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The next twenty years
RAYMOND
THE
NEXT
TWENTY
L.
WEBSTER,
D.M.D.,
YEARS R. I.
PROVIDENCE,
TITLES are oft,times misleading, may I at the outset assure anyone who AS may think he is about, to hear a prophecy, that such is not to be the case. If your essayist were a prophet, the demand for his services abroad would, no doubt, have removed him from these shores long ago. I have been asked to present a paper on the future of our special@-, treating the subject both from the mechanical angle, including myofunctional therapy, and from the social aspect. How can we do t,he most good for the greatest number of children? As to what the future holds for us, we should maintain the highest hopes. On what would these be based ? On our past history. We have come a long way in the last twenty years, but we must not get overconfident, there is still so much room -for improvement. This paper is divided into four parts: postgraduate instruction, mechanics of orthodontics, myofunctional therapy, and the social aspect, reviewing brief?> the lessons learned in the past and trying to interpret them for the future. i\I,v observations will be taken mostly from personal experience and by way of introduction to the first point which I wish to discuss, may I be pardoned in relating a mat,tcr of past personal history. Since 1915, as a st,udent with the late Mart,in Dewey, it has been my privilcq~ to be periodically exposed to the personal teachings of some of our outstanding men in orthodontics, eit,her in conferences or in intensive extension courses. At the beginning of a conference group at Nashville, Term., some pears ago, all that the three men asked who were giving of t,heir time and effort to a groul) of young orlhodontists from all over the States was, “ Throughout, this confercnce, keep an open mind. ” That was not, only sound advice then, it still is, and may I sa,v t,hat after being given first hand the philosophies of Rershon, .Johnson, Oliver, Rogers, Lischer, and St,rang, I could not hell) but be imbued 1)) thcl sinccrit,y and charact,er of ever- one of t,hcsr men. And so when I hrar sl1c.11 strollg tliflrrences of opinion rxprrsse0 ot1 c(Irtain Irlechallical pllases of’ ol+ll(,dontics, I cannot help but feel that if the pliilosol~liics of thcsc mpn wcrc l)(+tcr known, greater benefits would accrue t,o orthodontics. I’OSTGRA~UATE
INSTRUCTION
As universit,ics have right,fully taken the place OC prival.ely controlled sc~hoolsfor postgraduate instruction, I feel t,here should bc more diversification in the different teachings and techniques of orthodontics. Such procedure has for some time been adopted in one university, as was told us by the head of its orthodontic department,, Dr. Waugh, in a paper presented bcforc this Society t,hrce years ag0.l For practicing orthodontists, extension courses were institlltc~d at Columbia in 1927 and 1. have learned that since that time fourteen cours(~s have been given, a total of three hundred orthodontists have taken the courses, and t,hcy have come from thirty-nine states and from three foreign conntrics. Rcml
bcforc
the
New
York
Society
of
CWthodontists.
23
New
York,
N.
Y.,
Nor.
II,
1940.
Think what that has meant IO those orthodontists who conld come on lo New \‘ork, and think what it wonId mean if other 77nivcrsitics could likewise give cxlc77sion courses for the bcnctit- of men in their localities. I am sure there are many in this room today w-170have at some time found themselves in a wry serions yuarldar~ as to wllet,hcr the method lhcqhad Iw1l taught, and were using, was the best for the part-icular cast in hand. Until such extension eo77rses as abore mentioned were institnted, recourse to the literature was the only thing available to the orthodontist, outside of discnssing his problems with some orthodontic friend, and, if the friend were from another school of orthodontic teaching, this procedure was not always so simple. One of tl7e greatest things for the fntnre of orthodontics, in my opinion, will he not only the willingness but also the desire, on t,he part of the different .schools or groups, to beclome thoroughly acquainted with each other’s philosophies and techniques. If they did, with tl7at spirit of open-mindedness, I think they would bc willing to admit and make 71x of the good to be found in the other fellow’s teachings, and in addition to the fundamentals of orthodontics their postgraduate stndents would go out wit,17 a rounder knowledge of orthodont,ic techniclues and philosophies, and a greater sense of open-mindedness for fnturc stncly. ivH3CHIAsICS
