rmSzv tea

Columbia Winibt^tp
in tfje Cifj> of j^eto ^orfe

^cfjool of Bental anb 0tal burger?

^^eference %ihvavp

4'
 Digitized by tine Internet Arciiive
in 2010 witii funding from
Open Knowledge Commons

http://www.archive.org/details/principlesmethodOOIisc
No one ivho has written a book has of himself
become what he is; everyone stands on the
shoulders of his predecessors; all that was
produced before his time has helped to form
his life and. soul.
—Freytag
 PRINCIPLES AND METHODS

ORTHODONTICS
AN INTRODUCTORY STUDY OF THE ART
FOR STUDENTS AND PRACTITIONERS
OF DENTISTRY

BY

B. E. LISCHER, D.M.D.
PROFESSOR OF ORTHODONTICS, WASHINGTON UNIVERSITY DENTAL SCHOOL; MEMBER
OF THE AMERICAN SOCIETY OP ORTHODONTISTS; AUTHOR OF
" ELEMENTS OF ORTHODONTIA," ETC.

ILLUSTRATED WITH 248 ENGRAVINGS

LEA & FEBIGER

PHILADELPHIA AND NEW YORK
Entered according to the Act of Congress, in the year 1912, by

LEA & FEBIGER

in the Office of the Librarian of Congress. All rights reserved.
 PREFACE

The introductory study of the art here offered to students

and practitioners of dentistry was begun with the intention
of furnishing a plain statement of present-day tendencies.
But the author soon found it impossible to proceed with-
out Adopting a point of view which implied a more or
less "independent reconstruction of the existing situation."
This necessitated the omission of details which, historically
at least, are of great significance.
Many of the fundamental facts of the science (which
have been appropriated from such cognate studies as
anatomy) have likewise been omitted, on the assumption
that every student has had adequate previous training in
them. Similarly was it deemed advisable to eliminate the
description of such technical phases as plaster model con-
struction, details of soldering, etc., with which every dentist
is conversant and which rightfully belong to the laboratory
course. Nor has there been any attempt made to present
the more recent discussions and debates with which our
journal literature abounds. The dental school course does
not permit of, nor does the beginner require, such minute
exposition of the subject. In brief, the author presents the
volume in that limited sense which its subtitle implies, and
with the hope that its pages will prove ])oth interesting and
instructive.
vi PREFACE

The author desires to express his thanks to the pubUshers

for the many shown him during the preparation

courtesies
of the volume; to other publishers and authors for the use
of several cuts; and to his friend and collaborator, Dr.
M. N. Federspiel, of Milwaukee, for his valuable counsel.
B. E. L.
Washington TJnivebsity Dental School.
St. Louis. 1912.
 CONTENTS

INTRODUCTION
CHAPTER I

THE STUDY OF ORTHODONTICS

Definition and Scope of Orthodontics 17
The Literature of Orthodontics 20
The Practice of Orthodontics 23
The Technique of Orthodontics 26

PART I

PRINCIPLES OF TREATMENT

CHAPTER II

PREPARING THE MOUTH FOR TREATMENT

Examination of the Patient 32
The ReUef of Pain 35
Cleansing the Teeth 36
Instruction in Oral Hygiene 37
Treatment of Caries 38
The Extraction of Teeth 40

CHAPTER III

KEEPING RECORDS OF THE TREATMENT

Written Records 43
Plaster Models 46
Photographs 49
Radiographs 50
VUl CONTENTS

CHAPTER IV
THE ETIOLOGY OF MALOCCLUSION
Definition
 CONTENTS JX

CHAPTER IX
PRINCIPAL ELEMENTS OF MODERN METHODS

The Plain Band 154

The Anchor Band 156
The AHgnment Wire 159
Ligatures and Elastics 162
Miscellaneous Accessories 163

CHAPTER X
PRINCIPLES OF APPLICATION

Forms of Anchorage 164

Stationary Anchorage 165
Reciprocal Anchorage 166
Intramaxillary xlnchorage 167
Intermaxillary Anchorage 168
Extramaxillary Anchorage .
170

CHAPTER XI
DETAILS OF APPLICATION

The Anchor Band 173

The Plain Band 175
The Alignment Wire 176
Ligatures and Elastics 181

CHAPTER XII

PRINCIPLES OF RETENTION

Tissue Changes Caused by Tooth Movement 183

Definition of Retention 184
Maintenance of Tooth Position 18G
Maintenance of Arch Form 187
Maintenance of Arch Relation 189
X CONTENTS

PART II

METHODS OF TREATMENT
CHAPTER XIII
TREATMENT OF MALPOSITION OF THE TEETH
Labioversion and Buccoversion 191
Linguoversion 195
Distoversion 198
Mesioversion 201

CHAPTER XIV
TREATMENT OP MALPOSITION (CONTINUED)
Torsoversion . 203
Infraversion 208
Supraversion 210
Perversion and Transversion 212

CHAPTER XV
TREATMENT OF NEUTROCLUSION
Simple Neutroclusion 213
Complex Neutroclusion 226

CHAPTER XVI
TREATMENT OF DISTOCLUSION
Bilateral Distoclusion 245
Unilateral Distoclusion 265

CHAPTER XVII
TREATMENT OF MESIOCLUSION
Bilateral Mesioclusion 272
Unilateral Mesioclusion 281

CHAPTER XVIII
TREATMENT OF MALFORMATIONS OF THE JAWS . . 284
 ORTHODONTICS

INTEODUCTION

CHAPTER I

THE STUDY OF ORTHODONTICS

DEFINITION AND SCOPE OF ORTHODONTICS

Orthodontics is a term proposed by Sir James Murray,

the eminent philologist, to cover that branch of dentistry
which deals with the principles and practices involved in the

prevention and correction of malocclusion of the teeth, and such

other malformations and abnormalities as may be associated
therewith. Dr. Frederick B. Noyes^ defines it as "the
study of the relation of the teeth to the development of the
face, and the correction of arrestedand perverted develop-
ment." It is of dental origin, having been reared by dental
practitioners, and is a crowning achievement of the dental
progress of the last generation. The terms Orthodontia,
Odontorthosia, Dental Orthopedics, and Dental Orthomorphia,
which are less acceptable from a linguistic standpoint, are

1 The Dental Cosmos, January, 1911.

18 THE STUDY OF ORTHODONTICS

also used. Like general dentistry, orthodontics is a part

of the -vast field of medicine, and when we recall "that all

sciences which deal with life, with force, and with chemical
composition" entej' into the study of medicine, we may
fairly comprehend the breadth of its base.
Orthodontics as a Science. —As a science it is closely
related to many of the medical sciences, the basis of which
is biology, the science of life. "Life, that strange, unknown
something which flies through the viewless air, flashes through
the ocean's depths, blushes in the petals of a rose, and mani-
fests itself in thousands of marvellous forms —can science
grasp, define, or explain it?" In the present stage of our
knowledge probably not completely; but it teaches us that
all vital processes, including man and all his characteristics,
as well as those of all other species, are the result of the
interaction of certain law^s. To define these laws, to test
them in the crucible of observation and experiment, and
then to express them in terms of human experience — this is
the mission of science.
Now, the treatment of dental anomalies involves us in
countless difficulties, hence "we seek truth not merely for
the pleasure of knowing, but in order to have a lamp for
our feet. We toil at building sound theory in order that we
may know what to do and what to avoid." Thus the jDrocess

of dentition, its mechanism, causes, and various develop-

mental stages, as exemplified by comparative studies, is not
without meaning, but furnishes a field of compelling interest
to every intelligent dentist. It is further apparent that a
comprehensive knowledge of the development of the jaws, and
of the nasal passages and their accessory sinuses (which are
so intimately related to them), is also desirable. A frequent
attribute of malocclusion of the teeth is a marked inharmo7iy
 DEFINITION AND SCOPE OF ORTHODONTICS 19

of the facial lines. The true basis of a differential classi-

fication of such deformities is a wide familiarity with ethnic
variations of the head form. A valuable aid in the study of
the various forms of malocclusion of the teeth is an inquiry
into the classification of all anomalies, the relations of
anomalies to disease, and the foundations of teratology in
general. Again, a consideration of the causative factors
opens a large field of inquiry to the student of orthodontics,
owing to their intimate connection with the theories of inheri-
tance, the transmission of acquired characters, and other allied
Darwinian factors and biological problems. Another essen-
tial to a scientific comprehension of treatment is a careful
consideration of the tissues of attachment, i. e., the alveolus
and pericementum, and the changes they undergo during and
after tooth movement.
All these are questions for the scientific orthodontist to
investigate, and, if must search for
possible, to explain; he
the laws underlying them, tell why they are so, and indi-
cate the place they occupy in the scheme of things. Finally,
to render our studies less difficult, and to perfect the nomen-
clature of orthodontics, we must strive to develop a greater
accuracy of expression and uniformity of usage of the terms
we employ in our speech.
The practice of medicine, in any of its branches, consti-

tutes a remedial art; for art consists in doing, in the appli-

cation of knowledge. "The subject matter of art is life,

life as actually is; but the function of art is to make life

better. Operations become arts when their purpose is

conscious and their method teachable."

Orthodontics as an Art. —
As an art, orthodontics is con-
cerned with the principles and methods of treatment; what
these are the present \-olume briefly tries to show.
 :

20 ^ THE STUDY OF ORTHODONTICS

THE LITERATURE OF ORTHODONTICS

All endeavors to find adequate treatment of our subject

in the earliest historic times have been fruitless. Thus,
Farrar^ writes of a review b}^ Litch (1839), based upon some
four hundred works on dentistry, and all they contained
relating to the subject could have been gathered in one
volume of moderate size. And though Celsus (a.d. 30) is

said to have recommended finger pressure for the correction

of malposition of the teeth, we can find no attempts at
systematic treatment of the subject until the publication
of Fauchard's^ admirable book. The work of this eminent
pioneer was not exclusively devoted to orthodontics, but he
regarded the subject of sufficient importance to describe
various methods of treatment and to dwell upon the etiology
of malocclusion.
The work is that by the German
earliest recorded special

dentist, F. C. Kniesel, entitled Der Schiefstand der Zdhne,

in the German and French languages, and published in
Berlin in 1836. During the interval embraced by the dates
of publication of these two books the field of orthodontics
was variously treated by dental authors, notable among
whom were Bunon (1742), Bourdet (1757), Berdmore (1770),
Fox (1803), Delabarre (1806), and Catalan (1808). The
joint treatment of its subject matter with other phases of
dentistry continued the prevailing custom for many decades,
in fact, up to the present. Among the more prominent
dental texts that continued thus to treat it are the following
Handbuch der Zahnheilkunde, Linderer, 1842; Systematisches

' Irregularities of the Teeth, vol. i, p. 12.

