American Journal of ORTHODONTICS

VoZume 59, Number 1, January, 1971

ORIGINAL ARTICLES

Research related to malocclusion

A “State-of-the-Art” workshop conducted by
the Oral-Facial Growth and Development
Program, The National Institute of Dental
Research
Coenruad F. A. Moorrees, Charles J. Burstone, Richard 1. Christiansen,
Ernest H. Hixon, and Samuel Weinstein
l3oston, Mass.

To assess the wide ramifications of research related to malooolusion, State-of-the-Art

Worlcshops were conducted by the National Institute of Dental Research at the
initiative of K. Kenneth Hisaoka, chief, and coordinated by Robert J. Tacy, program
ofleer, of the Oral-Facial Growth and Development Program. In conjunction with
the authors listed above, the format for a series of worlcshops was developed and
participants were selected. The workshops were designed to provide in-depth review
of the achievements, directions, and needs of research concerning malocclusion and
dentofacial disfigurement (exclusive of cleft lip/pal&e). These worbhop conferences
were held at the National Institutes of Health in Bethesda, Maryland, on Nov. lY
and 18, 1969, and Feb. $5 and 86, 19YO. The ideas exchanged were integrated and
summarized by the planning committee to produce this report.

M an’s face and dentition serve as a mirror of expression and emotion,

an instrument of speech and communication as well as in the vital functions
of breathing, mastication, and swallowing.1 The psychologic and social implica-
tions of the dentition and its role in essential physiologic activities suggest that
the treatment of malocclusion and facial disfigurement must be considered as a
health service.
The premise of orthodontic treatment has been that the change toward a
normalized dentition enhances over-all functional adequacy and, as a conse-
quence, the survival of the denture during the life span of the patient.2
This aspect of health care poses many problems because a precise and
meaningful definition of malocclusion does not exist. Treatment need, or the
threshold at which different malocclusions actually cause functional impair-
ment and, conversely, treatment objectives, or the extent to which orthodontic
1
treatment must be carried to satisfy functional requiremelits, may be &fiicult to
determine in individual instances. Moreover, the etiology of malocclusion remains
largely unresolved, since information is not, available concerning the m&c of
action of the genetic and environmental factors as determinants of both normal
and abnormal development of face an(I dentition.

Ecologic and psychologic impact of malocclusion and dentofacial disfigurement

The social (ecologic) and psychologic significance of the human fact, its
role in human relations, coupled with cultural emphasis on external appearance,
physical attractiveness, and conformity, points t,o the fact that the problem of
the dentofacially handicapped is concerned directly wit,11 mental health.]~ 3, 4
Nonetheless, the severity of disfigurement does not invariably bear a direct
proportional relationship to psychic distress, owing to the capacit,y for atljust-
ment to malocclusion and facial disfigurement, or the lack of it, either in the
presence of severe or minor discrepancies.”
The study of the psychologic and ecologic sequelae of malocclusion requires
identification and definition of a large number of variables,“, 7 which, together
with their interrelationships, are of major importance in the design of such
research. Attention may be given to obvious but complex factors as fundamental
aspects of personality and self-image, attitudes, sex and age of the patient, family
background, and social class, together with intellectual ‘endowment and educa-
tions Malocclusion is a combination of heterogenous traits or symptoms, each
with a wide ra.nge of severity, and the implication of each trait as a handicapping
condition remains to be clarified.
In addition, the effect, of treatment may hc evaluated for determining to
what extent correction of the malocclusion contributes to the patient’s well-being.
This assessment must contend with the changing response of the patient during
the lengthy treatment period of approximately 2 years and with the influence
exerted on the patient by the orthodontist (his personality and behavior).
In summary, a highly complex set of factors is involved in determining the
impact of malocclusion and dentofacial disfigurement as well as the impact of
treatment. Both cross-sectional and longitudinal, Peated and untreated samples,
adequately representing the subgroups required, must be ascertained for testing
with both psychologic and case history methods.’
Studies of the demand” or motivation lo, I1 for treatment among different
population samples provide additional and invaluable clues with implications
for public health services, manpower needs, and the logistics of orthodontic care.
Fortunately, greater awareness of the significance of this kind of information
has already become evident by the at,tempts to develop indices which relate
anatomic aspects or traits of malocclusion to their presumed handicapping
effect.l”-I4 Some of these efforts have been conceived for administrative screening
to set treatment priority levels, ideally based on a rank order of the severity of
malocclusion. However, differentiation among milder forms of malocclusion for
treatment need by means of an index has not been achieved,l”, l” while the extent
of facial disfigurement has been inferred only indirectly by the malpositioning
of the teeth.
Volume 59 Research related to malocclusion 3
Number 1

