EDITORIAL

Fifty years of concern

I f we browse through the 1931 volume of our JOURNAL, then known as the INTERNATIONAL JOURNAL OF ORTHODONTIA, ORAL SURGERY AND RADIOGRAPHY, it is fascinating to explore the titles, graphic statements, and questions asked concerning dentofacial orthopedics. A few involved appliances, heredity, muscle training, nasal obstruction and oral deformities, orthodontic standards, physiotherapy, malocclusion of deciduous dentitions, cleft palate, missing teeth, deep overbite, nutrition and orthodontic treatment, open-bite, orthodontic treatment record, and diagnosis and treatment of Class II malocclusions. Editorials concerning nomenclature, dental laboratories, the public’s and general dentists’ knowledge about orthodontics, dental clinics, orthodontic economics, a new journal’s influence on teaching institutions, commercialism, changes in state dental laws, and public relations were prime topics 50 years ago, just as they are today.

Fifty years ago these conditions were recognized, acted upon, and sent to press. The statement that there is nothing new in dentistry gains validity only when one reflects upon all that has been published but not evaluated, organized, and summarized in order for clinicians to render optimal care for their patients.

Areas of concern do not seem to change over the years. We will mention four for illustration.

There is probably no condition that has had so many terms and meanings applied to it as has the “Class II” case. Many of Edward Angle’s students insisted upon using “Class II” when referring to postero-occlusal conditions. Martin Dewey’ indicated:

The unfortunate thing is that a great many of these men did not understand “Class II” to mean the same thing. Some of them say that a Class II condition is a posterior position of the mandible; others say that it is an underdevelopment of the mandibular arch, while another group says it is a distal relation of mandibular teeth to the maxillary teeth.

Milo Hellman’ stated:

I should also like to confess that, although my objective in treatment of Class II malocclusion is quite definite, I always approached the problem in a sort of doubtful sympathy. In other words, although I usually know exactly what I want to accomplish, I cannot escape the feeling that the treatment of each case of malocclusion is an effort to reach a goal by a trial and error method. There always appears some limiting feature which interferes with complete success. If anyone is inclined to the belief that classifying is diagnosing, he is perfectly welcome to it but the terms are not synonymous.

Another perplexing condition is the open-bite phenomenon, which was also discussed by Hellman3:

In SO far as the reason for success is concerned, I was until now inclined to give the credit to my knowledge, skill, and dogged determination. For the failures I usually blamed the patients. I am now beginning to change my attitude in this respect. It seems to me now that

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there is as little certainty about the knowledge for successful trcauncnt of open bite cases. as there is for their unsuccessful treatment. The fundamental growth characteristics of the tau in the developing child cannot be summed up in one word. “occlusion.“ It is too static a conception. Is there anything in the tooth surface relationship that indicates the sequence of developmental changes that will take place between the ages of 6 and l6? Nothing is more striking than the variations in the individual‘s development.

A constant source of unrest is in the area of respiratory dysfunctions or nasal obstruc- tion. W. Wallace Morrison” wrote:

There is a relationship between obstructed nasal breathing and the mouth-breathing which is the direct result, and the development and formation of the lips, the teeth, the alveolar processes, the head, palate, the bodies of the superior maxillae and the mandible as well as the rest of the structures of the face, including the bony skeleton of the orbit, the nose and the cheek, the facial musculature and other soft tissue parts as well.

That the relationship is, in all probability, not merely one of simple cause and effect is not so generally realized, however. The truth of the matter is that the relationship consti- tutes a problem that is not new and which cannot be fully answered even today, despite many advances in our knowledge.

One of the first papers on the subject was that of M. A. Robert in 1843. He called attention to the connection between high, small, hard palate and obstructed nasal breathing.

In 1873, Tomes, an English dental surgeon, believed that during respiration with the mouth open (obstructed nasal breathing), the tissues of the cheeks are drawn against the posterior teeth, causing them to tilt lingually. Yet many cases have been reported in which the patient had the facial and palatal deformity commonly known as “adenoid facies” without having any nasal obstruction at all.

