by Alan Ruskin
How Johnston, Gianelly, and Proffit helped to shape orthodontics
“‘If wishes were horses, beggars would ride.’ My father would say that to me in denying the likelihood of something. In the same manner, if wishes were horses, functional appliances would grow mandibles. My central message is that seeing how malocclusion is not a disease, that no one dies, that there is no agreed-upon outcome, nor any standards—then, if the truth says that there’s something even better than what you’re using to successfully support your practice, that truth will not be popular. It will be an inconvenient truth, as Mr. Gore has put it in his film. I may be known as a maverick, but I’m not a revolutionary. It’s like Vesalius returning to the truth of Galen. Vesalius wasn’t a revolutionary, he was merely a conservative wanting to reclaim the truth that Galen knew over 1,000 years before.”
—Lysle E. Johnston, DDS, MS, PhD, FDS RCS(E)
Are the above the utterances of a Socratic sage or an orthodontist from Michigan? In Johnston’s case, the answer is a bit of both. He has established a venerable reputation as an internationally renowned teacher and researcher of orthodontics.
A professor emeritus of dentistry at the University of Michigan in Ann Arbor as well as professor emeritus of orthodontics at St Louis University, Johnston officially retired in 2004, but continues to teach a modified schedule, not only at the aforementioned campuses, but also at Case Western Reserve University in Ohio (where he received his PhD in anatomy). He has chaired the orthodontic departments at all three universities, and regards his greatest accomplishment as “having trained 325 currently practicing orthodontists and advised in the master’s theses of over 100 candidates.”
Johnston’s original impetus toward orthodontics was not quite so academic. When he was a boy of 12 growing up in East Jordan, Mich, his father took him to an orthodontist for the first time to correct a minor malocclusion. “It wasn’t a very big job, but the bill was quite substantial. That gave me the idea that being an orthodontist was a pretty good gig.” He had always been a straight-A student but never felt a real calling in any particular direction until he met his first orthodontist. “That’s not unusual,” he comments. “You’d be surprised how many aspiring orthodontists, and I’ve interviewed many, were motivated by their childhood experiences. The orthodontist is often the first adult outside of the parents with whom the child has close and meaningful contact.” Johnston’s enthusiasm led him to enter the pre-dental program at Central Michigan College, which he completed in 2 years, so that he arrived at the University of Michigan Dental School at the age of 19.
He ventured abroad to attend the school of dentistry at Queen’s University of Northern Ireland. It was there that he was strongly influenced by one of his teachers, the noted anatomist James H. Scott, LDS, DSc, MD. “He didn’t abide fools gladly,” Johnston recalls, “and provided me with an intellectual standard that I have striven to uphold throughout my life.” Scott inspired Johnston to become a researcher specializing in craniofacial growth and development. In 1962, Johnston returned to the University of Michigan’s Horace H. Rackham School of Graduate Studies to pursue a master’s degree in orthodontics.
Perhaps genetically disposed toward academia—both of his parents were teachers—Johnston next went to medical school at Case Western Reserve, concentrating in neural anatomy. He was there for 6 years, the last 5 of which were spent as the chair of the orthodontics department. “I wanted to be a scientist, but I had a family to feed so I went into teaching. At first they didn’t even know I was a dentist, but when they found out I had an MA in orthodontics, they asked me to fill the empty chair. I wasn’t seeking it, but like many things in my life, I just seemed to be in the right place at the right time.”
Johnston’s fortunate odyssey continued at St Louis University, where he chaired the orthodontics department for 15 years until 1991, when he returned to Michigan to chair that department until his “retirement.” His current teaching assignments at all three of his former departments include classes in facial growth, statistics, cephalometrics, occlusal growth, and orthodontic history.
A major concern for Johnston that has characterized his career is an emphasis on professional integrity. He considers himself a “careful worker and honest,” and derides the culture of convenience that considers any appliance or technique appropriate as long as “it supports the practice.” He believes that objective study and research is paramount in producing results that truly serve the patient. “Orthodontics is a service based in science, and our success in the long run depends on how much of our service is evidence-based.”
