DIAGNOSIS IN ORTHODONTICS: THEORY AND PRACTICE

J. A. SALZMANN, D.D.S., NEW YORK, N. Y.

INTRODUCTION

The truism that “An honest confession is good for the soul,” has been a
constant feature of orthodontic meetings. Time and again, some of the fore-
most men in orthodontics have come before us in the true spirit of the humble
scientist to remind us how little we actually know about orthodontics. Their
words of admonition have often acted as a balance wheel, checking our tend-
ency to become overconfident of our practical accomplishments. Frequently
other men in the field of cognate research and science have come before us
bringing us their findings and correlations which have added to our enlighten-
ment. On occasion, however, some of the so-called enlightening talks were
found to solve no problems and only tended to render us more confused than
ever. The reason for this confusion is that many a man has seen fit, knowingly
or not, to present his contributions in a manner that, while creating the im-
pression of profound erudition on the part of the speaker, severely detracted
from the value of his contribution. Furthermore, there has been too much of
a tendency for writers and speakers in orthodontics to clothe the obvious and
well-known in terms of the mysterious.
There is an enormous lag at present between the science of orthodontics
as it is recorded in our literature and the art of orthodontics as it is practiced
in our offices. This being so, it seems to me that it is of importance for us
to stop occasionally and take stock of the wealth that we possess in the form
of accumulated scientific knowledge ; to appraise this wealth ; t,o consider whether
or not we are benefiting by it, and: indeed, if it is usable wealth. In other
words, it is just as important for us to correlate the facts that we already know
as it is to learn new facts.
Gesellll has stated that : “The practicing pediatrician has three functions :
diagnosis, therapy, and supervision, and the greatest of these is diagnosis.” One
might paraphrase his advice. The practicing orthodontist also has the same
three functions : diagnosis, therapy, and supervision, and likewise, “the great-
est of these is diagnosis. ”
BASIS OF ORTHODONTIC DIAGNOSIS

The term diagnosti may be defined as the determination of the nature of

disease or deviation from the normal physical, functional or mental state.
Therefore, a specific norm is a prerequisite of diagnosis. Various norms have
been established with the aid of the basic sciences, such as anatomic, physio-
logic, biometric and other norms by means of which the measurement of the
deviations from the normal state of man is effected.
Read before the New York Society of Orthodontists on Feb. 23, 1942.
414
 DIAGNOSIS IN ORTHODONTICS 415

In orthodontics, diagnosis is of an anatomic or morphologic nature because

dentofacial anomalies which concern the orthodontist are, in their final analysis,
deviations from an accepted anatomic norm. These anatomic deviations may
be pathognomonic of, concomitant with, or sequelae to certain local and gen-
eral bodily disturbances of prenatal or postnatal origin, or both.
Throughout the years orthodontists have erroneously used the term diag-
nosis as a synonym for classification and vice versa. It is not my intention to
question the validity of Angle’s classification which has successfully withstood
the test of time for over half a century. Nor, I believe, was it the intention of
Hellman to criticize Angle’s classification per se, when he recently called atten-
tion to the confusion resulting from Angle’s1 indiscriminate use of the term
diagnosis when speaking of classification. Hellman himself, however, in his
article on “Diagnosis in Orthodontic Practice ’ ‘I4 fails to clarify the issue, espe-
cially when he states: “It did not matter much (whether orthodontists confuse
diagnosis with classification) because the result was the same, insofar as the
outcome of orthodontic treatment was concerned.” Although the title of H’ell-
man’s paper is “Diagnosis in Orthodontic Practice,“14 what he actually dis-
cusses there is the measurement of facial growth in relation to his designated
stages of dental development which, while an important item in diagnostic
procedure, is not all of diagnosis.

