As most readers know, Dr. Ricketts passed away recently. In memory of one of the giants in the orthodontic profession, we continue with more insights from Dr. Ricketts in his extended interview with Dr. Larry White. We are honored to present these articles and share with the Ricketts' family, the orthodontic community and the world, the sadness of his loss and the joy of his life.

Part 5 of the Interview with Dr. Robert Ricketts, Interviewed by Dr. Larry White

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LWW: American orthodontic journals seem to have become foreign publications as non-USA orthodontists now contribute more than 50% of the articles. Why do you feel this has happened?

RMR: There may be a number of reasons for foreign authors in the

American journals.

First, it should be recognized that orthodontics has become more popular around the world. In addition, years ago there were only a few foreign programs. Now there are many. Thirdly, many of the students in our own schools are from outside the United States. Further, at the graduate level in many schools, we do not have dedicated research-oriented professors. Professorships in many foreign countries are very valued prizes and are coveted. In our present culture, the objective is more on economics than science, perhaps. Hence, there is not the scientific interest.

Some people have become concerned that heavy treatment loads in our graduate programs do not permit time and energy or interest to do much more than a clinical practice. For instance, as a student I was assigned only six patients. Now it’s more like 160.

I have often been asked what led me to a life of science combined with a practice. In fact, my practice has been a huge research laboratory, as I look back. I took records far, far more than the typical practitioner. I spent time in devising studies and accumulating evidence. Even now people accuse me of expressing only opinion, which I resent, but I forgive them because they have no idea of the work research entails or the number of studies I have conducted. If I had an opinion, I stated it. But I spoke from basic studies as evidence based.

Research is time-consuming. Also, studies cannot be performed and written up easily and without someone bearing the costs. It came out of my earnings from my practice together with Dr. Ruel Bench, who was a partner, for seventeen years.

To do research and write papers takes discipline. In order to design and conduct research, a curiosity must become a passion for learning the truth. Secondly, an intellectual background is required. The student must be prepared and ready. The student must also be hungry for success and the happiness that discovery yields.

Perhaps American students today are not the scholars we hope for. I doubt it is lack of brains, because the students I meet are as sharp as ever. Maybe research, writing and innovation are unimportant to the American student and clinician.

LWW: In the not too distant past, many of the articles in our journals were contributed by practicing orthodontists like yourself, Hayes Nance, Reed Holdaway, Silas Kloehn, Charles Tweed, Fred Schudy, etc., but recently there are fewer and fewer publications by clinicians. What do you think has contributed to this and how can we have a remedy?

RMR: If I am not mistaken, as past president of the organization, it was the original policy of the Edward H. Angle Society that members were required to contribute something. This could be only just a case report. But as single patients were labeled anecdotal and non-relative, such reports became frowned upon. However, single case reports are useful in order to demonstrate possibilities. If reported, they should be in long-range follow-ups, as it turns out. Also, with referees looking for faults, many articles from clinicians were rejected, and clinicians lost heart for that kind of effort and the criticism received.

In addition, statistical analysis came to be required for “proof”. Clinicians lose that knowledge, indeed, if they ever were adequate in statistics in the first place.

As mentioned, the designing, collecting of the material, the processing and the doing of analysis takes time and energy away from a clinical practice. It is also costly. After all that, and then having it rejected, is no fun.

In addition, journals have to make money in order to continue. The truth is, I have had several articles rejected because, first, editors have been biased and, secondly, because they feel their readers would not have interest in the subject. Pure research has no purpose for practical application; it seeks only the truth unto itself.

It would thus appear that private clinicians currently are ill prepared to overcome these obstacles.

The remedy is that it’s up to the individual. In the Foundation for Orthodontic Research, we hired Ph D assistants to guide and direct people with scientific interests.

LWW: You have visited, collaborated with and taught more orthodontists throughout the world than probably any other person alive. What do you consider the most common educational deficits of orthodontists, and what would you suggest to correct them?

RMR: It seems to me that schools do an adequate job of exposing the student to mechanics and appliances. This has led to a focus on the alignment of teeth as the first clinical priority. If students are only trained in straight wire Edgewise, then, as practitioners they must wait for the patient to develop the permanent occlusion before they can practice that which was taught and learned.

