this field.
Modern and more scientific head measurements have been at-
tempts to reduce a curious blend of morphology, beauty, and growth
to rigid numbers. With the invention of the cephalostat, longitu-
dinal studies of the same individual were possible and a more pre-
cise mathematical analysis become practicable. Prior to that time
(we are talking now of the late 1930's and early 1940's), the an-
thropologists’ calipers permitted only external measurements with
a high standard error. It is singular that both Broadbent (1931)
and Hofrath (1931) developed the cephalostat independently for the
same purpose, namely to study growth and its attendant variabili-
ties. It was fully ten years later before the first so-called cephalomet-
ric analysis appeared. Downs (1948), acting on the age-old assump-
tion of the relationship between idealism and measurements, studied
a small series of faces with “ideal occlusion” from both sexes and of
differing ages. The simplicity of this concept is the same idea that
has persisted for at least 2500 years. No statistical relationship was
demonstrated in Downs' study, nor has anyone yet proven strong
correspondence between subjective perceptions of idealized beauty
and the inexorable rigidity of quantitative measurement. One is
reminded of the words of e.e. cummings.
while you and I have lips and voices
which are for kissing and to sing with
who cares if some one-eyed son-of-a-bitch
invents an instrument to measure spring with.
We live in an age of precise measurements powerfully applied.
From studying the behavior of subatomic particles to sending astro-
nauts into space, our ability to measure, to calculate, and to inter-
pret and apply to our advantage is nothing short of miraculous. Let
us see now how we have used measurement and computational skills
to understand facial beauty, craniofacial morphology, and growth.
34
WHAT DO WE MEASURE7
Morphology
Morphology is shape and its measurement is the essence of
cephalometrics. In clinical practice we study morphology in the
single cephalogram by making size and form comparisons to appro-
priate populations and by comparing the relationships of parts of
the face.
Size Comparisons. Real size of a part is less useful than relative
size, for a harmonious face can be comprised of uniformly large or
Small bones. Although it is common practice to estimate size from
angles, linear measures are much more accurate for measurements
of size.
Form Comparisons. Traditionally, form comparisons have been
made by comparing cephalometric distances and angles to stan-
dards, but the behavior of usual cephalometric measures through
time is so varied that the results are often more confusing than re-
vealing. For example, an angle of six degrees may mean one thing
in young children and another in adults, or the same angle may
have different implications in different facial types. It is often not
realized that it is more difficult to measure facial form than it is to
measure changes in form. We tend to name shapes—brachycephalic,
mesocephalic, dolichocephalic, prognathic, and retrognathic—but
we can measure shape change. It is actually easier to describe pre-
cisely the shape (form) changes seen with growth or associated with
orthodontic treatment than it is to describe the initial form prior to
such changes, so we resort to “classes” and “facial types” to make
comparisons (Bookstein, 1982b).
Relationship of Parts. The “Counterpart Analysis” (Enlow et
al., 1969) was designed for the specific purpose of relating the sum-
mating effects of the various craniofacial components on the profile.
Growth
Growth is change; it occurs in many ways, most of which are
not easily observed in the cephalogram. These include changes in
size, shape (deformation), proportions, rate of growth, direction of
35
On Measurement of Facial Form and Growth
f
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Figure 3. A. From Albrecht Dürer's “On Measurement”.



36
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Figure 3. B. From Leonardo da Vinci's “Sketchbook”, approximately the
Same date as Dürer's “On Measurement”.
37

On Measurement of Facial Form and Growth
growth, etc. Displacement of parts, including translation and rota-
tion, is also involved in growth. Several of these growth changes are
worthy of comment.
Changes in Size. The rearrangements associated with develop-
ment are many and varied: cellular activities, translations of cells
and tissues, increases in size, etc. Of these, increase in size is the
only one that can fairly be discerned as growth from the cephalo-
gram. Measurement of growth is not as simple as it has traditionally
seemed. The choice of landmarks is critical to useful cephalometric
growth analysis; although registration and orientation are entirely
irrelevant to growth, they are not to our interpretation of growth.
Growth of the mandible is the same whether we study it registering
on condylion or gnathion, but our perception of that growth may
differ with the registration.
Changes in Shape (Deformation). Many skeletal changes ob-
served during growth and treatment, are deformations of form. Im-
portant as they are, they cannot be studied well with most current
cephalometric analyses (Moyers and Bookstein, 1979).
Direction of Change and Change in Direction. Vector changes,
particularly those resulting from orthodontic treatment, have not
been fully exploited in cephalometric analysis, although Bookstein’s
tensor methods now provide us with an elegant method (see Fig. 5;
Bookstein, 1978).
Displacement (Translation, Rotation). In cephalometric analy-
sis, displacement, i.e., movement of parts irrespective of size or shape
change, must be separated from all other changes.
Pattern (Persistence of Form Through Time). Even during pe-
riods of most active growth, certain aspects of facial form remain
relatively unchanged. We know this intuitively for persistence of
facial pattern is the basis for recognizing a person unseen for many
years. Invariance of facial shape through time is not studied as
much as growth changes, but it is just as important clinically and
conceptually. Pattern measures that do not change, i.e., craniofacial
constants, permit certain discriminating comparisons not possible
with growth measures (see Fig. 6). I shall return to this idea later.
38
1
Even casual consideration of the factors which comprise growth
changes leads one quickly to the conclusion that different methods
are needed according to what is to be studied.
PURPOSES OF CEPHALOMETRICS (Moyers, 1986)
Cephalometrics is a method for dealing with variations in crani-
ofacial morphology and growth. Its purpose is always comparison.
In practice, these comparisons are made for one of five reasons:
(1) to describe morphology or growth, (2) to diagnose anomalies,
(3) to predict growth, (4) to plan treatment, or (5) to evaluate the
results of treatment.
Description
Cephalometrics is a description, not a prescription: Cephalo-
metric description aids in the specification, localization, and un-
derstanding of abnormalities. The cephalometric description of a
patient comprises three kinds of comparisons: (1) comparison to a
standard, (2) comparison to an ideal, and (3) comparison to oneself.
Comparisons to Standards. Research populations provide ex-
tensive statistics for details of craniofacial morphology and growth.
Measures of central tendency, e.g., mean, median, mode, are often
used as norms to which an individual patient is compared; in this
sense, they present “normal” growth." But a norm is a descrip-
tive measure of a group's behavior; it is not designed as nor is it
appropriate as a goal for an individual.
Comparisons to Ideals. Like artists, certain clinicians have also
contrived ideals of facial form, but they use them to make clini-
cal comparisons. It is important to note that the patient is not a
member of the population from which either the norm or ideal was
derived. In fact, ideals are not usually derived from populations
statistically but are graphic representations of one person's sense of
facial esthetics.
It should be kept in mind that these populations usually include cases of
malocclusion.
39
On Measurement of Facial Form and Growth
Comparison to Self. Comparisons with self involve no notion
of “norm” in the sense above. A mandible, for example, is large
or small not in millimeters or when compared to a population, but
when related to its own maxilla. Comparisons to self are probably
the most practical, yet few cephalometric analyses have been specifi-
cally designed for intrasubject comparisons (Enlow et al., 1969). The
patient may also be described by self-comparisons with an earlier
cephalogram for “amount” or direction of growth.
Diagnosis
The diagnostic purpose of cephalometrics is to classify precisely,
to analyze the nature of the problem. For instance, cephalometric
diagnosis leads to assignment of facial types and classes. Since some
aspects of facial morphology are assumed to be relatively stable un-
der treatment, cephalometric diagnosis contains a strong component
of prediction.
Prediction
Description, diagnosis, and prediction are practically and con-
ceptually quite different. To make a cephalometric prediction is to
observe certain quantities, assume they will behave in determinate
ways, and extrapolate the consequences. The dangers of prediction
and extrapolations were carefully noted by Mark Twain in “The
Mississippi’’:
In the space of 176 years the lower Mississippi has short-
ened itself 242 miles. This is an average of a trifle over
one mile and a third per year. Therefore, any calm person
who is not blind or idiotic, can see that—742 years from
now the lower Mississippi will be only one mile and three
quarters long and Cairo (Illinois) and New Orleans will
have joined their streets together and be plodding com-
fortably along under a single mayor and a mutual board of
aldermen. There is something fascinating about Science.
One gets such wholesale returns of conjecture out of such
a trifling investment of fact.
The clinician would like to be able to predict future form (in-
cluding growth) in the absence of treatment, then estimate the ef-
fects of particular treatments on that prediction. Despite many
40
enthusiastic articles, certain commercial ventures, and expansive
use of the term growth prediction, we are not yet able to predict
well several aspects of craniofacial growth, e.g., changes in princi-
pal directions of growth, the precise onset of periods of accelerated
growth or its cessation. No one in all of biology has been able yet
to predict important elements of the sigmoid growth curve. There
seems to be a current tendency in orthodontics to think that a fine
idea excuses slovenly science and sloppiness in clinical application.
For now, the most practical predictive procedure involves the ex-
ploitation of “craniofacial constants” to supply predictions of shape
approximately independent of net amount of growth remaining.
Planning Treatment
Were the clinician able to describe, diagnose, and predict crani-
ofacial morphology, a clearer plan of orthodontic treatment would be
derived. All treatment occurs after the initial cephalogram in a face
that is constantly changing (and being changed). Clinicians use the
cephalogram to define expected changes due to growth and treat-
ment and to plan appropriate biomechanics. Planning Orthodontic
treatment is applied prediction.
Evaluation of Treatment Results
Successive cephalograms are used to discern the progress of
treatment and to plan any changes in treatment that may seem
necessary (Baumrind et al., 1983; Bookstein, 1983). Evaluation of
treatment results is recurrent description and diagnosis.
CEPHALOMETRIC ANALYSES
What do we do with measures? The obvious answer to this
question is “Use them!” Unfortunately, cephalometric measures are
often abused and misused quite unintentionally in practice (Moyers
and Bookstein, 1979). This is true of individual measures and of the
collections of measures that have come to be called cephalometric
analyses.
41
On Measurement of Facial Form and Growth
Definition
A cephalometric analysis is a collection of numbers intended
to compress much of the information from the cephalogram into a
usable form for treatment planning and assessment. An analysis
provides information about sizes and shapes of craniofacial com-
ponents and their relative positions and Orientations. The unit of
analysis should be the single patient over time-all cephalometric
analysis should be intrinsically longitudinal.
In practical use, a cephalometric analysis helps the clinician vis-
ualize three important aspects of craniofacial morphology: (1) what
the face is now (current morphology), (2) what it was or will be
(past growth or expected growth), and (3) what the clinician wishes
it to be (idealized or corrected morphology).
Requisites of Individual Measures in an Analysis
(Moyers et al., 1986)
Cephalometric analyses are collections of individualized mea-
Sures, norms and/or ideals that in combination provide information
needed for treatment planning and assessment. The total analysis is
dependent on the worth of the individual measures which comprise it
and on the adequacy of their combination. Here are some practical
criteria to aid in collecting measures in an analysis.
1. One should know whether the measure is a sample mean or
an esthetic objective. “Ideals” are neither “norms” nor means.
2. One should know how the value, whether mean or ideal,
changes with age, how it varies by sex or ethnic group, and how
it covaries with other measures in the analysis.
3. Measures that are esthetic objectives should be explained as
to their origin and clinical application. Ideals are contrived con-
figurations, not true values; a value that is “ideal” for one face is
quite inappropriate for another. Clinicians who prepare and ad-
vocate cephalometric ideals are trying to give us images of faces
they like, facial shapes to be achieved during treatment. Potential
users must ask how the values were determined, how they relate to
normal means, and how they vary according to sex, ethnic groups,
facial type, age, and the clinician's and patient's own sense of facial
esthetics.
42
4. When measures are derived from research populations one
should know the nature of that population and the variability of
the measure. Many measures commonly used show marked changes
in value during growth and significant differences between the sexes
and between various ethnic groups. As no patient is a member of
the sample from which a mean was obtained, the mean is useful only
if the sample that it summarizes is appropriate to the clinical com-
parison. All norms should be statistically described and identified
as to the population they sample: the method of sampling must be
specified. Furthermore, the norm is properly construed as a range,
not a single value. In clinical use, the extent of the range and its
changes with facial type and age often are of more practical interest
than the simple mean itself.