2 Le chirurgien dentiste, Paris, 1728.
 THE LITERATURE OF ORTHODONTICS 21

Handbuch der Zahnheilkunde, Carabelli, 1844; American

System of Dentistry, vol. ii, Litch — Guilford, 1887; American
Text-book of Operatire Dentistry, Kirk —Angle and Case,
fourth edition, 1911; Dental Surgery, Tomes, fifth edition,
1906; A Text-book of Operative Dentistry, Johnson — Pullen,
1908.
In 1880 Dr. Norman Kingsley, of New York, published
the American text on orthodontics, entitled Oral
first

Deformities. The volume embraced several chapters on

malocclusion of the teeth, their etiology, diagnosis, and
treatment; besides a consideration of cleft palates and
fractures of the maxillae and their treatment.
In 1888 appeared the two-volume work of Dr. J. N,
Farrar, of New York, entitled Irregularities of the Teeth.

These volumes are a veritable mine of orthodontic data,

and cannot be otherwise regarded than epoch-making.^
This eminent pathfinder of the art was the founder not
only of the "systems," but of present-day methods of
treatment.
In the meantime, general dentistry was making rapid
progress; every department was being influenced by the
vast extension of human knowledge during the last half of
the nineteenth century. The growth of dental literature
was now to proceed, and orthodontics claimed many enthusi-
astic workers. It will be convenient to arrange all recent
writers according to nationality, and by continuing our
discussion of American authors we come to the work of
Talbot, Irregularities of the Teeth, fourth edition, 1901. The
book is said by its author to be " an outgrowth of researches
which tended to oppose the too prevalent theory that irregu-
larities of the teeth and jaws were the result of local, not
1 Pfaff, Lehrbuch der Orthodontie, 2d ed., p. 373.
22 THE STUDY OF ORTHODONTICS

constitutional causes." Most of us believe this to be

extreme teaching; but it should be read, owing to its treat-

ment of the subject of degeneracy. Orthodontia, by S. H.

Guilford, fourth edition, 1905, has been a favorite intro-
duction for many years Malocclusion of the Teeth, by E. H.
Angle, seventh edition, 1907, is an exposition of the Angle
System, and, like other works published in the last decade,

open to criticism because of its exclusive originality of

presentation. The works of Knapp, Orthodontia Practically
Treated, 1904; of Jackson, Orthodontia and Orthopedia of
the Face, 1904; and of Case, Dental Orthopedia, 1908, are
treatises of the same group, each volume being a presentation
of the author's methods. These remarks, however, are not
intended as an index of the relative value of these works,
since they contain much that the student cannot afford
to ignore. The work by MacDowell, Orthodontia, 1901,
concludes the list of American authors.
The foreign literature, though not so large, is a creditable
showing for a speci^alty as young as orthodontics. In
England there is the excellent little volume of essays by
Wallace, entitled Irregularities of the Teeth, 1904; and the
more pretentious text by Colyer, of the same title, published
in 1900.
In Germany there is the work of Walkhoff, Die Unregel-
mdssigkeiten in den Zahnstellungen und Ihre Behandlung
(1891), and the texts by Jung (1906), Pfaff (second edition,
1908), Herbst (1910), and the excellent little manual by
Korbitz (second edition, 1911).
In France the art is represented by the works of Gaillard
(1909), Martinier (1903), and Donogier (1895). Spanish
dentists have recently (1909) welcomed a work by Subirana,
entitled Anomalies de la Oclusion dentaria y Ortodoncia.
 .

THE PRACTICE OF ORTHODONTICS 23

Controversial writings, the reports of cases, and modi-

fications of technical details (whose proper place is in the

journals) have been liberally })resented b}' dental maga-

zines, many them conducting departments of orthodon-
of
tics.^ In Germany a monthly journal exclusively devoted
to the art has recently (1907) been established, entitled
Zeitschrift fiir Zahndrztliche Orthoyddie

Much of the recent periodical literature represents the

proceedings of societies and scientific associations. In the
general bodies, such as State, national, and international
societies, sections are frequently organized for the more
deliberate consideration of orthodontic problems. Among
the societies exclusively devoted to orthodontics, mention
may be made of the American Society of Orthodontists,
the British Society for the Study of Orthodontics, and the
Deutschen Gesellschaft fiir Orthodontic, etc.

Thus the art, though hardly out of its teens, has, never-
theless, an extensive library; and at its present rate of growth
bids fair to equal in content, as well as in volume, the liter-
ature of other branches of dentistry. The recent proposal
of A. D. Black^ that the profession adopt the Dewey decimal
system of classification for dental literature will render
available the countless articles in our magazines, covering
every phase of the sub ect.

THE PRACTICE OF ORTHODONTICS

Recent advances in the methodology of the art and the

consequent extension of its boundary lines have abinidanth'
1 Items of Interest, New York.
2 Proc. Inst. Dent. Pedagogics, Sixteenth Annual Report.
24 ^ THE STUDY OF ORTHODONTICS

justified its separation from general practice in all com-

munities capable of supporting the specialist. The many
advantages of specialization are so well known that a
restatement of them here is deemed unnecessary. Ortho-
dontic services by their very nature readily constitute a
special and ample field. Hence the point we wish here
to emphasize is the dependence and independence of the
two fields, their limitations and relations, and to indicate
the course one ought to follow if one contemplates the
practice of orthodontics. This theme has been the subject
for numerous articles in the journals, though rarely has it

been so ably presented as in the paper by Dr. Ottolengui,

entitled "The Sphere of the Dentist in the Field of Ortho-
dontia," from which we quote the following:^
" I respectfully submit it is my view that the best ortho-
dontists of the future, as in the past, must be forthcoming
from the ranks of such men as begin in the regular practice
of dentistry, and gradually choose to practise orthodontia
exclusively from a pure love of the work, and especially
because of their inherent love for, and patience with,
children.
"If this be true, it follows as a logical sequence that the
dentist has the moral as well as the legal right to practise
orthodontia; but he should have no legal right, as surely he
has no moral right, to undertake orthodontic work without
a full and competent knowledge of the present requirements

and technique. Any physician may treat the eye, the nose,
the throat, or do any operation in surgery if he has the
ability to do so successfully; but he may be mulcted in
heavy damages if he attempt such work and fail, because of

I Items of Interest, November, 1909, p. 819.

 THE PRACTICE OF ORTHODONTICS 25

lack of proper training or skill. The medical degree is no

protection to the malpractitioner.
"It is the same in dentistry. Any dentist may undertake
the treatment of malocclusion, but he is guilty of malprac-
tice in some degree if he does not first acquire the needed
training and knowledge.
"The sphere of the dentist in orthodontia is, therefore, to
be considered from a dual aspect: (1) The general prac-
titioner who elects to treat malocclusion occasionally, and
(2) the dentist who decides to refer all such cases to the
specialist. The first man should have exactly the same
knowledge as the specialist himself. For, if the dentist treat
but one case a year, he is morally bound to know how, or
else refer the patient elsewhere.

"On the other hand, the general practitioner who decides

not to treat malocclusion, but elects to recommend a special-
ist, should at least inform himself sufficiently of the art to be
a competent judge of the success or failure of the specialist
into whose hands he takes the responsibility of placing the
management of the teeth and jaws of a growing child. For,
it should be remembered, there are degrees of excellence in all

crafts, and the mere fact that a man may announce that he

has decided to 'restrict his practice to orthodontia' does not

prove that he is competent."
As an additional word of caution, it is well to state that
no one should attempt the exclusive practice of orthodontics
without adequate preliminary training in general dentistry,
because a liberal knowledge in the treatment of the two
main groups of oral diseases {i. e., caries and lesions of the
pericementum, which can only be acquired in general prac-
tice) is absolutely indispensable. It is imperative that we
learn by experience what it means to keep a mouth well.
26 THE STUDY OF ORTHODONTICS

Finally, when combined with general dentistry (a neces-

sity in all outlying districts and rural communities) it will

be necessary to so systematize the office routine that a

definite number of hours be exclusively devoted to its prac-
tice. This should be regarded as a pleasant duty by all

conscientious dentists; for it has been estimated that fully

50 per cent, of the children in every community are afflicted
with some form of malocclusion of the teeth, which, in the
aggregate, means a vast army of countless thousands upon
whom, for obvious reasons, the specialist can never smile.
And last, but not least, the mastery of orthodontics implies
postgraduate study, which the dental hospitals of our
Such depart-
larger universities should liberally provide.
ments are worthy of the most liberal endowments, and it
need hardly be emphasized that they should be open to
graduate students the year around.

THE TECHNIQUE OF ORTHODONTICS

Many works on general dentistry contained

of the earlier
chapters on "Irregularities" and "Regulation," probably
because the correction of malocclusion has always been
regarded as a function of the dentist. A noteworthy char-
acteristic of these texts was the prominence given to the
technical phases of the art, the details of appliance con-
struction being constantly kept in the foreground. The
treatment of malocclusion being a mechanical process, in
which technical methods play an exceedingly important
part, it seems quite natural that the technique should have
been regarded as an important division. Indeed, it is still

so regarded; but the dawn of another era is upon us, the

 THE TECHNIQUE OF ORTHODONTICS 27

day of "home-made" appliances is rapidly approaching its

twihght, and an appreciation of greater possibiKties is

directing our attention and energy to other problems. The
mechanisms of former days were usually manufactured by
the operator, which consumed a great deal of his time, and
so magnified the details of construction that the principles
utilized were frequently lost sight of.