DIAGNOSTIC PROCEDURE IN ORTHODONTIC PRACTICE

The complete examination of the patient must, of course, precede any

attempt at diagnosis. Examination may include any or all of the following
procedures :
1. Written record:
a. Medical history of patient’s family.
b. Medical history of the patient.
c. Dental history of the patient.
2. Clinical dentofacial examination:
a. Facial
b. Dental
3. Biometric examination:
a. Skeletal
b. Cephalic
c. Gnathostatic
4. Roentgenographic and photographic examination:
a. Intraoral
b. Extraoral
e. Orthophoric”
d. Skeletal, e.g., carpal

The family medical history is an aid in determining the presence of sys-

temic disturbances, which may be of genetic, endocrine, nutritional or other
origin. The family dental history should include a record of the condition of
periodontal disease, marked caries and other oral diseases ; the prevailing types
of occlusion, abnormalities of tongue size ; abnormalities of the lips, masticatory
and facial muscles.
*Roentgenograms cm photographs taken along the same parallel lines but at different
intervals.
416 J. A. SALZMANN

The medical history of the patient should include congenital and acquired
defects, nutritional status, presence of infection, allergic manifestations, en-
docrine disturbances, and other diseases as well as accidental injuries. Posture
and gait should be noted. Pillowing and other pressure habits during sleep
should be ascertained, as well as the relative amounts of sleep, rest, and play.
The height and weight of the child at the time of the first examination and
at subsequent re-examinations should be fitted into the individual’s channel on
Wetzel’~~~ grid. Loss of weight may be due to malnutrition, tuberculosis,
metabolic disturbances, general chronic infections, extensive dental caries or
painful oral infections, nervous and emotional disturbances. To the contrary,
excessive appetite or thirst may be due to gastrointestinal disturbances, diabetes
mellitus, or fevers. The child should be followed according to his own normal
rate of physical advancement rather than compared with averages of other
children.
The clinical examination of t,he teeth should concern itself with the sequence
of eruption, velocity of eruption, and the time of shedding of individual teeth,
as well as the presence of infection in the teeth and gums. It should be deter-
mined whether the eruption pattern is in accordance with the ,general develop-
ment and state of maturity of the individual child. The teeth should be exam-
ined while in occlusion ; when the jaws are open, and when the mandible is
going through its various excursive movements.
The dental examination which confines itself to the physical inspection of
t,he teeth and the classification of the existing malocclusion, even when supple-
mented by dental roentgenograms and the usual plaster casts, cannot be con-
sidered a sufficient basis for determining the need for orthodontic treatment id
the growing child.
The biometric examination, in the form of facial measurement, has value
in the individual examination of the child only when considered in relation
to one or more previous or subsequent examinations at stated intervals. The
amount and rate of progress over a period of time are of significance in the
diagnosis of growth. A single examination in a growing child is not a reliable
method of determining the rate and direction of growth.
Measurements may be made on the face itself or on orthophor? distance
roentgenograms and on orthophoric” photographs. Direct measurements may
be compared and a comparison of percentage increments may be made, or
orthophoric roentgenograms may be traced and the tracings superimposed and
the differences in proportions noted.
Ordinary dental casts are not alone adequate for diagnostic purposes in
orthodontics for the following reasons :
1. Only the occlusal relation of the teeth is presented.
2. Lack of development cannot be shown in relation to adjacent landmarks
of the head.
3. Asymmetry of the arches is not related to the head in the three planes
of space.
4. The degree of angulation of the dentures or plane of occlusion is not
represented in relation to a fixed plane.
l Orthophoric-along the 8mne parallel linen.
 DIAGNOSISfN ORTHODONTICS 417
Dental castsshould presentan exactportrayal of the details of the anatomy
of the teeth, alveolar processes, alveolo-buccal folds, palate, attachments of
muscles and frenums, as well as the relationship of the maxillary to the man-
dibular arch and their relationship to the cranium and face. Dental casts
should also portray dentocranial deviations and abnormalities in height, width,
and length of the denture and its growth in one or more of the three planes of
space and of the angulation and inclination of the teeth in relation to the face
and cranium.
It is not always necessary to use all of the diagnostic techniques available
to the orthodontist for the practical purpose of establishing a diagnosis for
planning treatment in each individual patient. This is especially true in the
correction of positional deviations of individual teeth when sufficient space is
present to bring them into occlusal alignment. Although the examination
should be complete, it must at all times adhere to a practical basis. If no cor-
relative systemic conditions are disclosed, the orthodontist should confine him-
self to the dental findings alone. ’ Only such diagnostic methods should be fol-
lowed as might be of value in treatment planning, the observance of precau-
tionary measures, avoidance of contraindicated techniques and in obtaining a
successful termination of treatment.
Diagnosis in orthodontics actually includes consideration of the following :
1. Etiologic factors responsible for the deviation from the accepted ana-
tomic norm.
2. Classification of the anomaly according to the type or direction of devia-
tion from the accepted dentofacial norm.
3. Correlation of etiology and classification with the maturative age of the
patient, including bone age and nutritional status.
These three factors must be ascertained as accurately as possible in order
to decide on the time, type, intensity, direction, and duration of treatment. We
shall consider each item in this basic triology of diagnosis in turn.

