The Essence of Diagnosis
One of the most valuable lessons I ever learned was from an art teacher, rather than a dental professor or orthodontic colleague. It was the only art class I ever took, and although I couldn't draw or paint much better after the course than before, I--and I hope my patients--continue to benefit from what I did learn.
One day in class the instructor discussed the various motivations for artistic expression. He said artists draw, paint, or sculpt from what they know, what they feel, and what they see. He felt the secret to being a good artist was not to let what we know and feel interfere with what we actually see.
That isn't bad advice for the orthodontic diagnostician. If we can keep what we think we know and feel from interfering with objective findings, we will probably arrive at much more individualized and accurate diagnoses.
Most dentists enter orthodontic training as empty vessels, because undergraduate orthodontic classes teach little more than the Angle classification of malocclusions. So we are particularly impressionable and vulnerable to authoritarian influences early in our careers. This is when we learn much of what we may regard as sacrosanct from then on.
In my own training, I was taught to diagnose and plan treatment via the Tweed Triangle and the Steiner Analysis. These were systematic approaches available in the '50s and '60s. And they were enormously helpful in rescuing orthodontists from making ad hoc diagnoses.
I once heard a prominent lecturer, who graduated from a top U.S. orthodontic school in the mid-'50s, say that no one in his prestigious orthodontic department knew how to diagnose or plan treatment. They would simply put on some bands, brackets, and wires, and sometimes the teeth would straighten and sometimes they wouldn't. He added that the great appeal of Tweed and the reason Tweed produced such staunch disciples was that he had developed a predictable system of diagnosis and treatment planning when none had existed before.
Before Tweed and Steiner, many diagnoses were done on the basis of how the orthodontist felt about a particular malocclusion. This can be described as an intuitive method--and although some people are highly intuitive, it is a poor way to diagnose orthodontic patients. Besides, how do you teach an intuitive technique to others? You really can't, and that is why there was so much unpredictability in orthodontics at that time.
We now know that Tweed's and Steiner's regimens were too narrowly defined, because they were based entirely on skeletal tissue and there was little allowance for the many normal occlusions and faces that existed outside their strict limits. This is not to disparage the contributions of those orthodontic giants. All subsequent systems of diagnosis and treatment will owe them an enormous debt because they showed us the advantages of systems over no systems. But it is time now to move on to more sophisticated approaches that fully integrate growth potentials, racial differences, soft tissues, personality profiles, and even patients' desires.
For many years I treated every Class II malocclusion as though it were a maxillary protrusion--that is, almost every Class II case got some kind of headgear. And when cooperation was reasonable, we often achieved nice corrections. But I didn't always like the faces I created, because the headgears pushed the maxillae backward so much that the upper lips often lost their contours.
I simply knew that Class II malocclusions could and should be corrected with headgears. I wasn't looking at soft tissues; indeed, we had no good way of evaluating them. I will be eternally grateful to Reed Holdaway for making me aware of the importance of soft tissue analysis and the value of the Visualized Treatment Objective. It isn't the ultimate treatment planning tool, but it is a quantum leap from the reliance on only skeletal tissues.
Simplified systems of diagnosing orthodontic patients are probably doomed from the start, because pertinent data accumulate at an astonishing pace and we just can't ignore their implications. I'm reminded of Einstein telling a colleague that he wanted his Theory of Relativity to be simple, but not too simple. Orthodontic diagnosis should be as simple as possible, but it can't be as simple as we thought it in the past. What we previously knew and felt about diagnosis has been superseded by new information, and it's telling us that collective standards and population averages aren't good enough. We must see and evaluate every patient as an individual.