In the first four months of this year, I lectured at six graduate departments. I was embarrassed in all of them because current students lack knowledge in anatomy. Angle insisted that anatomy was the basic frame of reference from which all treatment plans are derived. In our graduate training we were each day assigned to learn a different bone of the skull. After an hour session, we went to the lab bench and, with flame and spatula, waxed up the bone by memory. I even tried to articulate them. It was a challenge.

In my advanced courses I have tried to teach the tracing of head films without first teaching the bones in three dimensions. It was always a disaster and I gave up. I found it was much more productive and satisfying to think or imagine in three dimensions. Anatomy learning before tracing was indeed productive.

If I would try to put it in one statement, the deficit in education is in the classification of biology. The prefix, “bio,” means life or living things. Biology is the study of functioning organisms and their processes. Biochemistry and biophysics are components that broadly pertain. But anatomy and physiology or form and function in the basics. I view the whole subject of occlusion as biological when traditional dentistry tends to teach it as mechanics. The growing and functioning joint is not like the balls on an articulator. Pathology is basic.

Growth is a biologic subject. Response to force application is biologic. Even esthetics is biologic as variation is respected. Everything but everything is characterized by a curve of distribution. Two standard deviations in either direction is often considered to be a sensible biologic range.

One aspect that has really disappointed me is the general lack of acceptance of the VTO. It was developed in 1950 and first reported in January, 1957. It is a tremendous tool for planning objectives and to serve as a matrix for the staging of mechanics. It is amazing how it is so misunderstood. Tests made on its accuracy have been conducted after the fact by patients treated without it having the guide in the first place. When it didn’t match the result, people say, “See there, it doesn’t work.” The VTO is a form of imaging, and it always has been. It is a biologic process of growth, but added is the feedback from the mechanics required to produce it. The Bioprogressive movement was developed as a result of “set-ups” on paper to include skeletal growth, mechanic effects and the esthetic influence on the nose, lips and chin. It doesn’t work if the clinician is incompetent and doesn’t produce the objective designed.

It is also ironic that some educators will declare it is not necessary. That lowers the profession to the level of a mechanic’s craft.

Another dilemma is the dearth of applying the root rating scales for anchorage or displacement calculations. In 1970, we presented, as a working medium, the size of roots in three-dimensions. They were to be used as a starting reference for calculating pressure. That’s over a quarter of a century ago. We modified them for orthopedic action for building bone or changing the ridge. Orthodontics is like the rules of baseball or golf; they are difficult to change due to tradition.

LWW: One of the current buzz phrases in orthodontic education and professional publishing is “evidence-based” therapy. What is your response to this development?

RMR: I’m not sure how “evidence-based” emerged in the last few years. Anything evident is obvious. But the meaning intended is to have proof. Ironically, I always assured that anyone presenting material and holding forth new theories had “evidence” or “documentation.”

As far as I can determine, there are certain fundamentals. Because we are referring to science, measurement in some form is required. This requires a method. The method should be as critical as possible. One problem in cephalometrics is that the measurement should be the best represention of the “intent” for which it is selected. The parameters employed are therefore most critical. When the method is selected to be the most trustworthy, the second step is to provide “controls” or normals as a frame of comparative reference. The third step is to acquire a sampling of material, which is also unbiased in its selection for study.

When data is charted and calculated, the typical treatment is to obtain the standard deviation and the characteristics of dispersion of the measurement.

The next step is to find an expression of differences and the extent. This is provided by the “T test.” Likenesses are also calculated from the standard deviation and expressed as coefficients of correlation. These are fundamental, but games can be played and are played with figures.

However, the greatest and most practical method for clinical comparison was the breakthrough for the construction of composites with computer programs. For some reason, these also are not really appreciated or respected. Here, data is visualized rather than expressed by asterisks on spreadsheets.

