Part 3 of the Interview with Dr. Robert Ricketts, Interviewed by Dr. Larry White
This is the third part of the Interview with Dr. Ricketts. The Orthodontic CYBERjournal wishes to thank him and Dr. Larry White for sharing these insights with us.
LWW: You have acknowledged that within the past few years it has been possible to dramatically reduce the number of premolar extractions in patients. What has accounted for this?
RMR: Yes, there is a wide pendulum shift. Surveys in the 1990’s clearly indicated the
trend emphatically was toward no extraction.
In my mind this is not due to only one reason but at least fifteen
factors are responsible. I will list
those that come to mind but three was no hierarchy intended.
1) Probably the most subtle and least
obvious was the advent of bonding. However,
it was not because of band space as some may think. What was produced in greater crowding was regained
at the end. Let us look at facts!
It was due to a change in arch wires.
Due to the stiffness of the rectangular
wire in the horizontal plane (with edgewise), the force employed for expansion
was exorbitant. We presently calculate
pressure not force. Theoretically for
the building of bone on the external aveolus a pressure of .5 grams per square
mm of enface root surface is appropriate.
This is calculated to mean that only thirty (30) grams is required
to grow alveolar buccal bone at the premolar roots. This area is the most affected with expansion
together with incisors. The .0215”
x .025” stainless steel wires could deliver fifteen hundred (1500) to two
thousand (2000) grams before yielding. In
addition, honored teachers taught that the wire was to be seated with double
torquing keys and ligated with ligating pliers. The result was that bony dehiscence was common.
The ridge concept thus emerged and expansion became a “dirty word”
to many clinicians from 1940 through the 1960’s.
As bonding started in the mid 70’s those
forces pulled the brackets off. By
now also “light wire” was suggested. So without the need for band space, and with
the desire for lighter expansion, contralinear movements were much less traumatic.
It was not the space, it was the ligation and lighter wires that was
the difference. Lighter and more continuous forces led to safer
expansion.
2) The second factor that made an impact was “rapid palatal expansion".
Space could be created for crowded upper incisors by splitting the
suture. The jackscrew was dramatic
and the quad-helix was shown to be even better.
Thus some patients deemed to require extraction in the past were now
expanded in the premolar area. Airways were also opened up.
3) In 1973 Rolf Frankel made an impact at the London England World
Congress by showing that a buccal shielding appliance produced remarkable
arch form changes. As analyzed, such
devices created a pull on the periosteum and also traped the tongue. This “functional appliance" had a profound
effect on the thinking regarding possibilities in the minds of many American
colleagues.
4) In 1981 Robert Little, et al, reported the long-range findings
of patients having had extractions. Two-thirds
of the sample displayed unacceptable crowding; some in the range of 100% but
now less four teeth.
Thus, extraction theory burst on the ground
like an egg as a panacea for crowding.
5) We reported in the 1950’s some patients in which there was
no sensible alternative to the moving of the whole lower arch forward. These patients, Class II and some Class I, were
characterized by a retruded complete lower arch or lower incisors were crowded
and lingually positioned on the mandibular base. It was shown that the lower arch could be moved
forward a full centimeter without the loss of the gingival attachment.
At first we practiced physiotherapeutic
measures for relief of tension of the lower lip. By 1980 we devised a surgical procedure for
relieving lower lip contraction. Our
sample, with successes, has reached almost 200 patients. Some popular present movie stars received the
operation.
6) Prior to surgery,
we also developed the “lip bumper” to free the incisors. This took lip pressure off the gingivae and
gum and we saw gingival hypertrophy develop in patients who had previous pressure
atrophy and gingival recession.
It was further found that lower lip pressure
could profoundly move the molars backward. Thus another link toward non-extraction was
the use of a sort of fixed shield.
7) With
the utility arch and wide custom loops, the bumper effect could be employed
with arch wires. But of significance
was the fact that the lower incisors, with the application of Utility Arches
with anterior loops, could be moved downward and forward or intruded into
a wider portion of the symphysis. Stripping
of the soft tissue became manageable. It
negated essentially all of the fear.