Issues such as the debate over one-phase versus two-phase treatment strike him as essentially contrived, never-ending controversies that merely serve to mask the truth that is available to anyone who researches the subject objectively. As one of his former students, Orhan Tuncay, DMD, now head of the dental program at Temple University, says, Johnston “has helped to dispel the myth of orthodontists as charlatans, a notion that would otherwise irreparably harm the profession.”
As a teacher, Johnston takes pride in doing things the old-fashioned way. “I’m known at the university as the last person to use the chalkboard. I believe that PowerPoint is for entertainment. Chalk is for teaching.” He is especially proud that his students have walked away with 20% of all prizes in the AAO research competition. “I am happy if my students emerge from a difficult course knowing more than they had expected to know, liking the subject a bit better than they had thought they would, and feeling a bit better about themselves than they did before the course.” Johnston deplores the current dearth of orthodontic students interested in going into teaching and research. “There’s a real market for straight teeth, but not for straight thought.” As serious a scholar as he is, Johnston is also noted for his humor (see online sidebar).
Despite his often contrarian approach, or perhaps because of it, Johnston has been the recipient of many honors. Among the accolades are the prestigious Albert H. Ketcham award, the 5th International Award of the Italian Society, and the Dewel Award of the AAO. He has lectured widely, delivering both the Mershon and Salzmann Lectures of the AAO, the Angle Memorial Lecture at the E.H. Angle Society of Orthodontists, and the Northcroft Lecture of the British Society for the Study of Orthodontics, among others. One of his former students (and current collaborators), S. Jay Bowman, DMD, MS, says of him: “He taught us how to write, to be skeptical, to fervently pursue excellence, and to honor and understand the history and ethics of our profession.”
Reflecting on his career, Johnston has no regrets. “In time, people come to appreciate your idealism and commitment to the truth. I’ve gotten respectable. Looking back, with the possible exception of one or two papers, I’ll stick with what I’ve done.”
Now living contentedly on the shore of Michigan’s beautiful Lake Torch with his Swedish-born wife, Agneta (along with such distinguished neighbors as filmmaker Michael Moore and actor Tom Selleck), Johnston, just shy of his 70th birthday, is hardly slowing down. He was too busy to be interviewed at first call, immersed as he was in tuning to perfection a vintage British sports car that a former student had gratefully bestowed upon him.
“The major influence in my becoming an orthodontist was a gentleman by the name of Wallace J. Gardner. He is a dentist and a devoted alumnus of Harvard, which is where I wanted to go. I liked him and enjoyed speaking with him in his office. He is still practicing in his 90s. As an undergraduate, my major was government. It was in Harvard dental school that my love affair with dentistry began.”
—Anthony Gianelly, DMD, PhD, MD
That the son of a liquor salesman went to Harvard is nothing special. There are many cases of intellectually gifted offspring whose parents had no higher education. That this son of a liquor salesman also wrote Bi-Dimensional Technique: Principles of Practice, a seminal book in orthodontics, adds gravitas, one might fairly say. That he was a starting fullback for the Harvard football team doesn’t hurt, either.
After receiving his BA in government, Gianelly earned his DMD from the Harvard School of Dental Medicine. He then went on to Boston University (BU), where he received his PhD (in biochemistry) and MD degrees, became chair of the Orthodontics Department in 1968, and is currently Chairman Emeritus of the School of Dental Medicine. Regarding his dual training as physician and dentist, Bowman, who was mentored by Gianelly as well as Johnston, says Gianelly “is probably the only orthodontist who ever delivered a baby in the morning and then placed braces in the afternoon. No, not on the same patient, even with the focus on early treatment.”
At BU in the 1970s, Gianelly began to develop the bidimensional technique, which he considers his most significant accomplishment. He went public with it in the early 80s, and his book was, after voluminous documentation, published in 2000. The book explains how the technique permits excellent torque control of the incisor positions by using two different-size slots in the same arch. As Gianelly states, “An NYU study in 1998 showed that only 3% of wires fill the slots; the bidimensional technique routinely fills them.” The book covers diagnosis, treatment planning, extraction versus nonextraction, retention, TMD, and adult orthodontics.
As is generally the case with academics in the field of orthodontics, Gianelly’s main concern is for evidence-based practice. “There seems to be within the orthodontic community a willingness to reject evidence. My concern is that a lot of orthodontists ignore information.” He echoes Johnston in his feeling that, “Orthodontics is not a disease-based specialty, there’s no right or wrong, so there’s this attitude of ‘do what you want because you can.’ There’s room for improvement if we are ever going to be an evidence-based specialty.”