Due to the fact that I have initiated so many movements in the profession, it has been incumbent on me to present data. Instead of 20 and preferably 30 subjects in samples, I usually sought 50 for more trustworthy conclusions, at least as a safety factor. When we measured with some new methods for cephalometrics, I accumulated 1000 patients. In our computer study, first presented in 1969, we analyzed 400,000 coefficients of correlation. In the classification of joint problems, it was based on a sample of nearly 200. Now that is evidence! Where’s the beef? Most of the time, mean values and standard deviations do the talking.

LWW: Dentists generally, and orthodontists specifically, by their training and patient expectation become therapists rather than diagnosticians. What would it take to reverse this emphasis?

RMR: I have tried to press for better diagnosis for my whole career. Let us first discuss general dentistry.

The nature of dentistry is mechanical. The pioneers made rules to follow in the preparation of a tooth for receiving a filling. When restoration of the occlusion was performed, there were “laws” of articulation to be followed. These were formulated in the thinking of mechanics. In the beginning they were based on the needs for artificial denture construction, which was transferred to the natural occlusion as a gross error.

It was, furthermore, a discipline to “follow the book.” Each step was checked, even to the point of state board examinations. Thus, lateral thinking had no place. Diagnosis and planning was built around techniques and the materials available.

In the typical general practice, occlusion was not often a concern except in leaving a filling or a restoration too high. In TMJ courses, I had dentists with years of experience who did not recognize that they had Class II malocclusion in their own mouths.

When we formulated the department of occlusion at USC in June of 1974, it was being taught in the anatomy department, and the whole prosthetic field, that “nothing could be seen in a joint x-ray.” I had to take sectographic joint x-rays in cadavers, read them, trace them, write a report and put it in a sealed envelope before the dissection to prove that tomograms were reliable. The diagnosis was 100% in six joints (three specimens). That experiment was only thirty years ago, in only one school, but what about the hundreds of other schools?

With that negative viewpoint regarding x-rays, the diagnosis was made on the articulator mounting. The dilemma was worsened by arguments regarding methods to register the mandible. In panels of discussion at meetings, these were heated and often emotional. High cusps and flat cusps are still argued. Bite raising is still practical, but few dentists take headplates in order to check five years later.

In 1953, I published an article in the JADA, Volume 46, on the causes of and classification of joint problems. In 1955, I published on the analysis of changes in the joint with orthodontic treatment. In that same year, “Abnormal Function in the Joint” was described in the classification published in the American Journal of Orthodontics. In 1955, I lectured to a joint session of the American Denture Society and the Pacific Coast Society of Prosthodontists. I was commissioned to write an article published in the Journal of Prosthetic dentistry on that presentation. It was a plea for the whole field of dentistry to employ head x-rays and was entitled, “The Role of Cephalometrics in Prosthetic Dentistry.” I wrote about physiologic considerations of the head, facial variations, the rest position controversy and the value of tomographs of the joint. This was before CAT scans and decades before MRI. Incidentally, recent findings with both methods have confirmed most of the conclusion drawn then.

I would imagine that, if this work was republished today, almost half a century later, it would be like something new to the dental profession. I now include some of the remarks, only a part of the discussion of that article:

Joint Disturbances Caused by Maloccluded Conditions of the Teeth

In the study of any structure of the body we learn how the normal should behave by determining the factors producing pathology. In other words, we learn the normal through the study of the abnormal.

In condensing the histories of more than two hundred pathologic joint conditions, it appeared that distinct types of joint disturbances could occur as a result of four distinct conditions of the teeth and jaws.

The first type (Fig. 9,A) is that of excessive range of function of the condyle. This type occurs primarily in patients with a severe horizontal overlap malocclusion, in which the condyle is called upon to function almost at the summit of the eminence or beyond, for the function of incision and for speech. Prolonged function in this anterior position has led to resorption of the articular surface of the condyle in some cases. It appears, therefore, that the condyle was not intended to function at the summit of the eminence for the usual act of chewing and for speaking. [We later found that the eminence could be damaged first.]