Informed consent was also a topic of concern 50 years ago in Ernest N. Bach’s presidential address to the Great Lakes Association of Orthodontists.S

The patient should be made acquainted with our limitations in work on his particular case. The impossible and doubtful prognosis, as well as the possible and encouraging termina- tion of the case may well be explained.

It is said that life is short, art is long, and sometimes science seems longer. Years of clinical observations and quantified research concerning the Class II malocclusion have yielded progress, much as a river meanders to the ocean. Many answers have been eroded from the problem’s edge and deposited into our sea of literature. Few individuals, how- ever, take the time to sift through the abundance of information. Most of us repeat history or some workable method of treatment and cling to old rocks and roots without venturing out into the fast and often turbulent current of the mainstream. Perhaps it is time to use a more direct and intense method of investigation, sorting, and recording. Today, 50 years later, many orthodontists treat all malocclusions alike without reference to valuable gains made in both differential descriptionsfi and modes of treatment.

Some use various headgears, some use elastics or springs, others try various combina- tions of tooth removal. Functional appliances are employed, and a few other clincians resort to orthognathic surgery. Never has there been a complete rendition or summary of what can be expected from each of these adjuncts to treatment toward the correction of the at least eleven separate classifications of Class II” that are known. Many descriptive and

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informative articles have been produced and buried under the layers of literature deposited in our libraries. Complete reviews are needed.

In order to spark your positive enthusiasm for investigation, let us partly survey the progress that has been made in the lust 50 years. Areas of improvement have been those of quantifying observations, methods of treatment, and technologic advances.

Obviously, the study of cephalometrics has given us invaluable insight into the de- scription and segregation of many conditions along with quantifying the growth, devel- opment, and treatment changes.

Technologic improvements have been explosive in nature with the sophistication seen in metallurgy, appliance design (three-dimensional bracket control, functional appliances), and plastics in bonding, to name only a few.

Orthognathic surgery has taken a tremendous leap with the onslaught of adult orth- odontics and the recognition of the untreatable nature of some dentofacial problems by orthodontic means alone.

Lacking in construction are those difficult mountain roads that lead toward discovery of the causes of dentofacial discrepancies and thus a development of methods to prevent them. Hypotheses of functional occlusion, which are the foundational roadbeds of orth- odontics, are in a constant state of reconstruction with many detours. The arduous and long-term task of experimental design to prove, disprove, or improve these hypotheses still looms ahead of us. What about the dentitions that have been restored or orthodon- tically improved with modern concepts in mind? Are they being followed long term with proper methods of quantification? Is the continuation of periodontal disease making the task impossible? Who should be providing this vital information?

Brilliant progress is made each year through our universities, various organizations, and as the result of individual efforts. We must keep this foremost in our minds and judiciously siphon off those bits of essential information rather than allow them to stagnate in a pond of unread journals.

Certainly, economic, social, and investigative conditions are not as difficult as they were 50 years ago during the days of Albert Ketcham, Milo Hellman, C.V. Mosby, Charles R. Baker, and Martin Dewey-concerned giants with progress in mind.

Wayne G. Watson

REFERENCES 1. Dewey, Martin: Nomenclature again, editorial, INT. J. ORTHOD. 17: 99-101, 1931. 2. Hellman, Milo: What about the diagnosis and treatment of Class II malocclusion of the teeth? INT. J.

ORTHOD. 17: 113-15.5, 1931. 3. Hellman, Milo: Open-bite, INT. J. ORTHOD. 17: 421-444, 1931.

4. Morrison, W. Wallace: The interrelationship between nasal obstruction and oral deformities, INT. J. OR- THOD. 17: 453-458, 1931.

5. Bach, Ernest N: President’s address, read at the fifth annual meeting of the Great Lakes Association of Orthodontists, Toledo, Ohio, Feb., 16, 1931, INT. J. ORTHOD. 17: 917-920, 1931.

6. Moyers, R. E., Riolo, M. L., Guire, K., Wainright, R. L., and Bookstein, F. L.: Differential diagnosis of Class II malocclusions, AM J. ORTHOD. 78: 477-494, 1980.