Mechanics, we must all admit, will ever be necessary in a certain percentage of our cases, and while the pendnlum swung back and forth as to the amonnt and kind of appliances to be employed, with the attending opinions as to the manner of tooth movement which could be expected of them, other problems also preseriting themselves in this connection bronghl- out some very important research. I refer to the problems of retention in which we were asking o77rsclves if o77r applianw t,herapy had been instituted at t,he best time. Howard’s invest,igations on endocrine disturbances were most valuable in determining if and when to render appliance therapy; and the studies of Ilclttnan, Todd, and many others helped LLS in determining the best, devclopmcntal ages at which to give appliance lrcatment. Next came gnathostatics wit,h t,hc claim Ihat it wonld aid 77sin dd.crmir7ing t,hc direction of toot,h movement necessary in cases of malocclusion and, by thus restoring them to their correct relationship to skull anatomy, give promise of morr permanency of our results. This was about the time that tt7c more complex al7plianccs were being most strongly eondcmned and the swing was to simpler tylws. 1 recall that my lwrsonal rea&on to gnathostatics was l,hat, wllilc T felt that it did show me the faulty relation of the dent,ures to skull anatomy, it left rt7e tathcr out on a limb in knowing how to correct that condit,ion with the ap17lianccs that I was then employing. This, as you may surmise, was most,ly in W111lc~d ion with the SO-CiIllCd (“lass II, or distocl77sior7, casts. I, Ihci~cfoi~c, made a snrvey of all eases 77ndcr trcatmmit~ mid fo77rid tti;it, wltilc I was pretty ~~11 satisfied with Ihc progress of the ncutroclnsion casts, 1 hc distocl77sion wses were giving mc some real Iro77ble. I was familiar witli all 1t7c wilic+wis I had heard, and perhaps contributed lo, of the so-called rigid ;ll)~)liil1lWS, hl7l T had ills0 SW11 som(: of Ill? fi1lc IYSlllts ol1laincd 1)y mCll wlio rt:alIy krtcw the mwhanism ; a77tl wii 17 1110077(~1ho11gh1 in nrirrd Ihal il’ J could
bring up my average by gett,ing better results in that one group of C~SCY that was giving me trouble, it would be worth while to try this type of appliance. Since taking that step may I give you my reactions. I feel there are certain types of cases that do present a mechanical problem, requiring tooth movement which calls for the most stable anchorage that it is possible to obtain and maintain; and if we wish to bring about t,he best possible result in this type of case, not only at the completion of active treatment, but also as the final result, we must, turn to the more complicated appliances. I have not found the matter of conspicuousness so important to the patient, as the period of active treatment with this type of appliance is of shorter duration than the less conspicuous type. As to cleanliness, if the patient cannot keep the teet,h clean above and below a properly fitted and cemented band, could we expect him to keep the enamel surface of a tooth clean under an arch wire which is continually in contact with the tooth itself? Naturally one would not, pick an uncleanly mouth in which to place extensive bands or allo\v a child to wear such an appliance if the child could not maintain thorough prophylaxis. The term rapid tooth movement is often misinterpreted. Its advocates do not mean the rapid movement, of individual teeth, but rather the mass movement of teeth which is made possible by the construction and action of the mechanism, hence the shorter time required in the wearing of this type of appliance. As to long retention bcirq necessary after this manner of tooth movement, may I say that I hare more often found t,he reverse to be the case and this maintains in Class I, or neut,rorlusion, cases, as well as in Class II cases. Experience has led me to agree with the princi,ple that if malposed teeth cannot he placed in their correct axial positions and relations to one another, we cannot expect nature to do too much in bringing this about. In regard to the lighter appliances, I would just as strongly urge that their value be better appreciated by the men brought up in the use of the more rigid type. There are so many types of cases that do not present complicated anchorage problems that to see extensive appliances employed in such instances makes the criticism of such a procedure wholly justified, and does much to bring qn undeserrcd condemnat,ion of the mechanism a~ a whole and the teachinKs behind it. Now a word about technique. Considerable has been written of late about orthodontic limitations and failures. I am wondering if in some instances this information has not been misinterpreted. To sa)- it another way, has it not somctimcs been employed as a simple means of letting us down easily on some rcsnlts of trcat,ment of which wc were none too proud? ~~00tD~ury says : “An interest in the biologic approach is no excuse fora sloppy technique. Growvth or its aberrations maJ- effect unpredictable changes during the course of any t,reatment, and it is impossible to know I)reciselg how mulch of 111~ change 1 ha.1 is taking I)lacc during treat,ment, be it, desirable or othcrwisc, is due to the operator and how much is due to nature. When changes occur that are undesirable, ii, bccomcs the dllty of the conscient,ious operat,or lo fact the matter as uncoml)rornisingly as possible as hc endeavors to find out, how rni1cli is due t,o fact,ors over which hc has no control and how mnch may bc laid at, the door of his poor judgment or unskillful manipulation. Only the lazy operator will liglit.ly l)lamc nalurc for his own mechanical ineficiency.“*
26
RAYMOND
L.