The following prophecy from the pen of Dr. J. N. Farrar^

appeared in 1878: "Although the simplification of regula-

tion has been a great desideratum for many years, it has for
some time been evident to me (though by. most people
thought to be impracticable) that the time will come when
the regulation process and the necessary apparatus will be so
systematized and simplified that the latter will actually be
kept in stock, in parts and in wholes, at dental depots, in
readiness for the dental profession at large, so that it may be
ordered by catalogue numbers to suit the needs of the case; so
that by a few moments' work at the blowpipe in the labora-
tory the dentist may be able, by uniting the parts, to pro-
duce any apparatus, of any size desired, at minimum cost of
time and money."
That prediction has been fulfilled; orthodontics has
passed through its elementary stages, and finally reached
as high a degree of development as other departments of
dentistry. There was a time when the operator made his
pluggers and other instruments, and the prosthodontist his
plate gold and solders; similarly was it considered an ortho-
dontist's duty to invent and construct the appliances for a
case in hand. But after years of ceaseless toil, "of immeas-
urable devotion of energy and time and genius" to a most

1 The Dental Cosmos, January, 1878.

28 THE STUDY OF ORTHODONTICS

worthy art, certain facts of experience have finally been

systematized. Indeed, the whole spirit of effort of the last
decade has been a reaction against former methods, and
has been characterized by a demand for a new arrange-
ment, for some settled principles in the art. A mere heaping
together of disconnected, confusing methods has long since
ceased to satisfy all serious students. Thus, there comes the
concession from all sides that appliances are but the means
to an end —the remedies, as it were —with which the operator
should so familiarize himself as to master their use and
manner of application, not their manufacture.
"Systems." —From the standpoint of this new and
higher perspective, and in response to the urgent demands
of progress, several so-called "systems" have been offered
to the profession, every one of which embraces much that
is good. But a system, at best, is but a compilation of
certain definite principles, elements of design, and methods of
treatment, and these rarely are the product of a single mind.
It usually represents the results of the separate efforts of
several individuals, and may even be compiled for private
gain. On the other hand, a system may have a higher motive,
and tersely emphasize the advantages of simplicity of tech-
nique, or the achievements of unusual skill. Doubtless their
influence upon our technique has been salutary, though our
resultant methods continue to impose definite technical
attainments. Hence, laboratory courses in orthodontics,
similar to those of operative and prosthetic dentistry, of
chemistry and bacteriology, have become permanent fixtures
in the dental curriculum.^ The student frequently under-
estimates the importance of this phase of the subject, and

1 Lischer, Elements of Orthodontia, St. Louis, 1909.

 THE TECHNIQUE OF ORTHODONTICS 29

defers its accomplishments until launched in private prac-

tice; when the demands of a growing patronage and the
unavoidable difficulties of treatment militate against the
acquirement of that special dexteritj^ so essential to success.
Moreover, it is immaterial which method of treatment an
operator will ultimately adopt —whether be a system as
it

such, or a combination of several —the technical training

enjoined in either case will always be considerable. Thus,
the application of appliances for treatment, the accepted
methods of keeping records, and the construction of reten-
tion appliances demand a very high order of skill; and one
arrives at skill only by patient labor, by the practice of an
exacting discipline. Let every student of orthodontics
remember, therefore, that the laboratory course is always
designed for a definite purpose, that it fits well into the
plan of things, and that there is no short cut across the
plane of accomplishment.
 PART I

PRINCIPLES OF TREATMENT

CHAPTER II

PREPARING THE MOUTH FOR TREATMENT

Surgical cleanliness on the part of the operator and his

equipment is the first rule in all operative procedures. Since
the founding of bacteriology by Pasteur, and its wonderful
development by medical scientists, leading to the discovery
of the relations of bacteria to animals in health and disease,
it has received a new interpretation. Were it not for the
fact that its omission continues the prevailing custom with
far too many operators, it would not receive mention here.
Indeed, its presentation is hardly appropriate in a work on
orthodontics.
Following the reception of the patient, the adjustment
of the operating chair and its accessories, should come the
preparation of the field of operation. In orthodontic prac-
tice this has a special significarce, and embraces a number
of important preliminary considerations. The aim of these
several preliminary details is the establishment of oral
health—in so far as this is possible prior to orthodontic
treatment — and to facilitate the treatment.
32 PREPARING THE MOUTH FOB TREATMENT

EXAMINATION OF THE PATIENT

The fundamental importance of a careful examination of

every individual applying for treatment need hardly be
emphasized, for it forms the very basis of every intelligent
diagnosis. A cursory consideration of the general health
and physical development of the patient constitutes the first
step of such examination. Should any doubt regarding it

arise, the patient (or parent) should be questioned and a

record made of recent recovery from serious ailment. Such
interrogations frequently prompt parents to relate the pres-
ence (or removal) of adenoids, and other conditions etio-
logically connected with the malocclusion. The attention
of the operator is commonly directed toward some "promi-
nent" incisor or cuspid, which he will for the present ignore,
and consider later in the course of a definite routine.
The thorough examination of the oral cavity should now
proceed, and include, besides the superior pharynx, the nasal
passages and form of the nose; the function of the Hps; the
and expression; the jaws beyond the immediate
facial lines

alveoli; the relativeimmunity or susceptibility to caries;

the condition of the gums and pericementa; the form of
the palate; the frena of the lips and tongue; and all surfaces
of the crowns of all teeth. Though a differential diagnosis
of the malocclusion suggests itself here, it is usually best to
defer the same until accurate models have been constructed.
Instruments. —The instruments required for an examina-
tion consist of a mouth mirror (Fig. 1), of non-magnifying
type, with metal handle. A plain, long-handled exploring
instrument, of a pattern as shown in Fig. 2, is used for the
location and exploration of carious cavities. The use of
 EXAMINATION OF THE PATIENT 33

Fig. 1 Fig. 2

Mouth mirror. Exploring instiument.

34 PREPARING THE MOUTH FOR TREATMENT

floss silk in the interproximal spaces and contact areas is

also advised. A tongue depressor of simple design (Fig. 3) is

used for the examination of the superior pharynx. Patho-

logical conditions of the nasal passages which may stand in
causal relation to the malocclusion and require the services

Fig. 3 Fig. 4

Tongue depressor. Nasal speculum.

of a rhinologist may frequently be detected with a nasal

speculum (Fig. 4). A pair of operating pliers and some
aseptic absorbent paper, for the drying of tooth surfaces,
are useful accessories. All of these instruments should be
in readiness upon the operating table, and all unnecessary
appliances removed. Finally, a memorandum of all obser-
 THE RELIEF OF PAIN 35

vations should be made upon a record card conveniently

placed upon an adjoining table or desk. The form of this

card is described in Chapter III.

THE RELIEF OF PAIN

The value of early treatment for malocclusion is increas-
ingly being appreciated, hence many of the patients in an
orthodontic practice are children in whose mouths temporary
teeth are still And though the treatment of tem-
present.
porary teeth more widely practised than formerly, extensive
is

caries, pulp exposure, and its sequeloB are all too frequently
met with. The proper treatment of such conditions should
invariably be insisted upon; and in this connection let it be
remembered that reckless extraction is not the remedy.
many cases demand their conser-
Indeed, the exigencies of
vation, especially we view the denture as a whole, and
if

always from an orthodontic standpoint. The disastrous

results following the neglect and early loss of temporary
teeth will be discussed in the chapter on Etiology.
The temporary teeth are frequently the seat of pain, which
many of the younger patients fail to mention. "In every
instance where there is suffering the manifest duty of the
professional man is to relieve it at once if possible, no matter
in what form it may present itself" (Johnson). The sub-
sequent application and operation of the appliances for
tooth movement are of sufficient annoyance to make the
above imperative. The student should therefore make a
study of the causes of pain and of all therapeutic aids
and methods employed for its alleviation. Such service is

always appreciated, and goes far in the promotion of con-

fidence,
36 PREPARING THE MOUTH FOR TREATMENT

CLEANSING THE TEETH

Cleanliness and health are synonymous terms in oral

hygiene, hence the next important preliminary consideration
is a careful cleansing of the teeth. "Dentists are not living
up to the highest possibilities of their art when they fail to
consider the importance of maintaining the tissues around
the teeth in a state of health, and this cannot be done short
of a careful removal of all extraneous material which may
be found adherent to the teeth." (Johnson.) Probably no
two operators will exactly agree as to the instruments to be
used and the particular methods to be followed in cleaning
the teeth but all must agree on the fundamental importance
;

of the procedure. The author is not aware of any definite

statistics regarding the matter, but he feels certain that only
one patient in every hundred presenting themselves prac-
tises oral hygiene to the extent that orthodontic treatment

could be instituted without first cleansing the teeth.

But aside from the beneficial effects upon the general
health of the oral cavity which every cleaning promotes,, it

must further be emphasized that appliances are shortly to

be adjusted. These are to be securely anchored to a number
of teeth, and in many instances remain for a period of weeks,
or even months. Upon their removal, after tooth movement
has been accomplished, retention appliances are to be
inserted for another prolonged period. Not infrequently the
anchorage of the latter are upon the same teeth previously
utilized. It is obvious, therefore, that only by the utmost
cleanliness during the entire period of orthodontic treatment
can the health of the oral cavity be maintained and caries
of the teeth prevented.
 INSTRUCTION IN ORAL HYGIENE 37

INSTRUCTION IN ORAL HYGIENE

The maintenance of physical vigor is a duty of every

human being, and imphes the practice of a rigid personal
hygiene. Among its many requirements few are of greater
importance than the proper care of the mouth. The vast
majority of individuals suffering from dental diseases is

incompetent in the practice of an efficient oral hygiene;

hence becomes the duty of the operator carefully to instruct
it

patients in this important detail. The most opportune time

for this instruction is immediately after the teeth have been

cleansed. It is an opportunity the conscientious practitioner

never neglects, and it should always be regarded as an
essential detail of a carefully planned routine, because all
regulating appliances interfere with the normal functions
of the mouth and favor the lodgement of food particles, thus
promoting caries of the teeth.
Owing to the rapid rise of orthodontics as a specialty,
this discussion brings us to the line of demarcation between
the fields of the specialist and general practitioner. An
orthodontist extends his acquaintance and wins patronage
in any one of three legitimate ways; patients are referred to
him (a) by the family; dentist, (6) b}^ the family physician,
or (c) by a member of the laity. Of course, if the ortho-
dontic treatment is instituted by the family dentist there
can be no question as to when, or how, and by whom these
services are to be rendered —they belong to the general
practitioner. On the other hand, if the specialist is consulted,
or if the case is referred to him by the dentist, the entire
treatment can be rendered with greater dispatch if both
can agree on a definite plan, since all of these preliminary
38 PREPARING THE MOUTH FOR TREATMENT

services should always be rendered prior to any orthodontic

treatment. But the specialist must not underestimate
responsibilities during the period his services are being
rendered, and in all cases showing a high degree of sus-
ceptibility to caries he should encourage the most liberal

consultation with the family dentist.