5. For any particular measure, one should know the circum-
stances under which it is systematically misleading. For instance,
anteroposterior measures of A point are consistently misleading dur-
ing the eruption of maxillary permanent incisors.
6. For any value of a measure, ideal or not, one must under-
stand the full range of configurations which have that measure. For
example, a wide variety of faces may show identical values for the
angle ANB, one of the commonest cephalometric measures, a fact
that greatly limits this measure's discriminatory use in practice.
7. Each measure should have a clearly understood subject mat-
ter, i.e., size, shape, relative position, or orientation. Some current
measures are mixed in nature, embodying both size and position.
A large SNA angle may be due to a long maxilla, a maxilla more
ventrally positioned than normal, a short anterior cranial base, or
any combination of these factors. The measure is not specific, and
the user cannot discriminate thereby.
Requisites of Cephalometric Analyses (Moyers et al., 1986)
Our literature offers many so-called “cephalometric analyses”
having several purposes and widely varying utility. Only the most
naive would assume that one analysis is as good as another or that
One “good” analysis could serve all purposes. Most are simply not
up to the tasks for which they are intended. Some of the most popu-
lar were contrived at a time when our knowledge was less secure.
Here are some practical criteria to aid in choosing and evaluating
an analysis.
43
On Measurement of Facial Form and Growth
1. An analysis should comprise a set of measures each of which
meets the requirements of individual measures listed earlier.
2. The purposes for which the analysis is intended must be
clearly stated.
3. Each measure in the analysis should have specific functions,
and there should be minimal redundancies. A parsimonious set of
proper measures is more practical than a large set of poorly selected
measures whose purposes are obscure.
4. Given the quantities of the analysis for an individual, one
should be able to reconstruct the major features of his/her crani-
ofacial form. If this is impossible with a particular analysis, then
significant parts of the facial form are unrepresented in it.
5. Faces having the same analytic values should grow in the
same way and respond to a particular treatment in a similar fashion.
If this requirement is not met, the analysis obviously is weak in its
discriminatory function.
6. Simple combinations of the variables in an analysis ought to
Segregate prognoses.
7. Treatment that purposefully alters one measure should have
predictable effects on other measures.
8. Individualized values of the analysis should correspond to
particular aspects of the treatment intervention planned, e.g., an
XYZ angle of 7% should prescribe one aspect of a consistent spe-
cific therapeutic procedure. But if an XYZ angle of 7% means one
treatment in one face, and another totally unrelated treatment in
another, then this measure by itself is useless to the clinician. To
state that an angle “must be reduced” is not a treatment prescrip-
tion since it does not tell how to reduce the angle in that particular
face.
When a patient’s measures are close to the mean, the analysis is
of lesser importance as the clinician can, with modern Orthodontic
biomechanics, easily camouflage mild skeletal dysplasia. The most
critical test of any cephalometric analysis is the detail it reveals and
the clinical insight it provides of patients who have several measures
far from their expected values. For such patients, routine treatment
obviously is inadequate. Should only the mean value be known and
no idea of variance given, the clinician cannot know how far from
the norm the patient's measures are. Those who might regard the
means as reasonable treatment goals would not do so if important
measures were known to be far from the normal value.
44
NEW CEPHALOMETRIC CONCEPTS
Conventional cephalometrics selects measures and observes what
affects them. Conventional cephalometrics chooses measures and
applies the same measures to all problems. There is, however, a new
cephalometrics (Moyers, in preparation). The new cephalometrics
begins with a specific problem and selects the most appropriate mea-
sures for its solution; it selects effects and determines what measures
them; it prompts the search for more varied and innovative methods
of measurement. The discussion here will be limited to three new
analytical concepts that deviate quite remarkably from the use of
the usual angles and distances. These are not the only new methods;
they are just three that are more familiar to me, since our group
has played a role in their origination or development.
Medial Aires or Skeletons
A psychologist, H. Blum, devised a method for the mathemati-
cal depiction of irregular figures. It is based on the construction of
points, the centers of overlapping circles whose circumferences are
equidistant from the edges of the figure to be measured. Just as one
can know the details of a circle given its center and radius, so one can
understand the details of some irregular objects knowing that the
points in sequence are equidistant from the margins (Fig. 4). If the
object branches or divides, separate series of points are constructed.
This method lay fallow for some years until Webber, working with
Blum at the National Institutes of Health, attempted to apply it
to the mandible (Webber and Blum, 1979). It turns out that the
points of bifurcation, called branches, provide natural registration
points for understanding mandibular growth changes (Bookstein,
1981). Thus far it has not been found useful elsewhere in the head.
Tensors
D’Arcy Thompson in his classic, “On Growth and Form” (1917)
Suggested that shape differences or shape change between two bio-
logic forms was an object of measurement in its own right. He sug-
gested that the geometric distortion or deformation moving one form
into the other was a better representation of the change than the
arithmetic differences of measures taken upon the separate forms.
45
On Measurement of Facial Form and Growth
Figure 4. Medial axes of the mandible (Bookstein, 1981).
Despite the dazzling inventiveness of Thompson's homologous de-
formations, more than 60 years went by before biometricians went
beyond his simple observations and formalized their specific appli-
cation. Bookstein not only was the first to mathematically formal-
ize Thompson’s concepts, but he did so using cephalometric data
(Bookstein, 1978, 1982a).
Traditional cephalometric tracings are radical abstractions of
the living head. Tissues are characterized solely by their radiopacity.
The three dimensions of the head are reduced by a standardized pro-
jection to summations of density along lines roughly perpendicular
to the midsagittal plane. Then, conventionally selected landmarks
are taken from the tracing together with bony edges to provide a
simplistic geometric representation.
In Bookstein's method, the ultimate object of study is a single
triangle comprised of cephalometric landmarks derived from many

46
successive acts of abstraction (Fig. 5). Just as for D’Arcy Thomp-
son's classic fish figures, the images of the triangle—perhaps before
and after treatment—are deformed in homologous transformation.
The interiors of these triangles are but mathematical devices to aid
in considering the changes in the configuration at the vertices. One
may construct Cartesian grids in the fashion of D’Arcy Thompson
and study the dilatations of the lines “before” and “after”. One may
avoid ratios by dilatating lines of constant length as the diameters
of a circle. Then one can read the dilatation function directly.
The dilatation is a distortion of a circle, an ellipse. An ellipse has
two axes, one the longest diameter of the form, and one the shortest.
The axes are orthogonal and are also the ellipse's axes of symmetry.
Bookstein (1981) restates these simple properties as aspects of the
shape change: “Any shape change between triangles has a direction
of greatest rate of change of length and a direction of least rate of
change of length.” These directions are at 90° both before and after
transformation. These two special dilatations are called the princi-
pal dilatations; neither usually lies parallel to any side of the starting
triangle. Thus, a principle cross for the mean shape change of that
population can be conveniently provided upon the mean starting tri-
angle. From two of the patterns of mean dilatation, it is possible to
derive a third representing differences direction by direction. Thus,
one arrives at an analysis of group means, and mean differences.
This method has been applied to the study of normal growth noting
both amount and direction of change between ages and sexes (Book-
stein, 1981). In a similar way, the effects of treatment by various
appliances have been studied (Bookstein, 1983). Thus, it is possible
to show how each appliance alters growth and how its effects differ
from the effects of other appliances.
The use of tensors emphasizes the fact that describing shape
change is a quite different problem from describing shape. The
introduction of tensors opens up new perspectives for understanding
growth and the effects of treatment on growth and morphology.
Constants
For several years the Craniofacial Group at The University of
Michigan's Center for Human Growth and Development has been
engaged in research on the cephalometric method. Some of our
studies have concentrated on craniofacial constants, i.e., measures
47
On Measurement of Facial Form and Growth
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triangles (Bookstein, 1982).

48
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Figure 5. B. Tensors depicting changes in treatment of Class II with dif-
ferent appliances. The numbers show the percent difference per annum
of each method when compared to controls—untreated Class II maloc-
clusions. The direction and amount of change of the greatest and least
differences are shown for each tensor triangle (Bookstein, 1983).


49
On Measurement of Facial Form and Growth
Me - N
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Figure 6. A. Three growth measures in the same individual.
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50

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AGE IN MONTHS
Figure 6. B. Three constants in the same individual.
of relative invariance (Moyers et al., 1979; in preparation). We be-
gan by hypothesizing that craniofacial constants had to exist since
one can recognize a face unseen for years and identify childhood
photos of friends known only as adults. The human mind has well-
developed capabilities for facial pattern recognition. Some recogniz-
able relationships persist through time despite size changes during
growth (Fig. 6). The problem for us was to identify and measure
this persistence of pattern in the face. Our research produced quite
a large number of measures that met our rigorous tests for constancy
and relative stability. By constancy we mean that a measure shows
little variation in mean values around a slope change of zero. By
relative Stability we mean that a measure maintains its relationships
with all other measures through time.
51
On Measurement of Facial Form and Growth
Diagnosis of craniofacial morphology depends on comparisons of
a patient's measures to known population values to determine the
extent and sites of abnormality. Cephalometric diagnostic measures
typically are not well characterized with respect to age differences,
and such information as we have about growth changes through time
is based usually on chronologic age and not developmental age. The
result is imprecision in clinical application. Using constants permits
better differential diagnosis by discriminating normal from abnormal
morphology independent of age (Moyers et al., 1980).
Orthodontic treatment planning always involves an element of
prediction, yet no one really does true growth predictions, since the
methods to predict the intricacies of the individual sigmoid growth
curve are not available. Until such time as mathematical models
and predictive statistical techniques have been greatly improved, it
is necessary for us, if we wish to predict, to do what we can do and
predict what we can predict. Even though we cannot yet predict fu-
ture growth accurately, we can, by the use of craniofacial constants,
predict future shape, since the behavior of constants through time is
known by definition—their change is minimal. The use of constants
in forecasting provides us with a sequence of craniofacial shapes in-
dependent of growth progressions. Thus, we are able to forecast
Some aspects of an individual’s future shape, but not how he/she
will grow to achieve that shape. William Houston made this point,
noting, “In view of the uncertainty of prediction, treatment plan-
ning should be based on facial and dental relationships that change
least with growth” (Houston, 1980).
From the hundreds of cephalometric measures studied and test-
ed on our serial data sets, a parsimonious set of the best constants
were chosen to provide a basis for a new type of a cephalometric
analysis (Moyers et al., 1986). This new analysis is modular in
form, each module comprising the smallest number of craniofacial
constants for a single purpose. There are modules for initial mor-
phologic Screening to ascertain whether or not there are any fun-
damental skeletal abnormalities, modules for specific discrimination
of Class II types, modules for the differentiation of various forms of
Class III, etc. (Fig. 7).
This research also revealed that most traditional cephalometric
measures are good measures of neither growth alone nor constancy
but are mixtures of the two, constituting a major source of diffi-
culty in cephalometric analysis and clinical application. Constants
52
BASIC
MORPHOLOG |C
ANALYS | S some skeletal 9HASS III
CLASS II Some Skeletol
Class III Signs ANALYS | S
A NALYSIS Class II Signs
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ome 3.10 S <2- º
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VERTICAL ANALYS | S
ANALYS | S OF
I MUSCULATURE
Figure 7. Flow diagram for a modular cephalometric analysis (Moyers et
al., 1986).
tend to localize in the regions of greatest craniofacial stability, while
those measures of the poorest relative stability identify clearly the
regions that are most adaptive to skeletal change and most respon-
sive to orthodontic therapy (Fig. 8). It seems clear that constants
can provide us with much information about the head and face and
can be used in a predictive way until such time as Some clever per-
son discovers how to predict accurately the intricacies of individual
growth measures.