Fig. 1.

CLASSIFICATION OF ETIOLOGIC FACTORS

Etiologic factors in dentofacial anomalies usually manifest themselves in

a highly interrelated state (Fig. 1) and may be classified as (1) prenatal, and
(2) p ostnatal
.. ? according
.-- _ to the time when they originate. It should be remem-
418 J. A. SALZMANN

bered, however, that what is sometimes accepted as cause of a dentofacial

deviation may in effect be but an incidental expression of some other pre-
existing cause or the precursor or some succeeding cause.
1. Prenatal causative factors may be grouped as follows:
a. Genetic or hereditary-those transmitted by the genes.
b. Differentiative-those which are inborn or engrafted upon the
body in the prefunctional, embryonic developmental stage.
c. Congenital-those which may be hereditary or acquired, but
which exist at birth.
2. Postnatal causative factors may be divided as follows:
a. Developmental-those which manifest themselves during the
active growth period.
b. Functional-those due to lack of, or faulty function or to over-
function.
c. Environmental or acquired.

PRENATAL ETIOLOGIC FACTORS

When considering the influence of heredity and environment, it must be

kept in mind that the genetic endowment, which is a prenatal factor, exerts a
definite influence on the method and severity with which both prenatal and
postnatal environmental phenomena are likely to express themselves on the
physical well-being of the child. In other words, it is not a question of attribut-
ing certain etiologic factors either to heredity or environment. Since one in-
fluences the other, it may well be heredity and environment which are respon-
sible for certain dentofacial anomalies.
The teeth and jaws, like other organs, and the body as a whole, may or
may not reach the full potentialities of their inherent prenatal growth pattern.
Genetic, ontogenetic and environmental forces which insure normal occlusion
by their proper interaction can produce malocclusion if they fail to react prop-
erly. Furthermore, all etiologic forces, whether prenatal or postnatal, may
express themselves either singly or in combination in a constitutional or dento-
facial form, or in both forms.
The various etiologic factors in malocclusion may produce disturbances
in the structure, function and form of the dentofacial tissues. These disturb-
ances may be symmetrical or asymmetrical and of varying degrees of severity.
They may be confined to one tooth, to several teeth, or to the entire denture;
they may involve the csseous structure of the jaws alone, or all of the foregoing.
Genetic factors are transmitted by the genes, which may endow the child
with unfavorable as well as favorable characters. Castle? describes as lethal
genes, those which produce babies so malformed as to be stillborn, and as sub-
lethal genes, those which are responsible for harmful, but not necessarily fatal,
anomalies which may be present at birth or may manifest themselves at any
period during the life of the individual. The harmful effects produced by the
sublethal genes may take the form of hereditary diseases and malformations
of the muscles, sense organs, the blood and other systems. They may render
the individual more susceptible to certain diseases, habits, or even to accidental
traumatic injuries in his postnatal environment.
 DIAGNOSIS IN ORTHODONTICS 419