TREATMENT OF CARIES
All carious cavities, in both temporary and permanent
teeth, should be treated prior to tooth movement and in the

FiQ. 5

Carious cavities rendered extremely inaccessible by the malocclusion.

best manner the conditions will permit. The choice of a

filling material is at times rendered difficult, since the factor
of accessibility may enter into consideration. Fig. 5 shows
an occlusal view of the upper arch of a patient, aged twelve
 TREATMENT OF CARIES 39

years, with cavities in the right and left centrals and laterals

as indicated by a and b. It is obvious that the insertion of

gold foil permanent repair is out of the question.
or other
A plastic like oxyphosphate of zinc is here indicated, and
will be protected by bands placed upon the teeth for their

movement. After the orthodontic treatment has been

completed they will be normally accessible, and will then
permit of permanent restoration.
In cases of extensive caries, requiring crowns and bridges,
the operator must likewise come to a definite conclusion
as to the most opportune time for their insertion. Accessi-
bility, though still a factor, now gives way to anchorage; for
should the affected tooth, or teeth, be required for anchorage
of the regulating appliance, they should be restored before
orthodontic treatment is attempted. Fortunately, the
necessity for such extreme remedial measures is decreasing,
and their consideration in orthodontic practice is becoming
extremely rare.
The author has recently treated a case of bilateral disto-
clusion, accompanied by labioversion of the upper incisors,
for a boy, aged twelve years,who, owing to an accident result-
ing in fracture, had a porcelain crown inserted upon the left

upper central during his ninth year.^ The behavior of the

root during orthodontic treatment did not appreciably
differ from those in which the pulps were vital. Numerous
similar experiences, therefore, predicate the conclusion that
if caries has progressed so as to affect the pulp, or to a stage
demanding an artificial crown, it should receive the custom-
ary treatment; that non-accessibility, or extreme malposition,
may occasionally postpone the more permanent restorations
until tooth movements have been accomplished.
» See Case K, Figs. 207 and 208.
40 PREPARING THE MOUTH FOR TREATMENT

THE EXTRACTION OF TEETH

The subject of the extraction of teeth prior to or during
orthodontic treatment divides itself into that (a) of tempor-
ary teeth, (6) of supernumerary teeth, and (c) of permanent
teeth.
—
Temporary Teeth. Temporary teeth too extensively
decayed to warrant attempts at conservation, and whose
retention would seriously affect the health of the oral cavity,
should always be removed prior to treatment. But in many
instances, especially in the very young, when several years
might elapse before the eruption of their successors, every

effort should be made to retain them. Again, in cases of

arrested development or "contracted" arches, with firm
temporary teeth present and postponement of treatment
inadvisable, their movement and subsequent retention
should proceed with that of adjacent permanent teeth to
induce growth of the alveoli and jaws beyond, and to pro-
mote the normal eruption of their successors. Extraction
is indicated in every case of prolonged retention, provided
there are no symptoms of deficiency in the number of perma-
nent teeth, or where the successor is in process of eruption.
—
Supernumerary Teeth.^ Supernumerary teeth should always
be extracted, especially when they operate as a cause of
malocclusion. It is best, however, to defer all extractions

until accurate models have been constructed. Every

operator should strive to record as many cases as his
practice affords.
Permanent Teeth. —The extraction of permanent teeth for
the facilitation of the orthodontic treatment is a question
regarding which many incisive papers, and more incisive

rejoinders, have been written. Prior to the development of

our present methods for the correction of arch malrelation,
 THE EXTRACTION OF TEETH 41

removal of certain permanent teeth was widel}' practised,

even regarded as a necessity. But with the perfection of the
details of arch movement as well as tooth movement, the
group of cases in which extraction is now permissible has
been greatly restricted. The literature pertaining to this

subject is voluminous, immensely interesting, and of the

utmost value, though the following two rules by Professor
Guilford^ serve as an excellent abbreviated version of the
entire discussion.
"1. Do not decide to extract until a careful study and
restudy of the case have been made from articulated models
and the patient in person, and until every available method
of procedure without extraction has been carefully con-
sidered."
"2. If extraction seems unavoidable, adopt the best
method of correction without it, and when, in the course

of the operation, it becomes absolutely evident that the

desired result cannot be obtained in that way, it will still

be time to extract and change our method of procedure."

Finally, it must ever be remembered that the loss of even
a single tooth produces a break in the continuity of the arch;
that the adjoining teeth always tend to move toward the
space thus created; that the abnormal inclination of the
adjacent teeth is accompanied by loss of contact in more
remote places in the arch; that a reduction in the size of the
lower arch is frequently followed by a deepening of the "bite"
and an increase in the difficulties of retention; and that the
harmony of facial form rarely permits of the sacrifice. The
numerous clinical phases of this subject can be more appro-
priately dealt with in subsequent chapters on the methods of

treatment.
' Orthodontia, 4th ed., p. 48.
 CHAPTER III

KEEPING RECORDS OF THE TREATMENT

Many of the advances in medical practice have been based

upon hospital statistics, where the facilities and methods
for keeping records have always surpassed those adopted by
individual practitioners. It is, perhaps, not inaccurate to
state that in dentistry the reverse is true. Dental clinics,

in most instances, are usually conducted for the purpose of

furnishing opportunities for experience to students and to
serve those in need, being only incidentally utilized as centres
of research. It is but fair to add, however, that the hospitals
furnishing the largest and most trustworthy mass of clinical
data for medicine are not, necessarily, the school hospitals;
and that the funds at the command of such institutions far
exceed those of the dental infirmaries. For purposes of
scientific research it is always advisable to procure clinical

data from both public and private records, though under

existing dental conditions the private records of practitioners
are preferable. It is to be hoped that an enlightened interest
in human health and an appreciation of the sociological
significance of preventive medicine (which should be provided
for all the people by the strong arm of the State) will revolu-
tionize this phase of dental service in the not distant future.
Now, it is not at all unusual for an average practice to
extend over a period of from thirty to forty years, thus
affording ample opportunities for the compilation of valuable
 WRITTEN RECORDS 43

data upon which scientific deductions and advances in

treatment can be based. It is exceedingly important, there-
fore, that the beginner adopt some plan for the keeping of
records, and the points to be emphasized are that such
records should be accurate, concise, and practical. When
they comply with these requirements, their value can hardly
be overestimated. They should be so designed as to provide
for the special needs of an orthodontic practice, which may
briefly be enumerated as consisting of written records, of
plaster models, of photographs and radiographs, and such
illustrations or appliances as are deemed worth recording.

WRITTEN RECORDS

Among the many methods that can be employed for the

keeping of written records, a specially designed card system
has been found most convenient. It should be of standard
size, preferably 5x8 inches, and provided with a filing

cabinet so arranged as to permit of comprehensive classifi-

cations. Figs. 6 and 7 exhibit the essential items of such a

record card. All of the scientific phases of a case, including
the patient's name and the case number, are placed upon
the face of the card. The reverse side is arranged for the
practical phases of the treatment. Several of the items upon
the front of the card are compiled from the reverse side after
completion of the case, or at the operator's convenience. In
addition, the author uses plain ruled cards of the same size as

the record for the compilation of all data of scientific interest.

These are reclassified by the use of extra guides, and can

be compiled by any competent assistant.
44 KEEPING RECORDS OF THE TREATMENT
WRITTEN RECORDS 45
46 KEEPING RECORDS OF THE TREATMENT

This system of records renders available for immediate

use or study all the material his practice affords. For
example, it enables one to instantly state the number of

patients of any given age, or sex; the number of cases where

the influence of a given etiological factor is exhibited in the
models, e. g., premature loss of temporary teeth. All models,

photographs, radiographs, etc., arenumbered and recorded

on the record card. Thus all items of interest of any given
case, or of a series of cases, can instantly be brought together
for comparison and study.
The possibilities of the card system are so numerous that
it appeals to every operator who values his records at their
true worth; it is so elastic in its application that any inquiry
or investigation may easily be carried out by its use.

PLASTER MODELS

In 1756 Ph. Pfaff ^ introduced the use of plaster of Paris

for model construction. That its use did not become
general, however, is evinced by the fact that Kneisel,^ eighty
years later, still relied on sulphur, though both employed
wax as an impression material. The latter frequently
resorted to the use of metallic models in the construction
of his apphances. These were made of fusible alloy and
obtained from plaster impressions of his sulphur models.
The construction of accurate plaster models of the upper
and lower teeth and adjacent parts is now considered a
necessary detail of every orthodontic record (Fig. 8), and,
as Angle has clearly emphasized, their value is enhanced in

' Zahne des Menschl. Korpers, Berlin.

2 Der Schiefstand der Zahne, Berlin, 1836.
 PLASTER MODELS 47

proportion to their accuracy. To obtain this accuracy

plaster should invariably be used for the impression from
which the model is made. When accompanied by written
records, they are of the greatest scientific value, especially
to the owner who is familiar with many of the unrecorded
details of their history.

Fig. S

A plaster model of a case of malocclusion prior to treatment.

