Malocclusion: Beyond the Wendell L. Wylie Legacy
In this journal in 1947, Wendell L. Wylie,1 one of the most respected orthodontists of his generation, posed for the time a profound question: Ought clinicians to regard malocclusion as a malady (a disease or an ailment) or a malformation (a deformity)?
The response to this question lay literally in the hands of the orthodontic specialty. If malocclusion was to be regarded as a malady, then it required treatment as provided for a disease state; if it was taken to be some form of malformation, then this dental condition should be modified to improve the form and function of tooth position and occlusion.
Some 40 years before, Angle2 offered a definition of malocclusion, which he asserted to be “perversion” of the normal relations of the “occlusal inclined planes of the teeth when the jaws are closed.” Orthodontia, as it was known, was regarded essentially as the correction of irregularities of teeth; those undergoing such correction were referred to as “regulation cases.” Angle replaced the term correction with the word treatment, and referred to subjects of regulation cases as patients. This change reflected Angle's broader rationale for orthodontic treatment, namely, that moving the teeth to normal positions promoted normal growth of the jaws, ensured normal function of the dentition, and improved the appearance of both the dentition and the face.
By the time Wylie entered practice, the attainment of best possible tooth position, occlusion, and facial appearance was the objective of orthodontic treatment. Nevertheless, Wylie disagreed that the reason for treatment is the need for eradication of a state of disease. Instead, he put forth the case for malocclusion as malformation. He argued that malocclusion reflects morphology, which is the relationship among parts of a structure or region of the body. Wylie introduced the term dysplasia to describe the occurrence of malrelationships, or “lack of ‘harmony' among various facial parts.” He did not appear to support Angle's view that restoration of normal function by orthodontic means would ensure the development of normal size and form.
Because terms such as dysplasia and malformation are now applied to the entire body, not just the dentition, the care taken by Wylie to find appropriate terminology for malocclusion as an expression of extreme variability may be regarded now as unsuccessful. With the benefit of hindsight, Wylie seemed unwittingly to have retained Angle's view of malocclusion as an abnormality that requires treatment in a “medicalized” context.
In the decades that followed, orthodontic treatment was delivered by clinicians who reserved to themselves decisions on the acceptability or otherwise of tooth position, occlusion, and appearance, that is, the need for treatment. The subjective “need for treatment” was based on severity, or the amount by which the malocclusion deviated from an arbitrary anatomic ideal. The overriding consideration was the presumed benefit provided to the patient by way of the prospect for improved oral health. During this time, orthodontic technology advanced considerably with the development of more refined and efficient methods of controlling tooth movement, thus allowing practitioners to achieve even better results.
In Wylie's era, the question most commonly asked of an orthodontist was, “Does my child need treatment?” A response asserting that malocclusion posed a threat to long-term oral health seemed, at first sight, to be an entirely logical justification for encouraging patients to undergo treatment. Poor tooth alignment and occlusion could likely limit effective oral hygiene or cause imbalance in occlusal loading. Yet no compelling evidence could be brought to bear to support such an apparently reasonable view. Since that time, neither epidemiologic nor empirical studies have produced evidence to substantiate such a claim. Thus continuing to view malocclusion as essentially a “medical-like” condition remains questionable.
Toward the close of the 20th century, a major change became evident in society in attitudes toward appearance. No longer satisfied with a focus on oral health and treatment of occlusal “disability,” children and adults turned increasingly to orthodontics as a means of enhancing appearance. Refinements in orthodontic technology continued to run parallel with refinements in means of enhancing appearance. Society by this time had set aside its taboo against medical or dental interventions aimed principally at improving appearance, dispelling the view that unless treatment was necessary in the traditional medical sense, it was somehow frivolous.
When carried out within the medical or dental domain, enhancing a common physical characteristic such as removal of wrinkles or whitening of teeth is medicalization. Although providers of health care do perform interventions directed at enhancement, what they do is not necessarily health treatment. Instead, these enhancements are intended to promote a greater sense of well-being by improving appearance and providing concomitant improvement in quality of life. Acceptance of the idea that enhancing appearance is not motivated merely by vanity but rather is a means of improving quality of life (wellness) is a major philosophical shift in the development of orthodontics. However, it was undoubtedly the medicalization of malocclusion that offered a rationale for orthodontics, and led to its popularity. People seek whatever help they can to enhance their ability to communicate with others, realizing that more attractive faces and smiles favor more effective communication. The face is, in essence, a communication panel.
Orthodontists have the opportunity provided by a society sensitized to appearance to gradually broaden their role beyond the restricted confines of the mouth and occlusion. The effect of this development is to extend, as it were, the Wylie legacy. Whereas Wylie argued for consideration of malocclusion as malformation—a lack of balance and symmetry in tooth position and occlusion—society regards it as having wider significance in terms of its effect on the way in which an individual sees himself or herself, and on how others might perceive that individual. Human communication is a close encounter, and any means by which it may be enhanced clinically is of high value. If treatment of malocclusion contributes positively to a sense of well-being and improved quality of life for patients, then orthodontic care is a useful and valuable service in the widest sense.
Today parents and patients seldom ask an orthodontist about the need for treatment. It is not for the clinician alone to justify orthodontic correction. Treatment desirability is no longer determined solely by the provider of care, but rather in collaboration with the consumer of the service. By the same token, the orthodontist does not establish in isolation the value of the service because the potential benefit is judged subjectively by the parent or patient. In short, the answer to the question “Who needs orthodontic treatment?” is “Any individual who desires treatment is potentially a suitable candidate for it.” The fact that orthodontics can be justified rationally, based entirely on the patient's desire for dentofacial enhancement, requires that we avoid confounding the terms need and desire for intervention. Need has a medical meaning and generally refers to a service that is essential to prevent the ill effects of some disease. For those malocclusions that are clearly less than handicapping, the desirability for enhancement ought not be referred to as need.
In the context discussed here, setting the goals for orthodontic treatment becomes a shared activity between orthodontist and patient, with the balance of the decision-making process, in terms of establishing the means to achieve treatment goals, resting with the orthodontist. When agreement is reached on the treatment plan, the orthodontist accepts the ethical and legal obligation to obtain informed consent. Provided that the patient understands fully the nature of the treatment and shares with the orthodontist an understanding of the risks and benefits of treatment, the clinical transaction respects the patient's autonomy and ensures the professional responsibility of the orthodontist.
The Hippocratic dictum “Do no harm” remains the fundamental obligation of every health practitioner. In this evolving paradigm, a parent or patient is encouraged to select an orthodontist for his or her knowledge and judgment, as well as clinical skill. As this becomes standard practice, the previously great burden of treatment justification will have been lifted from the shoulders of orthodontic practitioners and the leaders of the specialty, and will be shared, as it ought to be, with each and every patient.
The response to Wylie's 60 year-old quandary as to whether malocclusion is malady or malformation is unresolved no longer. In many if not most instances, malocclusion is an expression of morphologic and functional variation. Thus, for those disposed to resolving riddles, the answer to Wylie's question of whether malocclusion is a malady or a malformation, the answer is “Neither.” For an orthodontist or an orthodontic professional group to imply greater need for, or benefit from, orthodontic intervention than can be justified by available evidence runs counter to the very essence of informed consent and the dictates of scientific rigor.
Wylie, a man of admirable integrity and strong ethical principles, would surely admonish us accordingly if he were alive today.