116 It is quite clear that the most significara applcations of the cephalometric radiograph have been in clinical orthodontics.

Fifty years after its inception, it is a standard procedure for the overwhelming majority of orthodontists. Many have wondered why it took so long for the radiograph of the liead to reach tliis level of application. Originally limited to the study of changes, it was brandad as a research tool only. Then n the 1940's, the con-flict of opinin on extraccin further polarized the attitudes of clinicians. Conservative nonextraction practitioners were especially reluctant to accept cephalometric evaluation for direct use as an aid n treatment planning. This reluctance grew as those who accepted extraction as a therapeutic alternative derived in-creasingly valuable diagnostic infor-mation from cephalometric radio-graphs. DiH'erential diagnosis was of no valu to those whose minds were already made up.

Ricketts

SKCOND PHASE JN APPLICATIONPOINTS AND PLANKS CLINICAI .

The second major movenient was a concern among investigators for estab-lishing reference bases for description of morphology as well as for longitudinal comparison. Broadbent used the Bolton Triangle with "R" registration, while Brodie-* and Bjork0 con-centrated on Sella-Nasion and the anterior cranial base. Tracings were used by Brodie and his colleagues to study treatment results in the 1930's, cul-minating in a 1938 report." Downs 7 used that Information to choose or select treatment for the individual "pattern." In those years Tweed and his followers were already advocating extrac-

lion, and they were bent on placing the lower incisors "over basal bone." Ceplialometrics was an obviously use-ful method for evaluation of the posi-tion of the lower incisor relativa to the symphysis. The mandibular plae soon became a ira me of reference for planning, much to the consternation of the conservative faction. If the nonextraction group liad ob-served and studied tlieir own results, applied the tool for individual expres-sion and published their objectives, no one could have taken issue with this nieuns for aiding in the decisin of where to put teeth. However, they ohose to ridicule the methocl itself. In retrospect, this was not becatise of the methocl but because of the standard s and objeclives of tliose extractionists who fir.st embraced the clinical use of the liead film during that era. Orthoclontics at that time was

suffering uiider the doctrine of limitations in terms of both orthopedics and forecasting. The information in the radiograph was still largely unusable. Other objections raised were the use of a lateral film on a two-dimen-sional mdium to represent a three-dimensional object, and using such a "static" tool rather thari one of "dy-namics" which would take growth and physiologic changes into account. TiiiRD
MAJOR PHASE

MORPHOLOGIC
DESCRIPTION AND TYPING

The original Downs descriptive analysis7 was taught to the first reunin meeting of graduales of the University of Illinois orthodontic cle-partment in 1948. This was before Steiner 8 and Tweed u liad presented their own cephalometric interpreta-tions of their clinical ideas.

Wylie1" divided dimensions along the Frankfort plae into contributing The Angle Orthodonti st

Clinical Cephalometrics linear components, an approach that was later expanded by Coben11 measuring from point Basion. The profile describing osing SNASNB was developed by Reidel12 in the "Northwestern" analysis. All of these con-cepts were applied in various pur and combined approaches. On going to California in the early 1950's, the author was challenged by colleagues or a direct answer to the question of clinically useful information to be derived from cephalomet-rics that the practtioner could not also obtain from dental casts and ori-ented photographs. This key question, the practica! ap-plication in terms of helping to determine exactly what to do for the individual patient, continued through the years as Steiner, more than any-one else, refined and taught the ap-plication of cephalometrics to clinical problems. In 1960 tlie author publshed two clnica! papers in an attempt to answer some of those questions betng asked by students and clinicians. The first13 was a report on the morphologic findings in 1,000 cases consecutvely seen in clinical practice. t was an attempt to clarify applcation, entitled "A Foundation for Cephalometric Communication." Description of morphology and dental relationships was one aspect. The second was classification, cate-gorizing