Many clinicians with anxiety of forward
movement of the lower incisors were in shock on witnessing this successful
behavior with Herbst appliances. The
four lower incisors were rapidly driven forward. Many clinicians had overreacted to avoiding
the lower incisor damage produced with the edgewise methods mentioned before.
8) Many
older clinicians on observing patients returning later in their forties wondered
if the face would now be better if they had retained all their premolars.
The vacant buccal corridors were noted.
This led further to a doubt of the extraction theory.
9) Long
term studies during adulthood has shown that stomion (lip embrasure) Continues
to drop. By age fifty (50) the upper teeth may be concealed
even in women who had relatively short upper lips.
The fuller denture is a mark of youth!
This observation was an influence in the profession toward a greater
effort to preserve premolars.
10) Another reason for non-extraction is the concept of esthetics.
The mean and lean look of Madison Ave. models in the ‘50’s & ‘60’s
changed. Fuller lips and the more prominent denture were
deemed to be most attractive and sexy. The
fullness of mouths in the oriental and black races has changed objections.
This should not mean however, that severe protrusion and inordinate
lip strain is acceptable.
11) We actually found that patients started in the deciduous and
early mixed dentition in our practice received extracted premolars in only
7% of our sample. We enucleated lower
third molars. We rejected second molar
extractions as a substitute for premolar extractions.
12) Another subtle factor that is most profound is the effect of
cervical traction.
13) Still another subtle factor was the accuracy of long-range
forecasting to maturity. When the size
and form of the face of a five (5) year old is viewed in the forecast to adulthood,
a limitation concept changes to one of possibility. The profession at large has had such a negative
fixation against the technique that it has held back progress. Certain colleagues have done a disservice to
the profession. It was found that assumed
errors in the forecasts have been iatrogenic conditions produced by treatment,
which should have been monitored and corrected.
14) In the past twenty (20) years more and better information has
been accumulated to justify frontal cephalometrics. We have prepared substantial writing on this
subject, which will be coming out in 2003 in the World Journal. Frontal analysis has helped to produce surgically assisted
palatal dysjunction in adults. Cephalometric
application now helps to determine nonextraction potential instead of trying
only to keep teeth over bone. The teeth
must be reciprocally related to the skeletal maxillo-mandibular relationship.
15) The rates of extraction have shifted from 90% with the Begg
School to perhaps 10% in young patients in the Bioprogressive School. Extractions still have a place, however. Some educators have wondered if the non-extraction
movement has gone too far. In my opinion,
the pendulum has slowed down but it still has not reached its zenith.
It should finally be recognized that changes
in techniques and timing have made a sagacious influence. The advent of early treatment with development
of the ridges is now respected. Cortical
anchorage and sectional mechanics have changed the prognosis. A new dawn of possibility is at hand. There are undoubtedly other factors that I have
missed.
LWW: One of the reasons you mentioned for more nonextraction
patients nowadays was the expansion of the maxilla with the Rapid Palatal
Expander. Would you enlarge on this
idea?
RMR: The rapid disjunction of the palate was popularized
in the 1960’s following the work of Andrew Haas. We recognize it currently to be used with the
jackscrew and an acrylic base. Other
forms are employed such as the “High rack.”
However, jackscrews, or threaded wires
with nuts, were used by Farrar in 1875. Also
Coffin used a large wire embedded in vulcanite and overlaid the teeth on both
sides. From the literature, a palatal
bolt was used in 1890. In those days,
without x-rays for monitoring, the clinician could only speculate regarding
the effects.
Early treatment had a popularity swing
from 1900 until the 1920s. I never
counted but it was told that there were some forty (40) articles on palatal
division between 1900 and 1920. However,
in the twenties Dr. Angle together with Dr. Ketchum, condemned the method. Both claimed it was “not needed”. Angle of course, used nuts on a threaded .04”
(1.14 mm) expansion arch and was probably widening palates without recognizing
it as such.