The fact that certain characteristics of the face and teeth of vertebrates,
including man, are inherited with a regularity which would make possible the
prediction of the recurrence of these characteristics in subsequent generations
and in accordance with Mendelian laws, has been shown by numerous writers,
as StockardZg and his collaborators working with dogs, and recently in humans
by Lebow and Sawin,17 who presented a pictorial pedigree of seven generations,
including 42 individuals,
Ritter,Z4 in a study of 126 fraternal and 96 identical twins, found that
monovular twins generally show concordance of malocclusion, while discord is
more common in biovular twins. Burks6 found deficiency in number of the
teeth to follow a genetic pattern and to be transmissable both from the father
and mother. A high coefficient of correlation has also been found to exist. in
many of the facial dimensions of parents and their offspring.13
Genetic factors may be summarized as follows:
1. Dentofacial clefts.
2. Bimaxillary protrusion and atresia.
3. Macro- and micromandibular growth.
4. Anomalies of structure, size, number, and position of teeth.
5. Ectodermal dysplasias.
In order for an anomaly to warrant being considered of genetic origin, it
must have occurred and been well-defined in several relatives and must follow
the Mendelian laws of transmission. A genetic diagnosis of malocclusion should
not be made on the basis of a single case of recurrence in a family.
Diflerentiative factors in malocclusion may be recognized by the failure of
the embryo to undergo normal morphologic differentiation in one or more of
its dentofacial components. These are ontologic deficiencies which occur in the
early, prefunctional embryonic stage and are not necessarily of genetic origin.
Spemann28 has shown that inductive factors, present in certain cells which he
calls “organizers” or “organizators,” dominate t,he earliest stages of develop-
ment of the various organs of the embryo. Brodie4 is in fact referring to these
‘ ‘ organizers, ’ ’ as originally described by Spemann, when he speaks of “a series
of ‘fields, ’ or ‘differentiated areas, ’ each destined to give rise to its own par-
ticular tissue or organ,” as appearing in the nonspherical stage of the fer-
tilized ovum.
Failure of certain organizers to function may result, for example, in com-
plete arrest of development of, facial components. Dysfunction of the organ-
izers of the dent,ofacial components is responsible for certain developmental
deficiencies and abnormalities of the mouth and the teeth, including harelip,
cleft-palate and other dentofacial anomalies.
Congenital dentofacia’l malformations, i.e., anomalies present at birth, may
be due to an abnormal state of the mother during pregnancy, such as malnutri-
tion, endocrine disturbance, infectious disease, such as syphilis, as well as to
morphologic, metabolic, nutritional and traumatic disturbances of the fetus
itself.
Holt and McIntosh16 have shown that the so-called irposition of comfort”
or posture of the fetus during gestation is often responsible for gross, asym-
metries and developmental anomalies of the head, face, and jaws, ranging from
420 J. A. SALZMANN

dislocations of the mandible to atrophy of one or more of the dentofacial

components.
Accidents of pregnancy and childbirth as well as genetic and differentia-
tive causative factors are also responsible *for congenital anomalies which dis-
tort the inherent growth pattern.
MurphyZ1 found harelip and cleft palate to be the most common defects
involving the musculo-skeletal system. He found congenital abnormalities to
occur twenty-five times more frequently in families already possessing a mal-
formed child than in the general population.
Congenital factors may be summarized as follows:
1. Abnormalities in pregnant mother-nutritional, endocrinopathic, infec-
tious.
2. Disturbances of fetus-metabolic, nutritional, developmental.
3. Accidents of pregnancy and childbirth trauma.

POSTNATAL ETIOLOGIC FACTORS

Postnatal causative factors occur as a result of developmental deficiencies,

functional disturbances, and environmental interferences.
Developmental dentofacial anomalies of postnatal origin are dependent on
the nature and severity of the disturbance which occurs during the growth
period. Wetzel,34 by means of his “Grid Technique,” has shown that the
progress of ‘ ‘ physical fitness ’ ’ in the child is disturbed by disease, malnutrition,
and other unfavorable growth conditions. Todd 3o Broadbent 3 Francis e and
others found children retarded in general skeletal growth to be usually reiarded
also in tooth development and in facial growth.
General postnatal developmental factors may be summarized as follows:
1. Anomalies in rate of growth of various body organs.
2. Muscular weakness.
3. Endocrine, nutritional, metabolic and infectious diseases.
4. Anomalies of dentofacial growth.
5. Anomalies of tooth development, and eruption.
Postnatal fuw.ctional factors in malocclusion are especially important dur-
ing childhood, since function and form are interrelated. Baker,2 Cieszynski,s
Rogers,25 Wallis, and others have shown the interdependence of muscular
function and jaw growth. Rogers’25 method of myofunctional therapy is baaed
on the principle of modification of form by function. Selmer-Olsen,2s however,
points out that function has no effect on the basal growth of the jaws beyond
the limits set by the inherent growth pattern and that continued stimulation
of the jawbones beyond this pattern by orthodontic means or otherwise will
tend to break down the jawbones.
The functional effect of the physical nature of food, as well as the method
of mastication and deglutition, are considered by Wallace,s1 Waugh,33 Price,22
and others to be causative factors in normal, as well as in abnormal, jaw
development.
Postnatal functional factors may be summarized as follows:
1. Muscular disturbances.
2. Neurotrophic, endocrine, and nutritional deficiencies.
 DIAGNOSIS IN ORTHODONTICS 421