Different problems require different measurement, and different
measures lead to different conclusions. Traditional cephalometric
procedures do not distinguish among the measures either of their ef-
ficacy in use or their validity in application. The new cephalometric
concepts are frank attempts to divest ourselves of the cumbersome
inadequacy of current methods and to seek clear and more precise
understanding of the problems which beset us. While we may aban-
don some traditional methods, there is no reason to abandon our
knowledge of growth and morphology or even our hunches or be-
liefs about how the face grows. In his poem, “The Black Cottage”,
Robert Frost deals directly with this matter of old beliefs.






53
On Measurement of Facial Form and Growth
*—
|AIEET)
|
MAX|LLARY
CORPUS
Figure 8. Diagram representing regions of greatest constancy in the face
(quadrilaterals) and greatest adaptability (areas of muscle and tooth at-
tachment, shown crosshatched; Moyers et al., in preparation).
For, dear me, why abandon a belief
Merely because it ceases to be true.
Cling to it long enough, and not a doubt
It will turn true again, for so it goes.
Most of the change we think we see in life
Is due to truth being in and out of favor.
THE FUTURE OF CEPHALOMETRIC RESEARCH
Let us begin by noting that artists, plastic Surgeons, Orthodon-
tists, and others interested in quantifying perceptions of facial beau-
ty are apt to continue doing so; it has been a pleasant diversion for
nearly 3,000 years. It is also easy to imagine in the very near future
a graphic terminal on-line in each Orthodontic office with a large
data base of treated and untreated cases to which the individual
patient’s measurements could be instantaneously compared while

54
he/she sits in the dentist's chair awaiting the next adjustment of an
appliance. Indeed, several commercial schemes have been started
based on similar plans. None have been successful, however, largely
because the expensive electronic gadgetry provided no facts that
were not already available to the clinician. One might as well do
the cephalometric analysis with a plastic protractor during the odd
moment in the office or even at home with the comfort of a glass of
beer. Only when modern computer wizardry delivers a practical an-
alytical product not otherwise available will the desktop computer
invade the clinic for routiné diagnostic purposes.
Professor Aser Rothstein (1984), a colleague at the Hospital for
Sick Children in Toronto, recently reviewed the historical develop-
ment of membrane research, which he divided into three periods:
Early Membraneology 1850–1940, Classical Membraneology, 1940–
1970, and Modern Membraneology 1970-date. The early period
was characterized by imaginative conceptual leaps, but the experi-
ments were technically simple. The transitions into each of the new
periods, however, were based on important technical rather than
conceptual breakthroughs. He concluded that after the original ba-
sic concepts were outlined, technical advances tended to precede
new conceptual advances, that new technologies allowed new direc-
tions in experimentation and thinking, thus leading to new levels
of understanding. I believe that our understanding of craniofacial
growth, and the effects of treatment on such growth, places us at the
end of our Early Period, and we are entering a new period in which
concepts and understanding are derived from new techniques for
manipulating old data. We need new techniques for gaining insight
and understanding of old problems far more than we need another
conventional cephalometric analysis, wire alloy, or bracket. Albert
Szent-Györgyi said, “Scientific research consists of seeing what ev-
eryone else has seen but thinking what no one else has thought.”
All of us have seen anomalous faces grow differently, and all of us
have seen some clinical procedures succeed while others fail. Our
need in human craniofacial research, then, is for ways of thinking
about these old problems as no one else has thought about them.
To illustrate this point, let us examine two of the more funda-
mental and unsolved problems of the field which I assert are now
ready for solution: the effects of orthodontic treatment on facial
growth and the increase in craniofacial variability with age. They
55
On Measurement of Facial Form and Growth
are ripe for the plucking because newer analytical methods permit
the asking of questions not once possible.
The Effects of Orthodontic Treatment on Facial Growth
Until very recently, our methods really did not segregate tooth
movement from growth effects. Nor could we identify the effects of
treatment on growth. Nor are we yet able to show precisely the dif-
ferential effects of treatment on growth. We may display 100 cases
treated with appliance X and aver that the mean size and shape
is different than that seen in 100 untreated cases, but we cannot
unequivocally demonstrate how a single patient would have grown
without treatment or how treatment really altered one child's face.
We judge treatment results in crude, overall visual ways, not in
precise, localized measurements. However, both Baumrind and col-
leagues (1983) and Bookstein (1983) have recently presented new
methods that provide beginning insight into the way different appli-
ances affect different parts of the growing face; they are exciting first
steps. No one can read their articles without immediately posing
questions that never would have occurred to us a few years ago.
The Source of the Increasing Variability in
Craniofacial Morphology With Age
It is common knowledge that the face, like other parts of the
bony skeleton, shows increasing variability with time, and it is gen-
erally assumed that most of the increase in variability occurs at
the time of pubescence. While it is true that pubescence is the pe-
riod that provides the greatest increase in sexual dimorphism and
in variability, there are other periods that may be important. For
example, there is an increase in the variance of some cephalometric
measures with the advent of the permanent dentition, an event that
occurs several years prior to the endocrinal changes that mediate
pubescence. Are there genetic activities programmed to occur at
that time? Does the eruption of the new dentition trigger varying
skeletal responses? What role does changing neuromuscular activ-
ity at this time play in the increased variance observed, etc.? All
of us can see that there is very little variance in occlusal relations,
the skeletal profile, and most craniofacial measures during the first
56
few years of life. All of us are aware, as are lay people, that child-
hood brings variabilities not seen in infancy that become quite over-
whelming by the end of adolescence. Thus far we have dutifully and
crudely described the existence of an increase in craniometric vari-
ability with time, but we have not been able to think about this
problem in ways that would provide theoretically sound and clini-
cally practical insights. I suggest that methods are now available to
begin these studies and that the results to be obtained may alter
greatly our perceptions of growth and our strategies of therapy.
Because a person’s face is his/her single most distinguishing
physical characteristic, because the head and face are the locale of
the mental and sensory processes with which we interact with the
outside world and with other human beings, and because we judge
one another as much by facial behavior as any other activity, humans
have long held a curiosity about the face–its growth, its functions,
its beauties. There is a long history of attempts to reduce facial
beauty, morphology and growth to numbers, numbers which provide
quantification and insight. The growth of the craniofacial region is
one of the most complicated of all problems in human biology, and
the role that the face plays in our psychological development and
social behavior is surely unique; as Jean Cocteau has observed, “If
there is a defect on the soul, it cannot be corrected on the face, but
if there is a defect on the face and one corrects it, it can correct a
soul.” Study of the face is an important and difficult task in which
measurement has played and will continue to play an important role.
REFERENCES
Baumrind, S., E.L. Korn, R.J. Isaacson, E.E. West and R. Molthen. Quan-
titative analysis of the orthodontic and orthopedic effects of maxillary
traction. Am. J. Orthod. 84:384–398, 1983.
Bookstein, F.L. The Measurement of Biologic Shape and Shape Change.
Springer-Verlag, Berlin, 1978.
Bookstein, F.L. Looking at mandibular growth: Some new geometrical
methods. In: Craniofacial Biology, D.S. Carlson (Ed.), Monograph
10, Craniofacial Growth Series, Center for Human Growth and Devel-
opment, The University of Michigan, Ann Arbor, 1981.
Bookstein, F.L. Foundations of morphometrics. Ann. Rev. Ecol. Syst.
13:451–170, 1982a.
57
On Measurement of Facial Form and Growth
Bookstein, F.L. On the cephalometrics of skeletal change. Am. J. Orthod,
82:177–198, 1982b.
Bookstein, F.L. Measuring treatment effects on craniofacial growth. In:
Clinical Alteration of the Growing Face. J.A. McNamara, K.A. Ribbens
and R.P. Howe (Eds.), Monograph 14, Craniofacial Growth Series,
Center for Human Growth and Development, The University of Michi-
gan, Ann Arbor, 1983.
Broadbent, B.H. A new x-ray technique and its application to Orthodontia.
Angle Orthod. 1:45, 1931.
Downs, W.B. Variations in facial relationships, their significance in analy-
sis and treatment planning. Am. J. Orthod. 34:813–840, 1948.
Enlow, D.H., R.E. Moyers, W.S. Hunter and J.A. McNamara, Jr. A pro-
cedure for the analysis of intrinsic facial form and growth. Am. J.
Orthod. 56:6–23, 1969.
Hofrath, H. Die Bedeutung der Röntgenfern- und Abstandsaufnahme für
die Diagnostik der Kieferanomalien. Fortschr. Orthod. 1:232, 1931.
Houston, W. Relationships between skeletal maturity estimated from
hand-wrist radiographs and the timing of the adolescent growth spurt.
Europ. J. Orthod. 2:81–93, 1980.
Moyers, R.E., F.L. Bookstein, and W.S. Hunter. Analysis of the crani-
ofacial skeleton: cephalometrics. Chapter XII. In: A Handbook of
Orthodontics, 4th Ed., R.E. Moyers, Yearbook Medical Publishers,
Inc., Chicago, 1986.
Moyers, R.E., R. Wainright, and V. Primack. Craniofacial constants, their
use in cephalometrics. In preparation.
Moyers, R.E. The new cephalometrics. In preparation.
Moyers, R.E. and F.L. Bookstein. The inappropriateness of conventional
cephalometrics. Am. J. Orthod. 75:599–617, 1979.
Moyers, R.E., F.L. Bookstein and K.E. Guire. The concept of pattern in
craniofacial growth. Am. J. Orthod. 76:136–148, 1979.
Moyers, R.E., K.E. Guire and M. Riolo. Differential diagnosis of Class II
malocclusion. Am. J. Orthod. 78.477–494, 1980.
Ricketts, R.M. Planning treatment on the basis of the facial pattern and
an estimate of its growth. Angle Orthod. 27:14–37, 1957.
Rothstein, A. Membrane mythology: Technical versus conceptual devel-
opments in the progress of research. Can. J. Biochem. and Cell Biol.
62.1111–1120, 1984.
Thompson, D’Arcy W. On Growth and Form. Cambridge Univ. Press,
Cambridge, 1917.
Webber, R.L. and H. Blum. Angular invariants in developing human
mandibles. Science, 206:689–691, 1979.
58
EVOLUTION OF CONCEPTS OF THE FACE
I propose to discuss the human face: the attitudes, ideas, and con-
cepts that humans have held about their faces and how these ideas
have affected their behavior and their attempts to change their faces.
Remember that I am a scientist who has spent many years studying
how the face grows and that I am a doctor—an orthodontist—who
changes faces at the request of patients.
CONCEPTS OF FACIAL BEAUTY
Our understanding of what constituted facial beauty in ancient
cultures is derived largely from the records of archeology. Where
ideas remain as actual words, much more is known. Ancient Greece
provides abundant examples of both—the extant record of ancient
Greek thought is more complete than any other peoples, and Greece
was blessed with great artists and an abundance of beautiful mar-
ble. Therefore, we turn for a moment to the history of Greek sculp-
ture and writing, since they have influenced Western ideas of facial
beauty greatly.
We note that the technical detailing of the face has always been
more advanced than that of the rest of the body in Greek sculpture
whatever the period. Good examples of beautiful faces expressing
detailed emotion placed on bodies that are still somewhat stiff and
formal can be found in the Early Classical Period. At the peak of
the Classical Period, about the Fifth Century B.C., Greek art was
a refined expression of the Greek’s view of their Gods behaving as
men and of men behaving in a divine manner. The aesthetic result
of this combining of man and his Gods was an idealization of the
human figure aided greatly by the Greek’s traditional concern for
proportion, pattern, and balance. As a result, we know much about
idealized facial beauty; however, there was less representation of
the extremes of youth and age or of deep emotion. Even figures
participating in violent or painful activities often have a perfectly
calm, beautiful expression.
59
Evolution of Concepts of the Face
The Greek sculptors of the Fourth Century, notably Praxite-
les, Lysippus and Scopa, brought together and expressed in their
work the very best that had been learned through all previous ages
of composition, pattern, proportion, and human anatomy. In the
face particularly, they portrayed an emotional and aesthetic appeal
which has forever been a standard of facial beauty for our West-
ern civilization. No one can view Praxiteles’ Hermés carrying the
Infant Dionysus at Olympia without understanding how important
beauty of the face had become; this master truly could make flesh
of marble.