WEBSTER
The young man just starting out must, of course, he told of the limitations of treatment so that in his enthusiasm he will not attempt or promise too much. However, I think he should be told to guard himself at all times against letting himself off too easily in cases that may not turn out as well as he had hoped. Heredity, endocrine disturbances, individual variation, limitations, etc., all have to be reckoned with, but unless we have reason to believe that they arc involved in our so-called failures, should we not feel challenged to review most carefully the case in question, and be sure that the failure was not ours instead of nature ‘s ? In a paper entitled “Failures in Orthodontic Treatment, ” Hellman writes : “Failures due to inability to carry out successfully the measures indicated are, perhaps, the most numerous in orthodontia. . . . In my estimation, this group of failures should be the least if the skill and proficiency of the orthodontist arc what they are cracked up to be and if t,he treatment of a case is exclusively dependent upon them alone. ‘U Agreed that we have sufficient appliances to meet our needs; but are we as careful in our technique as we could be? The other day a patient from another city came in with as nicely made an appliance in her mouth as one could ask for. In getting her history it evolved t,hat she had been treated by a general practitioner and the appliances were made by an orthodontic laboratory. Now admitting that a poorly made appliance in the hands of an experienced man is better than a well-made appliance in the hands of one who is inexperienced, should wc riot go one step I’urthcr and say that when the general practitioner looks into the mout-h of an orthodontic patient, should he not have reason to feel that a specialist is treating the case? Busy practices do not always make for the most painstaking terhniquc, unless the operator has schooled himself in t,his. Again, are wv(l rendering thch most &icient service to the patient. by having cartfully planned our t.reatment stcl) by step, recorded it, and then followed it? T,ct me draw a picture of a busy orthodontist in the latter part of a full aft c1’110011. The reception room is full, t,he operator is behind in his appointments, and hc looks in the mo~llh of Ihc l)al,ient, just seated, and then looks al. I hc models. AI the institution of’ treatment, he outlined on the card what had t,o be done, but in no successive stages. Now let, us see, what did hc do last time, the appliances seem all right,; nothing loose or uncemented. Take another look at models, now another glance in the mouth. There goes the door buzzer again with another patient coming in. “All right, Mary, I will see you again in three weeks. ’ ’ Now does that mean anyt,hing to you ? It, does to me, for I am drawing this pidure from memory and at t,he end of a day I had seen a lot of patients, but what had I done for them? No harm, at least, perhaps you say. And isn’t such an afternoon tiring? Compare this picture with one in which a careful cast analysis has been made, detailed treatment has been noted and followed. The operator knows just what he has done and what he proposes to do. That does not mean that he has to make an adjustment, a.t every appointment, nor do things always progress as he bad planned. But at least that cast is progressing as st,cadily and in as orderly a manner as it is possible. To the operator who has not followed this
NEXT
TWENTY
YEXRS
27
p~~o~etl~~rc,t.his may all sound very complicated, bllt let me ;ISHIIN him that a1 t llr end of the day lie will no1 fool as 1ircd f’or hc has lY3llly accoml)lished somet tiing. MTOBUXCTIONAL
THERAPY
Here is a phase of orthodontic treatment that should occupy a whole paper itself, due to its importance, rather than bc given 0111-ya part of it. Looking back on the early days of this valuable contribution to orthodontic progress, OIIC of t,he greatest difficulties that the acceptance of myofunctional therapy appeared to have in the earlier teachings of Rogers was the misconception by so many men that it was being substituted for applia.nce therapy. Tt is true that in the very young vases where appliall(*es could Ilot l,e usctl, solt~e lllyofnuc.tioni11 therapy was beneficial; but in all instances at a later age of t,he child, when mechanical interference of the teeth was present, with the jaws held in their normal mesiodistal relationship, t,hese interferences were relieved by simple delicate appliances, and then the muscular development was instituted. For many years now men who have had the faith, the diligence, and the patience to give sufficient time, thought, and study to this phase of orthodontic therapy, which still has boundless potentialities, are receiving their due reward in the service they are rendering their paticnt,s. Men of all different schools of orthodontic teachings are at least pretty well in accord on this particular Its value is stressed in every modern textbook phase of orthodontic therapy. of our specialty and has been covered in many papers presented and articles written by its originator, Dr. A. P. Rogers. When it comes to predicting what the future holds for us in orthodontics, I should say much, in view of what is unfolded to us as we learn more about myofunctional therapy. SOCIAI~
ASPECT
The so&l aspect in connection with the future of orthodontics presents this question : How can we do the most good for the greatest number of children ? This might he discussed from two different angles : first, in private practicc ; second, in institutional clinics. Floyd E. Gibbin in 1936 had this to say: “If our profession is to attain the highest goal of useful service, then it must devise ways and means of providing orthodontic service for the 95 per cent of the population who earn only a modest income. ‘U He then went on to suggest that in our private practice, while maintaining the highest qualit,y of service, we endeavor to dcvclop a greater personal and office efficiency, thereby producin, m orthodontic service at a lower cost, in order that fees might be brought within the reach of a greater number of patients. Now on this point, might not this question he asked : Is it not usually true that in all walks of life the man who enjoys his vocation is the one who usually does the best work at it,? While some orthodontists are happiest with everything clicking in their office like an assembly line in an automobile plant, others could not carry on this way and do their best work. Extensive educational publicity amon, v both the dental profession and the laity regarding the beneficial results which may be accomplished through the interception and prevention of malocclusion was also suggested by Dr. Gibbin, and since that time, as we all know, much has been done in this endeavor.