Regarding the role of academics such as himself in orthodontics, Gianelly believes they have their special value. “We spend a lot of time gathering information, creating studies so that we can come up with some answers. We have what you might call a stake in the process, in trying to produce information and use it as a valid marker. So it’s a little discouraging when you spend all this time and effort and people aren’t willing to follow the marker.”
As a case in point, he refers to the long-running one-phase versus two-phase debate. “For instance,” he maintains, “all the evidence shows that there is no added value in two-phase treatments. There is no documented proof of any advantage to the patient by using this method.” “Some orthodontists,” he continues, “will use ‘soft’ answers, such as ‘kids like it,’ or, ‘it will help the parents.’ But there is no evidence to support justification of two-phase treatment.”
Gianelly had for many years a private practice that occupied about 40% of his time in orthodontics. When asked what he would do if parents showed up with their kids when they were 7, 8, or 9 years old and asked for the first of two phases of treatment, he responded firmly, “I would turn them away, which is exactly what I did. More importantly than the expense, would you put your kid through an experience that they don’t need?”
Gianelly’s dedication to truth and the welfare of the patient has been duly recognized. Like Johnston, he has received the prestigious A.H. Ketcham Award, along with many other honors. He has written three books and published more than 90 articles. The Gianelly Symposium on Orthodontic Excellence features presentations by upward of 15 outstanding practitioners, and in 2006 included a special program honoring Gianelly himself.
Gianelly lives close to Boston in Waban, Mass, with Ernie, his wife of 47 years. He has two children and two grandchildren. In the future, he hopes to continue to participate in the orthodontic program at Boston University on a clinical level. Reflecting on his career in orthodontics, he says, “I feel exceedingly lucky to have become an orthodontist and to have had the opportunity to pursue an academic career that was both stimulating and enjoyable.”
“If you don’t understand how things work, you can be fooled. The purpose of my book is to get people to try to understand the basics and then be able to deduce what would make sense for a particular patient.”
—William Proffit, DDS, MS, PhD
Proffit speaks perhaps a bit modestly about his comprehensive tome, Contemporary Orthodontics, which has been hailed as a masterpiece and is now a de rigueur text at dental and orthodontic schools worldwide. First appearing in 1986 and now in its fourth edition, the book has been translated into nine languages. One thing about the book that Proffit take special pride in and doesn’t mind mentioning is that “it contains over 1,000 new color pictures.”
Proffit is also the coauthor of three books on severe dentofacial problems, including Contemporary Treatment of Dentofacial Deformity, published in 2002. Other publications include some 160 scientific papers in refereed journals and more than 40 book chapters and invited contributions. He is a diplomate of the American Board of Orthodontics and has lectured widely in the United States and overseas.
Like his fellow luminaries Johnston and Gianelly, Proffit selected the academic side of orthodontics, although from the start he reserved 1 day per week to work with patients in a private practice. He’s a native of North Carolina (and still maintains the sweet, syrupy accent), and began his higher education at the University of North Carolina (UNC), where he received his BA and initial dental training. He then attended the Medical College of Virginia, where he earned a PhD in physiology, and subsequently headed west to pursue his MS in orthodontics at the University of Washington.
In 1965, after serving as an investigator at the National Institute of Dental Research, he joined the faculty of the University of Kentucky, serving as the first chairman of the orthodontics department there. From 1973 to 1975, he was professor of orthodontics and chairman of pediatric dentistry at the University of Florida.
He returned to his alma mater, UNC, in 1975, and has since then served as professor in the department of orthodontics and was department chairman until July 2001. In 1992 he was named Kenan Professor, a distinguished professorship at the university.
At 71, Proffit is a 35-percenter at UNC, teaching and doing research. One of the courses he most enjoys teaching is “Oral Pharyngeal Function,” because he believes that most orthodontists are better at anatomy than they are at physiology, and need a greater awareness of the maturational sequence involved in pharyngeal functions such as swallowing, speaking, and breathing. “A course like this is important and is not done as often as it should be. Orthodontists need to be aware that they’re treating growing individuals.”