THE FACE CAN BE CHANGED
The more vividly beauty could be defined and portrayed in
sculpture and painting, the more the latent desire was expressed
to change the actual face itself. If Phidias and Praxiteles could
change a lifeless chunk of marble into exquisite beauty and almost
into flesh and blood itself, might it not be possible to change the
real face?
Surgery began when man attempted to repair wounds and frac-
tures. Medicine began as an attempt to cope with the effects of
disease. Most of us think of treatment in these terms of repair or
cure, treatments necessitated by accident or disease. But another
need for treatment arose years ago and persists today, viz., the desire
to improve appearance. Such treatment had its beginnings in the
concepts of facial beauty just discussed. The earliest attempts to
improve facial beauty probably began in the mouth when someone
tried to align crooked teeth.
Orthodontics and orthodontic appliances had their origin in the
acceptance of an aesthetic concept: the desire to change the face
to make it more beautiful. For the first time, treatment was not
directed against the ravages of disease or the wounds of battle, but
rather against ugliness. Facial beauty was as important as health
and restored function. With this step, doctors accepted the respon-
sibility not only to fight disease and correct damages in the ill or
injured, but to try to improve the status of those who were not
sick and had not been physically harmed. Exact details are not
known, but it is clear from archaeological remains that treatment
for goals other than restoring physical health began in the mouth.
60
Concepts of facial beauty and the desire to attain better aesthetics
were well developed before the concepts of mental health, speech
therapy, etc. were developed. There were orthodontists before there
were psychiatrists, speech therapists, or occupational therapists.
CRANIOFACIAL MORPHOLOGY
The earliest record of purposefully planned changes in crani-
ofacial morphology is that described by Hippocrates in “On Airs,
Water and Places”.
First, concerning the macrocephali: There is no other race
of men which have heads in the least resembling theirs.
They think those the most noble who have the longest
heads. Immediately after the child is born, and while its
head is still tender, they fashion it with their hands, and
constrain it to assume a lengthened shape by applying ban-
dages and other suitable contrivances whereby the spheri-
cal form of the head is destroyed, and it is made to increase
in length.
In the Sixteenth Century, Dürer and Leonardo da Vinci each
made sketches of a series of faces of varying shape and drew on
each face straight lines depicting the relationship of parts of the
face. These artificially erected planes through the skull were the
first cephalometric analyses and in many ways are no different from
what is used in clinical practice today by Orthodontists and surgeons
when analyzing radiographs of the skull prior to treatment. Dürer
and da Vinci's drawings show clearly that the bony structures of the
face must be in harmony with one another to produce the ideal and
beautiful. The variations from that ideal give individual character
to the face and in their extreme forms produce ugliness and even
deformity.
Roentgen's first radiograph was of the human head. An Italian
radiologist, Paccini, and an American orthodontist, Broadbent, in-
vented an instrument for taking standardized x-ray pictures of the
head in which measurement might be made accurately. Clinicians
quickly understood that this new method enabled them to quan-
tify concepts of balance and beauty in the face, thus defining goals
for treatment. What began as an aesthetic concept of balance and
proportion conceived by famous artists has been transformed into
61
Evolution of Concepts of the Face
a modern, Sophisticated, mathematical and computerized research
method used throughout the world of science.
Growth
If one does not like one's face, there are three ways it can be
purposefully altered: (1) by camouflage, as with cosmetics; (2) by
surgery, to change its structural relationships; and (3) by growth.
The oldest of these methods, facial adornment and the use of cosmet-
ics, apparently appeared spontaneously in every culture. Surgery
evolved from treatment of trauma and tumors to plastic procedures
to change the nondiseased, nontraumatized face for aesthetic rea-
sons. The utilization of growth as a means to alter the face is more
recent in its clinical, technical applications, but growth intrigued
humans for many years before their knowledge of facial growth was
sufficient to allow them to attempt to alter the growth process in
order to change facial morphology to the patients' advantage.
Thoughtful men from the beginning of time have wondered how
change is wrought; how the simplest of beginnings can result in the
most complex of ultimate structure. Aristotle himself reports that
he asked how blood or flesh, for example, can come to be: “How
could hair come to be from not-hair or flesh, from not-flesh?” My
favorite ancient comments on growth and change are those of Her-
aclitus who said it all in one masterful sentence, “No man puts his
foot in the same river twice.” Heraclitus not only implied the growth
of the foot and body structures, but the changes in environment and
the interactions between the two.
Galen compared change wrought by nature during growth with
the changes Sculptors bring about when they transform the rough
stone into a work of art.
For Praxiteles and Phidias and all the other statuaries used
merely to decorate their material on the outside, insofar as
they were able to touch it; but its inner parts they left un-
embellished, unwrought, unaffected by art or forethought,
since they were unable to penetrate therein and to reach
and handle all portions of the material. It is not so, how-
ever, with Nature. Every part of a bone she makes bone,
every part of the flesh she makes flesh, and so with fat
and all the rest; there is no part that she has not touched,
elaborated, and embellished.
62
Possibly you can imagine that a house grows when it is
being built, or a basket when being plaited, or a garment
when being woven? It is not so, however. Growth belongs
to that which has already been completed in respect to
form, whereas the process by which that which is still be-
coming attains its form is termed not growth but genesis.
That which is, grows, while that which is not, becomes."
As Scientists learned much about craniofacial morphology and
growth from studies of humans and from animal experimentation, it
became obvious that even the most sophisticated of appliances which
moved teeth did not touch the basic problem, viz., disproportion
of skeletal parts; so, the surgeon began plastic procedures to try
to alter the parts of the face, and orthodontists started to learn
how to control differentially the growth of the bones of the face to
achieve by natural processes that which nature herself would not do.
The modern Orthodontist combines the ancient concepts of facial
beauty and the modern techniques of cephalometrics to quantify
facial morphology. Modern Orthodontists are sculptors of the human
face itself, but their medium is not wax, marble or bronze; rather it
is the living, growing tissues of the body which they shape.
* From “On the Natural Faculties”, Book II, Chapters 3–4. Trans-
lated by Arthur John Brock.
63
Evolution of Concepts of the Face
The Face and the Individual Personality
When the shape of the body is deformed, it changes the
disposition of the soul.
Aristotle
Undoubtedly, the face is a human's single most distinguishing
characteristic. It is the dominant and most persistent image indi-
viduals have of each other. If only one part of the body is to be
reproduced by photographs or sculpture, it is invariably the head.
For here are concentrated most of the sense organs with which we
maintain contact with the world of other humans; it is with the face
that we communicate our thoughts, our ideas, our hopes and our
emotions.
For right or wrong, facial appearance does make a difference
in most cultures. Persons judged by others to be more attractive
get preferential treatment and have greater success in their jobs,
in their interpersonal relationships with others and even in their
marriages. We may be reluctant to admit these facts, but there is
now strong evidence from psychological research showing that the
way we perceive beauty or lack of it in a person's face affects their
lives in many important ways.
Sir Thomas Browne nearly three hundred years ago said, “It is
the common wonder of all men, how among so many millions of faces
there should be none alike.” Therein lies a dilemma, for though there
are commonly accepted general ideas about facial beauty, treatment
should be individualized to suit one person alone. Treatment goals
must not be based on norms, but on the singular needs of a given
individual who is unlike any other in the world, for the face is the
expression of individual personality, it is the index of character.
Though it has been shown repeatedly that a person’s perceptions of
character, when based on facial appearance, are often wrong, most
people would like their faces to be as beautiful as possible. Clini-
cians who alter the face understand very well that they are not only
changing facial structures, they are potentially changing personal-
ity as well. For this reason, there is current interaction and shared
research among psychologists, facial surgeons, and Orthodontists,
for we have far to go in our understanding not only of treatment
techniques, but of the interaction of the face and personality. Aris-
totle many years ago gave us wise advice when he said, “Every man
64
should be judged by measures within him.” Our task is to under-
stand individual development and to help individuals achieve the
greatest possible use of that part of their body to which they are
most sensitive, their own face.
Implications to Education, the Professions, and to Society
By the time of the birth of Hippocrates, the two chief medical
schools were at Cos and Cnidos. The two schools resembled each
other in structure and organization, but in their teaching methods
and philosophy, one can hardly think of a greater contrast. They
displayed side-by-side for the first time in history the fundamental
difference in the concept of medicine as an art or as a science, a
difference that has persisted during the entire history of medical
education.
The physicians of the school at Cnidos held that medicine is
a science and worked hard to create a careful theoretical basis on
which a rational therapy could be built. The Cnidians felt that a sys-
tem of scientific medicine founded on well-grounded principles would
endure for all time. However, they were doomed to failure because
of the paucity of existing scientific knowledge. Their ideas failed
largely because they were at least 2000 years ahead of their time.
In contrast, the School at Cos, where Hippocrates was teaching,
viewed medicine as an art with its own boundaries; therefore, the
chief task of the physician was to work within those limits. Hip-
pocrates viewed sickness as a battle between the curative powers
naturally inherent in the body and the disease producing the injury.
The aim of the physician was to support the patient in his battle
against sickness.
These two important concepts, medicine as a science and med-
icine as an art, have existed together since their origins in Greece,
Sometimes in parallel, sometimes in conflict, but always enriching
the profession. Both views have surely been important in our under-
standing of the human face and its treatment. However, Galen gave
us still another perspective on medical education. Galen viewed the
physician as also a philosopher who must adopt an holistic view
of treatment. Modern plastic surgeons and orthodontists who turn
to the psychologist for help in understanding the interrelationships
of the body and the personality have really not advanced as far as
Galen himself who taught and practiced treatment of the entire man,
65
Evolution of Concepts of the Face
both physical and spiritual, within his environment. Indeed, some
of the writings of Galen and Aristotle read like modern treatises on
human ecology.
Medical education today has made a complete circle, appreci-
ating and using science, understanding art and, finally, attempting
to study the entire person. Those who would treat the human face
with all of its complicated technical, biological and artistic problems
must understand that treating the face, as it is the window of the
soul, requires an understanding of the personalities and sensitivities
of patients to a depth that is not required of medical or surgical
treatments of any other part of the body.
The technical difficulties of facial surgery, orthodontics and den-
tistry itself are so demanding that, during training, clinicians often
lose sight of the biological, aesthetic or psychological aspects of their
work. Furthermore, we sometimes have feelings of guilt that im-
proving facial esthetics is somehow less noble, less important, less
meaningful than the treatment of disease or trauma. Lay people are
wiser. They know perfectly well why they seek our services, for they
understand that the face is the most important part of the whole
person. Recreating a new face through surgery or by manipulating
growth may indeed be one of the most challenging opportunities to
serve our fellow human beings. Such service is more than mere cos-
metics of superficial structures; it is a treatment that often changes
one's entire personality, one’s outlook on life, and friends’ attitudes
toward one.
Patients’ response to treatment of their face is different than
for treatment of any other part of the body, since the face has spe-
cial meanings for them and since every person who knows them will
note and respond to the changes which have been wrought. Facial
treatment produces not only measurable structural changes and aes-
thetic improvements which are visible, but the treatment changes
patients’ mental health as well, for it alters their self-image and their
self-esteem. Thus, facial treatment sets in action a complicated cy-
bernetic system of intrapersonal and interpersonal psychosocial re-
sponses that changes the way in which patients think of themselves,
the way in which they respond to others, and the very manner in
which they approach life itself. Treatment of the face is more than
moving teeth or cutting and rearranging bones; it is even more than
the sculpture of living tissues noted earlier, for it often involves
serious alterations in the personality and in social interactions.