The second type of disturbance is that seen in posterior condylar displacement cases or those with a distal thrust (Fig 9,B). In these conditions, the influences of the teeth wedge the condyle deep into the fossa and produce a trauma at the posterior border of the condyle. In addition, the articular disc is sometimes thrown forward and the juxtaposition of the condyle with the eminentia is lost. These conditions account for the greatest amount of clicking observed in the author’s experience. Based on this pathologic entity, it appears that the most posterior or retruded position of the condyle that can be obtained is not in keeping with the normal functioning joint.

A. B. C. D.

Fig. 9: Pathologic Joints. A, Excessive range of function and prolonged function in the forward position; B, distal displacement; C, interference; D, loss of posterior support.

The third type of joint disturbance is that seen in interference conditions (Fig. 9,C). The supraeruption of a lower third molar is the best example of thus condition. As the mandible moves forward, it tends to rock on an overerupted molar, thereby dislodging the condyle and producing trauma in the joint. This is perhaps the most easily corrected joint condition. Simple removal of the tooth or grinding down the interfering structure will lead to dramatic improvement.

The fourth type (Fig. D) is perhaps the type the prosthodontist most frequently will be called upon to treat. This is the condition of loss of posterior support, usually through the loss of posterior teeth. Laminagraph roentgenograms have clearly indicated that the condyle in such instances is thrown upward, or upward and forward, against the eminence to a degree in which the duration of the force involved has been great enough to erode both articulating bodies. The normal joint is designed to take intermittent stresses, particularly of the gliding nature that it usually encounters. However, with the loss of posterior teeth, the stress is increased in both time and amount. In cases wherein the tolerances of the joint are overcome, a pathologic entity of degenerative joint disease ensues. This is degenerative arthritis in the true sense of the word. Isolated cases have been observed in which this degeneration has proceeded down the neck of the condyloid process. Based on these pathologic cases, it appears that a full complement of teeth is important to the normal functioning joint. It also appears that function in the molar area is significant.

DISCUSSION

When used in the proper manner, cephalometrics can be a useful tool to the prosthodontist. Each face has its own characteristics and these can be classified by the application of cephalometric procedures. A clear definition of the basic structures of the jaws and the base of the skull is available in the head film. The teeth can be related to the bony framework of the face in all dimensions. The relationship of the lips, the tongue, the soft palate, the throat walls, and the hyoid bone can all be evaluated and correlated to the various occlusal problems. In addition, many functions of the mandible can be measured. The interocclusal dimensions or the free-way space can be determined. The rest position of the mandible has been postulated to be of clinical significance. Even though the clinician does not subscribe to prevailing theories, cephalometrics is a tool whereby he can evaluate his own technique and treatment philosophy. The clinical use of cephalometrics should lead to better treatment prescription and prognosis for the individual. However, cephalometrics is weakened by the fact that the temporomandibular joint is obscured in the head film.

It may be wondered why the omission of one structure should be of so much concern. Is this area really that important? In order to answer this question, it is necessary to review the entire purpose and reasons for the existence of this joint. In other words, just why is this joint there and what does it do?

Probably the greatest contribution of this joint is the growth of the condyle. Without growth activity of the condyle we have little left that even resembles a normal mandible. During the active growth span, growth of the condyle predominates over everything else as nearly as can be determined. A second contribution in this joint is the provision for maintenance of the airway. During mouth openings the condyle is brought forward to prevent impingement of the chin and tongue against the cervical vertebrae. The third purpose of the joint is its role of guiding influence to movements of the mandible in chewing. It should be pointed out that, in this sense, in the normal dentition, it serves to disarticulate a portion of the teeth while action and energy is directed to other sections of the dentition. IN the edentulous condition the guiding influence must be considered even more in view of the need for bilateral functional contact in order to promote denture stability.

Now let us examine the problems in orthodontic diagnosis and how perhaps to reverse the emphasis on therapy before diagnosis.

Diagnosis per se is the determination of the nature of the condition. Prognosis is the forecasting of the probable outcome. By its definition, probability is included and value judgment is required.

