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Advantages and Disadvantages of Stock Appliances as Compared with Those Especially Constructed for the Case, from a Biologic Standpoint
E llis— Stock Appliances DISCUSSION
T h e odo r Blum, N e w York City. T h e dis cussion of D r. T h o m a s’ paper m ust be con fined m ainly to two points: (1) causes and prevention and (2) treatm ent. I m ust state fran k ly that, in accordance w ith my expe rience, a very appreciable num ber of cases of osteom yelitis a re due to m altreatm ent. T o prev en t such cases, the specialist and the general practitioner of d entistry m ust be ta u g h t a few things—first of all, asepsis in every one of the m any links of the chain w hich m ake up dental and oral surgical treatm ent, beginning w ith prophylaxis, the p re p a ra tio n of a cavity, root canal therapy, extraction, etc. T h e practitioner m ust be tau g h t th a t a lack of knowledge and u n d e r stan d in g is indicated if he curets the socket of a recently extracted tooth on account of p a in ; a procedure w hich to my m ind has caused the developm ent of a larg e num ber of cases of osteomyelitis. As fa r as the trea tm e n t of osteomyelitis itself is con cerned, the practitioner must also learn the uselessness of extracting a tooth du rin g an acute p urulent periostitis, usually called an alveolar abscess. W e cannot a t this point go into the discussion of this misnomer. In 1923, in a pap er on osteomyelitis of the jaw s read before the A m erican Society of O ral Surgeons and Exodontists,1 I stressed the im
621
portance of conservative trea tm e n t of osteo m yelitis. Especially d u rin g the initial stage, the infection is extrem ely virulent. T h e p atien t should be given every chance to build up his resistance and nothing must be done to re ta rd this or break it dow n by p rem ature operative interference su.ch as extraction of teeth, probing or lack of gentleness in exam ining the involved p a rts or in changing dressings. I do not believe in m aking in cisions anyw here or for any purpose but the evacuation of pu s; nor. in stripping off the periosteum fo r any o ther purpose, as it en d angers the patien t’s progress and m aybe his life, as any unnecessary interference would. T h e opening of the cortical plate I h ave n ever had occasion to resort to. It seems quite im portant to me to reexam ine the affected area s by the roentgen rays about every three weeks. T h is procedure is quite an im portant guide as to the progress of the disease and to treatm ent of the case. A ny one of you who w ish to read an instructive treatise on osteomyelitis of the jaw s, I w ish to re fe r to an article by W ilensky.2 T h e article is ex cellent, particu larly if one considers th a t it w as w ritte n by a general surgeon. T h ere are only a few points w hich seem to me not quite in accord w ith accepted dental or oral surgical view s.
2. W ilensky, A. O.: A rch. Surg., 25: 183I. Blum, T h e o d o r: Osteom yelitis of M a n 237 (July) 1932. dible and M axilla, J.A .D .A ., 11:802 (Sept.) 1924-.
ADVANTAGES AND DISADVANTAGES OF STOCK APPLIANCES AS COMPARED W ITH THOSE ESPECIALLY CONSTRUCTED FOR TH E CASE, FROM A BIOLOGIC STANDPOINT* By WALTER H. ELLIS, D.D.S., Buffalo, N . Y. C A S U A L consideration of th e title “ A dvantages and D isadvantages of Stock Appliances as Com pared w ith T h o se Especially C onstructed fo r the
A
*Read before the Section on O rthodontia a t the Seventy-Fourth A nnual Session of the A m erican D ental A ssociation, Buffalo, N. Y., Sept. 14, 1932.