Clean, perfect models are an incentive to render better

service and mark the dividing line between the amateur
and artist. They are absolutely necessary in making an
intelligent diagnosis; are useful in a study of the etiology
and prognosis; and particularly in planning the treatment
and designing the retention appliances. Tootli movement
usually extends over a period of several months, and is only
48 KEEPING RECORDS OF THE TREATMENT

ultimately successful if adequate retention is provided. The

latter is an extremely difficult phase of every treatment, and
is practically impossible without the aid of accurate models
of the original conditions. No operator can afford to rely
on his memory as to the exact nature of these original
conditions.
Facial deformities are frequently due to anomalies of
dentition, and their correction now occupies a large place
in orthodontic practice. A record of such service, for which

Fig. 9

Plaster models of the face before and after treatment. (After Case.)

two methods are at our disposal, is eminently desirable.

Professor Case^ recommends plaster models of the facial
lines. These may be made in full front and profile views,
and are of natural size (Fig. 9). But the construction and
filing of these models present difficulties which many
operators have sought to avoid. This has given rise to the

1 Dental Orthopedia, Chicago, 1908.

 PHOTOGRAPHS 49

adoption of the photographic method, a process introduced

by Professor John W. Draper, of the University of New
York, in 1839.
Fig. 10

Shows size of the unmounted photographs and the lines to which they are cut before
mounting on the record cards.

PHOTOGRAPHS
When made according to certain definite requirements,
photographic records of the facial hues answer every pur-
pose, and mounted on cards of the same
for convenience are
size The requirements are simply these:
as the record.
The same photographer should make all photographs of
4
 .

50 KEEPING RECORDS OF THE TREATMENT

any given series; he should use the same lens in every case
and adopt a uniform size and pose. The prints should
always be made upon the same kind of permanent paper,
and delivered unmounted. A good plan is to instruct the
photographer as to what is wanted, laying special emphasis
upon the fact that under no circumstances shall he retouch
any of the operator's negatives.
To avoid variation in size, particularly in the various
prints of any given case, the author has taken the precaution
to provide the photographer with a card upon w^hich accurate
measurements are marked. It is advisable further to agree
on the kind of background to be used, a dark ground being
usually best, because it affords the proper contrast.
In mounting, many of the unnecessary features of the

prints (such as dress, shoulders, hair ornaments, etc.) may

be eliminated by using a pattern cut from transparent
and marking to exact size before cutting (Fig. 10)
celluloid,

any given case may then be mounted upon a 5 x 8

All prints of
card, numbered and filed in the cabinet with the records.

RADIOGRAPHS
In the treatment of malocclusion of the teeth one fre-

quently meets with anomalies of number, or of eruption and

form. To establish certainty in the diagnosis of such cases
the a;-rays (discovered by Professor Rontgen in 1895), in com-
bination with photographs, are of the greatest value. Indeed,
for the elimination of guesswork they are invaluable, since
by their use it is possible to determine definitely deficiency
or redundancy in the number of teeth, and to ascertain
the peculiarities of anomalies of form and eruption. The
difficulties encountered in the movement of teeth may at
 RADIOGRAPHS 51

times be due to the fusion or malformation of their roots;

tardy eruption may occasionally be caused by perverted
position; a negative or indefinite history of premature
extraction rendered intelligible, instead of construed into

Fig. 11

Shows tardy eruption of the right central incisor due to the supernumerary tooth
shown in Fig. 12.

Fig. 12

vj \\
Radiograph of case shown in Fig. 11.

deficiency of number. Many cases might here be introduced

to illustrate the wide range of their usefulness, but Figs.
1 1 and 12 will suffice, for they clearly show the presence of a

supernumerary tooth as the cause of tardy eruption of the

right upper central incisor in a girl, aged eleven years.
 CHAPTER IV

THE ETIOLOGY OF MALOCCLUSION

Definition. — In medical science, the study of the origin of

disease and abnormahty is termed etiology. It embraces a
consideration of all causative factors, and of the provisional
theories advocated when the causes remain obscure. And
since it is the mission of orthodontics /o prevent, as well
as correct, certain anomalies of dentition, it is obvious that
all knowledge relative to their causation is of the very first
importance. From time immemorial, therefore, observant
operators have endeavored to ascertain and remove these
agencies, believing this to be the first aim of every rational
treatment. Unfortunately, this phase of the art frequently
presents problems exceedingly difficult of solution.

CLASSIFICATION OF THE FACTORS

In order to diminish these difficulties, several authors

have attempted a classification of the etiological factors;
though a review of the literatur pertaining to this subject
impresses one with the fact that a quite general disagreement
yet exists. Some writers accept the time-honored division
into hereditary and acquired, finding little difficulty in formu-
lating definitions for these two terms. Others exhibit a very
evident skepticism regarding the "influence of heredity," and
thus lean strongly toward the acquired group.
 CLASSIFICATION OF THE FACTORS 53

Heredity and Predisposition. —Of course, there was a time

when heredity explained it all, when it served as a cloak
for our ignorance; when most diseases and abnormalities
were believed to have been transmitted from parents to
offspring. But the ijhysical basis of heredity (a mechanism
existing within the germ cell) is now fairly well established.

Many of the recent advances in biology have fostered a

strong opposition to the old views, forcibly emphasizing the
influence of environmental (acquired) factors, which cannot
be ignored. "As to the inheritance of the effects of extrinsic
forces upon the individual, we find little in the way of direct
evidence. Mutilations of any sort are not inherited."
(Jordan and Kellogg.) This new^ teaching, it must be

admitted, has served as a healthy antidote; it was needed.

On the other hand, the claim of the opponents of heredity
— "that nature never transmits the abnormal," that all

anomalies are but the result of certain lapses in nature's

processes, always due to local and extraneous influences —
is equally untenable. In the light of modern biological
science either view is now considered extreme.
Unfortunately, in these days of the "systems," with their
truly wonderful achievements in technique, we are prone
to rest content with our superficial calculations—for we
love to cling to seeming bounds. But accepting, as we must,
the physicochemical explanation of life, we are constrained
to adopt those causomechanical factors of its flux which are
recognized by biologists generally, and w^hich "involve no
philosophical assumptions." These are heredity, variation,
adaptation, selection, isolation, and (probably) mutation.
With the first of these we are here briefly concerned.
Heredity may be defined as " the genetic relation between
successive generations, as the transference, of similar char-
54 THE ETIOLOGY OF MALOCCLUSION

acters from one generation of organisms to another, as a

process affected by means of the germ cells." All peculiar-
ities or characteristics that are imparted to an individual
through these germinal cells of the parents are spoken of as
inherited. Any peculiarity that is imparted a'fter conception
has taken place is spoken of as acquired. If before birth, it
is termed an intra-uterine acquisition; after birth, an extra-
uterine acquisition.
All inherited peculiarities are also said to be congenital,
whether recognizable at birth or not. Likewise, all intra-
uterine acquisitions are congenital; whereas extra -uterine
acquirements are spoken of as extragenital. The careless
(many writers believing it to be
use of the term congenital
synonymous with hereditary) has been the cause of much
confusion.
Concerning predispositions, Professor Orth, of Berlin, says:
"Every incapacity of the body to resist the external causes
of disease, every peculiarity of the constitution which renders
the latter unable in the struggle of the body with the cause
of disease to maintain the normal course of the vital phe-

nomena, every such peculiarity of the constitution may be

designated as a tendency, as a predisposition, to disease.
All these predispositions to disease must be congenital and
inherited, for they are a result of the phylogenetic develop-
ment; they have their origin in the general characteristics

inherent in the germ cells. This conception of what con-

stitutes predisposition to disease does not contain anything
mystical; it is not beyond the domain of science, and is just
as capable of scientific treatment asany other pathogenetic
question, though we must admit that our knowledge of the
predispositions to disease does not go much beyond a few
generalities."
 INTRINSIC FACTORS 55

Heredity, therefore, is not as definite a factor as formerly,

though we must continue to regard it as of great importance
in the study of organic continuity. "Heredity repeats
strength or weakness, good or ill, with like indifference."
(Jordan and Kellogg.) Furthermore, one phase of this
vast theme stands out very prominently, viz., all dental
research relative thereto, and thus far conducted, is entirely

inadequate. For this reason alone we should pause long

before boldly denying its probable "influence" in the causa-
tion of malocclusion of the teeth. Another very plausible
reason why we should be less hasty in excluding the heredi-
tary factors is, that many anomalies of other organs of the
body (notably the eyes, e. g., errors of refraction, imbalance
of the ocular muscles, etc.) are largely congenital and fre-

quently transmitted from generation to generation. Surely,

the teeth and jaws are not exempt from the "influences"
which control such maldevelopments.
"Our present plight seems to be exactly this, we cannot
explain to any general satisfaction" all the causes of mal-
some hereditary
occlusion of the teeth without the help of
factors; "and on the other hand, we cannot assume the
actuality of any such factor in the light of our present
knowledge of heredity." In view of this very unsettled
state of our knowledge the author has, for some years
past, preferred the terms intrinsic and extrinsic, instead of

hereditary and acquired.