In the cil.ics where lhwc arc’ dental schools or clinics such as the Eastman Or F’orsyth, the I)oorer (glasses i,ll’C receiving some orthodontic scrvicc, l)ut as in all branches of tlic healing art, the middle class really gets ilic least charit,ablc They cannot, afford the specialist and do not feel inclined to ask consideration. for help in clinics. Xor should the>-, in my opinion; and WC as a profession can do much for them and the good name of our specialty bg giving some of the less valuable hours of our day to rcndcring the necessary service to them. By thus making it, financially possible for these people to have our services, I have found them more than glad to make the effort, of getting their children to the office mornings, other than Saturdays, and furthermore WC find them the most appreciativc parents that WC have to work with. Comparing this with giving our time to clinic work, it is my opinion and experience that, except in such a field as fracture or cleft, palate service, more can be accomplished and our efforts arc more appreciated in our own office in the manner just given than in a clinic. Before concluding this paper, I wish to discuss one further subject llpon which I feel the future of orthodontics is most vitally dependent, namely, the orthodontist ‘s obligation to the patient. the parent, and thereby to the spccialt> of our profession. Owasionally a child while away from home will need some repair or adjustment rnadr to his applianre, and the mother will ask the orthodontist to whom she has bocn rclfwrcd, ‘I How mwh lorqer do you think this has got to go on I ” ,\ftcr many long years she is disroura:;cd, and it, takes only a. split second for him lo bc ec&llly, if not more, discourapd, aftcl, looking the rigging over. So thinking, but ncvcr mumbling to himself. that hc dots not blame her for her loss of faith in orthodontic t,reatment,, he puts on his best, professional manner and gives her the stock answer. h-ow you know what hc sees. Perhaps, a poorl,v fitting baad loose, or an appliance that has to be remade and reshaped in lhc mouth, and when it is all done hc wonders what good it will bc, or was. LC,cr1. Arc they fair ously, though, should such things be in a spwialty such as ours 0’ to the patient, parent, or orthodontics? In my opinion, patients should not be sent, away to schools without propel rcfcrc~ncc t,o another orthodontist which should include original models, etc., and the plan of trcat,ment, step by step, if the referrimg orthodontist wishes to retain the responsibility of the case. Tn most cases where ihc patient goes away to who01 his orthodontist (aan plan on seeing very little of him from th(9 on, for the vawtions during the school term arc short and infrequent, and then when summery (homes, he is away agail). 1 have al\vays thought it ~norr fair all around in such instances to turn that cusc over’ to the man who could carq Let him nianagc it his w;i~ on tlic Ircatmcnt eight or nine months of the par. in all d&ails, the first, man giving him all phases of the case, cvcn to the financial arrangements. Quite naturally the parents may feel that they prefer to continuc and have the work finished by the orthodontist who started the cast, and by being turned over to another they have a feeling of being tossed around. 110~ many times, howcrer, have we seen the+ wishes carried out, with t,he case 1)rolonged and no progress made and much dissatisfaction final 1;~resulting.
We owe it to the layman to explain what is best for his child, giving him the benefit of our experience in such cases. He will see it the right way if we will take the time to discuss it with him from every angle, and he w-ill be grateful to us in the end. ,Z summary of the suggestions made in this paper might be as follows: 1. More diversification of teachings and techniques in postgraduate courses. Adoption by the universities of extension courses for practicing orthodontists. 2. A recognition and desire to make use of what is of real value in the other fellow’s teachings and appliances. 3. Resolve to get more out of myofunctional therapy b>- putting more time and thought into it. 4. Try t,o do more for a greater number of deserving children by utilizing the less valuable office hours of the day. 5. Appreciate your obligation to the patient, the parent, and orthodontics. In closing, may I quote a fe\\, lines which I found in the front of Thwo Score Years and Nine 1~7J>r. (1. I~~dmund Kclls : Yesterday Tomorrow Today-this
and its mistakes are history, Forget them not. is a mirage-is always afar, Count not upon it. glorious day-is here, is I\‘OU~S, Make the most of it. REFERENCES
1. Waugh,
Leuman M.: Tile Trentl of CliC!al Orthodunticaa, Part I, Ar. J. O~TII~U~~TIC~ 25: 419, 1939. 2. Woodhur,y, William \Y. : Tlw Treml of Orthotlontic Teaching and Investigation as a Prmary Dental Concern, AK J. ORTHODWTICS 26: 130, ltJ40. 3. IIellman, Milo: Failures in Orthodontic Treatment, Ax J. ORTHODCPXTICS 22: 343, 1936. 4. Gillbin, Floyd E.: Efficient Practice Management as a Means of Increasing the Quality of ant1 Extending the Availnl,ility of Orthodontic ,Ser\-ice, IST. J. OETHODOXJTII 22: 1126, 1936. 155
ANGELI,
STREET
THE
NEXT
TWENTY
L.