Jour. A .D . A ., April, 1933
C ase” m ight lead to th e conclusion th a t com parison w as to be m ade by illustration and slides between b eautiful custom m ade appliances and the usual m ail order lab o r atory o r supply house product th a t in cludes fu ll trea tm e n t instructions. A fte r the exposition the audience w ould be ex pected to see the obvious, and p refer the
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T h e Journal of the A m erican D en ta l Association
p retty pictures. T h is presentation w ould be easy, but any conclusions draw n from it w ould be rath e r casual and certainly em piric. A n intelligent in terp retatio n of the general subject w ould seem to be one of logic rath e r th an of illustration. T h e r e fore, I have added to the original title prin ted the phrase, “ from a biologic stan d point.” T h e dental jo u rn als contain countless illu strations of each type of appliance, the w ell-m ade esthetic appliance and its opposite, both in the scientific pages and in the advertising sections. T h is recorded literatu re carries a story or teaches a lesson only as our ow n intelligence and know ledge of orthodontia in its broad sense leads us to the proper concept of the principles involved and a correct in terp retatio n of n a tu re ’s law s considered from the biologic aspect. In this discussion, stock appliances w ill be understood to be those m ade by laboratories, w hen the m aker has not re ceived adequate instructions from th e practitioner, and the ordinary supply house appliances m ade by the inexperi enced. T h e appliances especially con stru cted for the case w ill be understood to be those m ade up by, or u nder th e im m ediate supervision of, the orthodon tist, a fte r adequate diagnosis based on case history, models, photographs and roentgenogram s. E nvironm ental and etiologic influences and oth er factors are so intim ately con nected w ith correction and retention as to necessitate their receiving considera tion in all cases. I f these factors are ig nored, mechanics are of questionable value. M echanical therapy m ust be com patible w ith the biologic factors. I f w e all had, by education and from experience and practice, the proper biologic con cept of orthodontia, serious consideration of my subject w ould be unnecessary, be
cause the question raised w ould be satis factorily answ ered before w e started. W e m ust realize th a t m any men do look too casually into o rth o d o n tia, both in theory and in practice. O rth o d o n tia is not m erely a m a tte r of appliances. C ertainly any given case needing ortho dontic therapy can be treated by any one of several m ethods and by m eans of any one of innum erable appliances. N o case can be adequately handled by appliances w ith o u t know ledge, experience and in telligent in terp retatio n of the m any bio logic factors in th e case. A child in need of o rthodontic tre a t m ent is a sick child. A n y th o u g h t of appliances alone w ith o u t consideration of the child as a w hole w o u ld imply the trea tin g of b u t a single sym ptom , and failure to consider the w hole picture, w hich is so necessary to the successful practice. F irst, w h at is o rth o d o n tia? M cC oy w ell defines it as “a study of d en tal and oral developm ent . . . to determ ine the factors w hich co n tro l th e g ro w th proc esses to the end th a t n o rm al functional and anatom ic relationship may be. realized, and . . . to learn the influences necessary to m aintain such conditions w hen they are once established.” T h e r e is n o t one w ord about appliances in th is or in any other adequate definition. W o u ld stock appliances or those con structed especially fo r th e case best fit in w ith this conception of o u r field? N o answ er w ould be reasonable b ut th a t each case should receive such adequate diagnosis as to dem and th a t an appliance be especially constructed to fill a ll the individual needs of the case, and so handled as to m eet environm ental influ ences and to fit the p a tie n t’s ow n func tional individuality. T h is means th a t a careful study of the case history m ust be m ade before the m alocclusion itself
E llis— Stock Appliances can be considered from a treatm ent standpoint. F requently, th e study of the child is of m ore value th an study of the models. I t m ay bring into the picture anything from endocrine im balance to unfavorable environm ent, either of w hich w ould contraindicate success in treatm en t unless elim inated. T h e corrective appliance itself should n atu ra lly be designed to fit the individual need of the case at hand. In planning it, definite questions have to be con sidered seriously: Should the case be treated at a ll? I f so, w hen and in how m any of th e several dimensions should the teeth be moved in relation to the cranium ? Should all o r some of the teeth be m oved? Should they be moved bodily o r tipped or should only a delicate pressure be applied and in such a w ay as to stim ulate the developm ental processes of the child? Should th e appliance be fixed or rem ovable? Should the A ngle ribbon or edgewise arch be used ? Should a plain arch or one used in connection w ith the M cC o y open