INTRINSIC FACTORS

Several anomalies of dentition, and sundry constitutional

peculiarities, causing malocclusion of the teeth, are due to
certain inherent, systemic influences. We term these the
56 THE ETIOLOGY OF MALOCCLUSION

intrinsic factors; some of them being congenital, and probably

inherited, others not.
Anomalies of Number. —These are found in both the tem-
porary and permanent series, and frequently stand in causal
relation to a malocclusion. Thus there may exist a deficiency
Fig. 13

Congenital absence of the left upper temporary first molar, permitting the mesioversion
of the second temporary and first permanent molars.

number of teeth (Fig. 13) which permits the adjoining

in the
members to migrate into abnormal positions. When more
than twenty teeth appear in the temporary dentition, or
more than thirty-twoin the permanent, we term it redun-
dancy. This may lead to a crowded arrangement of them in
tfeeir respective arches (Fig. 14).
 INTRINSIC FACTORS 57

According to Biisch/ there are three kinds of super-

numerary teeth: (a) Those with conical crowns and root;
(6) tubercles; and
supplemental teeth, or those of normal
(c)

form (Hollander). Premature extraction of a temporary

tooth, or other traumatic influence, might occasionally be

Fig. 14

Shows the result of redundancy of number; note the supernumerary tooth between
the upper centrals.

responsible for a deficiency in the permanent set, but it

isobvious that most anomalies of number are not due to

extraneous causes. Atavism has long been regarded as a
cause of redundancy; and more recently, their budding off
from the common dental lamina has been suggested as a
probable explanation of supernumerary teeth. But according

1 Deutsch. Monatsschr. f. Zahnheilk., 1886-87.

58 THE ETIOLOGY OF MALOCCLUSION

to Tomes/ "our present knowledge of the subject will not

enable us to recognize the cause which has produced"
anomalies in the number of teeth, though syphilis, rickets,
and other maladies have frequently been mentioned.
IMcQuillen,^ Tomes,'^ and many other investigators have
recorded numerous cases where anomalies of number were
transmitted through several generations of the same family.
Fig. 15 shows the model of the upper arch of a father and
Fig. 16 that of his daughter, taken from the author's collec-
tion. Frequent!}'' the histories of such cases are so vitiated
by premature loss of teeth, by caries and extraction,
i. e.,

that they are of little value. Yet it is undoubtedly true

that, in most cases, they are congenital and therefore
transmissible.
Anomalies of Form. —Though rarely met with, anomalies
of form occasionally enter into a malocclusion, and they
suggest interesting morphological questions. They may
express themselves in various ways, e. g., deficiency, redun-
dancy, dichotomes, etc. When affecting the anterior teeth
they usually present a disfigurement, and frequently cause
malocclusion of the adjoining teeth. Fig. 17 shows the
models of a boy, aged nine years, exhibiting a fusion of the
upper centrals and laterals. Fig. 18 illustrates a case of
redundancy of form in a right upper central incisor, being
fully one-third longer than the left central. Irregularity of
size may also be complete, affecting the entire tooth, or
crown or root.
partial, being limited to the

—
Frenum Labium. Occasionally, cases present
Abnormal
themselves with an abnormal space (diastema) between
the central incisors.* In the upper arch it is usually due to

> Dental Surgery, 5th ed. ^ Dental Cosmos.

ilbid. < Angle, Dental Cosmos, 1899.
 INTRINSIC FACTORS 59

an excessive development of the frenum of the hp. The

fibers of this muscular attachment are of sufficient density,

Fig. 15

Shows model of a father with deficiency in size of the right upper lateral, and
of number of the left lateral.

Fig. 16

From the upper arch of his daughter, exhibiting the same anomalies, though on the
opposite side of the mouth.
60 THE ETIOLOGY OF MALOCCLUSION

and its movements so constant, that it prevents the teeth

from coming into normal contact.

Fig. 17

Anomaly of form due to the fusion of tooth germs.

Fig. 18
 INTRINSIC FACTORS 61

This factor is usually classified as an acquired cause, or as

a "local" cause, but the author is fully convinced that this
is an error. show
Clinical experience uniformly tends to
that in all cases brought under early observation the same
abnormal conditions exist during the period of the temporary
dentition. Wiedersheim^ has shown that the raphe and
gapilla palatina^ are more highly developed in the embryo
and during early infancy than in later life. This papilla has
been investigated by Merkel,^ who found it to be a sensory
organ, and that it probably assists the palatine ridges in

the trituration of food. Wiedersheim has also offered the

suggestion that the raphe is "the remains of palatal teeth
handed down even to man."
In the absence of any authentic cases showing that an
abnormal frenum is due to extraneous influences, we are
constrained to regard it as an evidence of faulty develop-
ment during embryonic life. Atavism suggests itself as a
probable cause of such faulty development; but whatever
the cause, it is plain that it is intrinsic. Fig. 19 shows the
models of a case, aged eight years, in which the frenum of the
upper was found to be the cause of the very wide space
lip

betw^een the upper centrals. Ketcham's extended investiga-

tions with the x-rays conclusively demonstrate that such
maldevelopments are in no wise related to an opening of the
maxillary suture.
Cleft Palate. —A congenital malformation of the palate
usually so interferes with the development of the maxilla
that if allowed to persist to the completion of the permanent
dentition a malocclusion is an inevitable sequela. Fig. 20
shows the models of a girl, aged fourteen years, in which
1 The Structure of Man, p. 155.
2 Ibid, p. 146.
62 THE ETIOLOGY OF MALOCCLUSION
Fig. 19

Abnormal frenum labium.

Fig. 20

Upper arch of a case of malocclusion after an operation for cleft palate.

 INTRINSIC FACTORS 63

this deformity and the accompanying malocclusion are very

evident. Fortunately, such cases are rare, though, as
Bland Sutton^ long ago pointed out, they are transmissible.
He says: "Cleft palate has been known to occur in offspring
of affected members, and if it were possible to practise
selective breeding in man as in dogs, a race of men with
cleft palates and harelips could be produced." The treat-
ment of the maxillary deformity usually falls to the oral
surgeon, though subsequent orthodontic interference may
occasionally be indicated. Dr. Dunn has reported the
treatment of such a case to the American Society of
Orthodontists (Denver, 1910).
Anomalies of Position. As — already intimated, recent
studies by orthodontists tend to emphasize the extraneous
influences which are responsible for malocclusion. There
remain a few forms of malposition, however, which cannot
be attributed to them. I refer to transposition and those
extreme forms of impaction for which Grevers- has suggested
the term perversion.
Fig. 21 shows the cast of a denture, sixteen years of age,
in which the upper laterals, canines, and first bicuspids have
exchanged places. Fig. 22 is from Dr. Cryer's collection,
showing two impacted canines in the intermaxillary region.
The causes of such anomalies are unknown, though obviously
intrinsic.

—
Asymmetry of the Jaws. The jaws, or foundation structures
upon which the teeth and their alveolar processes are placed,
may, according to Talbot, be malformed in approximately
30 per cent, of apparently normal individuals. It is clear
that if these structures are inharmoniously developed to

1 Evolution and Disease.

2 IV International Dental Congress, St. Louis, 1904.
64 THE ETIOLOGY OF MALOCCLUSION

any considerable degree, the superimposed teeth are very

apt,upon closure, to come into malocclusion. Both the

Fig. 21

Transversion of the upper lateral incisors, canines, and first bicuspids.

Fig. 22

Perversion of the upper canines. (After Cryer.)

 INTRINSIC FACTORS 65

upper and lower jaw may be thus affected, and while many
development are traceable to abnormal occlusion,
arrests of
and therefore abnormal function (which speedily corrects
itself after orthodontic treatment), there are rare instances
which cannot be so easily disposed of. The causes of such
developmental disturbances are not well understood. (See
Chapter V.)
Anomalies of the Tongue. — Congenital anomalies of the
tongue, which have been described by Virchow, Holt, and
others, exert their abnormal influences upon the dental
arches, resulting in deformity. SchendeF and Angle^ have
reported cases of this kind. When the tongue is excessively
developed (macroglossie) it tends to enlargement of the
dental arches, causes a spreading of the teeth, and conse-
quent loss of contact with their neighbors. When arrested
development exists (microglossie) the full normal influence
of its muscular action is absent, which is usually followed
by a crowded arch. (Compare Fig. 28.)
Nutritional and Specific Infectious Diseases. —Diseases of
nutrition, like rachitis, scorbutus, and marasmus, generally
affect the process of dentition, though they are usually con-
fined to the period of infancy. Congenital syphilis very
often affects the permanent teeth, and, according to
Hutchinson, "typical syphilitic teeth have notches in their
incisal edges and are dwarfed both as regards their length
and breadth." According to Keyes, Black, and others, such
teeth are not invariably an evidence of this disease. It has
also been claimed by Hill,^ Saleeby,^ and other English

> Deutsch. Monatssch. f. Zahnheilk., 1903.

2 Malocclusion of the Teeth, 7th ed., 1907.
' Heredity and Selection in Sociology, London, 1907
* Parenthood and Race Culture, New York, 1909.
66 THE ETIOLOGY OF MALOCCLUSION

writers that racial poisons, like alcohol and lead, are capable
of producing malformations. And the late Herbert Spencer^
suggested the deleterious influence of vaccination as a prob-
able cause of the alarming increase in teeth and eye affections
among the inhabitants of Great Britain.

EXTRINSIC FACTORS

The factors embraced in this group are more readily

recognized, probably because the operator comes in daily
contact with them. A thorough knowledge of them is also
imperative, since it enables one to successfully combat their
action and thus obviate the development of many forms
of malocclusion.
Premature Loss of Temporary Teeth. —^The necessity for
the conservation of the temporary teeth during their allotted
period is a truth that is gaining wide acceptance. The
cumulative evidence of the disastrous results following their
early loss through promiscuous extraction, or neglected
progressive caries, is becoming a sufficient argument to
all conscientious practitioners. Premature loss and pulp
exposure due to neglected caries tend seriously to interfere
with normal function; and in the development of the denture
and its related structures normal function plays the leading
role. Furthermore, the loss of a single tooth, or even of a
part of a tooth, produces a break in the continuity of the
arch and permits abnormal movements of the adjacent teeth.
Premature Loss of Permanent Teeth. —The early loss of
permanent teeth, especially of the first molars, is now

1 Facts and Comments.

 EXTRINSIC FACTORS 67

regarded as an established etiological factor of malocclusion.

In action it is similar to the loss of temporarry teeth as
described above, and is very frequently accompanied by
a deepening of the "bite," or a destruction of the normal
plane of occlusion.
Prolonged Retention of Temporary Teeth. —The prolonged
retention of temporary teeth, should they persist long
after the need which occasioned them has ceased, r^nother
prolific factor in the causation of malocclusion. An erupt-
ing tooth is suspended, as it were, by its soft attachment
tissues, and the slightest pressure, if it be constant, is

sufficient to deflect it in its course. The orifice through

which a tooth passes in its journey of eruption is greatly
enlarged by the absorption of the crypt walls. Of course,
we have our eruption tables, but many teeth deviate from
the averages there set forth; and clinical observation teaches
us that there is an opportune time for the exfoliation of
each temporary tooth. The operator should, therefore,
exercise judgment in every case of removal of temporary
teeth. Fig. 23, a, shows the evil results of the premature
loss of temporary molars, permitting the mesial eruption of
the upper first molar. Subsequently, the first and second
bicuspids were also forced into mesioversion, and thus
encroached upon the space the cuspid should occupy, which
came at a still later period. The left upper temporary
lateral was retained too long, causing a linguoversion of its
permanent successor (b) On the right side (c) the elongated
.

first molar is noted coming in contact with the lower gingival

ridge, which is due to the early loss of the lower first perma-
nent molar.
Nasal Obstruction. —^The importance of normal respira-
tion and of a rational nasal hygiene, particularly during
 THE ETIOLOGY OF MALOCCLUSION

Fig. 23

a, mesioversion of the upper permanent molar resulting from premature loss of

temporary molars; 6, linguoversion of the upper lateral due to prolonged retention of

its predecessor; c, beginning supraversion of an upper molar which has been deprived
of occlusal contact.
 EXTRINSIC FACTORS 69

the developmental period, can hardly be overestimated.

