Obituary: Professor Clifford Ballard

In the early, formative, post- war years Clifford Ballard was a commanding figure in dentistry - and orthodontics in particular.

Orthodontic practice at this time varied in different parts of the world. In the United States, dentistry was quite separate from medicine and dental and orthodontic technology were in advance of any other country. Treatment methods were usually by fixed appliances of more or less complexity. In Europe dentistry was regarded as a sub-specialty of medicine and orthodontic problems were regarded in terms of pathology or function.

In the British Isles, dentistry was taught concomitantly with medicine and dentists, while having specialist treatment skills, were always aware of the wider implications of disease and illness and possible dental implications arising from them. Orthodontics was a skill practised by a very few specialists who could produce excellent clinical results but who could not always explain how or why they made their decisions or determined their lines of action in any particular case.

Ballard entered this varied scene as the post-war leader in Great Britain in the field of postgraduate orthodontics and an authority on aetiology, diagnosis, prognosis and treatment of orthodontic problems. In 1948 he was appointed to the newly formed Department of Orthodontics at the Institute of Dental Surgery within the Postgraduate Medical Federation of London University.

His early experiences in the management of small children with respiratory problems had fixed his attention on respiratory function and the activities of the orofacial musculature which seemed to him to follow or to lead the development of the bony structures of the face and jaws.

The action of the musculature of the whole face and the form of the jaws had been the subject of intense observation, description and speculation in the orthodontic literature for many years, but Ballard made this the object of his focused attention and the lynchpin of the diagnostic, prognostic and treatment rationale that he taught.

It had long been recognised that in a complex like the human face many factors must influence the final result; and, while most parts and organs of the body are defined and formed at an early age, the face cannot be said to be complete until all the teeth have erupted and come into position, a condition which does not arise until the age of 18 years or later. It is during this period of development that orthodontic management must take place.

In those halcyon post-war years, the air was full of new ideas. The monumental work of J.C. Brash on the aetiology of irregularities of the teeth had explored exhaustively the argument as to whether nature or nurture was the dominant influence; X-ray cephalometry provided a more accurate measure of the size and relationships of the head and face; the concept of the apical bases, that part of the jaws and face occupied by the roots of the teeth, proposed by Axel Lundstrom of Stockholm, and the suggestion that deficiencies therein of size and relationship would account for misalignments of the teeth, all provided wide fields in which investigations and speculations could flourish. And flourish they did, at the conferences and in the proceedings of the orthodontic societies in Great Britain and in Europe.

Ballard gathered together these elements and welded them into a doctrine and philosophy which he taught to his students and enjoined to conference audiences with passion and conviction. His message emphasised the dominating influence of the musculature and soft tissues in immediate proximity to the developing jaws and dental arches.

Orthodontists brought up in their own comfortable traditions were not too ready to look kindly on a new prophet with a highly original viewpoint of the complex problems of dental irregularity. But Ballard shook them out of their complacency and fostered more lively discussions and question times than had been the rule since Edward Angle in America so forcibly enjoined the virtues of his accurate but complex fixed appliance. While there were those who agreed that what Ballard was saying should be marked, learned and digested, there were others who were apoplectically dismissive.

Ballard attracted large numbers of postgraduate students from far and wide thirsting for a training in the clinical skills of orthodontics and an attitude to the largely unresolved problems of aetiology, diagnosis and treatment planning.

As a measure of the impact of his teaching there was the episode when an orthodontic postgraduate attended a clinic run by the famous Sir William Kelsey Fry who stated that the patient they were examining suffered from lack of development of the anterior nasal spine, a spicule of bone on the front of the upper jaw, which explained why the lower jaw appeared prominent. The orthodontic postgraduate, emboldened by his new-found learning, diffidently remarked that the patient had an abnormal skeletal pattern affecting both jaws and the dental base relation was disturbed.

The great man stopped the proceedings, clutched his brow and reeled a few steps backward, deeply affected by the new and alien language and, forming his class into a circle and seizing the luckless student by the lapel, demanded a dissertation on the new terminology that was flooding through the hallowed halls of the institute.

Clifford Ballard graduated from the Royal Dental Hospital in 1934 and from Charing Cross Hospital Medical School in 1940. On graduation he returned to the Royal Dental Hospital and commenced a 12-year period of teaching of undergraduates and formulating his ideas on orthodontics. During this period he also began postgraduate teaching and was appointed clinical assistant at St George's Hospital with special responsibility, with E. Gwynne Evans, for the Upper Respiratory Clinic.

After appointment Ballard remained at the institute until his retirement, with the title Professor Emeritus. His career coincided with a period in British history of intense activity including the Second World War and peacetime reconstruction. Ballard was involved in much outside his immediate department, having wartime medical responsibility for a number of aircraft factories and, later, acting as Consultant in Orthodontics to the Royal Air Force, as well as work in practice and for the Middlesex County Council and on committees. In addition, he travelled extensively to attend conferences in Europe and America and teaching in orthodontic departments as far apart as Finland, Israel, Malaysia and Portugal.

He was the recipient of many honours and distinctions, including a WHO Travelling Fellowship to the US and Canada; he gave memorial lectures at Tufts University, Boston, to the British Society for the Study of Orthodontics and at the Royal College of Surgeons, London, where he received the Colyer Gold Medal.

Ballard was concerned to place training, of clinicians and ancillary staff, on a sound basis, with teaching and research, the development of orthodontics, and dentistry as a service to the wider community. He established an annual two-day seminar for orthodontic consultants which provided a forum for discussion of clinical and organisational problems. It was through such activities that the foundations for the regional consultant orthodontic service as we know it today were laid.

Clifford Ballard, despite his somewhat stern exterior, had a keen sense of humour, was a kindly and caring man, hospitable, loyal and tolerant towards his staff and students.

Clifford Frederick Ballard, orthodontist: born 26 June 1910; Dental Surgeon, Victoria Hospital for Children 1948-64, Tooting 1964-71; Head of Department of Orthodontics, Institute of Dental Surgery, British Post- Graduate Medical Federation, London University 1948-72; Professor in Orthodontics, London University 1956-72 (Emeritus); married 1937 Muriel Burling (one son, one daughter); died 16 July 1997.