tube or the K etcham hook be considered? Should lingual arches be em ployed? I f so, w h at type? Soldered to m olar band o r re movable, w ith round or oval soldered anchor post? A nd, in this case, how should w e lock the appliance ? O r should the one piece lingual arch w ith th e torque lock be used ? T h ese and other types of appliances may be considered. W h e n the choice is made, th e p ractitio n er m ust decide how frequently the appliance shall be adjusted, and how m uch pressure shall be applied. T h e re is also th e ques tion as to w hether the pressure should be continuous o r in term itten t. W h e n in te rm itte n t, how long should th e rest periods be? Is the tissue tolerance no r mal or lim ited ? A gain, w hen th e technic is determ ined and th e appliance placed, the question m ust be answ ered, as to
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w h eth e r the tissues w ill take up the m echanical stim ulus as applied by the appliance an d in terp ret it in actual de velopm ental change. If so, w ith w hat speed? T o w h at extent is the patient a good orthodontic subject from this stand point? H o w can all these problem s and others be best solved— by using a stock appli ance o r by using one especially con structed fo r the case by an experienced o rth o d o n tist? I know your answer, but even th e specialist know s too little of his problem s. H e has solved m any of those problem s and discovered diagnostic principles adequate to b ring orthodontic practice o ut of th a t chaos of experim en tatio n and invention of th irty years ago, progress w hich is indeed gratifying, but there are still so m any unsolved prob lems facing us th a t w e feel hum bled, even though stim ulated and intrigued by the tho u g h t of the fu tu re th a t m ust be so fu ll of promise, if th o u g h tfu lly and honestly approached by the young men of today and tom orrow , w ho m ust carry on the research so necessary fo r tru e progress. V aluable as is research, it m ust be coupled w ith or b u ilt upon ex perience, so th a t the m ind w ill subtly m arshal this experience into new com binations an d grad u ally such experience w ill “ click” w ith th e new idea and thus produce the new w ay of solving a prob lem. W e are told by M ershon and Johnson th a t w e can move teeth anywhere, b ut can hold them only w hen they are in conform ity w ith function, and w ith the p atien t’s individual norm al. T h is em phasizes th e im portance of the environ m ental phase of orthodontia, w hich has been accepted by orthodontists, and brings out W o lf ’s law , w hich states th a t modification of stru ctu re in the living individual conform s w ith the m anner of
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T h e Journal of th e A m erican D e n ta l Association
use. T h is law has long been accepted by the m edical profession. W e should make use of m echanical orthodontic appliances only in accordance w ith n a tu re ’s laws of g row th and development. H o w a rd goes so fa r as to say, “T h e theory th a t bone w ill grow u nder the influence of m echanical stim ulation and th a t bone g ro w th can be initiated by m echanical pressure alone has no place in the proper conception of ou r w o rk .” H e fu rth e r states th a t “mechanical stim uli are subservient to inherent gro w th impulses and th e ir application should be sim ultaneous w ith periods of g ro w th ,” and th a t w e should know th ro ugh statistical investigation “ the best psychologic age in w hich to assist n atu re in tre a tm e n t.” H e states also that there are “certain types of g ro w th cases on w hich m echanical stim uli have little or no effect,” “ and th a t th e re certainly are periods of g row th and nongrow th and a propitious period fo r the application of appliances in accord w ith these grow th cycles.” H eilm an calls ou r atten tio n to “ the very com plex n atu re of developm ent as it concerns the hum an fa c e ; th e efficiency w ith w hich this developm ent has been atten ded to for hundreds of thousands of years w ith o u t the aid of orthodontic appliances; the g reat care necessary to determ ine ju st w hen these n atu ra l phenom ena are in need of assistance; and the risk of attem pting to do som ething w ith orthodontic appliances th a t m ight be accomplished in the course of tim e by n a tu ra l developm ent.” T h e decision as to w hich cases w ill im prove w ith o u t trea tm e n t and w hich w ill not is n o t to be arrived at casually. M a rsh all, of C alifornia, has lately shown by experim ent th a t monkeys fed faulty diet show root absorption and do not respond to orthodontic treatm ent,