Like most academics, Proffit is concerned that relevant, scientific information is being routinely ignored by orthodontists who get caught up in empty controversies. He is particularly irked by the clamor over myofunctional therapy, which he believes is essentially bogus. “Some orthodontists can be fooled by people selling things in that area. If you understand how things really work, you wouldn’t be interested and wouldn’t get sucked in.” Likewise, he believes there’s a lot more controversy about the one-phase versus two-phase issue than there needs to be. “If you choose to ignore the documented information, you can find good indications either way. What should matter is that each patient be dealt with individually.”
Proffit’s outstanding work in the laboratory has been noted by the ADA, which presented him with the Norton Ross Award for excellence in clinical research. He has garnered a host of other accolades, including the AAO’s Jarabak Award for teaching excellence, the Southern Association of Orthodontists Distinguished Service Award, and, like Johnston and Gianelly, the Ketcham Award of the American Board of Orthodontics.
Despite some misgivings, Proffit believes that orthodontics has come a long way. “We treat patients better, and I feel we’re in an excellent position at the moment. I’d like to see that continue.”
Perhaps the impact of these deans of orthodontics—the respect they’ve earned and the direction they’ve provided—is best expressed by former student Tuncay: “The triumvirate of Johnston, Proffit, and Gianelly is principally responsible for the good fortune of orthodontics. They have given to orthodontics in ways we had not seen since the inception of the specialty.” Tuncay concludes in a manner with which the three men, devoted idealists all, would surely concur: “We can only hope and pray that they are not the last prophets of orthodontics. We hope not to just stand on their track record, but instead, build on it.”
Alan Ruskin is a staff writer for Orthodontic Products. For more information, contact
The Legend of the Rubber Chicken
Lysle Johnston, Jr has probably had a hand in educating more orthodontic residents than any other orthodontic chairman, with more than 220 graduates from his tenure at Case Western, St Louis University, and The University of Michigan. Although “retired,” he continues to teach at all three programs (along with Sydney University Hospital in Australia), so he hasn’t curbed his enthusiasm or tempered his influence within our specialty.
Lysle personally interviewed all of the applicants for all three orthodontic programs throughout his tenures. Every interviewee has a story tell about that intimidating experience: Some were accepted on the spot, and others may have kicked a dent in their car. Lysle always asked applicants, “Why do you want to be an orthodontist?”
The mundane and unimaginative responses became routine. In 1984, Lysle wrote one of these common responses (“I like to work with children”) on a slip of paper and placed it into the bill of a rubber chicken that someone had given him. The next residency candidate was asked the $64 question and, sure enough, his answer matched the “secret words.” Just as it might have happened on Groucho Marx’s You Bet Your Life television program, Lysle brought the rubber chicken out and said, “My friend has a message for you.” Unfortunately, the paper fell out and Lysle just picked it up.
Before he exited the interview, the interviewee, a rightfully apoplectic Rich Joseph, pleaded, “I gotta know! What was on the paper?” Lysle just gave him the missive without explanation. With all the color gone from his face, the shaken applicant asked the first resident he found, “What does it mean? I got the rubber chicken?” I told him, “I don’t know, but it doesn’t sound good.” Actually, Rich was accepted!
Although interviews with Johnston were already legendary, the mythology of the plastic poultry grew. Rumors spread that the chicken made regular appearances during interviews or that Lysle would hit people with the chicken when they were not accepted. He started to receive rubber chickens as gifts. Students made T-shirts featuring the rubber chicken and the phrase, “I like to work with my hands.”
Rich Joseph got the last laugh. A couple years later, the residents were attending the Moyer’s Symposium in Ann Arbor. At the reception, Rich came up to a table of influential orthodontists where Lysle was holding court in a heated discussion. He had slipped in some convincing “Billy-Bob” teeth that he had made and proclaimed, “Hey, Dr Johnston! Do you remember me? I was one of your patients, and I really love my smile!”
The rubber chicken is now retired and resides in a special place at Johnston’s Fortress of Solitude in northern Michigan. Lysle even had an art-glass window of a rubber chicken created for his home. Although the students he has influenced and taught critical thinking will remember their own Johnstonisms, the rubber chicken will likely be an enduring legacy that will always be associated with Lysle Elwin Johnston, Jr.
—S. Jay Bowman, DMD, MSD