The RPE (Rapid Palatal Expansion) is very
heroic and spectacular. It truly gives
the patient the notion that something is being done. It is certain and positive and creates space
from the “inside”.
In the 1960’s we studied many patients
with frontal sectographs or tomographs. We
found that the widening was more anterior than posterior. We also found that the separation of the hard
palate with the vomer bone could be of three different types. There is no doubt about it, research has pointed
out narrow maxillae to be characteristic of all these kinds of malocclusions:
Class I, II and III.
But in 1966 I quit using the RPE. The readers may be interested in why!
First, I had a background of almost 20
years of use with the “W” appliance in .040” (1.0 mm) gold and we had developed
the .038” (.98 mm) quad-helix in Elgiloy.
We obtained frontal head films routinely. Many laminagraphic cuts were obtained in special
patients.
One day after fussing with a patient with
the RPE, I thought “wait a minute”, this is not as good as I have experienced
with the soldered quad-helix. I then
gathered records of many formerly treated patients and reviewed the behavior
in the frontal head plates. I had obtained
a widening of the palate previously with the quadhelix, but at a slower pace.
But that was only the start. With the RPE the upper molars were moved transversally
but I the rotated positions. A second
step in treatment was needed for their rotation. Also the RPE did not correct Class II but sometimes
worsened it. The quad-helix on the
other hand, rotated the molars and corrected mild Class II – both!
In addition the RPE requires a costly
laboratory procedure and the quad-helix is custom made at the chair in a total
five-minute operation.
The RPE is adjusted by the patient and
the quad-helix is adjusted intraorally by the doctor. The RPE is dirty and must be held in place for
three months if rapid relapse is to be avoided. The quad-helix is clean and in three months
is quite effective. We usually take
three months and hold it another three months for function to be established.
With the RPE, despite the sleeves for
straight movement, the molars tipped further buccally. With the anterior bridge intraoral adjustment,
the quad-helix could control buccal molars tipping quite nicely.
In about 1961 Dr. Tony Storey from Australia
spent one week with me in my home. Dr.
Hendrickson had conducted a PhD work on sutures. With RPE the new bone is very thin and lacey
and not stable. The new bone built
with the quadhelix is bundle bone and much more solid.
Another factor that influenced my decision
to terminate RPE was that one patient developed blurred vision with it.
The maxilla forms the floor of the orbit, and in this patient I did
not like the prospects of risking that harassment.
Why all the hurry?
In the 1970’s a study was conducted in
one of the clinics in Sweden. They
took a sample of patients treated with RPE and compared them with a similar
sample of children treated with QH (quad-helix).
The conclusion was that the results were better with the QH and that
all things considered it was at 60% the cost.
The RPE is not easy to cement and requires
attention. It is crude by comparison.
Another factor with the quadhelix is that a tongue thrust can be mitigated. The tongue should be behind the lower incisors.
I know there are many who will defend
the RPE. That is fine for them, but
the RPE is not for me.
Dr. White, it is a sort of a joy to make
these answers in first person. Such
being the case, I don’t need to be political or beat around the bush. These are the facts as I perceived them and
I ask critics to show me their data.
LWW: A few decades ago there was great interest in
using the Visualized Treatment Objective (VTO) for diagnosis and treatment
planning. Lately interest and use of
the VTO has waned. What do you think
has contributed to this and do you see any appealing alternative to the VTO?
RMR: The truth is, I see no sensible alternative
to the VTO. It is just as important
now as it ever was. Several factors
have interfered with its acceptance.
Surveys by the JCO in about 1990 indicated
that only 1% (one) of orthodontists on the east coast used the VTO.
In the Southwest, it was 10%. I am not aware it ever was of great popularity
and application even though it may have held some interest by the typical
orthodontist. Many wanted magical mechanics
where no thinking would be required for the individual patient.