w hile those on a norm al diet show no such condition, and respond satisfactorily to orthodontic stim ulation. I f these deductions are correct, there are m ore cases w ith poor orthodontic prognosis th an w e have realized. T h is new tho u g h t w ill broaden o u r therapy and place it m ore intim ately in contact w ith the w o rk of the pediatrician, or em phasize that, to un d erstan d o u r prob lem, the o rthodontist should be first a pediatrician. A s ou r problem s become m ore com pli cated, I ask again w hich is m ore ad vantageous for treatm en t, the stock ap pliance or one especially m ade fo r the case afte r a consideration of th e individ ual patien t? D en tists and orthodontists, by the very n a tu re of th eir restorative and corrective w ork, are, in all probability, dealing too generally w ith m aterials and appliances as related to the largely m ental field of prescribing and giving advice and coun sel. A fte r all, the things called appli ances th a t w e use in our w ork are only the relatively u n im p o rtan t tools in an intricate process of therapy. T hose w ho know little an d care less about the biologic n atu re of this process are those w ho th in k and w o rk in term s of appli ances only. T h a t is w h a t I should call m echanistic orthodontia. T h e practice of using m ail o rd er appliances, m ade by laboratories whose service presumes to include advice, is p articularly em piric and mechanistic. In the opinion of the w ell inform ed, m uch dam age can be done by the inadvised use of this arm am en tarium . N o adequate diagnosis can be m ade thro u g h the m ail. E ven if it w ere made, the clinical experience and o rth o dontic ju d g m en t are lacking to in terp ret the findings. T h a t the volume of such appliances used is large is not because there is value in this attem p t to tre a t
E llis— Stock Appliances malocclusion. I t is but a trib u te to the pow er of m odern advertising. A dvertising, by speaking to thousands, usually gets action from a few. I t makes th e individual conscious, by beautiful w ord pictures, of new products th a t are frequently beyond his reach, both finan cially and m entally. A prom inent ad vertising m an says, “ So fa r as advertis ing goes, w e are fallen on evil days. E ven a brief excursion through the aver age new spaper o r m agazine is fo r the advertising m an w ho respects his calling a disheartening experience. T ru e , m uch of the advertising is good, but m uch of it is bad. T h e public does not discrim i n ate.” T h e trea tm e n t of disease by m ail and the advertising relative thereto is fast disappearing, for such advertising is not acceptable to ou r best periodicals and newspapers. O u r ow n attitu d e and th a t of the dental trad e should be equally high m inded as regards th e same prob lems in ou r profession, the treatm en t of malocclusion by m ail by laboratories. A ctually, m ethods of trea tm e n t are sold u n d er the guise of appliances. A n o th er consideration, and w h a t to me is m ore im portant th an any other feature of the interpretation of all our know ledge as applied to diagnosis and treatm en t and how to use it to best serve the interests of ou r little patients, is w h at I w ill te rm orthodontic conscience or judgm ent. T h is last argum ent w ill close my plea fo r especially constructed appliances to best answ er the dem ands of orthodontic treatm en t. As M ille r1 has w ell said, craftsm anship and even know l edge of facts are of sm all value unless interpreted by judgm ent. Surgeons term this surgical ju d g m e n t: w e w ould in this case say orthodontic judgm ent. O rth o dontic ju d g m en t may seem to be almost 1. M i l l e r , C. J . : A m . J. Surg., 13 :325 ( A u g . )
1931.
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intuition, b ut it is m ore th an th at, for it is based upon experience, w hich is the tran slatio n of w h a t w e and others have seen and done and th o u g h t, and also profit gained from o u r mistakes and those mis takes observed in others. O u t of all this comes to th e honest m an an orthodontic conscience w hich dictates w h at he can or cannot do. W e so recognize the o rth o dontic and personal lim itations w hich are present in m any cases. T h is quality in a m an w ill m ake him call for assistance from his confrères m ore frequently, or frankly state the inadvisability of tr e a t m ent. H onesty and sincerity of purpose are certainly m ore im p o rtan t than m a t ters of technic. T h e m an of tru e o rth o dontic conscience, possessing safe ju d g m ent, w ill apply sound principles in thinking his cases th ro u g h before g etting fa r beyond his depth. H is responsibility is indeed a serious one, not to be taken inadvisedly. T h e fu tu re happiness of m any children, in relation to th eir h ealth and appearance, is definitely his obliga tion— an obligation w hich no honest m an w ill take lightly. Im p o rta n t as is an appliance in suc cessful treatm en t, more im portant still is this orthodontic ju d g m en t and ex perience of the men behind the appliance. T h e correct selection, construction and use of the appliance in a given case is the determ ining factor, n ot th e appliance itself. A ppliances may, of course, be constructed to advantage by the p racti tioner, or u n d er his direction, of machine made parts such as w ire, band m aterial, tubes, arches, and brackets, to in terp ret his diagnosis. I t m ust be realized th a t the appliance itself has not inherent ability. I t cannot be purchased as a complete u n it or stock appliance, like a car. T h e o rth o dontic appliance functions efficiently only as it interp rets the know ledge, experience and ju d g m en t of the m ind th a t directs it — no m ore and no less.
