The myth of Janus: Orthodontic progress faces orthodontic history.

As a third-generation orthodontist, I am often asked by the parents of my patients to explain how the practice of orthodontics has changed over the past century. Many of the children I treat are second or third generation orthodontic patients, so this question is especially probing. The parents are asking, in effect, how will their child’s orthodontic experience differ from their own? To answer this question, we must view today’s mode of orthodontic practice in light of a century of orthodontic history. Traditionally, the key attributes of a clinical orthodontic practice have been the infrastructure (office equipment and materials), the clinical staffing, the diagnostic technique, the treatment-planning regimen, the clinical treatment rendered, and the philosophy of retention. Each component contributes to how we treat a malocclusion. But missing from this list is the individual orthodontic patient with his or her chief concern and physiologic and anatomic limitations. Today, the patient is the single most important element in orthodontic treatment planning. Without summarizing the numerous advances in orthodontic office design, staff training, material science, bioinformatics, and information technology, I will examine our progress in clinical orthodontic practice. The doctrine of informed consent and the emphasis on the interaction between the orthodontist and the patient shifted our practice paradigm in the 1990s. Before then, patients and orthodontists were thought to have the same goal in treatment: an occlusion characterized by the interdigitation of the mesiobuccal cusp of the maxillary first permanent molar into the buccal groove of the mandibular first molar with little overjet and overbite within the framework of acceptable esthetics and reasonable stability. Orthodontists took a paternalistic stance, viewing all deviations from this ideal as disease and the patient as needing a cure. Although some clinicians defined malocclusion as more of a malformation than a malady, mainstream orthodontics was still wed to the idea of disease. Wylie defined malocclusion as “disproportion between facial parts— parts which in themselves may be within the limits of normal variation, but which are disproportionate when combined with other facial structures and lead therefore to a disproportionate whole.” The central tenet in Angle’s paradigm was that attaining the occlusal ideal would concomitantly produce harmony and balance in the face. Summa’s skull, referred to as Old Glory or Secretum Apertum, was the basis for “ideal” dentoskeletal hard tissue relationships, and the face of Apollo Belvedere was the model for soft tissue facial beauty, balance, and harmony. Even without the aid of modern computer analysis, one can readily discern the lack of correlation between the bimaxillary dentoalveolar pattern of Summa’s skull and the orthognathic facial profile of Apollo Belvedere. Aligning all 32 teeth would not ensure a beautiful profile, as Angle had thought. Although Tweed’s reintroduction of extractions as part of orthodontic treatment was clearly an advance, his reduction of the decision-making process to a simplistic formula, ie, FMIA, was as dogmatic as Angle’s nonextraction philosophy. Today, with the reemergence of the soft tissue paradigm in orthodontics, we recognize that facial appearance and animation, in particular the smile, are multifactorial. When did orthodontic practice diverge from assessing and integrating soft and hard tissue interrelationships? I would argue that the advent of cephalometric radiography was central to this disconnect. Broadbent and Hofrath gave clinicians the ability to look within the dentoskeletal complex and quantify hard tissue relationships. Although this tool was later applied to the integumental profile, it was better suited for measuring hard tissues. Cephalometric radiography allowed orthodontists to serially measure craniofacial growth. Growth studies in Cleveland, Ann Arbor, and Philadelphia used this new technology to create normative data sets. Cephalometric analyses abounded in the 1940s and 1950s, with angular and linear measures used to quantify craniofacial structures. Data from small crosssectional studies and the large longitudinal growthcenter databases were included with these analyses and Am J Orthod Dentofacial Orthop 2003;123:594-6 Copyright © 2003 by the American Association of Orthodontists. 0889-5406/2003/$30.00 0 doi:10.1016/S0889-5406(03)00251-8