WEBSTER,
D.M.D.,
YEARS R. I.
PROVIDENCE,
TITLES are oft,times misleading, may I at the outset assure anyone who AS may think he is about, to hear a prophecy, that such is not to be the case. If your essayist were a prophet, the demand for his services abroad would, no doubt, have removed him from these shores long ago. I have been asked to present a paper on the future of our special@-, treating the subject both from the mechanical angle, including myofunctional therapy, and from the social aspect. How can we do t,he most good for the greatest number of children? As to what the future holds for us, we should maintain the highest hopes. On what would these be based ? On our past history. We have come a long way in the last twenty years, but we must not get overconfident, there is still so much room -for improvement. This paper is divided into four parts: postgraduate instruction, mechanics of orthodontics, myofunctional therapy, and the social aspect, reviewing brief?> the lessons learned in the past and trying to interpret them for the future. i\I,v observations will be taken mostly from personal experience and by way of introduction to the first point which I wish to discuss, may I be pardoned in relating a mat,tcr of past personal history. Since 1915, as a st,udent with the late Mart,in Dewey, it has been my privilcq~ to be periodically exposed to the personal teachings of some of our outstanding men in orthodontics, eit,her in conferences or in intensive extension courses. At the beginning of a conference group at Nashville, Term., some pears ago, all that the three men asked who were giving of t,heir time and effort to a groul) of young orlhodontists from all over the States was, “ Throughout, this confercnce, keep an open mind. ” That was not, only sound advice then, it still is, and may I sa,v t,hat after being given first hand the philosophies of Rershon, .Johnson, Oliver, Rogers, Lischer, and St,rang, I could not hell) but be imbued 1)) thcl sinccrit,y and charact,er of ever- one of t,hcsr men. And so when I hrar sl1c.11 strollg tliflrrences of opinion rxprrsse0 ot1 c(Irtain Irlechallical pllases of’ ol+ll(,dontics, I cannot help but feel that if the pliilosol~liics of thcsc mpn wcrc l)(+tcr known, greater benefits would accrue t,o orthodontics. I’OSTGRA~UATE
INSTRUCTION
As universit,ics have right,fully taken the place OC prival.ely controlled sc~hoolsfor postgraduate instruction, I feel t,here should bc more diversification in the different teachings and techniques of orthodontics. Such procedure has for some time been adopted in one university, as was told us by the head of its orthodontic department,, Dr. Waugh, in a paper presented bcforc this Society t,hrce years ag0.l For practicing orthodontists, extension courses were institlltc~d at Columbia in 1927 and 1. have learned that since that time fourteen cours(~s have been given, a total of three hundred orthodontists have taken the courses, and t,hcy have come from thirty-nine states and from three foreign conntrics. Rcml
bcforc
the
New
York
Society
of
CWthodontists.
23
New
York,
N.
Y.,
Nor.
II,
1940.
Think what that has meant IO those orthodontists who conld come on lo New \‘ork, and think what it wonId mean if other 77nivcrsitics could likewise give cxlc77sion courses for the bcnctit- of men in their localities. I am sure there are many in this room today w-170have at some time found themselves in a wry serions yuarldar~ as to wllet,hcr the method lhcqhad Iw1l taught, and were using, was the best for the part-icular cast in hand. Until such extension eo77rses as abore mentioned were institnted, recourse to the literature was the only thing available to the orthodontist, outside of discnssing his problems with some orthodontic friend, and, if the friend were from another school of orthodontic teaching, this procedure was not always so simple. One of tl7e greatest things for the fntnre of orthodontics, in my opinion, will he not only the willingness but also the desire, on t,he part of the different .schools or groups, to beclome thoroughly acquainted with each other’s philosophies and techniques. If they did, with tl7at spirit of open-mindedness, I think they would bc willing to admit and make 71x of the good to be found in the other fellow’s teachings, and in addition to the fundamentals of orthodontics their postgraduate stndents would go out wit,17 a rounder knowledge of orthodont,ic techniclues and philosophies, and a greater sense of open-mindedness for fnturc stncly. ivH3CHIAsICS