T h e odo r Blum, N e w York City. T h e dis cussion of D r. T h o m a s’ paper m ust be con fined m ainly to two points: (1) causes and prevention and (2) treatm ent. I m ust state fran k ly that, in accordance w ith my expe rience, a very appreciable num ber of cases of osteom yelitis a re due to m altreatm ent. T o prev en t such cases, the specialist and the general practitioner of d entistry m ust be ta u g h t a few things—first of all, asepsis in every one of the m any links of the chain w hich m ake up dental and oral surgical treatm ent, beginning w ith prophylaxis, the p re p a ra tio n of a cavity, root canal therapy, extraction, etc. T h e practitioner m ust be tau g h t th a t a lack of knowledge and u n d e r stan d in g is indicated if he curets the socket of a recently extracted tooth on account of p a in ; a procedure w hich to my m ind has caused the developm ent of a larg e num ber of cases of osteomyelitis. As fa r as the trea tm e n t of osteomyelitis itself is con cerned, the practitioner must also learn the uselessness of extracting a tooth du rin g an acute p urulent periostitis, usually called an alveolar abscess. W e cannot a t this point go into the discussion of this misnomer. In 1923, in a pap er on osteomyelitis of the jaw s read before the A m erican Society of O ral Surgeons and Exodontists,1 I stressed the im
621
portance of conservative trea tm e n t of osteo m yelitis. Especially d u rin g the initial stage, the infection is extrem ely virulent. T h e p atien t should be given every chance to build up his resistance and nothing must be done to re ta rd this or break it dow n by p rem ature operative interference su.ch as extraction of teeth, probing or lack of gentleness in exam ining the involved p a rts or in changing dressings. I do not believe in m aking in cisions anyw here or for any purpose but the evacuation of pu s; nor. in stripping off the periosteum fo r any o ther purpose, as it en d angers the patien t’s progress and m aybe his life, as any unnecessary interference would. T h e opening of the cortical plate I h ave n ever had occasion to resort to. It seems quite im portant to me to reexam ine the affected area s by the roentgen rays about every three weeks. T h is procedure is quite an im portant guide as to the progress of the disease and to treatm ent of the case. A ny one of you who w ish to read an instructive treatise on osteomyelitis of the jaw s, I w ish to re fe r to an article by W ilensky.2 T h e article is ex cellent, particu larly if one considers th a t it w as w ritte n by a general surgeon. T h ere are only a few points w hich seem to me not quite in accord w ith accepted dental or oral surgical view s.
2. W ilensky, A. O.: A rch. Surg., 25: 183I. Blum, T h e o d o r: Osteom yelitis of M a n 237 (July) 1932. dible and M axilla, J.A .D .A ., 11:802 (Sept.) 1924-.
ADVANTAGES AND DISADVANTAGES OF STOCK APPLIANCES AS COMPARED W ITH THOSE ESPECIALLY CONSTRUCTED FOR TH E CASE, FROM A BIOLOGIC STANDPOINT* By WALTER H. ELLIS, D.D.S., Buffalo, N . Y. C A S U A L consideration of th e title “ A dvantages and D isadvantages of Stock Appliances as Com pared w ith T h o se Especially C onstructed fo r the
A
*Read before the Section on O rthodontia a t the Seventy-Fourth A nnual Session of the A m erican D ental A ssociation, Buffalo, N. Y., Sept. 14, 1932.