A major advantage of these efforts has been to re-establish the need for
epidemiologic studies, but approaches to such studies must be revised if they
are to serve their intended purpose. Improved methods to select, assess, and
measure pertinent morphologic traits of malocclusion are essential for statistical
description of the incidence of each trait separately, their combinations, and
interrelationships. This information is currently not available.
Since the present anatomic model is inadequate for measuring the handi-
capping effect of malocclusion, new and meaningful methods are yet to be devel-
oped for objective and standardized determination of the impact of malocclusion
and its treatment. This methodology should be independent from that used to
evaluate the occlusal morphology itself, for the effect of malocclusion cannot be
measured by measuring malocclusion.1F
Physiologic impact of malocclusion

Speech. The general awareness that the teeth are involved in the production
of speech does not imply a causal relationship between malocclusion and speech
problems.17
The vocal tract functions as an integrated unit during speech production.
Since the tract is flexible and modifiable, a deviation in one portion can be
minimized frequently by modification of ot,her portions of the tract. Sounds can
therefore be produced in a variety of ways. Most speakers compensate automati-
cally for all but the most severe structural deviations to maintain intelligibility
of the acoustic signal because of the impelling need to communicate.
The adaptability and compensatory action of the vocal tract to a wide variety
of deviations do not negate the fact that in individual instances improvement in
speech disability can be secured by orthodontic treatment in conjunction with
speech therapy. Moreover, the greater the number of structural deviations, the
greater the demands placed upon compensatory adjustments and, consequently,
the greater the likelihood that defective speech and particularly consonant pro-
duction can be remedied by correction of the malocclusion.
The diagnosis of occlusion in its relation to defective speech is primarily
concerned with the sagittal relation of the dental arches (overjet), the vertical
relation of the anterior teeth (overbite), the continuity of the incisal edges of
the anterior teeth (spacing), the configuration of the hard palate, tongue
mobility, and the adequacy of the velar pharyngeal valve mechanism.ls
Future research requires better identification and quantification of diagnostic
procedures to determine the anatomic and physiologic adequacy of the oral
structures for speech, tongue activities in swallowing to evaluate such assumed
clinical entities as tongue-thrust,lg and conditioning techniques to modify neuro-
muscular behavior as well as the interaction of reflexive and voluntary behavior
with oral sensation and perception.“O a~b
These investigations do not pertain exclusively to orthodontics but transcend
to the general area of oral physiology (speech, deglutition, and mastication)
for which this fundamental knowledge is also desirable.
Mastication and digestion. The mastication of food is a primary function of
the dentition in the process of digestion. Masticatory efficiency is known to be
4 Moorrees et al. Amer. J. Orthodont.
January 1971

impaired with the loss of teeth, but almost no difference has been reported be-
tween subjects with excellent occlusion and those with most types of malocclu-
sion.‘l Although unmasticated food may leave undigested residues,“” the degree
of mastication required for maximum absorption of foods is seemingly readily
attained by subjects with inadequate dentitions.
Actually, little research has been done on mastication, and no evidence exists
that malocclusion (excluding conditions that cause severe functional impair-
ment) affects the digestive process and general health. Nevertheless, the ease of
chewing and swallowing, freedom from interdental food impaction, self-cleansing
action, and the enjoyment of taste are factors which cannot be quantitated but
which must be satisfied according to individual requirements.
More refined nutritional studies arc needed to determine whether differences
in the transport of food across the digestive membranes depend on the degree of
preparation in the mouth and whether mastication has any bearing on resistance
to disease or longevity of man.
Periodontal health. Some forms of malocclusion have been linked with oc-
clusal trauma and breakdown of tooth-supporting tissues.23* 24 Conversely, the
assumption has been made that the change to a more optimal occlusion will safe-
guard periodontal health.
Gross functional impairment and tissue damage, as observed in some patients,
obviously requires correction. In the absence of destructive and degenerative
symptoms, prediction of future periodontal breakdown as a result of occlusal
trauma is hazardous,25 for measurement of magnitude and direction of occlusal
forces and adaptability of tooth-supporting tissues to these forces in time remains
beyond the present state of diagnostic art.
In spite of repeated but undocumented statements, one may still question
whether specific traits or characteristics of malocclusion initiate or accelerate
periodontal pathosis.
Experimental and therapeutic modification of occlusion should aim at
clarification of the conditions under which adaptation of periodontal tissues is
no longer possible and pathologic changes occur. This objective involves numer-
ous investigations which include functional and nonfunctional force loading of
the teeth during extensive time spans. The complexity of such a project should
not be underestimated, because instrumentation has to be developed for
measuring the three-dimensional distribution of forces and the tissue response
to these forces.
Occlusion has become a central core in dentistry, transcending the boundaries
of various specialties. Considerable efforts have been made during the last two
decades to study occlusal function and its sequelae in greater depth. Sophis-
ticated instrumentation has been used to investigate patterns of closing, oeclusal
contacts, tooth mobility, and muscular activity, as well as effects of overloading
individual teeth.
For instance, the use of telemetry to relay tooth contacts during closing26
has been helpful, although its application is obviously limited. Nonetheless, long-
standing concepts are being challenged by new evidence which suggests that
functional or habitual contacts are attained during chewing and swallowing
rather than in the more posterior centric position.27
-volume 69 Research related to malocch&on 5
Number 1