Mechanics, we must all admit, will ever be necessary in a certain percentage of our cases, and while the pendnlum swung back and forth as to the amonnt and kind of appliances to be employed, with the attending opinions as to the manner of tooth movement which could be expected of them, other problems also preseriting themselves in this connection bronghl- out some very important research. I refer to the problems of retention in which we were asking o77rsclves if o77r applianw t,herapy had been instituted at t,he best time. Howard’s invest,igations on endocrine disturbances were most valuable in determining if and when to render appliance therapy; and the studies of Ilclttnan, Todd, and many others helped LLS in determining the best, devclopmcntal ages at which to give appliance lrcatment. Next came gnathostatics wit,h t,hc claim Ihat it wonld aid 77sin dd.crmir7ing t,hc direction of toot,h movement necessary in cases of malocclusion and, by thus restoring them to their correct relationship to skull anatomy, give promise of morr permanency of our results. This was about the time that tt7c more complex al7plianccs were being most strongly eondcmned and the swing was to simpler tylws. 1 recall that my lwrsonal rea&on to gnathostatics was l,hat, wllilc T felt that it did show me the faulty relation of the dent,ures to skull anatomy, it left rt7e tathcr out on a limb in knowing how to correct that condit,ion with the ap17lianccs that I was then employing. This, as you may surmise, was most,ly in W111lc~d ion with the SO-CiIllCd (“lass II, or distocl77sior7, casts. I, Ihci~cfoi~c, made a snrvey of all eases 77ndcr trcatmmit~ mid fo77rid tti;it, wltilc I was pretty ~~11 satisfied with Ihc progress of the ncutroclnsion casts, 1 hc distocl77sion wses were giving mc some real Iro77ble. I was familiar witli all 1t7c wilic+wis I had heard, and perhaps contributed lo, of the so-called rigid ;ll)~)liil1lWS, hl7l T had ills0 SW11 som(: of Ill? fi1lc IYSlllts ol1laincd 1)y mCll wlio rt:alIy krtcw the mwhanism ; a77tl wii 17 1110077(~1ho11gh1 in nrirrd Ihal il’ J could
bring up my average by gett,ing better results in that one group of C~SCY that was giving me trouble, it would be worth while to try this type of appliance. Since taking that step may I give you my reactions. I feel there are certain types of cases that do present a mechanical problem, requiring tooth movement which calls for the most stable anchorage that it is possible to obtain and maintain; and if we wish to bring about t,he best possible result in this type of case, not only at the completion of active treatment, but also as the final result, we must, turn to the more complicated appliances. I have not found the matter of conspicuousness so important to the patient, as the period of active treatment with this type of appliance is of shorter duration than the less conspicuous type. As to cleanliness, if the patient cannot keep the teet,h clean above and below a properly fitted and cemented band, could we expect him to keep the enamel surface of a tooth clean under an arch wire which is continually in contact with the tooth itself? Naturally one would not, pick an uncleanly mouth in which to place extensive bands or allo\v a child to wear such an appliance if the child could not maintain thorough prophylaxis. The term rapid tooth movement is often misinterpreted. Its advocates do not mean the rapid movement, of individual teeth, but rather the mass movement of teeth which is made possible by the construction and action of the mechanism, hence the shorter time required in the wearing of this type of appliance. As to long retention bcirq necessary after this manner of tooth movement, may I say that I hare more often found t,he reverse to be the case and this maintains in Class I, or neut,rorlusion, cases, as well as in Class II cases. Experience has led me to agree with the princi,ple that if malposed teeth cannot he placed in their correct axial positions and relations to one another, we cannot expect nature to do too much in bringing this about. In regard to the lighter appliances, I would just as strongly urge that their value be better appreciated by the men brought up in the use of the more rigid type. There are so many types of cases that do not present complicated anchorage problems that to see extensive appliances employed in such instances makes the criticism of such a procedure wholly justified, and does much to bring qn undeserrcd condemnat,ion of the mechanism a~ a whole and the teachinKs behind it. Now a word about technique. Considerable has been written of late about orthodontic limitations and failures. I am wondering if in some instances this information has not been misinterpreted. To sa)- it another way, has it not somctimcs been employed as a simple means of letting us down easily on some rcsnlts of trcat,ment of which wc were none too proud? ~~00tD~ury says : “An interest in the biologic approach is no excuse fora sloppy technique. Growvth or its aberrations maJ- effect unpredictable changes during the course of any t,reatment, and it is impossible to know I)reciselg how mulch of 111~ change 1 ha.1 is taking I)lacc during treat,ment, be it, desirable or othcrwisc, is due to the operator and how much is due to nature. When changes occur that are undesirable, ii, bccomcs the dllty of the conscient,ious operat,or lo fact the matter as uncoml)rornisingly as possible as hc endeavors to find out, how rni1cli is due t,o fact,ors over which hc has no control and how mnch may bc laid at, the door of his poor judgment or unskillful manipulation. Only the lazy operator will liglit.ly l)lamc nalurc for his own mechanical ineficiency.“*
26
RAYMOND
L.