"Obstruction of the free passage of air through the nose
is one of the most frequent and important consequences of
nasal disease. The obstruction may be partial or complete,
periodical or constant. When chronic nasal obstruction
occurs at an early age, it exercises deleterious effects on the
neighboring parts, on the general well-being, and on the
development and growth of the whole body. The full

consequences of nasal obstruction are most frequently seen

in children suffering from adenoids." It may be due
to one or more of the following anomalous conditions:
(a) Adenoids, (6) deforviities of the septum, (c) hyper-
trophies of the turbinates, and (d) nasal polypus. Another
condition frecj[uently met with, and ver}' often associated

with lymphoid hyperplasia of the nasopharynx, is hyper-

trophy of the tonsils, constituting an hypertrophy which
includes what has been called the "lymphoid ring," or
"ring of Waldeyer."
~TKe'~more important direct effects of nasal obstruction

Lack^ places as follows: Loss of nasal function, the open

mouth and its mechanical consequences, deficient oxygenation
of the blood,and deformity of the chest walls. The symptoms
due to a constantly open mouth, and which especially
appeal to the orthodontist, he enumerates thus: The typical
fades, malformation of the jaws, malposition of the teeth,

and collapse of the alee nasi.

In Figs. 24 and 25 are shown the models and photographs
of a girl, aged twelve years, which are typical of the conditions
under discussion. In his very able investigation of this type
of deformity Lack concludes as follows:

" Diseases of the Nose, p. 56.

70 THE ETIOLOGY OF MALOCCLUSION
Fig. 24

Malocclusion resulting from nasal obstruction.

Fig. 25

'•r.

Facial deformity accompanying case shown in Fig. 24.

 EXTRINSIC FACTORS 71

"Thus most observers agree that the deformities in

question are frequently, if not invariably, associated with
mouth breathing. Ziem's experiments demonstrate con-
clusively that they may result from it. He obstructed the
nostrils of puppies and other young animals, and found that
great deformity of the bones of the face resulted in later
life. There seems every reason to believe that nasal obstruc-
tion precedes and causes the facial deformity. The latter
is never congenital, but it follows after years of mouth
breathing; the changes can be arrested, and will even retro-
gress, if the cause be removed."
Vertical and mesial malrelations of the lower dental arch,
and malformation of the mandible, are frequently associated
with mouth breathing. Case^ suggested the latter as a cause,
and that hypertrophy of the tonsils frequently stands in
causal relation to them.
But the subject of nasal obstruction is a vast one, forming
a large part of the field of rhinology, and would carry us
it

far beyond the confines of the present chapter to attempt a

detailed treatment of it. For further study, the student is
referred to text-books on diseases of the nose and throat.
Habits. —Another rather fruitful cause of malocclusion are
sundry habits of childhood. Foremost among these may be
mentioned the habits of thumb and tongue sucking, and
that of lip biting. The first is probably the most common,
and very frequently hardest to discontinue. They are
usually acquired during infancy, when the parents or nurse
regard them as harmless, or even pleasing. But when we
reflect on the mechanics of maxillary development, on the
ease with which growing tissues are moulded into form, and

1 Dental Review, July, 1894.

 EXTRINSIC FACTORS 73

on the constancy of these subtle influences,we readily appre-

ciate their gravity and harm when continued for a
soiu'ce of

long period. Fig. 26 shows the influence of thumb sucking,

causing the labioversion of the upper incisors and the lingual
inclination of the lower. The constant biting and sucking

Fig. 28

Tongue sucking.

of the lower lip causes similar deformity, as shown in Fig. 27.

Tongue sucking, though less common, permits the elonga-
tion of the posterior teeth (allowing an abnormal elevation
of their occlusal planes) and prevents the normal contact of
the anterior teeth. Fig. 28 shows a case of this type.
Some writers have classified mouth breathing as a habit,
74 THE ETIOLOGY OF MALOCCLUSION

though it is obvious that it is but a symptom of pathological

conditions of the respiratory tract. Herbst^ also mentions
the probable influence of the following, which are frequently
overlooked: The use of pacifiers during infancy, the sucking
of cheeks, the biting of the upper lip in mesioclusion of the
lower arch, resting the cheeks upon the hands, resting the
chin upon the hand, and sleeping on one side. According to
this author, Peckert has suggested the biting of cigar tips
as practised by cigarmakers; Palltorf the biting of threads
among seamstresses; the playing of musical instruments
like the flute, etc., and the artificial deformities of the teeth
as practised by many primitive races (Schroder), as causing
deformities of secondary importance.
Accidents and Traumatic Influences. — Falls, or violent
blows upon the teeth, and fractures of the alveolar processes
and maxillae, may cause malocclusion if their treatment is

neglected; though Angle and other writers have conclusively

shown that such deformity can readily be prevented if the
proper treatment is provided. Tomes^ reports a case of

malocclusion accompanied by malformation of the mandible,

in a patient,aged twenty-one years, which was due to a
burn about the neck and chest at the age of five. Fig. 29,
taken from the author's collection, shows the casts of a
youth, aged eighteen years, who was kicked in the mouth
by a mule during his eighth year.

Dr. Chilcott,^ of Bangor, Me., presents a paper in which

he describes an "Obstetrical Deformity of the Mandible,"
which he attributes to a breech presentation. Jt is claimed
that such presentations may cause a straightening of the

Zahnarztl. Orthopadie, p. 84.

2 Dental Surgery, 5th ed. p. 166.
3 Dental Cosmos, March, 1906.
 EXTRINSIC FACTORS 75

mandible, resulting in mesioclusion of the lower arch and

malformation of the mandible.

Fia. 29

Malocclusion due to an accident.

Pericemental Affections. — It is well known that chronic

infections of the pericementum and alveolar processes,
commonly termed pyorrhea alveolaris, or alveolitis, may
cause malposition of the teeth. shows the cast of a
Fig. 30
denture, thirty-eight years old, in which the upper incisors

were the seat of such infection, and which had gradually

caused their labial movements during a period of two years.
The distoclusion of the lower arch (which is evident) must
not, however, be attributed to this cause, but to nasal
76 THE ETIOLOGY OF MALOCCLUSION

obstruction in childhood, which the history of the case

clearl}^ established.
Fig. 30

BB
 UNKNOWN FACTORS 77

discharging in a sinus. At the meeting of the Missouri

State Dental Association for 1906, the author reported a
case of a j^outh, aged sixteen years, who suffered from such
neglect during his eighth year. The point of infection was
in the left lower deciduous first molar, and caries soon
destroyed all of the remaining tooth tissue that was not
resorbed. The membranous surfaces of the adjacent tissue
being inflamed, together with a cessation of suppuration,
so coalesced as to result in a fibrous adhesion. This hyper-
plastic formation of connective tissue caused the impaction
of the first bicuspid, completely preventing its eruption
(Fig. 31).

Disuse and Artificial Nursing. —Disuse of the dental organs

during childhood or the developmental period, and the
artificial nursing of infants, are frequently mentioned as
causes of arrested development of the maxillse and their
processes. The modern methods of cooking food and
neglected caries are also said to be largely responsible for
the prevalent practice of improper mastication.
In his study on The Mechanical Formation of the Denture,
Korbitz^ has carefully analyzed such influences as active
muscular pressure; the passive pressure of the soft parts;
atmospheric pressure; pressure of the adhering tongue, as
noted by Cryer; the functional influence of occlusion, etc.,
all which are minimized, or even perverted,
of in cases
where the above-mentioned factors are operative.

UNKNOWN FACTORS
The author has tried to enumerate all of the accepted
factors of causation, yet he realizes that the facts here

' Oegt.-Ungar. Vierteljahrgch. f. Z^hnheilk., 1900.

78 THE ETIOLOGY OF MALOCCLUSION

presented form but the merest outline of this subject. The

problems of causation represent a field so vast that its
boundary lines are hardly discernible. Many of the truths
therein enclosed are reserved for future investigation. Some
of the causes already mentioned,and others less generally
accepted, might quite advantageously be grouped into a
class and labeled as unknown.
Some authors contend that civilization is a cause, that
our modes of life in contrast with primitive man make for
retrogression and degeneration. But there is little in the
way of direct evidence regarding this, and it is probably
only "one of those delightfully vague suggestions which
are thoughtlessly advanced."^ Wallace very significantly
adds: "Knowing, as we do, that 'thousands' of Chinese
skulls have been examined, and only one trivial case of
irregularity has been observed, and knowing also that the
Chinese belong to the most ancient civilization extant, and,
further, having been taught that irregularities are frequent

among Hawaiians, we must be careful about laying too much

credence on the idea that civilization is anything more than
a frequent concomitant of irregularities."
Race mixture has been suggested as a cause, especially in
America, which has very aptly been called "The Melting
Pot." It has been claimed that in mixed types, "the product
of a cross between a broad- and a long-headed race, one
contributes the head form, while the other the facial pro-
portions." Anthropologists have frequently reported dis-
harmonisms of this kind, but the data upon which similar
deductions regarding the teeth are based are very scanty.
In conclusion, it may be worth emphasizing the one great

I Wallace, Irregularities of the Teeth, p. 98.