The use of electromyographic techniques in the recording of muscular activity

in the presence of occlusal anomalies and cuspal interferences has attempted to
define the timing, duration, and phasic relationship of muscle contraction.28* 2g
From these action patterns, inferences have been made about muscle behavior
which, in turn, has been linked to occlusal relationships. However, the inherent
difficulties and limitations of the technique,30 as well as the inability to obtain
simultaneous recordings from the large number of facial muscles, explain the
limited contribution of electromyography to diagnosis and treatment of occlusal
anomalies.
Much work remains to be done in the area of occlusion, but expectations must
be tempered until it becomes possible to record the many aspects of occlusal
function, reliably and without interference, to the normal physiologic status of
test subjects. Within individual variation in oral function requires special con-
sideration in the experimental design of such research.
Tooth movement

The literature abounds with reports on tissue changes on which tooth move-
ment for correction of malocclusion is dependent. The findings of these investiga-
tions had a profound effect, resulting eventually in modification of force dosage
to prevent necrosis. During the last two decades analysis of force magnitude and
force duration has been given continued emphasis for optimal biomechanical
appliance design. 31,32 These attempts have been successful insofar as the devel-
opment of a variety of methods for precise three-dimensional control of tooth
movement is concerned. Nonetheless, variations in individual response33 to these
perfected force systems demand further study of the biologic reactions to the
carefully computed direction and strength of forces and couples, both for tooth
movement and for preservation of anchorage, as needed. Research in tissue
reaction to forces from orthodontic appliances involves ascertaining the mode of
action of osteoblasts and osteoclasts in matrix formation and calcification as well
as resorption of bone.
It should be realized, however, that the mechanism by which pressure and
tension are converted into two different cellular responses is unknown.34 Changes
in tissue vascularity35 and altered oxygen-carbon dioxide levels3s have been
implied, but more generally pressure has been linked with differentiation of
osteoclasts and initiation of resorption and tension with osteoblastic deposition
of new bone owing to distention of the collagenous periodontal fibers.
Current thoughts suggest that the principles of bone remodeling characteristic
of bone growth in the long bones37 and sku1138 are also involved in tooth move-
ment following bending of alveolar bone,3g in addition to the compression and
distention of the periodontal membrane for initiation of cellular changes.
The mechanical energy expended in alveolar bone has been related to the
piezoelectric effect, which is expressed in terms of transient electric fields that
arise when bone is dynamically loaded and presumably induce profound meta-
bolic changes in cells. The rate of bone deformation is proportional to amplitude
and the polarity of the electric potential to the direction of deformation.40
Similarly, inferences may be made about root resorption, since piezoelectric
potentials have also been demonstrated for the dentine and cementum of the
 tt?eth.4’ StrcsS tlistribution in a mat,h~l~lutical modrl 01: tlic pcrio([ontal ligi]m(‘[)t
indicates that the largest stresses oc(+ur at the ~mentnltl snrfa~ rat,hcr t ban it,
the bone surface of’ the alreolns. The highest ratio of thcsstresses WI tlltls(a s~f’a~s
for Cllly locat,ion in this 11~od~l is follnil tht: ;ll)ir*al ill'Vil. \\hfxW
ilt ro(jt rc5orption
also occursL.,I’!
Yet the origin of the piczoelcctric efYWt, and its function ilS a tr;LnsduccI
mechanism in living systems for cellular rcsponsc to force applic*ation require
further investigation. The electric potentials at thcl tension alIt1 compression
sites of the periodontal membrane may bc studied to cletrrmine \vhether they
result from the elastomer tissues of the ligaments or Cram an interaction at the
bone-elastomer interface. Likewise, tlic polarit>- of electric potential differc~ncrs
remains to be determined in the metlullary spact~s on the innrr surface of t,he
cortical plate at areas of undermining resorption.
The time lag in the response and tlifferentiation of osteoblaxts and ost,eoclasts
after force application and the registration of an c1lectric potential difference
would clarify the significance of the piezoclectric effect as a transducing mecha-
nism or as an associated phenomclnon to a primary rcll-mediated biochemical
process.
Conversely, the piezoelectric effect may be used as an experimental tcchniquc
to study changes in bone architecture during tooth movement to reveal the site
and extent of alveolar bone bending.
As is often the case, attempts to csplain the mediating mechanism of tooth
movement demand fundamental biologic, research, particularly since electric
potential differences are known t,o (K’PW already at the intracellular level and
across cell membranes. The unrarcling of a causeand-effect relation is therefore
implied between ionic exchange anal an electrical phenomenon.