WEBSTER
The young man just starting out must, of course, he told of the limitations of treatment so that in his enthusiasm he will not attempt or promise too much. However, I think he should be told to guard himself at all times against letting himself off too easily in cases that may not turn out as well as he had hoped. Heredity, endocrine disturbances, individual variation, limitations, etc., all have to be reckoned with, but unless we have reason to believe that they arc involved in our so-called failures, should we not feel challenged to review most carefully the case in question, and be sure that the failure was not ours instead of nature ‘s ? In a paper entitled “Failures in Orthodontic Treatment, ” Hellman writes : “Failures due to inability to carry out successfully the measures indicated are, perhaps, the most numerous in orthodontia. . . . In my estimation, this group of failures should be the least if the skill and proficiency of the orthodontist arc what they are cracked up to be and if t,he treatment of a case is exclusively dependent upon them alone. ‘U Agreed that we have sufficient appliances to meet our needs; but are we as careful in our technique as we could be? The other day a patient from another city came in with as nicely made an appliance in her mouth as one could ask for. In getting her history it evolved t,hat she had been treated by a general practitioner and the appliances were made by an orthodontic laboratory. Now admitting that a poorly made appliance in the hands of an experienced man is better than a well-made appliance in the hands of one who is inexperienced, should wc riot go one step I’urthcr and say that when the general practitioner looks into the mout-h of an orthodontic patient, should he not have reason to feel that a specialist is treating the case? Busy practices do not always make for the most painstaking terhniquc, unless the operator has schooled himself in t,his. Again, are wv(l rendering thch most &icient service to the patient. by having cartfully planned our t.reatment stcl) by step, recorded it, and then followed it? T,ct me draw a picture of a busy orthodontist in the latter part of a full aft c1’110011. The reception room is full, t,he operator is behind in his appointments, and hc looks in the mo~llh of Ihc l)al,ient, just seated, and then looks al. I hc models. AI the institution of’ treatment, he outlined on the card what had t,o be done, but in no successive stages. Now let, us see, what did hc do last time, the appliances seem all right,; nothing loose or uncemented. Take another look at models, now another glance in the mouth. There goes the door buzzer again with another patient coming in. “All right, Mary, I will see you again in three weeks. ’ ’ Now does that mean anyt,hing to you ? It, does to me, for I am drawing this pidure from memory and at t,he end of a day I had seen a lot of patients, but what had I done for them? No harm, at least, perhaps you say. And isn’t such an afternoon tiring? Compare this picture with one in which a careful cast analysis has been made, detailed treatment has been noted and followed. The operator knows just what he has done and what he proposes to do. That does not mean that he has to make an adjustment, a.t every appointment, nor do things always progress as he bad planned. But at least that cast is progressing as st,cadily and in as orderly a manner as it is possible. To the operator who has not followed this
NEXT
TWENTY
YEXRS
27
p~~o~etl~~rc,t.his may all sound very complicated, bllt let me ;ISHIIN him that a1 t llr end of the day lie will no1 fool as 1ircd f’or hc has lY3llly accoml)lished somet tiing. MTOBUXCTIONAL
THERAPY
Here is a phase of orthodontic treatment that should occupy a whole paper itself, due to its importance, rather than bc given 0111-ya part of it. Looking back on the early days of this valuable contribution to orthodontic progress, OIIC of t,he greatest difficulties that the acceptance of myofunctional therapy appeared to have in the earlier teachings of Rogers was the misconception by so many men that it was being substituted for applia.nce therapy. Tt is true that in the very young vases where appliall(*es could Ilot l,e usctl, solt~e lllyofnuc.tioni11 therapy was beneficial; but in all instances at a later age of t,he child, when mechanical interference of the teeth was present, with the jaws held in their normal mesiodistal relationship, t,hese interferences were relieved by simple delicate appliances, and then the muscular development was instituted. For many years now men who have had the faith, the diligence, and the patience to give sufficient time, thought, and study to this phase of orthodontic therapy, which still has boundless potentialities, are receiving their due reward in the service they are rendering their paticnt,s. Men of all different schools of orthodontic teachings are at least pretty well in accord on this particular Its value is stressed in every modern textbook phase of orthodontic therapy. of our specialty and has been covered in many papers presented and articles written by its originator, Dr. A. P. Rogers. When it comes to predicting what the future holds for us in orthodontics, I should say much, in view of what is unfolded to us as we learn more about myofunctional therapy. SOCIAI~
ASPECT
The so&l aspect in connection with the future of orthodontics presents this question : How can we do the most good for the greatest number of children ? This might he discussed from two different angles : first, in private practicc ; second, in institutional clinics. Floyd E. Gibbin in 1936 had this to say: “If our profession is to attain the highest goal of useful service, then it must devise ways and means of providing orthodontic service for the 95 per cent of the population who earn only a modest income. ‘U He then went on to suggest that in our private practice, while maintaining the highest qualit,y of service, we endeavor to dcvclop a greater personal and office efficiency, thereby producin, m orthodontic service at a lower cost, in order that fees might be brought within the reach of a greater number of patients. Now on this point, might not this question he asked : Is it not usually true that in all walks of life the man who enjoys his vocation is the one who usually does the best work at it,? While some orthodontists are happiest with everything clicking in their office like an assembly line in an automobile plant, others could not carry on this way and do their best work. Extensive educational publicity amon, v both the dental profession and the laity regarding the beneficial results which may be accomplished through the interception and prevention of malocclusion was also suggested by Dr. Gibbin, and since that time, as we all know, much has been done in this endeavor.