3. Respiratory disturbances.
4. Postural defects.
5. Disturbances in forces of occlusion.
6. Dentofacial muscular insufficiency or hyperfunction.
7. Loss of teeth or disease interfering with mastication.
Postnatal environmental or acquired factors of malocclusion are perhaps best
known to practitioners of orthodontics and include all of the various general
and local physical disturbances which interfere with the growth and normal
relationship of the teeth and jaws. If it is possible for orthodontists to produce
desirable modifications in the occlusion of the teeth and relationship of the
jaws by means of force exerted locally by orthodontic appliances, it is reason-
able to conclude that local forces resulting from disease, malnutrition, trau-
matic accidents, malfunction, harmful pressure habits, etc., to which persons
may be subject during life, may exert a deleterious effect on the rate and
direction of growth as well as on the anatomic relationship of their dentofacial
components.
Whether or not local forces, as just mentioned, will produce, or can produce,
dentofacial anomalies in a specific individual depends on their combination
and interaction in each case. For example, neither malfunction nor harmful
pressure habits are likely to produce malocclusion unless some other factor
which affects bone stability is present.
Postnatal environmental factors may be summarized as follows:
1. Diseases indirectly affecting the dentofacial components.
2. Accidental trauma.
3. Disturbance in forces of occlusion.
4. Premature loss or prolonged retention of deciduous teeth.
5. Delayed or accelerated eruption of teeth.
6. Diseases of the dentofacial components.
7. Dentofacial trauma.
8. Dentofacial habits ; pressure habits.
The following, based on an elaboration and modification of terms employed
by Lischer,ls may he regarded as a primary diagnostic classification of dento-
facial anomalies from the standpoint of their etiologic origin and according to
the extent and severity of the manifested deviation:
I. Cephalic anomalies: Deformities of the osseous components of
the head in general which affect dental occlusion and dentofacial
development. Treatment of malocclusion by orthodontic means
alone in these cases is not effective and is usually of questionable
value even as an adjunct to surgery.
II. Dysgnathic anomalies: Gross developmental abnormalities of the
jaws and oral structures which influence dentofacial relationship.
These gross abnormalities may affect the maxilla, the mandible,
or both jaws. They are usually not amenable to orthodontic
treatment,, excepting as an adjunct to surgical or other therapy
or when confined to the dental arches alone when sufficient basalar
bone is present to accommodate all of the teeth, otherwise extrac-
tion of individual teeth may be necessary.
422 J. A. SALZMANN

III. Eugnathic anomalies: Positional anomalies of the teeth alone

which influence occlusion. Orthodontic therapy is, as a rule,
highly effective in these types of malocclusion.
Dentofacial deviations, when considered from the etiologic point of view,
may thus be seen to be the local symptomatic manifestations, the end results,
or both, of underlying causes which, as a rule, cannot be specifically determined.
Different etiologic factors may be responsible for the same type of malocclusion
and, contrarily, malocclusions of the same type may be due in whole or in part
to various unrelated etiologic fa.ctors. Orthodontists are well aware that
patients with malocclusion of similar classification and degree of severity may
respond differently to the same method or so-called “system” of treatment.
In view of the foregoing, etiology alone is not sufficient for establishing a
diagnosis requisite to the choice of a procedural method in the treatment of
malocclusion.