66
If these thoughts are true, and I feel strongly that they are,
the clinician who is effecting changes in the face of such a compli-
cated nature needs to have a much broader perspective than is often
the case at present. Orthodontists may be too engrossed with the
mechanical details of their complex tooth-moving appliances or the
theories of facial growth and methods of measuring it. Surgeons may
be too preoccupied with the technical difficulties of their operating
procedures. If the whole patient is to be treated well, it requires,
Surely, a completely whole doctor: that is, a scientist, an artist, and
a philosopher. p
Thus far I have spoken about the face and how clinicians and
laymen think about it. Let me now address students—all students
who will serve others in their professional lives as physicians, den-
tists, teachers, social workers, etc. We teachers often emphasize
the technical details of a field and obscure the total view. Many
problems are like those of facial treatment; that is, they are more
complicated in Solution and in response to solution than they seem.
Many professions other than the health professions have failed to
integrate all knowledge to society’s total advantage.
The Cnidian medical teachers were right in more ways than they
knew; there is a scientific approach to all that we do. Research must
keep it alive in the universities, and it must be utilized for the good
of all.
Hippocrates and his colleagues at Cos were right too; not only
is medicine an art, but there is a sensitive sympathetic approach
necessary in all professions in service to people that must not be
lost in our concentration and hurry to gain scientific knowledge.
Galen was correct, also; perhaps the most correct of all, for when
he said that the physician had to be a philosopher, he was insisting
that complicated problems require complexly broad-minded people
to solve them.
It is the right of students to insist on their anciently defined
prerogatives, viz., an education that exceeds the mastery of technics
and the accumulation of facts.
It is the duty of universities to preserve our precious heritages,
rephrase the ancient ideas in modern idiom, and apply them in their
broadest sense to modern problems.
It is the obligation of those of us who serve other individuals—
patients, students, clients, customers, the sick, the injured, those
who are learning, and those who need help-to serve them wholly
67
Evolution of Concepts of the Face
in all their needs, physical, social, emotional, and intellectual. We
cannot do more; we dare not do less.
68
CHANGING ROLE OF THE PROFESSIONS
|N OUR SOCIETY
I hold the distinct bias that while the past is glorious and appreci-
ated, the future is where we all will live. Accordingly, I shall address
three major topics: first, current issues in dentistry; second, the im-
pact of society on the health professions; and third, some coming
changes.
We, Americans, tend to look at history selectively, remember-.
ing our victories, heroes, and successful struggles and putting less
emphasis on our defeats, frustrations and misdirections. We have a
tendency to reinforce the concept of “the American Way of Life”, re-
membering especially those who have achieved the great American
dream. We may forget those who have attained success in different
ways. We look askance at the unconventional, at those who seem
out of step with that which we feel to be proper and good and true.
I wish to tell you of a deliciously funny moment in early American
history in order to make this point, but first I ask you to conjure up
in your mind the most vivid images you have of the early settlements
in this country.
Perhaps you will recall brave John Smith and noble Pocahon-
tas in Virginia, or the Swedes and Lord Baltimore in Maryland
or the good Pilgrims and the first Thanksgiving in Massachusetts.
My story involves them. At the time of the Pilgrim colony, forgot-
ten by many today, there was nearby another colony called Merry
Mount headed by one Thomas Morton. Now Thomas Morton, who
was not a member of the adjacent religious “establishment” at Ply-
mouth, decided to show his staid and stuffy neighbors how to cele-
brate the arrival of Spring. At Merry Mount, his colony nigh to
Plymouth, he erected an 80-foot pine Maypole and, according to
his own record, “brewed a barrel of excellent beare” which he dis-
tributed with “other good cheare, for all comers of that day”. The
host invited some Indian maidens along for the occasion, for, in a
poem written by himself, Morton said:
Lasses in beaver coats, come away,
Ye shall be welcome to us night and day.
69
Changing Role of the Professions in our Society
The combination of beer and women was too much for the Pil-
grim “establishment”, and Myles Standish, leading what was un-
doubtedly America's first vice squad, broke up the party, arrested
Morton, placed him in stocks, and eventually shipped him back to
England. The struggle for America's soul may have begun that May
Day in 1627. In his short story, “The Maypole of Merry Mount”.
Nathaniel Hawthorne tells us that the sound of the Psalms from
Plymouth would occasionally be mixed with the “Chorus of a Jolly
Catch” from Merry Mount—an echo in rare confusion.
I am not enough of a social historian to make judgment about
whether Myles Standish was right or not or whether Plymouth or
Merry Mount contributed more to American history. I simply want
to remind us that we have a tendency to remember the Pilgrims and
forget the Indian maids frolicking with the beer drinking men from
Merry Mount. The good things that survive to serve us today persist
because they met the challenges of other ideas, the temptations of
other ways of life, and the continuing questionings of the cynics,
the thinkers attuned to new and unconventional wave lengths, the
marchers out of step with the regular troops of history.
Perhaps no segment of society better represents middle class
morality and the establishment than the health professions. But
we forget how we arrived at this secure and comfortable position.
We forget that the outcasts of one generation may in historical per-
spective seem as heroes—the heretics as saints. Charles Kettering,
the great automotive genius, one time said, “When you hear some-
one say something that seems like a crazy idea, you’d better listen
to that man; one of you is apt to be a damn fool, and it makes a
difference
Like many other Americans these days, most professional people
find themselves somewhere between impulsive change for the sake of
changing and too much traditional interaction, between too much
passion and too much reason. In such times, self-analysis is no
luxury. I won’t pretend that I have anything very deep or original
to offer, but profundity may be less important, just now, than simply
taking stock of the problems of our professions today, some of the
strange new solutions offered, and what we appear to be doing or
not doing about them. It seems necessary for the professions to
squarely address the issues of the day and to examine our special
role in this changing Society.
70
CURRENT ISSUES IN DENTISTRY
A number of important issues face the profession today; issues
which must be resolved, issues which bring up divergent viewpoints,
issues which may alter our enviable role. Even in dentistry we have
our Thomas Mortons as well as our Myles Standishes. I shall discuss
these issues under four headings: (1) the changing nature of den-
tal practice, (2) research, (3) education, and (4) public-professional
relations.
The Changing Nature of Dental Practice
Not very long ago, most dentists in this country had a solo
practice in a private office where they delivered their services for
fees which they determined and the patients themselves paid. Now
new methods of payment for dental services abound, including gov-
ernmental sponsored clinics, third party Schemes, dental insurance,
and capitation programs. No single event has changed the nature
of dental practice in the State of Michigan more than that which
occurred when the United Auto Workers bargained for and received
payment for dental treatment by the company as part of their health
benefits package. Dentistry may still be the last stronghold of the
independent businessman, but the dentist-businessman will be paid
in many different ways.
For many years there were no specialties in dentistry. Orthodon-
tics evolved first as a specialty not only because there was a body of
skills and a literature of special knowledge, but because the dental
school curriculum persisted in neglecting the teaching of orthodon-
tics at a sufficient level to enable the general practitioner to partici-
pate. Later, for a while, orthodontics and oral surgery were the only
recognized dental specialties. Now there are many, in fact, so many
that the very nature of general dentistry seems to be threatened
and the general practitioner himself has almost become a specialist.
There are signs that this trend is reversing, and we see a resurgent
strengthening of general practice and a redefining of the specialties.
Recently there was a great expansion in the number of den-
tal students being trained and an increase in the number of dental
schools. Preparing more dentists may have served society better
then, but now there are less patients for each dentist, a fact made
71
Changing Role of the Professions in our Society
acutely obvious in days of economic distress. There is pressure to re-
duce the number of students being trained because many dentists in
practice are not making the decent living they expected and several
dental schools have closed.
Without being judgmental, it is fair to state that all of us in
dentistry are affected by the changing nature of dental practice.
While we may be nostalgic for the good old days of many patients
all willing to pay their own fees for services rendered, most of us for
the rest of our professional lives will be adapting to the issues just
discussed.
Research
Except for accidents to the face and dentition, there are only
three major problems in dentistry: caries, periodontal disease, and
developmental difficulties, including malocclusions. Much of dental
teaching and practice consists of various techniques for treating the
ravages of a single disease, caries. Some dental school departments
are defined and differentiated from others simply by the differences
in the techniques taught for restoring the effects of caries. The
discoveries of fluoride and other preventive methods have revolu-
tionized dental practice far more than they have changed the dental
school’s curriculum or organization. An active focus of research
now is on periodontal disease, since it too presents the possibility
for eradication. Malocclusion and other developmental difficulties
are not diseases and, therefore, are not susceptible to the logic of
Koch’s postulates. Research in this area is not undertaken with the
hope of mass prevention but for better understanding and improved
treatment methods.
Research in dental materials has been so magnificent that, while
there is much to be done, we will probably see more minor improve-
ments than major breakthroughs in the near future.
A neglected area of research in dentistry, which seems ready for
rapid exploitation, is that of behavioral studies. The psychology
of the face and human attractiveness is of immense importance to
all, yet I do not know a single dental school that gives a systematic
series of lectures on this topic. Parents and orthodontic patients
know nothing about the Angle Classification, facial growth, or the-
ories of occlusion. They seek our help because of the impact of facial
72
appearance on mental well-being. Dentistry needs psychological re-
search in people's attitudes towards self and dental care much more
than it needs further studies on the crushing strength of amalgam
or another new orthodontic bracket.
Education
Several critical difficulties persist in dental education today.
The number of applicants for dental schools has decreased dramat-
ically in recent years. A principal reason given is the high cost
of study in dentistry. As a result, an increasingly high percentage
of dental and medical students come from wealthier families and
the remainder finish dental school with debts totaling thousands of
dollars. At the time of high school graduation, only one-fifth of the
students in the top ten percent academically come from professional
or white-collar families. Yet, a few months later, that one-fifth of
the top ranking high school students comprises about two-thirds of
the entering freshman class in four-year colleges and universities.
As a result, those of us in the health professions are becoming an
increasingly homogenous group. We have similar opinions, attitudes
and interests because most of us come from middle or upper socioe-
conomic classes. I do not challenge our sincerity, our dedication or
our training, but society has a right to ask if this selection process
best serves its needs. Not enough of us come from those parts of
society in which many of the current predicaments of the profession
lie. We have a surfeit of Myles Standish types; the need is for an
infusion of those with different backgrounds and outlooks, those out
of step with the dental establishment but more sensitive to society’s
needs. Where are the modern day Thomas Mortons in dentistry?
With the diminution of government support for dental education
and the decrease of applicants, it can be expected that some dental
Schools will close. As costs of dental education rise, it follows that
Some aspects of the curriculum will be damaged, diminished or done
away with totally. The luxuries of the last twenty years may not be
with us in the near future, and the decisions faced by dental school
administrators affect all of our futures, all of us in the profession,
and society itself. -
73
Changing Role of the Professions in our Society
Public-Professional Relations
We have become a consumer-oriented Society and our watch
word is accountability. Ralph Nader, the Food and Drug Adminis-
tration, and other governmental agencies produce daily news stories.
The consumer wants nothing but quality in product and service and
holds accountable those who cannot deliver what is expected.
Furthermore, we have become a participatory Society, a natural
development in a country of democratic traditions. Lay people are
now on boards and commissions once reserved for the elite, the
specialist, or the professional. Most state boards of dentistry have
lay members, and physicians no longer control Blue Cross.
These are not all the current issues in dentistry, but they are
important ones and typify the impact of society on the health pro-
fessions today.
IMPACT OF SOCIETY ON THE HEALTH PROFESSIONS
A great change has occurred in societal attitudes towards hal-
lowed institutions. Citizens, once respectful and trusting of gov-
ernment agencies, the schools, manufacturers, and the professions,
now stand to challenge procedures and processes once accepted with
docility. Consumerism and democratic traditions combine and pro-
duce the notion that everyone has a right to be involved in decisions
that affect them, their children's schooling, the safety of their cars,
the efficiency of their health delivery systems, etc. It is also an age
of science—science, that great new God from whose temples, the
laboratories, have come so many miracles.