Stability of tooth position

Teeth are known to drift from the time that the deciduous teeth emerge,
throughout the mixed dentition,4” to t,he early thirties in the unmutilated
permanent dentition,4” and probably throughout the entire life span of the
individuaL4” Thus, tooth position and occlusion are dynamic entities probably
in response to functional forces and growth changes of the face, however minute
these may be.
Tooth positioning for the correction of malocclusion is guided by a well-
established anatomic norm modified 1)~ individual criteria, such as maintaining
the original dental arch shape and breadth as well as the position of the man-
dibular incisors. Dental arch continuity through contact relations of the proximal
surfaces of the teeth, proper root positioning of anterior and posterior teeth, and
overcorrection of overbite and rotations arc additional objectives of treatment.
Furthermore, assessment of occlusal relations during functional activities in the
last phase of treatment is undertaken to eliminate excessive forcaes and grm
occlusal interferences.
In spite of adherence to these objectives, varying degrees of relapse occur
after orthodontic treatment and even after prolonged retention. These relapses
cannot be readily explained other than by the fact that alveolar bone responds
 Rescad related to malocclusion 7

to mechanical stresses on the teeth to maintain homeostasis by differential growth,

as in any stimulus-response or closed-loop negative feedback system.46 The
obvious conclusion must be that the teeth are not in coronal equilibrium when
subjected to the system of forces produced during the patient’s physiologic
activities.47 These force vectors cannot be determined at the present time, as
stated above, and it may be concluded that empirical concepts of crown and root
positioning do not necessarily correspond to the physiologic requirements of
each patient.
Since teeth are in equilibrium at all times (that is, the sum of all coronal
forces and all moments equaling zero), any deviation in coronal equilibrium must
be compensated by forces developed through stresses in the periodontal ligament.
When such stresses exist for periods of time sufficient to permit differentiation
of osteoblasts and osteoclasts, the teeth will migrate toward a position in which
coronal equilibrium is re-established. This concept may also explain the seemingly
continuous migration in the untreated dentition.
The tolerance limits of this force equilibrium remain obscure. Moreover, it is
not known to what extent cusp-fossa relations of opposing teeth, slippage in
approximal contacts of neighboring teeth, root positioning, as well as gingival
and transseptal fibers, singly or jointly, contribute to a train of events that
disturbs a seemingly excellent treatment result. Furthermore, the value of pro-
longed retention to prevent relapse has not been demonstrated in terms of its
buttressing effect on the dentition to withstand facial growth changes after
treatment, particularly in the case of differential growth of the two jaws, and to
allow adjustment of muscle behavior. The last, factor may not be pertinent, for
adaptation of muscular activity to the changing tooth environment., if it occurs,
should already have t,aken place during treatment.
Persistent tongue-thrust in the presence of open-bite tendencies poses special
problems for correction and stability of results as a neuromuscular disorder
uncorrectable by conditioned learning experience. Its incidence is, however, low
and recognizable.
The balance between tongue, lip, and cheek forces has been considered
especially decisive for maintenance of arch form, and myometric studies have
been conducted to verify this hypothesis. Results so far have not been conclusive ;
in fact, buccolingual forces seem to be rarely in complete balance at any moment
in time.
A number of factors can be cited which point to the limitations of these
studies. Transducer design, transducer placement against the buccal or lingual
tooth surfaces, presence of lead wires, and inability of transducers to withstand
prolonged use in the mouth all point to the need to improve instrumentation.
Some progress has been made, for transducers have been incorporated in artificial
teeth,48 and it has been possible to design transducers with strain gauges that
accurately represent the force exerted by muscles without artifacts resulting
from the extent of muscle contact on the transducer platform area.49
The marked variation during repeated testing of the same person requires
that force measurements are obtained during long time spans. So far, muscle
balance has been estimated only from 24-hour activity and swallowing records,
8 Moorrees et al. Amtw. J. Orthodost.
January 1971

transmitted with telemetry, Subsequent test measurements, in the laboratory,

of various oral functions, such as chewing, speech, swallowing, and rest, with
different head postures were used to compute the estimated contributions of these
activities during the 24-hour period.4g
Although myometric research may well produce clinically significant data,501 51
additional variables must be brought to bear on the balance concept. That is, a
lack of balance between labial and lingual muscle forces may be compatible with
other forces which, together, determine the total force system. Moreover, the
effect of muscle forces, per se, may differ in various segments of the dental arches.