Jour. A .D . A ., April, 1933
C ase” m ight lead to th e conclusion th a t com parison w as to be m ade by illustration and slides between b eautiful custom m ade appliances and the usual m ail order lab o r atory o r supply house product th a t in cludes fu ll trea tm e n t instructions. A fte r the exposition the audience w ould be ex pected to see the obvious, and p refer the
622
T h e Journal of the A m erican D en ta l Association
p retty pictures. T h is presentation w ould be easy, but any conclusions draw n from it w ould be rath e r casual and certainly em piric. A n intelligent in terp retatio n of the general subject w ould seem to be one of logic rath e r th an of illustration. T h e r e fore, I have added to the original title prin ted the phrase, “ from a biologic stan d point.” T h e dental jo u rn als contain countless illu strations of each type of appliance, the w ell-m ade esthetic appliance and its opposite, both in the scientific pages and in the advertising sections. T h is recorded literatu re carries a story or teaches a lesson only as our ow n intelligence and know ledge of orthodontia in its broad sense leads us to the proper concept of the principles involved and a correct in terp retatio n of n a tu re ’s law s considered from the biologic aspect. In this discussion, stock appliances w ill be understood to be those m ade by laboratories, w hen the m aker has not re ceived adequate instructions from th e practitioner, and the ordinary supply house appliances m ade by the inexperi enced. T h e appliances especially con stru cted for the case w ill be understood to be those m ade up by, or u nder th e im m ediate supervision of, the orthodon tist, a fte r adequate diagnosis based on case history, models, photographs and roentgenogram s. E nvironm ental and etiologic influences and oth er factors are so intim ately con nected w ith correction and retention as to necessitate their receiving considera tion in all cases. I f these factors are ig nored, mechanics are of questionable value. M echanical therapy m ust be com patible w ith the biologic factors. I f w e all had, by education and from experience and practice, the proper biologic con cept of orthodontia, serious consideration of my subject w ould be unnecessary, be
cause the question raised w ould be satis factorily answ ered before w e started. W e m ust realize th a t m any men do look too casually into o rth o d o n tia, both in theory and in practice. O rth o d o n tia is not m erely a m a tte r of appliances. C ertainly any given case needing ortho dontic therapy can be treated by any one of several m ethods and by m eans of any one of innum erable appliances. N o case can be adequately handled by appliances w ith o u t know ledge, experience and in telligent in terp retatio n of the m any bio logic factors in th e case. A child in need of o rthodontic tre a t m ent is a sick child. A n y th o u g h t of appliances alone w ith o u t consideration of the child as a w hole w o u ld imply the trea tin g of b u t a single sym ptom , and failure to consider the w hole picture, w hich is so necessary to the successful practice. F irst, w h at is o rth o d o n tia? M cC oy w ell defines it as “a study of d en tal and oral developm ent . . . to determ ine the factors w hich co n tro l th e g ro w th proc esses to the end th a t n o rm al functional and anatom ic relationship may be. realized, and . . . to learn the influences necessary to m aintain such conditions w hen they are once established.” T h e r e is n o t one w ord about appliances in th is or in any other adequate definition. W o u ld stock appliances or those con structed especially fo r th e case best fit in w ith this conception of o u r field? N o answ er w ould be reasonable b ut th a t each case should receive such adequate diagnosis as to dem and th a t an appliance be especially constructed to fill a ll the individual needs of the case, and so handled as to m eet environm ental influ ences and to fit the p a tie n t’s ow n func tional individuality. T h is means th a t a careful study of the case history m ust be m ade before the m alocclusion itself
E llis— Stock Appliances can be considered from a treatm ent standpoint. F requently, th e study of the child is of m ore value th an study of the models. I t m ay bring into the picture anything from endocrine im balance to unfavorable environm ent, either of w hich w ould contraindicate success in treatm en t unless elim inated. T h e corrective appliance itself should n atu ra lly be designed to fit the individual need of the case at hand. In planning it, definite questions have to be con sidered seriously: Should the case be treated at a ll? I f so, w hen and in how m any of th e several dimensions should the teeth be moved in relation to the cranium ? Should all o r some of the teeth be m oved? Should they be moved bodily o r tipped or should only a delicate pressure be applied and in such a w ay as to stim ulate the developm ental processes of the child? Should th e appliance be fixed or rem ovable? Should the A ngle ribbon or edgewise arch be used ? Should a plain arch or one used in connection w ith the M cC o y open tube or the