117 conditions in terms of their clinical requirements and difficulty. The third was the study of change, comparing the morphology of a single patient at different stages of development or treatment. The fourth was its application in communication of the first three among clinicians and re-searchers, and between clinician and patient. The fourth application made the

clinician using cephalometrics stand above the rest. With the ability to describe and compare, carne the ability to explain things and to find out new informa tion never before avail-able. Above all, was the ability to communicate with the rest of the pro-fession in a sophisticated and meaningfil language. The clinician lack-ing the tool of cephalometrics simply liad no sound bass to supplement conjecture in selecting treatment or analyxing changes. The second 1960 publication by the author was on the analysis of treated cases.11 The possibilities and the effects of treatment using multibanded orthodontic techique and extraoral traction, the main sources of correc-tion of that day, were explored in depth with cephalometrics. Previous cephalometric and laminagraphic findings published by the author in 1955in nsed no controls. Jn 1960 one Vol. 51 No. 2 April, 1981

hundved non-treated patients were in-cluded as controls. Fifty of the control occlusions were Class J, and fiity were Class II. As a treatment comparison, hree different groups o' fifty Class JJ patients treated by three dilterent modilities were ana-lyxed. One group liad been treated with intraoral elastic traction only. Only extraoral (cervical) traction was used in the second group, while for the third group a combination of intraoral and extraoral traction was employed. Changes were measured in five different reas in a logical sequence. First were the changes in the cranial base. The second rea was changes in the lower jaw complex, the third in the upper jaw complex, and the fourth in the upper and lower denlures. The fifth rea was soft tissue changes in the nose and lips. Some 35,000 measurements were

118 made. Methods of analysis included superpositioning to supply data for natural changes as well as typical behavior in the course of therapy. The outstanding conclusions were, first, the finding that significant orthopedic change was accomplished. Secondly, tooth movement possibili-ties and control were more extensive than had previously been believed possible. At the time of the foregoing publications it had already taken some thirty years for cephalometrics to reach that level of knowledge and utility at the practical level. It had previously been used for numerous "analyses" as compiled by Krogman and Sassouni10 in 1955. These were mostly descriptive orientations used to evalate growth. However, the tool had become confusing with endless suggested landmarks and points of orientation for comparisons. That was the situation as we entered the fourth decade of cephalometric practice.
FOURTH PHASE

Ricketts
GROWTH FORECASTING AND TREATMENT PLANNINC

The ourth major movement in cepha lome tries was ule aernpL ai pre-diction of treatment results. During the previous period the subject of growth forecasting had also been un-der exploration by the author.17 This was an outgrowth of cephalometric laminagraphy of the temporomandibular joint. I,ongterm growth forecasting liad not proven trustworthy with the methods of projection used during the years of 1950 to 1965. However, shortterm forecasting did prove adequate for the period of actual treatment when combined with the likely effects of the treatment. Treatment designs incorporating growth effects had proven to be quite appropriate, and indeed could be

recommended at a clinical level for the establishment of objectives and the planning of anchorage. This idea was picked up by Hoklaway18 and termed a "Visualized Treatment bjective," which was descriptive of the application. Existing morphology and expected growth in modular increments provided u reerence base.19 Superimposed on this behavior were the requirements for the individual patient, in terms of objectives and the reqtiired tooth movement. Desired changes in anterior teeth could be followed by the setup of the molars, depending on the needs and estimates of anchorage and arch form change. This brings us to approximately 1965.
THE FIFTH PHASE CONFUSIN OF DKSCRIPTION WTTH GROWTH ANALYSIS

It was during this period that two other essential subjects needed to be straightened out. First was a determination of which of all of the possible

points and planes of reference were the most useful and dependable for description and, secondly, which were most useful and dependable for evalu-ation of growih or trearment changes. Some cephalometric analyses were confusing because they attempted to combine descriptive morphology, analysis of growth and treatment changes, and establishment of treatment objectives without distinction. Point sella had become popular due more to its case of identification than to its scientific merit or anatomical dependability. This problem was clearly apparent from the transcripts of the second cephalometric workshop at the Bolton Foundation in 1959,20 in which it was all but recommended that cephalometrics had no place at the clinical level. Very little agree-ment was reached regarding specific

The Angle Orthodonti st