Let me say also that I do not believe
it ever has been really well understood. Many
originally thought of it as crystal ball gazing, teachers as well as leaders
in the clinical field were obviously fearful of it. If many of that same group have done it damage.
It has been ridiculed from the beginning. Strangely indeed, some department
heads, still reject the idea of clinical cephalometrics per se.
That is poor service in my view
The Evolution of Forecasting
The person who had the original idea of
trying to predetermine facial behavior during treatment was Dr. William B.
Downs. He was my mentor. He was still working on his analysis when I
was his student. He published it in
1948.
Downs routinely monitored behavior of
patients during treatment. He worked
from the Frankfort Plane. By interpreting
the “pattern” of the face he would try to foretell whether a change in the
chin would be zero or plus or minus and to what extent. That intuitive sense would be likened today
to the behavior of the chin on the Facial Axis.
By prejudging direction of the chin, it helped him in making the decision
to extract or not. Remember in the
late 1940’s the “doctrine of limitation” was red hot. Any severe mandibular rotation, iatrogenically
produced as we understand now was at that time explained as simply an unfortunate
“vertical growth”. In retrospect, we
really did not know much then. No one
even made attempts to trace the joint area before I started with laminagraphy
in 1947.
In 1950 Downs invited me to his home for
a discussion. He challenged me to work
on the problem of growth and facial changes during treatment processes.
He explained that the answer lay in the posterior face and the joint
where I was studying. I decided with some misgivings to “give it a
shot”.
I already had three years of research
behind me with a fairly large database. We
soon recognized the value of Basion-Nasion reference. The cranial base was connected to the mandibular
plane via the condylar plane. For the
procedure we grew the cranial base, added the condyle growth and ramus height
and then extended the body of the mandible. The maxilla was carried with Nasion.
Three processes were to be integrated.
The first was the behavior of the cranial reference.
We later eliminated Sella. The
second was simply the normal growth of the mandible for a typical two year
experience.
But the third was the unknown factor.
It was the estimate of the influence of the necessary treatment on
the rotation of the mandible. This was found to be influenced by the specific
treatment modality to be employed.
It was therefore necessary to determine,
from the available data, behavior as suggested from three original conditions
of the malocclusion. The first was
the severity of deep bite. In order
to forecast rotation with bite leveling with straight wire, this was a factor.
The second was the severity of Class II that needed correction because
elastic traction extrudes teeth also rotate the mandible.
The third was the modification of Point A or torque to be attempted
in the upper anterior segment.
These three factors required a “feedback”
or cybernetics before it had that name. In the computer such would be called a “conditional
statement”.
Three weeks later I asked Dr. Downs for
patients for a blind test of a procedure that I had by now tested on personal
patients. He was to select a boy and
a girl and record to the nearest mouth the time intervals between the beginning
and final head x-ray films. I was not
to see the final records.
Accuracy Required
We both were surprised to find amazing
accuracy of the very first two patients in which the data was reversed. That experience was encouraging. Some of the data were published in 1953 and
1955.
Immediately we asked the question regarding
the accuracy required to be of clinical significance. What was practical? I get blank expressions whenever this subject
is brought up. The method was described
seven years later in 1957. This was
after it had been applied to hundreds of patients. Please keep in mind that the extension of the
selected skeletal matrix was the base over which treatment effects and orthodontic
objectives were superimposed and perceived.
The VTO is not a prediction. The VTO is a statement of objectives set forth
with common sense in the light of knowledge of effectiveness of techniques.
It works if the operator can produce it.
The orthodontist arranges mechanics forthwith.
It is employed as a guide for mechanics.
Testing it by others on their treated patients, without having VTO
as a guide for planning, is total misunderstanding.
The truth was that very few people took head x-rays and even less traced
them accurately or monitored treatment behavior so they had no basis for judgments.
Cephalometric Application
Now let us shift to other happenings.