K etcham hook be considered? Should lingual arches be em ployed? I f so, w h at type? Soldered to m olar band o r re movable, w ith round or oval soldered anchor post? A nd, in this case, how should w e lock the appliance ? O r should the one piece lingual arch w ith th e torque lock be used ? T h ese and other types of appliances may be considered. W h e n the choice is made, th e p ractitio n er m ust decide how frequently the appliance shall be adjusted, and how m uch pressure shall be applied. T h e re is also th e ques tion as to w hether the pressure should be continuous o r in term itten t. W h e n in te rm itte n t, how long should th e rest periods be? Is the tissue tolerance no r mal or lim ited ? A gain, w hen th e technic is determ ined and th e appliance placed, the question m ust be answ ered, as to
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w h eth e r the tissues w ill take up the m echanical stim ulus as applied by the appliance an d in terp ret it in actual de velopm ental change. If so, w ith w hat speed? T o w h at extent is the patient a good orthodontic subject from this stand point? H o w can all these problem s and others be best solved— by using a stock appli ance o r by using one especially con structed fo r the case by an experienced o rth o d o n tist? I know your answer, but even th e specialist know s too little of his problem s. H e has solved m any of those problem s and discovered diagnostic principles adequate to b ring orthodontic practice o ut of th a t chaos of experim en tatio n and invention of th irty years ago, progress w hich is indeed gratifying, but there are still so m any unsolved prob lems facing us th a t w e feel hum bled, even though stim ulated and intrigued by the tho u g h t of the fu tu re th a t m ust be so fu ll of promise, if th o u g h tfu lly and honestly approached by the young men of today and tom orrow , w ho m ust carry on the research so necessary fo r tru e progress. V aluable as is research, it m ust be coupled w ith or b u ilt upon ex perience, so th a t the m ind w ill subtly m arshal this experience into new com binations an d grad u ally such experience w ill “ click” w ith th e new idea and thus produce the new w ay of solving a prob lem. W e are told by M ershon and Johnson th a t w e can move teeth anywhere, b ut can hold them only w hen they are in conform ity w ith function, and w ith the p atien t’s individual norm al. T h is em phasizes th e im portance of the environ m ental phase of orthodontia, w hich has been accepted by orthodontists, and brings out W o lf ’s law , w hich states th a t modification of stru ctu re in the living individual conform s w ith the m anner of
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use. T h is law has long been accepted by the m edical profession. W e should make use of m echanical orthodontic appliances only in accordance w ith n a tu re ’s laws of g row th and development. H o w a rd goes so fa r as to say, “T h e theory th a t bone w ill grow u nder the influence of m echanical stim ulation and th a t bone g ro w th can be initiated by m echanical pressure alone has no place in the proper conception of ou r w o rk .” H e fu rth e r states th a t “mechanical stim uli are subservient to inherent gro w th impulses and th e ir application should be sim ultaneous w ith periods of g ro w th ,” and th a t w e should know th ro ugh statistical investigation “ the best psychologic age in w hich to assist n atu re in tre a tm e n t.” H e states also that there are “certain types of g ro w th cases on w hich m echanical stim uli have little or no effect,” “ and th a t th e re certainly are periods of g row th and nongrow th and a propitious period fo r the application of appliances in accord w ith these grow th cycles.” H eilm an calls ou r atten tio n to “ the very com plex n atu re of developm ent as it concerns the hum an fa c e ; th e efficiency w ith w hich this developm ent has been atten ded to for hundreds of thousands of years w ith o u t the aid of orthodontic appliances; the g reat care necessary to determ ine ju st w hen these n atu ra l phenom ena are in need of assistance; and the risk of attem pting to do som ething w ith orthodontic appliances th a t m ight be accomplished in the course of tim e by n a tu ra l developm ent.” T h e decision as to w hich cases w ill im prove w ith o u t trea tm e n t and w hich w ill not is n o t to be arrived at casually. M a rsh all, of C alifornia, has lately shown by experim ent th a t monkeys fed faulty diet show root absorption and do not respond to orthodontic treatm ent,