In the history of orthodontics, the first diagnosis was just the tooth alignment. This was because little was known in arch correction. Jaw relation was then included later, and it wasn’t until about 100 years ago that functional and esthetic equilibrium was added. Gnathostatic mounting of casts started about 1920. The relation of the teeth to the jaws was considered. By then, appliances were produced commercially. In the early 1930s, cephalometrics was developed for study. In the same era, the edgewise system began to dominate. But it was almost twenty years before cephalometrics was proposed by William B. Downs to be a part of routine orthodontic practice. He classified the facial types to be integrated with the position of the teeth in the face.

By 1950 we had included the definitive objectives for denture emplacement, and by 1960 the definitive fit of the teeth for optimum stability. Scholars such as Steiner and Tweed, after years of loose objectives, found a haven in the cephalometric x-ray to describe their conclusions reached over their careers. But treatment modalities, not a decadence of facial size, led to a plethora of extraction.

For the VTO, growth was added and prospective changes with treatment were built onto the mandible. Orthopedics of the maxilla were speculated in 1955 and proven in 1960. Ricketts had added soft tissue and prescribed lip relations in the first VTO in 1950.

With a plethora of extraction techniques, there seemed to be a barrier to expansion. Diagnosis came to be the amount of crowding in the lower arch. If more than 5.0 mm of imbrication (overlapping) was present, the clinician thought he or she was obliged to extract. Techniques were then applied and standardization was demanded. Diagnosis was therefore diminished to arch length in the lower arch. Extraction rates climbed to as much as 90%. But something was amiss.

The cephalometric film was employed to match “the state of the art” in many instances. Due to rejection of expansion, the student was trained in two-dimensional thinking. The frontal headfilm was deemed to be useless for the next twenty years.

Meanwhile, by the mid-1970s, bonding started replacing banding. The clinician was forced to use lighter wires lest the bonds would break. With the earlier treatment and the benefits of extraoral traction, the extraction rates plummeted. With the knowledge of polarity with growth, generated by work with the computer and with observations of adult facial changes, a further arrest of rates of extraction occurred.

As an assist to the techniques, we developed prescription brackets for torque, rotation and angulation of teeth. As raises were added, the “straight wire” idea was formulated. Palatal dysjunciton was popularized. We then went to work on arch forms. Unfortunately, diagnosis slipped badly as now non-extraction ruled and diagnosis became a matter of whose brackets and what wire was to be used. As mandibular posturing methods were adapted, diagnosis slipped backward again because of the assumption of control of the mandible.

Yet, as a part of the clinical problem, order was needed. Angle classified the malocclusion and Down’s classified facial types in lateral perspective. Yet two or three studies indicated that a facial classification could not be made from the lateral view alone. Therefore, new classification was required for the purpose of establishing order. In 1950 we set about to classify the types of joints. By 1958 we had classified problems in the pharynx and the tongue and proved them in 1960. By 1953 we had added the E line for soft tissue diagnosis and classified lips by 1958. Classification of crowding was proposed in 2003.

Long-range forecasting followed the findings of growth behavior on a curve with the mandible in 1971. A two-part book was written on the subject in 1998. Four books were written on the diagnosis and treatment of young patients in 2000.

The conclusion is that “description” derived from current lateral and frontal analysis is only the starting matrix. Diagnostics (plural) is a Determination, Resolution Process. It involves the decisions made which include the prognosis, the forecast and a statement visualized on paper of the individual treatment objectives, the VTO. When in long-range, this is called a Visualized Treatment Goal (VTG). The adult treatment objective without growth is the ATO. When orthognathic surgery is added, it is the Surgical Treatment Objective, which is the STO, which also was started in 1950.

Finally, with the MRI there is an added value for soft tissue imaging of the disc and muscles. With the “Newtom” scanner, the three- dimensional concept can come into full play.

If orthodontics is a specialty, it should be treated as such. Simple alignment of teeth is where it started. The goal today is the whole face and the integrity of the stomatognathic system. This includes functional diagnosis and even psychological considerations. As I wrote in 1969, the advances in technology freed the clinician of the need for much of the customizing of appliances. He was free now to perform his role of the diagnostician and apply all the tools and all the accumulated knowledge for the benefit of patients. My response to the lack of appreciation of Diagnostics is that a consummate awareness has been lacking.