At about that time Alton Moore and Richard Reidel went to the University
of Washington. They offered a course in cephalometrics for
the clinical orthodontist. Cecil Steiner
and Charles Tweed were among the first students. Both had developed treatment techniques and
both wanted definitive objectives to “shoot for”. Tweed adapted the Margolis triangle using the
ear rods as porion, which induces error from the beginning. It took me a long time to convince Downs of
the difference that could exist.,
Steiner started with SN and Reidel’s A
and B differences. Both Tweed and Steiner
were delighted to be able to observe the relation of teeth to the basal skeletal
framework.
But Downs, Steiner, Tweed and many others
looked at the jaws as “static”. The
idea was just to rearrange the teeth to fit the existing face. That is an articulator concept and the idea
of plaster setup. Four factors were missing.
The first was growth, the second was treatment response to mechanics
and the third was arrangement of orthopedics in the jaws. The fourth was a statement of esthetic and functional
objectives. None of the previous analysis
had included soft tissue to include the nose, the lips and the chin.
We tried to incorporate the previous four
factors in the “prediction” process. We
also did not accept the dogma of maintaining teeth “over the ridge”.
Reciprocal relations of teeth were found to be mandatory with our planning
process. This fact we tried to clarify but failed to
do so. Many considered the procedures
beyond their intellectual capacity apparently or an exercise in futility.
But, Dr. Reed Holdaway caught the spirit
of the idea. He tried to maintain SN.
We had tried to give names such as Cephalometric Synthesis.
He gave it the label Visualized Treatment Objectives. – VTO.
That name has stuck.
Very clearly over time, as all diagnosis
slipped, so did the VTO application. Clinicians
leaped on the idea that the Mandibular Plane Angle alone was a predictor.
Even though they maintained that growth was unpredictable.
They then would ask, “How do you treat your high Mandibular Plane Angle
patients?” This is an ironic twist of thinking.
Long Range VTG
The foregoing was only a part of the story.
We obtained our first access to the computer in 1964.
By 1966 a very large project was compiled and forty untreated children
were studied serially and measured in three dimensions for eight years. It was a four-year effort. Forty contributions to the science resulted.
By 1971 a curve for mandibular growth
was discovered. It was tested and proved
to be a “core phenomenon.” Data were
either reconfirmed or it was corrected. The
result was the ability to forecast long range for the first time.
If the VTO was controversial the Visualization
of Goals to maturity was considered a total laugh. In long range from age 4 or 5 years to maturity
and with goals to adulthood, the process was now called VTG. Our eight years of computer research was branded
a hoax. Attempting to prove it in the
computer was deemed by a department head as a “gimmick” for suckers.
Other people called it a “comic opera.”
Some educators still tried to keep cephalometry and computers from
the clinicians altogether.
The procedure has been improved and is
truly sophisticated. A two-volume book
was published in 2000 as a final statement on the subject by the author. It was entitled, Understanding the VTO: Its Construction and Mechanics for Execution.
The forecasting works in a practical manner
completely within the range of accuracy required for clinical usefulness.
It is the best educational tool for the study of facial growth that
is available to the student currently. Many
recognize that fact but still teach old ideas.
The VTO and VTG are a great gift to the profession, and they are there
for the taking. The power of the clinician by accessing this
knowledge is greatly enhanced. The
concept has changed and accuracy continues
to improve. The concept is presently
supported by the process of images. Computer
imaging from the photograph is extremely loose by contrast to the x-ray as
a foundation. Why not use both for
ultimate sophistication?
LWW: Three-dimensional scanning has received a lot
of notoriety recently, but so far seems limited to providing orthodontists
with virtual models. Is this a great
advance for the profession or perhaps only a precursor to more therapeutic
applications?
RMR:
It is a precursor to progress. In
1990, Dr. R. Varnarsdal addressed the AAO with the statement that this would
be a decade of the “transverse dimension.”
In fact, that was a statement emphasizing in a three-dimensional concern
for the whole profession. Previously
we had already conducted studies, which precipitated five practical arch forms.
