A Few Comments on an Elegant Answer in

Search of Useful Questions

Lysle E. Johnston, Jr

hat does the specialty hope to gain from

the widespread application of 3-dimensional imaging? Beyond the generation of pretty
albeit realistic and impressivepictures, I think we
seek answers to the sorts of cephalometric (head
measurement) questions that have been asked by
orthodontists for well over a century. To this end,
clinicians probably would like, at the very least, to be
able to execute familiar measurements, both in 3
dimensions (cone-beam versions of such standard
descriptive and treatment analyses as Downs,1-3
Steiner,4-6 Ricketts,7,8 McNamara,9 Tweed,10,11 and
the like) and in 4 dimensions (change during and
after treatment). Change, however, implies superimposition, and superimposition is even more of a
work in progress than is description and treatment
planning.
As we begin to explore cone-beam superimposition, I think we have no choice but to be
guided/constrained by Bjrks 2-dimensional
work; it is the only gold standard we have.12-14
Indeed, it may be the only gold standard we will
ever have. Further, our methods will have to be
consistent with what we know of facial growth.
Which structures change; which do not? When
does change take place? Where? How? To some
extent, we know the answers to these questions;
however, my experience working with superimposition has demonstrated problems that I think
can only be rectified by the programmers.
As in the movie, The Matrix, we see what
the programmers want us to see in the way they
want us to see it. As displayed in 3 dimensions,
bony surfaces look good; unfortunately, they
dont seem to be able to support meaningful

Professor Emeritus of Dentistry, The University of Michigan,

Ann Arbor, MI.
Professor Emeritus of Orthodontics, Saint Louis University, St.
Louis, MO.
Address correspondence to Lysle E. Johnston, Jr, 12305 Third
Street, Torch Lake, MI 49627. E-mail: lejjr@umich.edu
2011 Elsevier Inc. All rights reserved.
1073-8746/11/1701-0$30.00/0
doi:10.1053/j.sodo.2010.08.003

superimposition, given that meaningful must

be defined as producing results consistent, not
only with our knowledge of craniofacial biology,
but also with the 2-dimensional patterns reported by Bjrk and co-workers.12-14 Therein lies
the rub.
Few of Bjrks key, stable structures are on the
surface, and none are anatomical points. Instead, they are projected outlines of internal
structures. Programmers, therefore, will have to
make it possible for us to draw these lines and
the points derived from them in space or as
projected on 2-dimensional slices of our choosing. The result would be points and outlines that
can be oriented and registered: anterior arm of
the key ridge (an outline traversing all 3 dimensions); outline of cribriform plate in the sagittal
plane; anterior symphyseal sagittal outline; lingual palatal curvature, again in the sagittal
plane; perhaps the outline of the greater wings
on some frontal plane, mandibular molar germs
(A point in the center? An outline? A sphere?);
the mandibular canals (structures that probably
diverge over time, but which appear stable when
viewed in norma lateralis), etc. Time, however, is
of the essence.
It took Broadbents cephalometric technique
30 years to achieve widespread clinical application.15 Unfortunately, much like the chimney
sweeps top hat, the cephalogram has become
for many little more than a badge of office
symbolic, but of little day-to-day utility beyond its
presumed significance in a court of law. With the
advent of 3-dimensional techniques, history
teaches that we will have to do better and, whatever we do, we will have to do it more quickly.
For now, the cone-beam computed tomography
is mostly an expensive answer in search of questions, important or otherwise. To this end, I
think it has to be demonstrated that the conebeam data actually will be of significance to the
treatment of real patients. We need to know who
would benefit and how. Given this information,
the generation of measurements in 3 dimen-

Seminars in Orthodontics, Vol 17, No 1 (March), 2011: pp 13-14

13

14

Johnston

sions truly might be an idea whose time has

come. If, however, it turns out that, for many, it
doesnt matter, it probably is even more important that our colleagues be informed so that we
dont waste time and money and, in the process,
allow undeserving procedures and techniques to
become meaningless, but legally binding, standards of care.

References
1. Downs WB: Variation in facial relationships: their significance in treatment and prognosis. Am J Orthod 34:812840, 1948
2. Downs WB: The role of cephalometrics in orthodontic
case analysis and diagnosis. Am J Orthod 38:162-182,
1952
3. Downs WB: Analysis of the dento-facial profile. Angle
Orthod 26:191-212, 1956
4. Steiner CC: Cephalometrics for you and me. Am J Orthod 39:729-755, 1953
5. Steiner CC: Cephalometrics in clinical practice. Angle
Orthod 29:8-29, 1959

6. Steiner CC: The use of cephalometrics as an aid to

planning and assessing orthodontic treatment. Am J Orthod 46:721-735, 1960
7. Ricketts RM: The influence of orthodontic treatment on
facial growth and development. Angle Orthod 30:103133, 1960
8. Ricketts RM: Perspectives in the clinical application of
cephalometrics. Angle Orthod 51:115105, 1981
9. McNamara JA: A method of cephalometric evaluation.
Am J Orthod 86:449-469, 1984
10. Tweed CH: Evolutionary trends in orthodontics, past,
present, and future. Am J Orthod 39:81-108, 1953
11. Tweed CH: The Frankfort mandibular incisor angle
(FMIA) in orthodontic diagnosis, treatment planning
and prognosis. Angle Orthod 24:121-169, 1954
12. Bjrk A: Facial growth in man, studied with the aid of
metallic implants. Acta Odontol Scand 13:9-34, 1955
13. Bjrk A: Variations in the growth pattern of the human
mandible: longitudinal radiographic study by the implant method. J Dent Res 42:400-411, 1963
14. Bjrk A, Skieller V: Facial development and tooth eruption: an implant study at the age of puberty. Am J
Orthod 62:339-383, 1972
15. Broadbent BH: A new x-ray technique and its application to orthodontia. Angle Orthod 1:45-66, 1931