The Public’s Perceptions of the Power and Limitation of Science
Science, technology and medicine are not discretely separate
fields, for they have in common three important characteristics: pro-
cess, a body of acquired knowledge, and practice or delivery of that
knowledge to society. By process I mean the method of science, the
design of experiments, the rigorous testing and retesting of assump-
tions, the Sophisticated instrumentation, the scrutiny and revision
of all truths, and the very rigorous ground rules by which research
is done. Process is the integrity of science, for if the facts have not
74
been accumulated properly and carefully, the body of knowledge is
in error and application is flawed. Those of us who apply the fruits
of science, whether dentists, physicians, or directors of space cen-
ters, have a common heritage, for we understand that probity and
honor are inherent in the process of science. This is the reason that
scientists have been so disturbed by the revelation of faked findings
from prominent university laboratories and why they always lead
the fights for academic freedom.
Individuals who have some concept of and dependence on the
process of science are in a better position to absorb and appreciate
new knowledge. It is quite possible that that large part of the public
that has had no experience with Science perceives the world quite
differently than those who have, and that difference in perception
is greater than those of us in science may realize. Those who have
not studied science are not in a good position to think clearly about
new methods of treatment and are more apt to be impatient for
science to quickly solve each new problem that arises. Those who
have never written a science thesis or a research paper may not
be as appreciative of the importance of maintaining libraries and
computer retrieval systems. They may not understand why the
time from discovery to application is so lengthy. Novels, television,
movies and scientists themselves have given the lay public a glossy
image of Science, and many intelligent lay people lack the experience
in science to understand the realities.
The Public’s Perceptions of the Scientist and the Health Professional
There is a strange and naive willingness on the part of society to
assign the scientist and the health professional the role of remediator
of all of Society’s errors while society at-large maintains a strange
passivity. It is supposed to be the scientist who will solve the prob-
lems of pollution, drug abuse, and over-population. The scientist is
cast in the role of magician, and there seems to be no bottom to the
public’s belief in his omnipotence. Unfortunately, this naivete is en-
couraged by too many professionals eager to accept responsibilities
that they cannot handle.
There are signs that society’s quaint indulgence of the scientific
professions is changing. There seem to be two reasons why the pub-
lic's image of the health professional has become tarnished. In the
75
Changing Role of the Professions in our Society
first place, newspaper reports of advances in medical science are of
ten so colored and dramatic that the consumer has come to expect
more in routine medical health care than our system can deliver.
Every newspaper carries stories of artificial hearts or heart trans-
plants, cancer cures, new vaccines, caries preventives, invisible and
electronic Orthodontic appliances, etc. Laymen come to expect mir-
acles, many of which we cannot yet deliver efficiently, as an everyday
occurrence. Blame for the shortcomings of our health care system
often is transferred unconsciously in the layman’s mind to the indi-
vidual physician or dentist and emerges as a lack of confidence in
the technical or professional skills of the physician or dentist.
The second factor, which has influenced society’s image of scien-
tists, is the fragmentation of the health professions into specialties.
As clinical science has grown more complex, individual practitioners
pay more and more attention to narrower and narrower fields and
less attention to the interrelationships of these fields, but it is the
complex interrelationships of the several clinical fields that often are
a part of an individual patient’s problems. Perhaps you have read
about the man in Boston who had to give up his job and go on wel-
fare because he was forced to spend all of his days waiting with his
handicapped child at a variety of specialty clinics. The specialized
technical skills on the part of each individual practitioner did not
make up for the lack of coordinated care for his family.
Not long ago laymen had an awesome respect for the friendly
family physician, a man whose professional skills were represented
more as a personal touch than as vast technical knowledge. Now the
layman views health care as a utility to which he is entitled and the
physician as the representative of a medical care system that does
not always work. When a big public service system does not work,
the layman blames the one individual in that system with whom he
has personal relations: Johnny's fifth-grade teacher, the policeman,
the social worker, the physician or the dentist.
The Public’s Perceptions of the Health Professions
A profession is an organized group, dedicated to serving Society
but further dedicated to abolishing the need for its services. The
best teacher trains the pupil to teach himself. The best pastor hopes
for the day when his flock will no longer need his admonitions. By
this definition, the best physician or dentist is the one who restores
76
the health of the patient so that the doctor's services are no longer
needed. This is not merely a definition but a value system which
expresses itself in whom we honor and why. All physicians and den-
tists are trained to be technicians employed in curing disease, but
society reserves its highest honors for those who learn how to oblit-
erate or prevent disease, thus diminishing the need for the technical
and curative aspects of practice. You and I may judge a colleague
in dentistry or medicine by their technical skill, their titles in the
profession, the size of their practice or their list of publications, but
I ask you who now remembers the name of the leading surgeon in
France at the time of Louis Pasteur?
While there is a long and honorable tradition of denigrating
doctors, practiced by Aristophanes, Shakespeare, and Molière and
continued today by cartoonists and stand-up comedians, Ameri-
cans have always viewed the health professional with esteem and
affection. Society historically has assigned us four functions: (1) a
priestly role, (2) a technical role, (3) a scientific role, and (4) a social
role.
The Priestly Role. Doctors once served a sort of priestly func-
tion and acted as wise and trusted personages in the community.
The old fashioned family doctor has left us, but there still is a de-
mand for sympathetic personal relationships with all health profes-
sionals. We will never get rid of this sacerdotal role because of the
very personal nature of our service, because the public wants it that
way and because, quite frankly, we enjoy serving as the priests of
health. Even though technology and science have become increas-
ingly complicated and inaccessible and increasingly incomprehen-
sible to lay people, responsiveness to the patient’s personal needs
remains one aspect of practice by which most people continue to
judge us. Such personal and priestly functions have always been
expected but have not come to be specified until very recently when
they have been prominently listed in malpractice suits.
The Technical Role. We dentists place as great an importance
on the technical aspects of our service as do surgeons. Patients in
commenting on dentists do not compliment us on the fit of inlay
margins or the precision of an achieved molar relationship. Rather,
they consider we do our best work when we are painless and quickly
achieve a beautiful result. The American public takes for granted
that American dentistry is technologically the best in the world.
77
Changing Role of the Professions in our Society
The Scientific Role. I find in my practice that patients in a uni-
versity town not only assume that I am technically skilled but that
I also am applying the very latest scientific findings of which they
have read. Just now, for example, I am answering many inquiries
about invisible or electronic Orthodontic appliances, inquiries result-
ing from newspaper articles describing bracketed appliances placed
on the lingual not the buccal surfaces of the teeth, and reports that
bone deposition and resorption can be controlled by locally varying
the electromagnetic field. Lingual appliances are now manufactured
and in wide clinical use, yet at this time no single clinical study has
reported as many as twenty consecutively treated cases. Electronic
appliances have been used on animals only and no single human
malocclusion has been treated by their use. Patients expect me to
be able to discuss with them these latest scientific findings, assum-
ing that I will protect them from fadism and apply new findings to
their needs at the proper time.
The Social Role. The definition I gave previously of a profes-
sion admittedly lacked a certain social realism. Let me now supply
it, quite bluntly. The health professions are licensed monopolies.
Only those who have been accepted into accredited schools, passed
rigorous scholastic examinations, and have been licensed by the re-
spective states can practice these professions. The justification for
these relatively recent obstacles to admittance into the guild is that
the professions are supposed to guarantee the quality of the service
to be rendered to society. Said another way, society demands that
the standards of professional service be maintained through proper
training and governance by the professions themselves. But who
watches the watchdog? It is not society that sets the curricula of
the dental and medical schools, or supervises them, or gives licensing
examinations, or inspects actual practices. Society not only assumes
that those in the profession know what society needs, but also that
they will automatically take necessary and appropriate action. As
society has learned that the professions have tended to serve them-
selves rather than those who gave them their charter, society’s image
of us has changed and its demands on us have altered.
A strong public interest in “consumerism” and the government's
new interpretation of antitrust concepts have combined to blur the
distinction between the professions and business enterprises. The
78
health professions have always felt it proper to adhere to higher
ethical standards and nobler and more stringent obligations to serve
the public’s needs, but governmental intrusions reduced greatly local
quality control by the professions and did not replace it. This new
ambivalent attitude of society and the government towards the pro-
fessions must soon change as the professions’ attitudes of themselves
and their role in Society must change.
Our Own Perceptions of Dentistry
A number of studies have been done through the years to as-
certain the personality and attitudes of young people who select
different professions. The image each of us has of dentists, or for
that matter of ourselves, may be disturbed by Prof. Benno Fricke's
finding that we dentists are something like the physician and the
biologist, but our attitudes and interests mostly resemble, in our
opinions, those of the businessman. Herein lies a major problem for
each of us, since society has not cast us in this role.
Most laymen have an idealistic ambivalent view of the health
professionals, seeing us both as dedicated, white-coated scientists
producing marvelous new cures and, as practitioners, easing pain
and enriching patients’ lives without fault or personal gain and at
considerable self-sacrifice. This ambivalence and fantasy may have
its origins in American literature, movies and television—Sinclair
Lewis' Arrowsmith, Lloyd Douglass' Magnificent Obsession, Paul
DeKruiff’s Microbe Hunters or Dr. Kildare or Marcus Welby, M.D.
We view ourselves as practitioners trying to make a decent living
while serving Society, but the working man who cannot procure the
medical and dental care to which he thinks his family is entitled may
hold a different image of physicians and dentists. In the last twenty
years, dentists and physicians have substantially increased their in-
come relative to the national average income. As society continues
to emphasize our social role, the independent entrepreneurship of
the dentist or physician becomes an issue, and our motives are more
apt to be perceived as greed.
Political, Economic and Social Factors Determining the
Direction and Progress of the Professions
Ours is a democratic society in which the public has the right
and responsibility to make decisions concerning the quality of life,
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Changing Role of the Professions in our Society
including health. There is a naive tendency sometimes to believe
that if each citizen clearly understood the issues and science in-
volved, each would make the same decisions. This, of course, is not
true. Equally well-informed individuals may take different ethical
or social positions with regard not only to technology but to the
delivery of health services. While some education in science for ev-
eryone helps clarify general understanding about technical matters,
it is not a sure route to unanimity about such personal affairs as
health. Surely we understand today that political, economic, and
social factors in the future are as apt to control the destiny of our
profession as we are ourselves.
In a rather flattering and profound sense, many of the current
attacks on health professionals compliment them. People expect
more of us than they do of any other professional except possibly
the clergy. Americans have come to expect the health professionals
to furnish comfort, happiness, well-behaved children and protection
from the environment, as well as health itself. When we cannot do
all this readily and inexpensively—disillusionment sets in.
Beyond the priestly, technical and scientific requirements of
the health professions, one of the well-understood demands soci-
ety makes of us, in granting us the special status of a monopoly, is
that all of our activities be harmless to society. Traditionally, the
issue of whether or not the monopoly granted us was harmful had
to do with the malpractices of individual doctors, but as health ser-
vice became a general expectation for all, criticisms were leveled at
our failure of self-policing. More recent critics of the performance
of health professionals not only decry our monopoly and the mal-
distribution of health care, but have loaded us with any number of
other social transgressions. The continuing politics of the socialized
medicine debate, combined with other social and economic forces,
has tended to impair the trust, confidence and freedom that once
marked the attitude of the public toward the health professions.
SOME CHANGES COMING
If the professions are to stay attuned to the changing moods,
needs, and attitudes of society, it will be done through one or more
of these three mechanisms: (1) changes in the individual members of
the professions, (2) changes in the schools that train professionals,
80
or (3) changes in professional organizations. Let us take each in
order.
The Individual Professional Person
I have already discussed some of these problems: the difficulty
in changing basic behavior, the selection of the person who enters
the profession, and the image that professionals have of themselves.
Professional Schools
Like a river, a profession can rise no higher than its source. Its
source is the professional school. Many of our ideas of education are
too narrow, simplistic, even too primitive to allow us to deal with
the sorts of problems we face today. We teach technologies but not
how to use them, how to control them and give them direction, or
how to relate them to our values. We have emphasized training at
the expense of education, especially the kind of education needed
to enable individuals to grow in the service of their professions. A
very large percentage of my undergraduate time in dental school was
spent mastering clinical technics, few of which are used in practice
today; a very Small percentage of my time was spent on the basic
human principles of patient care, principles that do not change. I
spent more time learning how to survey a partial denture and more
time trying to fit molar bands than I did learning how to deal with
anxiety, fear, and pain. We do our students a great disservice if
we teach them excessive dependence on technics. Such dependence,
the essence of trade-school training, is a poor basis for professional
growth, professional personal relations, and even the development
of professional skills.