Growth and development

Malocclusion is only rarely conditioned by gross anomalies in facial develop-

ment, for the face with malocclusion is generally well within the range of normal
variation, although characterized by disharmony of parts5”
Family research has indicated a strong hereditary component of the develop-
ment of the face and dentition. 53 Polygenic control is assumed because simple
Mendelian models have failed to yield an explanation of genetic mechanisms.
Because of the known phenotypic plasticity, this multifactorial system is also
susceptible to environmental modification. In this context, postnatal factors have
been given greatest importance in the etiology of malocclusion, perhaps because
the embryo and fetus have been assumed to develop in a protected environment
and the prenatal period has been described more in terms of a static than a
dynamic process.
Since etiology, diagnosis, and treatment of malocclusion are closely linked
to growth of the face and dentition, a variety of approaches for research in this
area is needed. Twin studies can define the contribution of genetic and environ-
mental factors to facial morphology. 54y55 Heritability can be determined at
various immature levels of facial development in twins and, when longitudinal
data are available, the twin method can be applied to the study of heritability
of growth increments. Through cross-twin analysis,5G genetic and environmental
components can be determined for the interrelationships between different
growth parameters, both absolute and incremental.
Families are less efficient than twins for defining the contribution of genetic
and environment factors, because of the lack of genetic unity that exists in
monozygotic twins, but family data arc needed for the study of genetic mecha-
nisms. However, differences in the ages of subjects and changes in environment
restrict the usefulness of two-generation family data. Moreover, single-generation
studies of full siblings, half-siblings, and cousins require extremely large num-
bers of subjects as well as age controls. Thus, only limited results c;w1 be
anticipated from present analytic techniques, particularly since the mode of
inheritance of most attributes is complex.57
Comparison of siblings to their parents has been used to make inferences
about sex chromosome effects upon certain growth processes.58 When propositi
with chromosomal aberrations can be ascertained, family comparisons can iden-
tify the relationship of a particular abnormality with specific chromosomes.
Inbred-animal studies can serve to test theoretical models for the analysis
volume 59 Research related to malocclusion 9
Number 1

of craniofacial growth in man. For example, breeding studies may be carried out
to determine the efficiency of a mathematical model derived for the purpose of
partitioning quantitative differences in a growth parameter by the use of marker
genes, such as red cell antigens. Through embryologic research in animals, it
would be possible to associate the effects of gene action on different tissues,
systems, or traits. 5s This research is just in a beginning state in genetic
laboratories.

Nongenetic factors

The contribution of nongenetic factors to phenotypic variation brings into

focus the fact that, invariably, hard tissues have been used for human and ani-
mal studies, which leads to oversimplification of the true complexity of the
problem of growth and development. Bone exists in a milieu and, irrespective
of its form at a given developmental horizon, it is subject to modification by
adjacent tissues. This interrelationship may be so prominent that primary genetic
control cannot be readily discerned, as, for instance, in the mandible in the
Pierre Robin syndrome. The proportionate effect of genetic (biochemical) and
environmental factors will be particularly difficult to evaluate at earliest levels
of morphogenesis.
At present, models of bone growth are concerned with the effect of function-
form interrelationships, an adaptive capacity that concerns size, shape, structure,
and position of bony elements, recognizing a degree of individuality of bones
or areas thereof within the totality of the organism and discarding a bone as an
isolated anatomic specimen.@‘~w 85
This concept does not negate the role of genes, as is often assumed, but,
rather, broadens genetic study to include morphogenesis of all tissues (soft and
hard) and their subsequent interaction. It involves the central nervous system,
which guides voluntary and sensory-receptor-induced muscle activity. Thereby,
architectural aspects become subjugated to the underlying factors that create.
The definition of function as a property and vitalistic force and of a func-
tional component as a part of a structure which performs a function, as well as
the definitions of functional matrices and functional units, has so far been made
in operational terms. 61 In view of the true nature of this concept, the function-
form intera,ction works both ways, since adaptation of form yields adaptation
of function as a form-function relation. In fact, it is not known whether the
latter is the proper term for the earliest developmental horizons or whether at
that moment in time both soft and hard tissues are differentiating within a
genetically coded pattern.
The experimental model for pursuing the functional approach to morphology
should consider the interdependence of functional factors on each other, ex-
pressed either at the site of the functional component studied or beyond this
area.

Neuromuscular patterns and bone development

This research also involves the field of neuromuscular physiology to in-

vestigate the role of muscle activity as controlled by the motor neurons and
10 Moorref~s et ul.

the experimental induction of disturbances in the ~~~ntral n~r~-ous systf:m.‘:z

Muscle removal itself is a relativ-cly cructc techniques and more cstensivc use
Of SUCh methods as sectioning of the fac.ial n(‘rvc 01’ tri#kmina] J))[)tw nmt ;it