We had found that the AG Point (antegonial tubercale) was a usable
reference in the mandible. As early as 1950 we had emphasized maxillary
orthopedics in three-dimensions. Dr.
Vanarsdal’s recognition of the problem and possible solutions were indeed
rewarding.
Together with the arch forms and sizes,
which were the same for both arches, we prescribed a “therapeutic finish.” It was later called the “fourth-dimension.”
This was an inference to time in that it was an arrangement to insure
best against a relapse in the future. More
recently we have reformed to a fifth-dimension as the electromagnetic aura
of the body, but that is a subject for another discourse.
Certainly, the virtual model produced
with tomographic imaging is striking. I
was quite impressed to see a model of an adult patient after having orthodontic
expansion. The premolar and molar roots
were sticking out the alveolar processes.
It was only a matter of time until massive periodontal recession would
follow. The portrayal of paucity of
bony tissue in maxillary constructed patients is truly remarkable with this
diagnostic method. We can literally
see through the soft-tissue.
The views in the lateral perspective do
not seem to be remarkably advantageous to the ordinary headplate. I can still see an advantage in patient with
fractures, congenital deformities and for candidates for surgery. These may include surgically assisted rapid
skeletal disjunction. This method
will provide better detail and help more with treatment planning.
However, in keeping with the last question
regarding the VTO, I do not see this method with dynamic application for growth
and orthopedic planning on a routine clinical basis. What it has proven, however, is that the clinician
should take the frontal headplate more seriously. By request we have submitted a lengthy paper
on the Frontal Application to Dr. Graber and the World Journal of Orthodontics about the current appreciation of the
transverse consideration. This was
mentioned in a previous answer.
The frontal and transverse dimension has
lagged far behind the lateral. The
lateral supplies depth and vertical dimensions. Because expansion with the old edgewise practices
came to be so ridiculed the frontal received a dearth of interest.
When we started with the computer service, there was a dearth of interest,
and we tried to present the minimal information as a result.
I tried to include the premolar area, but we lacked the ability to
convince the profession of its merits. This
was still a time in 1970 when extraction of all four first premolars was the
concept of “four-on-the-floor.” If
extractions were conducted in three out of four patients, the first premolars
were often considered necessary. Consequently,
these teeth were regarded in a very cursory manner.
Yet we found that the arch form is produced
to a great extent by the transverse dimension in the first premolar area.
Its position is of significance, therefore.
In addition, the lower first premolar sits precisely in the buccal
plate. The buccal lamina dura is one
and the same with the buccal plate. Delicate management of the lower first premolar
has been overlooked. Its average width
in normal occlusion is 39.8mm ± 1.8mm. It is slightly greater in males. The subject of fit and function of occlusion
in the first premolars has been neglected.
Ironically, all three of the classifications
of malocclusion principally have narrowed upper arches at the molars and buccal
areas. This includes Class I crowded
and lingual crossbites. Most severe
Class II malocclusions have a recorded crossbite in the frontal view, as the
upper fits a smaller part of the lower arch. It was shown in 1950 that two out of three Class
III malocclusions are characterized by diminished maxillae, yet the majority
of Class III condition was attached as mandibular problems alone since 1900.
I have talked about early maxillary expansion
for fifty years. It is, therefore,
comforting to see through 3-D viewing the subject receiving proper attention.
Years ago I lost my popularity with the Tweed Society and even lost
friends as a result of exploration in expansion.
That was unfortunate. Looking
back at the dogma, many of us were victimized by meager science.
We suffered from a lack of understanding of biology. We reacted to ostentatious prophets. It showed the kind of continued effort that
is needed in communication and education.
From more detailed views and from the
deeper perspective, it would seem obvious to the student that the clinician
is obliged to treat to the condition of the basal jaws that will be or that
can be produced in the future.
In January of 2003 I lectured for a straight
9 hours at a prominent graduate department of orthodontics in the U.S.
I was shocked to find out that students had never used a quadhelix
appliance. Yet around the world, it is considered to be the most beneficial
and efficient appliance available.