I doubt that there is a medical or dental school in this country
that does not have a series of lectures on “The History of Medi-
cine” or “The History of Dentistry”. Do you know of a series of
lectures on “The Future of Medicine or Dentistry”? The conquest
of dental caries is one of the great victories in public health. This
disease, which previously occupied fully three-fourths of the average
dentist’s time, will soon be, in most communities, truly a minor con-
cern; yet the average American dental school spends approximately
50% of the students’ time on technics of reparative or conservative
dentistry. Tomorrow’s practitioner will need to know less about re-
pairing the damage caused by caries and much more about other
81
Changing Role of the Professions in our Society
subjects including periodontics, public health, preventive dentistry,
and orthodontics; however, today’s student learns relatively little
about these subjects.
There are problems in the way that dental teachers are typically
chosen. Teachers in the dental clinical sciences usually arrive at their
posts by a route different from that travelled by professors in the
rest of the university. Clinical departments are made up mostly of
persons who have been trained in the departments in which they
serve. We thus deny our students and residents the advantages of
intellectual hybrid vigor and a diversity of viewpoints.
In the average professional school, the simplest path to change
would be to base the curriculum on the answer to one question:
“What will be the problems facing our students as they, practice
in the next 30 years?” No one can really foretell the future, but
feedback mechanisms to the curriculum committee from prominent
successful alumni, the public, consumers, and public health officials
would be helpful. Professional schools must undergo a constant
examination and reevaluation of all aspects of their training pro-
grams if they are to produce graduates capable of adaptation and
change as Our Society and our profession changes. I do not suggest
that we should teach or adopt every crackpot idea suggested by So-
cial reformers, the Ralph Naders, or government bureaucrats. I do
plead for us to be sensitive to the societal needs or attitudes that
underlie their proposals. Then, instead of ignoring or fighting, we
listen, bring forth our own answer to the problem, and teach our
students accordingly. The dental school curriculum should reflect
how we want dentistry to be in the future and not how it is today,
for the professional School's first obligation is not to the profession,
but to the public; not to the faculty, but to society; not even to the
students, but to the patients those students will soon serve.
Professional Organizations
George Bernard Shaw said that every profession was a conspir–
acy against the laity. As usual, Shaw makes a point by overstate-
ment. Each profession carefully maintains its own organization to
serve its needs, very much like a trade union. I suggest that, un-
less professional organizations also serve the needs of society, the
82
differences between them and the Teamsters are relatively unim-
portant. The need for professional organizations to be less self-
serving and more sensitive to changing social requirements is quite
clear. When the public's expectations diverge from what the profes-
sions are willing to consider, consumers turn for help to governmen-
tal agencies, unions, insurance companies and others. Important
decisions relating to our work may then be made without us.
As the rate of social change accelerates, basic problems become
more exposed. The problems which I shall cite are all related to
the health professions, but similar ones confront other professions
as well.
The Professions’ Goals are not Consonant with Consumers’
Needs. Several years ago, a militant black leader disrupted church
and synagogue services in Ann Arbor with demands for large sums
of money from the congregations as reparations for alleged damage
done by whites to blacks. He demanded that the funds be dis-
tributed to needy blacks in our community by the organization he
headed. Before he came to visit my own church, a group of our lead-
ers met, pledged a large sum of money and set about deciding how
to spend that money. It is important to note that no black members
of our congregation were on the committee. A social work graduate
student, experienced in the interview method, quietly questioned
a large number of poor black people and compiled a list of their
needs. It was a shock to learn that the need mentioned most fre-
quently by the poor people had not even been considered by the
church committee—access to dental care. I am proud to report that
the dental profession rallied and soon a new dental clinic was estab-
lished where high quality dentistry is provided and people pay as
they are able. The clinic runs well, is financially sound and is quite
frankly a proud lesson for us all-profession and public alike.
We Cannot Deliver Known Services to All the People. Research
on the basic problems of disease has advanced faster than innova-
tions in delivery of health care. This matter involves not just the
ethics and financial logistics of heart transplants, kidney dialysis and
intensive care for the premature neonate at risk but also treatment
of malocclusion and provision of dentures.
83
Changing Role of the Professions in our Society
There Has Been a Loss of the Personal Touch, of Human Val-
wes, in the Delivery of Health Care. Many of us are afraid that new
health delivery schemes will destroy the doctor-patient relationship,
while some consumers are willing to accept a loss of personal rela-
tionships just to obtain some kind of care. Perhaps you have heard
a story from England that illustrates at least one version of the dif-
ference between governmental and private health care. Mr. Brown
suffered from marked obesity. He consulted an eminent physician
who prescribed seven pills, one of which was to be taken each night
at bedtime. That night Mr. Brown took the first pill, fell asleep,
and immediately dreamed that he was shipwrecked near an exotic
South seas island. As he came ashore, he saw a beautiful girl on
the beach beckoning to him, so he ran after her. He chased her
all night long and awoke in the morning exhausted and drenched
with sweat. This same exhilarating experience happened on suc-
ceeding nights. When he returned to his physician at the end of
the week, he had lost 25 pounds. Naturally he was very pleased,
and he reported this remarkable therapy to all his friends, one of
whom, Mr. Jones, was also obese. Mr. Jones went immediately to
the same physician, received his prescription, and went home joy-
ous and expectant. He promptly fell asleep after taking the first
pill and began to dream that he too was shipwrecked near a lovely
south sea island. As he scanned the shore, however, he saw no
beautiful young girl. Instead, as he came up on the beach, he was
greeted by a pack of wild savages who chased him around the is-
land all night. He awoke in the morning, exhausted and sweating.
After a week of similar dreams, he returned to the physician and
discovered that he had also lost 25 pounds. Mr. Jones was pleased
with his weight loss; nevertheless, he felt compelled to protest the
difference in treatment. To his complaint, the physician replied,
“But you must understand—Mr. Brown is a private patient—you
are National Health Service.”
The Costs of Health Care in Recent Years have Risen Much
More Sharply than the General Cost of Living. Doctors worry about
the quality of care; administrators, legislators, and taxpayers worry
84
about the cost of the care; potential patients worry about the avail-
ability of health care services. It is therefore important to exam-
ine critically each new proposal for health care services, for quality
control is as important as containment of cost.
Not long ago, the vice-president of one our major automobile
companies in Michigan, a man whom no one would call a social-
ist, commented to the Dean of our School of Public Health that
“. . . health does not lend itself to the entrepreneurial system.” Some
people, even automobile executives, feel that the competition of pri-
vate entrepreneurs is not the most efficient method to achieve a
sensible balance between the public’s needs and the resources re-
quired to provide adequate health services for all at a reasonable
cost. I do not agree with the automobile executive, but we cannot
fail to listen and respond to such comments.
These problems are not the only ones facing medicine and den-
tistry today, but they illustrate the significance of social changes as
they affect the professions.
Let me conclude as I began, with a look at our origins. This
country was born with the people half-Tory, half-revolutionary.
There have always been at least two strong forces struggling to
determine the course of American history. Our country has sur-
vived possible divisions because we have been able to come to grips
with change. We are a people born in change, continued in change,
strengthened by change.
The rate of social change shows no sign of slowing. We in
the professions must participate in the mechanisms that determine
change if we are to continue our special role, if we are to maintain
the gains of the past, if we are to fulfill future obligations to the
people we serve.
85
MAINSTREAMS IN
AMERICAN ORTHODONTIC THOUGHT
History may be written by chronologically detailing events, describ-
ing the personalities who have shaped events, or analyzing critically
the ideas that prompted change. American Orthodontic progress is
sometimes described as a series of ill-defined periods, each desig-
nated by a title such as “the expansion or preextraction period”.
“the cephalometric age”, etc. This paper is a history of the evolving
critical concepts that have sequentially launched each new epoch in
the treatment of occlusofacial problems.
A new period begins when a majority of the clinicians feel the
necessity to move in an important new direction (Kuhn would call
this a scientific revolution), each new direction having been deter-
mined by the advancement of a fundamentally new concept. These
new concepts have largely resulted from the thinking of one or two
persons whose innovative and persuasive ideas have led others to
general progress. New methods of treatment have then been de-
vised to meet newly defined needs. Therefore, new appliances have
resulted from, rather than caused, each major advance.
I will discuss each of the emerging new concepts, how the con-
cepts were translated into clinical practice, and how the new prob-
lems, which were thereby uncovered, laid the groundwork for the
next new concept. The new concepts did not arrive as precisely
sequentially as described, as there has always been a complicated
interweaving of ideas and overlapping of their exposition and pro-
mulgation.
CONCEPT-ALIGNMENT
Historians and archeologists may argue about which people de-
vised the first orthodontic appliance and why." Indeed, orthodontics
Professor V. Haralabakis at the Aristotelean University of Thessaloniki has
a skull with a gold wire interwoven around the crowns of the lower anterior
teeth, presumably to improve their alignment. The skull has been dated
87
Mainstreams in American Orthodontic Thought
may have been invented several times in several different cultures
whenever someone decided that teeth looked better aligned. The
first primitive orthodontic concept included only the teeth of one
dental arch and had nothing to do with mastication, occlusion, oral
health, speech, or the many other related factors which were to come
later. If alignment of the teeth in one arch was all that was needed,
then the very simplest mechanics would suffice. So for hundreds of
years, orthodontic appliances consisted of little more than devices
to push or pull the teeth back into the line of the arch. Little clinical
or scientific advancement resulted, for such simple tooth movements
were not thought to be any kind of specialty practice within either
dentistry or medicine. New, ingenious—but crude—appliances were
developed through the years; however, no theory was devised, and
orthodontics essentially stood still until dentists began to study the
relationships of the teeth in one arch with the teeth in the other.
at approximately 300 B.C.; this may be the earliest known Orthodontic
appliance.
88
CONCEPT “NORMAL” OCCLUSION
Some observant clinician lost in the shrouded mists of history
must one day have noticed that the teeth in one arch met the teeth
in the other arch in varying manners and that occlusion of the teeth
was more complicated and more important to oral health than just
simple alignment. We would like to be able to name and honor
this great clinical observer, but his name is lost to us. However,
at about the beginning of this century, Angle introduced the con-
cept of “normal” occlusion: the idea that there was a proper or
ideal relationship for each tooth to adjacent teeth in the same arch
and antagonistic teeth in the opposite arch. While the concept was
Angle's, its greatest advancement came when Friel described, in
graphic three-dimensional terms, the ideal relationship of each tooth
in occlusion. Angle's use of the word “normal” to describe an ideal
relationship was most unfortunate, and the semantic difficulties per-
petrated by that misusage persist until today. Angle, not Friel, felt
that positioning each tooth in the ideal relationship, which he called
“normal”, would cause sufficient bone to be produced to support the
teeth in their newly aligned and perfectly occluded relationship.
This new occlusal concept required the orthodontist to be able
to control the position of every tooth in all three dimensions, some-
thing impossible with the simplistic “push-pull” alignment appli-
ances in use at the time. Therefore, Angle abandoned his own “E”
or expansion arch and quickly developed a series of ingenious or-
thodontic appliances designed to provide precise, three-dimensional
control of every tooth during treatment. The “pin and tube” appli-
ance was followed by the “ribbon arch”, and that finally by what An-
gle modestly called “the latest and best in orthodontic appliances” –
the edgewise mechanism. Clinicians appreciated the advantages of
these new appliances and hastened to adopt and master them, but a
number of old, familiar problems still remained, including frequent
arch disintegration at the end of treatment.
Angle insisted that all 32 of the permanent teeth had a specific
appropriate place in the jaws, and clinicians generally believed that
it was possible to align all the teeth within the bones, using the so-
phisticated new appliances. Angle was a confident, forceful teacher
who produced many disciples but few exegetes. His students valued
his words but forgot his example of challenging old ideas. Angle's
89
Mainstreams in American Orthodontic Thought
effectiveness as a teacher diminished when he became a text, for
he spoke ea cathedra and his pronouncements were followed as if he
were indeed the Pope of Orthodontics.