specific stages of postnatal development and unilateral sretionillg 0f the h~p0-

glossal nerve to produce asymmetric tong;u(~ action is indicated.
Unilateral sectioning of the al~ola 13IWJY’ soon aft,chr birth should rc~veal the
effect of the trophic influence on tooth formation, t oath eruption, and bone
gro\vth. Bilateral sectioning prevents sc~nsory input from the mandibular denti-
tion to the central nervous system. It also interferes with the inhibitory brake
mechanism on the jaw-closing mus(~Ics, at least by c4iminating prriodontal
receptors in the mandible, and thereby affects mus~lc action ancl muscle force.
Activation of n~nsclcs through elect rodcs implanted in the mcsrncephalic or
motor nucleus of the trigcminus may 1)~ another approach to overactivation of
muscles. Similarly, removal of the affercbnt feedback from the tongue pan reveal
effects on bone growth owing to 1ac.k of control of the tongue or its orrractivit,g.“”
At birth, an intricate pattern of‘ the organization of the central nervous
system in response to input from oral sensory receptors has been achieved to
assure the vital oral-pharyngcal function of the nowborn. The additive effect
of the teeth, onc~~they emerge, and their related sens(~ organs as modifiers of
these patterns in the developing ner~us system will bc of inter&. Furthermore,
the changes in tooth position during Orthodontics offer additional experimental
conditions owing to concomitant modification of il(:l1roIr1usc~~lar activit,y and
thereby mandibular posture.
Current research on oral-pharyngeal rcflexeP, (i5may provide tests to charac-
terize reflex patterns and their relation to bone development. At present no firm
experimental evidence is available t,o ascertain the role of the nervous system,
and methods for its study are yet to bc perfected. Nevertheless, this a.rca of
research requires attention because it is directly relat(ad to the investigations
that have occlusion of the dentition for their objcctivcl.
Patients with neurologic disorders, developmental anomalies, endocrinop-
athies, and chromosomal defects provide another source for the study of growth
and devclopment.6F-G” Careful documentation and longitudinal follom-up by a
team of investigators representing various disciplines remain to be attained as a
prerequisite for interpretation of the data which these experiments by nature
can reveal.
For instance, subjects with significantly altered growth and development
associated with specific hormonal deficiencies or excesses, for which appropriate
therapy is available, may be used to define the role of the endMarine system in
growth. This information is especially valuable with respect to hormones respon-
sible for normal adolescent development, since specific techniques are now avail-
able for measuring separately gonadal, adrenal, and growth hormone concen-
trations under different physiologic states. The role of sex hormones on the rate
of development of the face during adolescence would be of particular interest,
possibly for growth prediction. Further study in man or experimental animals
of the effect of hormones on tooth formation, tooth eruption, and tooth emergence
is still indicated for a more definitive understanding Of this aspect of oral
Volume
Number
59
1
Research related to malocclusio~z 11

physiology.6s~ 69 In view of the recent advances in hormone assay, endocrinologic

research may prove to be valuable in clarifying mechanisms involved in skeletal
growth.
Topographic study of the normal child with and without malocclusion has
been a traditional approach in orthodontics. Cephalometric tracings and dental
casts have been used, but sometimes they have been augmented with an-
thropometric data, as well as hand-wrist and dental radiogra.phs, to assess skeletal
maturation and dental age, respectively.
In spite of the battery of reports from cross-sectional or longitudinal studies,
a precise description of normal facial and dental development is not available.
Relationships between somatic growth and facial growthi and the value of using
a physiologic age scale remain to be clearly defined. As a result, attempts to
pursue prediction of facial growth hare been premature and unfruitful.

limitations of growth prediction

In fact, the unrealistic premise has been entertained that growth in absolute
terms may be predicted for the postadolescent from quite immature levels at
childhood (say, 5 years of age), Such efforts have generally involved correlations
of univariate parameters.” They have been useful not so much for their findings
but, rather, for pointing to the need for identifying the sources and their
contribution to individual differences in the growth and developmental process.
Recognition of the multivariate nature of the problem is a first requirement in
any experimental design aimed at prediction. Yet it implies recognition of the
limitation to which the precision of growth prediction can be pushed in absolute
terms. Instea.d, the objective may well be limited to ascertaining growth trends,
and that at relatively short time intervals, to gain better insight into the nature
of growth changes.
The shortcomings of the cephalometric technique as a two-dimensional pro-
jection and the inability to locate all desirable landmarks for defining growt,h
in various areas of the head do not condemn this method. In the first place, the
radiographic record is indispensable for the study of the living, and a great
deal of information currently not available can be obtained from these films.
Metallic implants have given an improved means for superposition of serial
records to define the effect of growth more accurately.72 Their use demands
accurate duplication of head positioning during serial study with image screen-
ing prior to exposure. Moreover, the combined study of frontal and sagittal
head projections for a partial three-dimensional analysis has already been de-
veloped,731 74 and metallic implants can further enhance their yield. Finally, the
caudad-cephalad projection can be obtained for complete t,hree-dimensional
study.=
Longitudinal studies generally evoke criticism based on limitations in
sample composition and sample size. Consequently, the representativeness of
the sample to the general population is questioned.
In spite of the difficulty and cost of conducting longitudinal research, it
should be remembered that individual variations in growth increments can
be defined only by the repeated observation of the same subjects. Any attempt
12 Moorreeset al. Anwr. J. OrthocZmat.
January 1971