CLASSIFICATION IN RELATION TO THE DENTOFACIAL NORM

According to Quetelet, 23 biometrics is one of the methods that may be

used in establishing biologic norms. The norm is accepted to be M + u (M
denoting the middle value), in other words, the norm is the middle value with-
in a range of certain plus or minus deviations. It may readily be seen that
some anomalies may well fall within the limits of the norm. Whether or not
certain occlusal and dentofacial deviations actually are within the normal or
the abnormal range in a particular individual depends on the body-type of the
particular individual in whom they occur.
Types of classification according to various norms may be summarized as
follows :
1. Tooth and jaw relationship-Angle.
2. Skull and denture relationship-Simon, Broadbent.
3. Facial growth related to dental development.-Hellman.
Norms for the classification of dentofacial anomalies have been variously
established by different men. However, the reliability of the different norms
has been questioned and their postulation has led to interminable discussion
and a great deal of objection, mainly because the norms were found to be not
invariable. The fact remains that the men who established the different norms
usually admitted their shortcomings. Thus SimonzT pointed out that his norm
must be regarded in the light of the “as-if” theory propounded by Vaihinger ;
that it was a “necessary fiction. ”
The aim of diagnosis in orthodontics, however, is not the blind pursuit
of the elusive dentofacial or dental norm. Consideration must be given to the
body-type and general state of health of the patient, the rate and direction of
facial growth and dental development, such as the presence or absence of teeth
in their accepted or normal positions, and in their proper sequence according
to the state of maturation, bone age, and nutritional status of the individual
patient. As an important afterthought, it should be remembered that true
symmetry is never found in biologic entities. It can be seen, therefore, that,
while classification is one part of diagnosis, it is by no means all of diagnosis.
 DIAGNOSIS IN ORTHODONTICS 423

“DEVELOPMENT AND GROWTH” IN DIAGNOSIS

In view of the dynamic influence of what is generally known as “develop-

ment and growth” on the occlusion of the teeth, it was only natural that the
deficiency ‘of the static method of classification of malocclusion should become
generally recognized and other methods should be sought as a basis of classifica-
tion as an aid in diagnosis.
Mershon,*O as a result of his clinical observations, was among the first
to call attention to the factor of inherent differentiation and growth which takes
place in the child regardless of the presence or absence of orthodontic treatment.
Hellman,15 Broadbent, Brodie,5 and others in our country and orthodontists
elsewhere then began to probe into the question of so-called “growth and
development, ’ ’ which has since become a fetish in orthodontics. In a recent
publication Hellman states : “Now, there is more being claimed about growth
and development than is reconcilable with actual results in orthodontic prac-
tice. ’ ‘l*
In 193’7, Hellman announced his polygons or “wiggles” for the appraisal
of facial dimensions in correlation to his stages of dental development. These
standards are not absolute, but are constructed on a t variation about the mean
of each of the facial dimensions.
Hellman found most faces to show deviation from his normal standards,
or facial polygons. Faces may conform to the normal standard in two planes
and show deviation in the third plane, thus accounting for the variation in
facial measurements in the presence of normal occlusion. Hellman’s standards
are useful in diagnosing the progress or lack of progress in growth of the
face but, as he himself points out,“- appraising the faces of orthodontic
patients does not imply the diagnosis of malocclusion of the dentition.”
While the appraisal of facial growth and dental development alone, as has
been shown, is not all of diagnosis, it is, or we should say, it could be, an
important factor in diagnosis when sufficient knowledge is made available and
the accurate use of facial growth norms and the use of the instruments for
obtaining facial measurements, are more generally understood.

THE MATURATIVE AGE OF THE PATIENT

Age, as used here, refers to the chronologic, anatomic, physiologic, and

maturative or developmental ages. These three ages may or may not coincide
in the same patient. It is important, nevertheless, to correlate these ages in
order to give them due consideration in diagnosis.
Diagnosis in the deciduous dentition has been the terra incognita of
dentistry. The approach to the examination of the dentition of the child
patient by the orthodontist, until comparatively recent years, and this is true
of the general practitioner of dentistry even today, has been that of dealing
with a small-sized adult. However, the examination of the dentition of the
child, whether for general dental operations or orthodontic purposes, must
always be made from the standpoint of the dynamic changes which the occlusion
of the teeth is undergoing as a result of dental development and facial growth.
According to Gesell, l2 “It is not the status at a given moment, but the
growth characteristics of the individual career which are important, from the
424 J. A. SALZMANN