w hile those on a norm al diet show no such condition, and respond satisfactorily to orthodontic stim ulation. I f these deductions are correct, there are m ore cases w ith poor orthodontic prognosis th an w e have realized. T h is new tho u g h t w ill broaden o u r therapy and place it m ore intim ately in contact w ith the w o rk of the pediatrician, or em phasize that, to un d erstan d o u r prob lem, the o rthodontist should be first a pediatrician. A s ou r problem s become m ore com pli cated, I ask again w hich is m ore ad vantageous for treatm en t, the stock ap pliance or one especially m ade fo r the case afte r a consideration of th e individ ual patien t? D en tists and orthodontists, by the very n a tu re of th eir restorative and corrective w ork, are, in all probability, dealing too generally w ith m aterials and appliances as related to the largely m ental field of prescribing and giving advice and coun sel. A fte r all, the things called appli ances th a t w e use in our w ork are only the relatively u n im p o rtan t tools in an intricate process of therapy. T hose w ho know little an d care less about the biologic n atu re of this process are those w ho th in k and w o rk in term s of appli ances only. T h a t is w h a t I should call m echanistic orthodontia. T h e practice of using m ail o rd er appliances, m ade by laboratories whose service presumes to include advice, is p articularly em piric and mechanistic. In the opinion of the w ell inform ed, m uch dam age can be done by the inadvised use of this arm am en tarium . N o adequate diagnosis can be m ade thro u g h the m ail. E ven if it w ere made, the clinical experience and o rth o dontic ju d g m en t are lacking to in terp ret the findings. T h a t the volume of such appliances used is large is not because there is value in this attem p t to tre a t
E llis— Stock Appliances malocclusion. I t is but a trib u te to the pow er of m odern advertising. A dvertising, by speaking to thousands, usually gets action from a few. I t makes th e individual conscious, by beautiful w ord pictures, of new products th a t are frequently beyond his reach, both finan cially and m entally. A prom inent ad vertising m an says, “ So fa r as advertis ing goes, w e are fallen on evil days. E ven a brief excursion through the aver age new spaper o r m agazine is fo r the advertising m an w ho respects his calling a disheartening experience. T ru e , m uch of the advertising is good, but m uch of it is bad. T h e public does not discrim i n ate.” T h e trea tm e n t of disease by m ail and the advertising relative thereto is fast disappearing, for such advertising is not acceptable to ou r best periodicals and newspapers. O u r ow n attitu d e and th a t of the dental trad e should be equally high m inded as regards th e same prob lems in ou r profession, the treatm en t of malocclusion by m ail by laboratories. A ctually, m ethods of trea tm e n t are sold u n d er the guise of appliances. A n o th er consideration, and w h a t to me is m ore im portant th an any other feature of the interpretation of all our know ledge as applied to diagnosis and treatm en t and how to use it to best serve the interests of ou r little patients, is w h at I w ill te rm orthodontic conscience or judgm ent. T h is last argum ent w ill close my plea fo r especially constructed appliances to best answ er the dem ands of orthodontic treatm en t. As M ille r1 has w ell said, craftsm anship and even know l edge of facts are of sm all value unless interpreted by judgm ent. Surgeons term this surgical ju d g m e n t: w e w ould in this case say orthodontic judgm ent. O rth o dontic ju d g m en t may seem to be almost 1. M i l l e r , C. J . : A m . J. Surg., 13 :325 ( A u g . )
1931.
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intuition, b ut it is m ore th an th at, for it is based upon experience, w hich is the tran slatio n of w h a t w e and others have seen and done and th o u g h t, and also profit gained from o u r mistakes and those mis takes observed in others. O u t of all this comes to th e honest m an an orthodontic conscience w hich dictates w h at he can or cannot do. W e so recognize the o rth o dontic and personal lim itations w hich are present in m any cases. T h is quality in a m an w ill m ake him call for assistance from his confrères m ore frequently, or frankly state the inadvisability of tr e a t m ent. H onesty and sincerity of purpose are certainly m ore im p o rtan t than m a t ters of technic. T h e m an of tru e o rth o dontic conscience, possessing safe ju d g m ent, w ill apply sound principles in thinking his cases th ro u g h before g etting fa r beyond his depth. H is responsibility is indeed a serious one, not to be taken inadvisedly. T h e fu tu re happiness of m any children, in relation to th eir h ealth and appearance, is definitely his obliga tion— an obligation w hich no honest m an w ill take lightly. Im p o rta n t as is an appliance in suc cessful treatm en t, more im portant still is this orthodontic ju d g m en t and ex perience of the men behind the appliance. T h e correct selection, construction and use of the appliance in a given case is the determ ining factor, n ot th e appliance itself. A ppliances may, of course, be constructed to advantage by the p racti tioner, or u n d er his direction, of machine made parts such as w ire, band m aterial, tubes, arches, and brackets, to in terp ret his diagnosis. I t m ust be realized th a t the appliance itself has not inherent ability. I t cannot be purchased as a complete u n it or stock appliance, like a car. T h e o rth o dontic appliance functions efficiently only as it interp rets the know ledge, experience and ju d g m en t of the m ind th a t directs it — no m ore and no less.