to predict growth must rely on the longitudinal method, and these data furnish
the basic reference for the study of children with abnormal developnlerlt,. It is
particularly unfortunate with reference to malocclusion that little longitudinal
research has been conducted on growth from the early postnatal period to the
establishment of the deciduous dentition.76
The dentition counts as a separate tissue system in the growth process, and
the timing of its growth changes is dependent on the formation of the teeth.77
Facial growth, on the other hand, may be studied in relation to somatic growth
and bone age, particularly with respect to its acceleration during adolescencc.78
Comprehensive documentation of the timing, duration, and magnitude of the
adolescent growth spurt is of particular interest because of its pronounced but.
variable effect on the individual’s growth cycle.7s
Precise assessment of the relationships between dental, facial, and somatic
growth demands careful selection and precision of observations. For instance,
an over-all rating of epiphyseal and carpal development in the hand-wrist
region will not reveal to best advantage the detail required for scaling growth
data on physiologic age. 8o Likewise, for sibling or twin studies, meaningful
information may be lost unless differences can be accurately determined.
The statistical analysis of growth data is now generally described in terms
of multivariate analysis. Yet specific statistical approaches and computer pro-
gramming must be developed according to the inferences which the investi-
gator wants to make from his growth data. Comput,er technology provides no
more than a means of realizing the biostatistical objectives of a study.
Research in growth and development cannot be lirnited in any case to one
specific approach; that is, neither the experimental study7’jWi8nor the clinic for
human studyTg alone can give the answers needed to clarify the etiology of
malocclusion and to determine the probable effect of growth during ortho-
dontic treatment and thereafter on the result obtained.

Manpower needs for research related to malocclusion

The wide ramifications of research related to malocclusion obviously require

a highly diversified group of investigators with competence in a variety of
disciplines of the basic and related sciences. For this reason, it is necessary that
orthodontists, particularly those in a university setting, seek active collabora-
tion for the joint conduct of research. The complexity of the problems involves
sophisticated approaches to experimental design and methods of study. Con-
sequently, orthodontic departments cannot be expected to accumulate a staff
to deal with these problems efficiently.
The establishment of research institutes and clinical research centers pro
vides a means to realize two objectives, namely, to interest faculty of the
university at large in the challenging research projects relating to malocclusion
and to provide the orthodontic department with expert assistance.
The orthodontist has a primary role in research undertakings, for he must
pose the problems, define their significance, and interpret the findings. More-
over, he will be responsible for clinical observations and clinical application of
test procedures which will be part of most research. His motivation and his
skills are indispensable for the programming of teamwork. Moreover, he must
Volume
Number
69
1
Research related to malocclusion 13

be expected to have a broad scientific background if he is to utilize the re-

sources of the biologic sciences and the health sciences of the university.
Massive expenditure of funds into areas of research without assurance of
collaborative efforts by those trained and knowledgeable in both the clinical
and the relevant scientific disciplines is no longer warranted.
The major key to research manpower is the team effort, whenever required,
and a realistic appraisal of the actual collaboration that can be obtained. The
training programs for orthodontists aiming at full-time academic careers must,
of necessity, include the perspective that research related to malocclusion de-
mands.
Although much information is needed to better define indication and need
of orthodontic treatment, it may be safely assumed that present manpower is
insticient to deliver this care to larger segments of the population, regardless
of the outcome of such research. Apart from extending facilities for specialty
education, greater efficiency can be obtained by allowing a multitrack ap-
proach in the latter part of the undergraduate curriculum, whereby students
can pursue their specific areas of interest in either the clinical or the basic
science areas. In the future, these elective studies may well become acceptable
as part of the educational requirements for specialty practice.
Furthermore, a large percentage of routine tasks in orthodontic practice
can be performed by auxiliary personnel. Their training should not raise
serious problems, for auxiliary personnel in orthodontics, as in medicine, serve
as a link in a chain rather than providing complete services.
Orthodontics, as an integral part of dentistry, should also receive greater
emphasis in undergraduate education in accordance with the guidelines of the
Council on Orthodontic Education of the American Association of Ortho-
dontists and the Council on Dental Education of the American Dental Associa-
tion. Moreover, the wide implications of research related to malocclusion may
serve in postgraduate programs to broaden horizons and educate future
generations of orthodontists in true academic tradition and, hopefully, in
preparation for their participation in new and imaginative research.
Conclusions

This report has raised a number of fundamental questions regarding maloc-

clusion and facial disfigurement which are ultimately related to improved
patient care. Answers to these questions demand recognition of the complex
nature of the problems to be solved. Much of this research involves active col-
laboration of investigators from various disciplines. Likewise, it requires a
variety of approaches to experimental and clinical studies as well as advanced
methodology. Future investigations may include focus on the following areas:
1. Dentofacial disfigurement and its relation to mental health, with
specific attention to self-image, personality, social acceptance, and
behavior.
2. Functional impairment as a result of malocclusion, particularly
in terms of tooth-supporting tissues and dental health, speech, and
possibly mastication.
3. The contribution of orthodontic treatment to functional improve-
14 Moorrccs et 07.