standpoint of child health and protection. Periodic diagnosis then becomes

the basis for developmental supervision.” The same may also be said of ortho-
dontic supervision.
The time factor constitutes a fourth dimension in the measurement of the
dentofacial development of the child and is the basic difference between the
dental or orthodontic examination of the child in contradistinction to that of
the adult.
Differential diaposis in the deciduous and the mixed dentitions is not to
be based on a single examination. The alignment of the permanent teeth
cannot be predicted on the degree of perfection present at any time in the
alignment of the deciduous teeth, nor is interdental spacing in the deciduous
denture an invariable diagnostic sign of normal alignment in the incoming
permanent dentition. Premature loss of deciduous teeth, as we know, is not
necessarily followed by malocclusion. Likewise, the size of the deciduous teeth
is not an index to the size of the permanent dentitian.
Diagnosis of mnlocclusion in the mixed dentition (transition period)
usually is a difficult procedure because the jaws and teeth are undergoing rapid
changes of growth and position, so that many cases of apparent malocclusion
are in effect phases of growth. Conditions in the individual patient that may
be classified as malocclusion at one age level may be considered normal at some
other level, while treatment indicated at one age level may be contraindicated
at some other age level. For example, FriellO has shown that deep overbite in
the unworn deciduous denture at age 3 to 4 years may disappear as wear of the
occluding surfaces of the teeth takes place and the mandible grows, forward.
Similarly, Broadbent has described what he terms “the ugly duckling stage. ”
LewisI* found over 50 per cent of cases of normal occlusion in the deciduous
denture to show malocclusion during the mixed dentition period.
Serial examinations are of especial value during the mixed dentition period,
when the deciduous teeth may be abnormally resorbed, prematurely lost, or re-
tained beyond their physiologic age. Broadbent, Lewis,18 Hellman14 and others
have shown that certain self-corrective changes take place during the mixed
dentition stage.
Diagnosis of dentofacial anomalies when the permanent dentition has
erupted is more positive, and more sustained treatment of the various classifica-
tions of malocclusion, as well as of individual teeth may be undertaken.
Occlusal conditions after the twelfth year are usually the end results of previous
growth changes, although some facial changes still occur, and there is a slight
increase in length of the dental arches when the third molars are erupting.
In conclusion, it is important to point out that each of the foregoing
diagnostic considerations and procedures does not stand alone and cannot be
used individually, but should be employed collectively as a basis of diagnosis
for planning treatment.
There has always been a tendency on the part of so-called practical men
in dentistry, and this is no less true of orthodontics, to deride theory and theo-
rists. Some go so far as to express the belief that we are “too scientific.”
Medicine and its specialties have outgrown these men; how long will it take
dentistry to outgrow them? The one who calls himself a practical man is apt
 DIAGNOSIS IN ORTHODONTICS 425

to ask ‘(What good are all of these theories?” One may as well ask, says
Zinsser,36 “ What good is a newborn baby I ”
Lately there has been such an upsurge in the ranks of the practical men
that mothers now ask us if we can treat children in eleven months and what
kind of bracket bands and wires we intend to use. It is hard to imagine a
mother asking a surgeon what kind of an incision he intends to make, or
what kind of instruments he is going to use. After all, orthodontic appliances
are the instruments-the means-that we use to accomplish desired ends.
The attitude of the practical man who attempts orthodontic treatment
toward those who direct his attention to the basic scientific theory underlying
treatment brings to mind a modified version of a well-known story. I have
reference to the old fable of the sick horse who had fallen and of the professor
who sat down beside him and tried to figure out theoretically how to get the
horse up on his feet, when along came a farmer who twisted the horse’s tail,
quickly bringing him on his feet. However, after the horse walked a few
paces, he again fell down, this time never to get up again. The practical farmer
had neglected to make a diagnosis. It is not a question of getting the horse
up on his feet only, but also how to keep him there.
In orthodontics it is not only a question of therapy-pushing teeth around
-but rather, therapy based on proper diagnosis to determine when and where
teeth belong and whether they will remain in their new positions after they
have been moved. It is the proper correlation of diagnostic method, largely
the work of the theorists, to practical treatment planning that should be the
determining factor in the adoption of a procedural method for the successful
treatment of malocclusion.
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