So strongly heeded was Angle's admonition against extraction
that when some orthodontists first said it was impossible to achieve
normal occlusion of all the teeth in some faces, they were roundly
criticized. George Grieve from Toronto, in a paper before the Amer-
ican Association of Orthodontists in the 1920's, advocated the ex-
traction of teeth as the only means to successfully treat certain mal-
occlusions and was publicly admonished by his colleagues for such
heretical views; but Tweed, Strang and others quickly showed that
extraction of teeth was a practical way to solve serious discrepan-
cies between the size of teeth and jaws and that good occlusion with
twenty-eight teeth was better than relapse with thirty-two.
While Americans were emphasizing variabilities in tooth size,
Axel Lundstrom in Sweden introduced the term apical base, noting
that the size of the bony bases supporting the dentitions was a
limiting factor in the size of the dental arches. He thus introduced
the idea of jaw size variability. Grieve and Tweed said, “The only
way you can put marbles neatly into a box, when they are too big,
is to throw some away”; Lundstrom said, “Boxes come in different
sizes too.”
CONCEPT-SKELETAL MORPHOLOGIC VARIABILITY
In formulating his classification system, Angle spoke of the rela-
tionship of the arches to one another, implying that it was not only
the individual teeth that might be in malrelations in malocclusion.
Students of facial growth, notably Broadbent, Higley, and Margo-
lis in America and Hofrath in Germany, subsequently developed
and perfected the technic of radiographic cephalometry for longi-
tudinal studies of craniofacial development. Cephalometrists soon
realized that craniofacial skeletal disharmonies could contribute as
significantly to malocclusion as could extremes of tooth size and
position.
Brodie, a pupil of Angle's, using the new idiom of cephalomet-
rics, described facial patterns through time, thus showing the persis-
tence of facial harmony or disharmony. And Downs, a colleague of
Brodie's, reasoned that ideal occlusions probably would be found in
90
faces of ideal skeletal relationships, that an ideal morphology should
be the setting for an ideal occlusion, and that malrelationships of
skeletal parts predispose to malocclusion. Thus was born the first
cephalometric analysis.
Downs, Wylie, Margolis, Tweed, Steiner, Ricketts and many
others presented cephalometric-geometric methods for assessing
skeletal morphology, assessing the positions of the teeth within the
face, and depicting where they wished to place individual teeth.
Clinical problems became easier to describe and delineate as the
cephalogram provided a quantitative method of communication
among clinicians throughout the world. Furthermore, cephalomet-
ric analysis provided a means of testing clinical hypotheses. Favored
treatment methods were abandoned because they failed when tested
by the objective methods of cephalometry.
CONCEPT MUSCLE FUNCTION
A number of years prior to the advent of cephalometrics, Rogers
called attention to the role of the musculature in the development
of occlusion and in the stabilization of occlusal relationships and
advocated the use of muscle exercises to improve the tonicity of the
muscles. Furthermore, Andresen and other Europeans developed
appliances that harnessed neuromuscular forces to guide the teeth
during eruption and, some claimed, altered the growth of the crani-
ofacial skeleton itself. Thompson wrote of the importance of the
resting position of the mandible and the significance of functional
malocclusions.
In 1949, I introduced facial and jaw electromyography and along
with Jarabak, Perry, Eschler, and others analyzed the differences in
jaw function among patients with varying malocclusions and cranio-
facial skeletons. Thus the idea that the muscles were a determining
and variable factor in relating the jaws to one another was intro-
duced. No new appliances were born out of this concept with the
exception of the Activator and its many derivatives, which Andresen
had introduced earlier in Europe. Americans, however, generally
paid little heed to functional jaw orthopedics. Perhaps this was
because the photographs appearing in journals of treated cases re-
vealed less precisely positioned teeth than Americans could achieve
with bracketed appliances, or perhaps it was because Europeans
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Mainstreams in American Orthodontic Thought
were slower to adopt cephalometrics, so that studies of the skeletal
effects of functional jaw orthopedic appliances were long delayed.
Though Americans were sensitized to the craniofacial musculature
at this time and our basic knowledge was given a broader base, the
attention drawn to the musculature did not itself alter orthodontic
mechanotherapy or treatment concepts.
CONCEPT-BONE GROWTH, PATTERN
For years orthodontists and their colleagues in anthropology
and anatomy wrote extensively but indefinitely about craniofacial
growth, for there was no good method for its study in humans. The
first cephalometer was described by an Italian radiologist, Pacini,
in 1922. Hofrath in Germany and Broadbent in the United States
presented more sophisticated instruments in the late 1930's. Mar-
golis and Higley also devised and described cephalometers at about
the same time. While most modern cephalometers are derived from
Higley's instrument, it was Broadbent’s paper on the growth of the
normal face that altered forever orthodontic thinking. It is impor-
tant to note that Broadbent, Margolis and Higley all devised instru-
ments for accurate positioning of the head to obtain serial, stan-
dardized radiographs in order to study growth of the bones of the
craniofacial skeleton and not to diagnose malocclusions. These in-
struments made it possible to study the growth of the entire cranio-
facial skeleton and its effects on occlusal relationships. There quickly
followed the classic papers of Brodie, Higley, Meredith, Krogman
and many others, for it was now possible to study quantitatively
craniofacial growth and occlusal development in live humans.
The ability not only to measure growth but also to assess
changes in morphology was to become very significant later, for the
early clinical cephalometrists, following Brodie's ideas on pattern,
assumed rigid and unchanging relationships of all parts of the fa-
cial skeleton during growth. They spoke of the “genetic pattern” of
facial growth, but there were no genetic studies to confirm the inflex-
ibility of the prevailing attitudes. Wylie, a geneticist, orthodontist,
and pupil of Brodie, derisively spoke of this strict misinterpretation
as “orthodontic Calvinism”, for some believed the face was almost
predestined to grow in its own preordained pattern, thus limiting
92
orthodontic treatment to simple positioning of teeth within an im-
mutable facial skeleton. (Later genetic, clinical and animal stud-
ies revealed this misconception to be due to the crudeness of the
measurements and the statistical designs.)
Misperceptions about the growth pattern encouraged interest
in prediction of facial growth and the inappropriate use of cephalo-
metric standards in Orthodontic practice. The elaborate cephalo-
metric data which had been developed enabled comparisons of a
patient to a standard derived from an appropriate population or to
a standard (“ideal”) conceived to be superior in esthetics or sta-
bility. There still remained the problem with respect to standards,
however, as to what is best for the individual patient. (Some aspects
of the problems of growth standards in Orthodontics are dealt with
in another essay in this volume—“On Measurement of Facial Form
and Growth”) Cephalometric research revealed morphologic and
growth variations, but the question remained, could orthodontists
purposefully alter the bones of the growing face?
CONCEPT-BONE GROWTH, ADAPTABILITY
AND ALTERABILITY
The idea of tight genetic control of facial growth persisted as
a strange paradox in a field necessarily dependent on its ability to
alter bone to achieve success. Laboratory studies on animals indi-
cated that there was likely no direct genetic control of bone, while
Dutch biologists, notably van der Klaauw and van Limborgh, de-
scribed skull growth as passive responses to encircling functional
components. Moss, a dentist and an anatomist, following the lead
of the Dutch, promulgated what came to be known as “the func-
tional matrix hypothesis”; all changes in bone origin, growth and
maintenance are secondary, compensatory, and obligatory responses
to the functional needs in nearby nonskeletal tissues. The theory,
while hard to prove or disprove, has been provocatively useful to
bone biologists and clinicians alike, for its appearance forced a re-
thinking and realignment of ideas about bone growth and its possible
alteration.
While the theories were debated, a series of important animal
experiments were reported by Petrovic in France and McNamara
and Carlson in the United States that clearly demonstrated that
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Mainstreams in American Orthodontic Thought
rats’ and monkeys’ facial and jaw bones could be altered remarkably
under laboratory conditions. Whatever the genetic control mecha-
nisms affecting bone, they were obviously far more imprecise than
many Orthodontists thought; further, both the French and American
studies somewhat simulated the conditions of certain functional jaw
orthopedic appliances. Americans suddenly discovered appliances
that Europeans had used for nearly half a century. (Ironically, Euro-
peans had begun to adapt the American bracketed appliances.) The
result was a new interest in early treatment of skeletal dysplasias by
craniofacial Orthopedic appliances and the role of abnormal function
on facial growth (e.g., “mouth breathing”), a general reassessment
of the modes of action and limitations of all orthodontic appliances,
and attempts to define just which bony areas in the face and jaws
could be altered and what were the optimal times for doing so.
CONCEPT-INTEGRATED TREATMENT
The fusion of ideas of dental development, muscle maturation,
and bone biology into an interrelated cohesive understanding of
craniofacial growth and adaptation is now rapidly taking place. Fur-
thermore, clinical research, which in my opinion is usually more dif-
ficult to do well than animal experimentation, is starting to adopt
new standards of rigor. With such progress in methods and un-
derstanding, it seems but a short step to the idea that muscles,
teeth, and bones all should be integrated conceptually and practi-
cally in any treatment of malocclusion or craniofacial dysmorpho-
genesis, and it follows that this treatment should not be geared to a
population mean or “ideal” arbitrarily imposed because of the clini-
cian's perspectives. Rather, it is necessary to relate the activities of
the muscles, the positions of the teeth and the growth of the jaws to
the needs and demands of an individual face, to the functional econ-
omy of one child in its own ecology. This idea is not new; A. Leroy
Johnson in the 1920's spoke of an “individual norm”, and Aristotle
suggested that each person should be judged by a measure within
him/her. But only now is it possible for the clinician to begin to
think of this concept in a practical way.
To apply an integrated, individualized treatment concept to one
patient, it is necessary for orthodontists to devise modes and meth-
ods that will permit treatment at any age required by the individual
94
patient and to relate such treatment to the individual’s growth. For
this new concept to work, we must also have advanced far enough
in our diagnostic skills to quantify the individuality of each patient
in order that treatment goals may be derived primarily from the
patient being treated and applied to his/her specific needs (esthetic,
psychological, oral health, etc.).
Of course this concept is not in daily practice, as are major
portions of all concepts discussed thus far, but research and under-
standing have advanced sufficiently to enunciate it, to understand
its significance to practice, and to plan and foresee its imminent
development.
CONCEPT EXTENSION OF ORTHODONTIC SERVICES
TO ALL WHO NEED THEM
Societal pressures, the control of dental caries by fluoridation of
communal water supplies, third-party payment schemes, and a large
increase in the number of dentists have all been factors altering the
nature of dental practice, including orthodontics, in America. Fam-
ily dentists and pedodontists are treating many more malocclusions,
but dental school curricula have not correspondingly increased the
amount of Orthodontic training for the undergraduate student. In-
surance companies make provisions for Orthodontic care but not for
control of the quality of service. The public seems to appreciate
orthodontists, but some who need treatment cannot pay for it and
many do not understand the differences between orthodontic treat-
ment and other services (this matter is discussed in the opening
essay in this volume).
Society and the dental profession wish to see all orthodontic
needs met in an equitable manner, but the role of the professions
in our society is changing as are the modes of delivery of health
professional services. A few years ago professional ethics meant fair
treatment of one's own patients. Now we ask, “Who is responsible
for those who receive poor treatment or no treatment at all?”
The problems resulting from general acceptance of this concept
place new responsibilities on the whole dental profession and the
specialty of orthodontics, responsibilities that will be shared, un-
doubtedly, by insurance companies, public health officials, and lay
leaders as well.
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Mainstreams in American Orthodontic Thought
CONCLUSION
Orthodontic thinking has evolved from worry about the posi-
tions of individual teeth to a holistic concern for the individual.
Now the quality and delivery of orthodontic treatment have be-
come a responsibility and interest of many other than orthodon-
tists. It will be interesting to see how we adapt to these exciting
new challenges—and adapt we will, for adaptation to need is the
business of orthodontics.
96
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