ll~cllt and psychosocial well-being in I)oth the yo~u~g ;tncl adults t’o18<‘;lvIl
of the different, traits that constitute? malocclusion.
4. Tissue response to forces from orthodontic appliances, bone forma
tion and remodeling, I~~L~~OI~USCLI~~~ adaptation to tooth rnovemc~nt~ ill~tl
effect of tooth-supporting ligaments on tooth movement.
5. Mechanisms through which I’orcc application res,nlt,s in cellula.1
activity.
G. Oral physiology in terms of occlusal function at various develop-
mental levels.
7. Embryology of dentofacial development, tissue differentiation, and
their interrelationships during prenatal growth.
8. Growth of face and dentition, its relation to orthodontic treatment,
and long-term stability of treatment results.
Manpower provides a key to the advancement of knowledge and improvc-
ment of clinical orthodontics, while education provides a key to the production
of the qualit,y, quantity, and diversity of the manpower required.
Acknowledgment
I<. Kenneth Hisaoka, Chief, Oral-Facial Growth and Development Program (NITlIt),
Robert J. Tacy, Program Officer, and the authors are indebted to the following consultants
for their valuable contributions to this State-of-the-Art Workshop which made these conferences
a most stimulating experience: C. Andrew I,. Bassett, Professor of Orthopedic Surgery,
Columbia University College of Physicians and Surgeons; David Bixler, Associate Professor
of Dental Sciences and Medical Genetics, Indiana 7Jniversity, . -James P. Carlos, Chief, Biometry
Section, National institute of Dental Research; Donald B. CherJk, Professor of Pediatrics, The
Johns Hopkins University; Lois R. Cohen, Chief, Applied T<oh:trioral Studirx, Division of
Dental Health, National Institutes of Health; *John F. Crigler, Jr., Assoc+~te Profrssor of
Pediatrics, Children’s Hospital-Harvard University; Vincent T)eAngclis, Assistant Professor
of Orthodontics, Harvard School of lfental Medicine-Forsyth Dental Center; Pieter
Dullemeijer, Professor of Zoology, Universit,y of Leiden, The Netherlands, and Visiting
Professor of Dentistry, School of Dental and Oral Surgery, Columbia University; J,ouis J.
Goldberg, Assistant Professor of Anatomy and Oral Biology, 7:niversity of California;
Eugene Goldwasser, Professor of Bioehemistr,v, Argonne Cancer Research Hospital, I-niver-
sity of Chicago; William Th. Green, Harriet M. Peabody- Professor of Orthopedic Surgery,
Emeritus, Children’s Medical Center-Harvard 7:niversity; .Don C. Haack, Professor of
Engineering Mechanics, University of Nebraska; James T. Irving, Professor of Physiology,
Emeritus, and Senior Staff Member, Harvartl [:llivarsitv-E’orsvth Dental Center; Malcolm
C. Johnston, Visiting Scientist, Human Genetics Branch, Sational Institute of Dental
Research; C. C. Lit Professor of Biostatisticn, Trniversity of Pittsburgh; Frances (1. AMac-
gregor, Professor of Social Science, Sew York University; .lerry I). ?&wander, Chief,
Human Genetics Branch, National Institute of Dental Research; Albert Norris, Professor
of Psychiatry, University of Iowa; Henry .J. Ralston, Research Physiologist, University of
California; Alexander F. Roche, Chairman, Department of (Growth and Genetics, Fels
Research Institute; I)uane C. Spriestersbach, Vice President for Research and Ilean of the
Graduate College, 7:niversity of Iowa; Sigmund 8. Stahl, Professor of Periodontics, Uni-
versity of Southern California; Richard E. Stallard, Professor of Periodontics, State T’ni-
versity of New York at Buffalo and Assistant to the J)irect,or, Eastman Dental (lenter;
and George Stricker, Associate Professor of Psychology, Atlelphi .Irniveraity.

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Volume 69 Research related to malocclusion 17
Number 1

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Sennior author:
Forsyth Dental Center
140 The Fenway
I3oston, Mass. 02115

. . . It should be obvious to the student that orthodontia is not a mechancial art as

popular rumor would have it, but is largely a biological problem. However it does not
necessarily follow that mechanics has no part in it, for such an inference would be as far
from the truth as to say that it was wholly mechanical. Just as in orthopedics and in
other branches of medicine and surgery, mechanics and mechanical means must be used,
so in orthodontia we must utilize mechanical means to influence and control certain physi-
ological processes which in turn make possible the normal development and functional
perfection of the teeth and their correlated parts. (McCoy, James David: Applied Ortho-
dontia, ed. 3, Philadelphia, 1931, Lea 8, Febiger, p. 58.)