In the cil.ics where lhwc arc’ dental schools or clinics such as the Eastman Or F’orsyth, the I)oorer (glasses i,ll’C receiving some orthodontic scrvicc, l)ut as in all branches of tlic healing art, the middle class really gets ilic least charit,ablc They cannot, afford the specialist and do not feel inclined to ask consideration. for help in clinics. Xor should the>-, in my opinion; and WC as a profession can do much for them and the good name of our specialty bg giving some of the less valuable hours of our day to rcndcring the necessary service to them. By thus making it, financially possible for these people to have our services, I have found them more than glad to make the effort, of getting their children to the office mornings, other than Saturdays, and furthermore WC find them the most appreciativc parents that WC have to work with. Comparing this with giving our time to clinic work, it is my opinion and experience that, except in such a field as fracture or cleft, palate service, more can be accomplished and our efforts arc more appreciated in our own office in the manner just given than in a clinic. Before concluding this paper, I wish to discuss one further subject llpon which I feel the future of orthodontics is most vitally dependent, namely, the orthodontist ‘s obligation to the patient. the parent, and thereby to the spccialt> of our profession. Owasionally a child while away from home will need some repair or adjustment rnadr to his applianre, and the mother will ask the orthodontist to whom she has bocn rclfwrcd, ‘I How mwh lorqer do you think this has got to go on I ” ,\ftcr many long years she is disroura:;cd, and it, takes only a. split second for him lo bc ec&llly, if not more, discourapd, aftcl, looking the rigging over. So thinking, but ncvcr mumbling to himself. that hc dots not blame her for her loss of faith in orthodontic t,reatment,, he puts on his best, professional manner and gives her the stock answer. h-ow you know what hc sees. Perhaps, a poorl,v fitting baad loose, or an appliance that has to be remade and reshaped in lhc mouth, and when it is all done hc wonders what good it will bc, or was. LC,cr1. Arc they fair ously, though, should such things be in a spwialty such as ours 0’ to the patient, parent, or orthodontics? In my opinion, patients should not be sent, away to schools without propel rcfcrc~ncc t,o another orthodontist which should include original models, etc., and the plan of trcat,ment, step by step, if the referrimg orthodontist wishes to retain the responsibility of the case. Tn most cases where ihc patient goes away to who01 his orthodontist (aan plan on seeing very little of him from th(9 on, for the vawtions during the school term arc short and infrequent, and then when summery (homes, he is away agail). 1 have al\vays thought it ~norr fair all around in such instances to turn that cusc over’ to the man who could carq Let him nianagc it his w;i~ on tlic Ircatmcnt eight or nine months of the par. in all d&ails, the first, man giving him all phases of the case, cvcn to the financial arrangements. Quite naturally the parents may feel that they prefer to continuc and have the work finished by the orthodontist who started the cast, and by being turned over to another they have a feeling of being tossed around. 110~ many times, howcrer, have we seen the+ wishes carried out, with t,he case 1)rolonged and no progress made and much dissatisfaction final 1;~resulting.
We owe it to the layman to explain what is best for his child, giving him the benefit of our experience in such cases. He will see it the right way if we will take the time to discuss it with him from every angle, and he w-ill be grateful to us in the end. ,Z summary of the suggestions made in this paper might be as follows: 1. More diversification of teachings and techniques in postgraduate courses. Adoption by the universities of extension courses for practicing orthodontists. 2. A recognition and desire to make use of what is of real value in the other fellow’s teachings and appliances. 3. Resolve to get more out of myofunctional therapy b>- putting more time and thought into it. 4. Try t,o do more for a greater number of deserving children by utilizing the less valuable office hours of the day. 5. Appreciate your obligation to the patient, the parent, and orthodontics. In closing, may I quote a fe\\, lines which I found in the front of Thwo Score Years and Nine 1~7J>r. (1. I~~dmund Kclls : Yesterday Tomorrow Today-this
and its mistakes are history, Forget them not. is a mirage-is always afar, Count not upon it. glorious day-is here, is I\‘OU~S, Make the most of it. REFERENCES
1. Waugh,
Leuman M.: Tile Trentl of CliC!al Orthodunticaa, Part I, Ar. J. O~TII~U~~TIC~ 25: 419, 1939. 2. Woodhur,y, William \Y. : Tlw Treml of Orthotlontic Teaching and Investigation as a Prmary Dental Concern, AK J. ORTHODWTICS 26: 130, ltJ40. 3. IIellman, Milo: Failures in Orthodontic Treatment, Ax J. ORTHODCPXTICS 22: 343, 1936. 4. Gillbin, Floyd E.: Efficient Practice Management as a Means of Increasing the Quality of ant1 Extending the Availnl,ility of Orthodontic ,Ser\-ice, IST. J. OETHODOXJTII 22: 1126, 1936. 155
ANGELI,
STREET