 UNKNOWN FACTORS 79

difficulty confronting investigations of

this kind, viz., the
lifetime of an observer is too brief to comprehend
more than
three generations; and even in cases where this
is possible the
data are frequently so vitiated that they are of little
value.
Our greatest hope for the future, therefore, must lie in
the
realm of experiments on the lower animals.
 CHAPTER V
THE DIAGNOSIS OF MALOCCLUSION
FIRST PRINCIPLES

The dental axiom that only a normal denture can perform

normal functions is gaining wide acceptance. This not only
implies immunity to cariesand the absence of sundry lesions
of the oral tissues, but a denture whose architectonic form
approaches the ideal. To perform the complex functions in
response to which the teeth were brought into being, they
develop characteristic forms and assume very appropriate
anatomical positions. An intimate knowledge of these fine
symmetrical relations is ver}^ essential in orthopedic practice,
for in the correction of every malocclusion we are confronted
with the two queries:
(a) What is the nature and extent of the abnormality to
be corrected?
(6) What is the condition we wish to establish?
Ultimately, these inquiries always lead us to ask the
further questions:
(c) What movements will be necessary?
id) What method of treatment will best accomplish these
movements?
To the beginner the selection of the remedy, or the answer
to question {d), seems most important; but it requires very
little experience to show that this is an error, and that the
only logical approach to the problems is in the order in
which they are here presented.
 FIRST PRINCIPLES 81

The answer to the first query (a) imphes an accurate

diagnosis, an interpretation of the abnormahty on a basis
of normahty; and since the aim of every treatment is the
estabhshment of normal relations, the significance of what
constitutes a normal denture becomes evident.
The arrangement of the teeth in the form of two parabolic
curves within the alveolar processes of the jaws is called their
alignment. When a tooth deviates in its position from this

Fig. 32

Alignment and malalignment.

ideal line, it is said to be in malalignment, or malposition

(Fig. 32). When brought together in the act of mastication,
normally arranged teeth are found to interdigitate very
accurately. This intimate relationship existing between the
cusps of the lower teeth in normal contact with those of the
upper is termed occlusion. It is a primal function of the
teeth, and is dependent upon their position. When a tooth
occupies an abnormal position, and hence, on closure, comes
into abnormal contact with its antagonists, it is said to be
6
82 THE DIAGNOSIS OF MALOCCLUSION

in malocclusion (Fig. 33). The latter is a generic term used

to collectively designate the various abnormal forms of
occlusion. Occasionally, teeth assume such extreme mal-
positions that they are actually in non-occlusion, failing in
contact with their antagonists (Fig. 28).
Malocclusion of the teeth presents itself in an almost end-
less variety of forms, and for many years it was an accepted
belief that their classification constituted a hopeless task.

Fortunately, numerous investigators were not similarly

Fig. 33

Occlusion and maloccluaion.

minded, but endeavored to bring order into this apparent

confusion, to detect similarity in so vast a number of devia-
tions from normality. They realized that a comprehensive
classification constituted the main problem in the difficult
and hence devised systems for this purpose.
art of diagnosis,
The first recorded attempt was by the German dentist,
Kneisel,^ who proposed the two groups, partial and complete.

' Der Schiefstand der Zahne, Berlin, 1836.

 DEFINITION 83

By the term 'partial, he ment malposition of the individual

teeth; and by compkie, he had reference to the abnormal
relations of the dental arches. From among the many
other methods proposed since then, we may mention those
by the following authors as the most important: Carabelli/
Magitot,^ Iszlai,^ Sternfled/ Angle/ Welcker/ Grevers,^
Herbst,^ Zsigmondy,^ and Villain.'"
Most of these efforts at conceptual shorthand are more
or less comprehensive, and are largely based upon patho-
logical manifestations. Many others proposed from time
to time were based upon the treatment to be instituted, and
were, needless to state, fallacious. Furthermore, several
of these schemes contained proposals for an improvement
in our nomenclature, embracing systems of terms which,
by their very etymology, would convey a picture of the
conditions implied. But desirable as such efforts appear,
they have not altogether removed our difficulties, and, at
the present writing, not one of them has gained universal
acceptance.

DEFINITION
Broadly interpreted, every diagnosis implies a considera-
tion of several general conditions, e. g., the age, general and
oral health of the individual, the relative degree of growth
and development, the recognition of causative factors, etc.

' Handbuch der Zahnhl., Wien, 1844.

2 Traits des anomalies du systSme.
3 Internat. Med. Cong., London, 1S81.
^ Ueber Biszerten und Bisanamolien, Miinchen, 1888.
' Dental Cosmos, 1899.
^ Archiv f. Anthropologie, 1902.
"
IV Internat. Dental Cong., St. Louis, 1904.
s Deutsch. Zahnarztl. Woch., 1904.
' Oestr. Zeit. f. Stomatologie, Wien, 1905.
'» Zeit. f. Zahnarztl. Orthopadie, Berlin, 1910.
84 THE DIAGNOSIS OF MALOCCLUSION

Custom, however, limits the use of the term to the art of

differentiating one affection from a group of abnormahties

having similar symptoms. Thus in orthodontic practice it

embraces: (a) The distinguishing of one form of mal-

occlusion from another; (b) the detection of anomalies of
dentition (and of the jaws and related structures) other than
those of position and occlusion; and (c) the degree of facial
deformity associated therewith.

GENERAL OUTLINE OF THE ANOMALIES OF

DENTITION
In 1877 the French dentist Magitot^ proposed a com-
prehensive scheme for the many deviations from normality
found in the denture of man. Though based upon the
records of 2000 cases, was formulated
it prior to the introduc-

tion of many of our present methods of treatment, which

latter have greatly extended the field of dental orthopedics.
He therefore omitted mention of the deformities of the
facial lines, and of the maxillary structures beyond the
teeth, presenting a classification substantially as follows:
(a) Anomalies of eruption; (b) anomalies of number; (c)

anomalies of form and structure; and (d) anomalies of

position.
The anomalies of eruption may be further classified into
premature and tardy; those of number, into deficiency and
redundancy; those of form and structure, into partial and
complete, etc. Orthodontic art occupies itself largely with
the correction of what Magitot termed the anomalies of
position,but it should not be forgotten that any of the other
forms mentioned above (and anomalies of the jaws) may be
found associated with them.
1 Traits des anomalies du systeme.
 . —

THE DIFFERENTIATION OF THE VARIOUS FORMS 85

THE DIFFERENTIATION OF THE VARIOUS FORMS

Let us first ask ourselves, What conditions usually enter

into a malocclusion? The answer to this question must be
stated as follows: There are just three conditions which
may conjoin in a malocclusion —conditions so fundamental
that most writers now recognize their basic significance
and each one of these conditions is reducible into element-
ary divisions, regardless of their manifold combinations.
Concisely expressed, these three conditions are: (1) Mal-
formation of the jaws and their ijrocesses; (2) malrelation of

the dental arches; and (3) malposition of the teeth. Let us

briefly consider these three conditions in the order of their

gravity.
Malformation of the jaAvs is the most serious condition
we have to deal with, and at times constitutes a deformity
so severe that its correction lies outside of our domain.
Therefore, when a case presents a pronounced malformation
of one or it should be emphasized and receive first
both jaws,
mention in thenaming of the deformity (Fig. 34)
If we could remove all of the soft, overlying tissues from
the mandible in such a case, exposing it to full view, there
can be no doubt that the general deformit}^ of this bone, and
not the superimposed teeth and their occlusion, would attract
our first attention (Fig. 35) . And as we ponder over it, how
futile all orthodontic efforts at correction would seem,
especially if they blindly ignored this foundation. Of course,
the age of the patient is an important factor in the treatment
of these cases; and recent developments in the methodology
of our art have established the fact that early treatment
of malocclusion (by securing normal dental function),
 Fig. 34

Mandibular macrognathism.

Fia. 35

Shows the maloccltision of Fig. 34. The bilateral mesioclusion is but a

symptom of the jaw deformity.
THE DIFFERENTIATION OF THE VARIOUS FORMS 87

invariably corrects the menacing deformity beyond the

teeth and their alveoli.
It is obvious, moreover, that malformations of the jaws
may express themselves in several ways, hence it is desirable

to enumerate the various kinds and to adopt a satisfactory

terminology. Now, medical literature has for years recog-
nized the congenital deformities of the jaws under the
group-term polygnatJiism, embracing epignathism, agnathism,
hypognathism, etc. And continental European writers have
used the ending gnathia (meaning jaw) quite liberally, so

that it is not entirely new in dental science. The author,

therefore, suggests its adoption in this connection.
Deformities of the jaws may unfold themselves as over-
developments, for which the term macro gnathism serves
admirably; or they may express themselves in arrested
development, in which case it is termed micrognathism.
When confined to the upper jaw, it may be indicated by the
word maxillary; or, if confined to the lower, it is termed
mandibular. When both jaws are similarly affected, the
term himaxillary is used. Furthermore, the author is of

the opinion that these terms should only be used for those
extreme deformities which are not amenable to orthodontic
procedure.
The arrangement of the teeth in the form of two arcades
or graceful curves (an upper and lower, each with its right
and left sides) demands a fine adjustment of the individual
members of each if a symmetrical, well-balanced ensemble
is to be established. Bearing in mind that we are here
dealing with bilateral symmetry, we can readily see how all

of the upper teeth, or all of the lower, could be in perfect

alignment in their respective arches, and yet, on closure,
fail to come into normal occlusion. In other words, either
 :

88 THE DIAGNOSIS OF MALOCCLUSION

arch (even though it retain a normal form) may be so

displaced upon its osseous base that normal contact with
antagonists becomes impossible. We term this condition

arch malrelation (Fig. 36). It is obvious that this is invari-

ably accompanied by malposition of the teeth, though the
latter frequently exists without the former. Differently
expressed, in cases of simple malposition, accompanied by
normal relation of the arches, we have to deal only with
anomalies of arch form.
Since the publication of Kneisel's book many writers have
recognized a few of the various forms of arch malrelation,
but it remained for Angle to emphasize their far-reaching
significance and to discover the unilateral and bilateral
deviations. He also proposed diagnostic points, by means
of which the mesial and distal variations may easily be
detected. The mesiodistal relationship, or occlusion, of the
first permanent molars is thus made to serve as an aid in
the diagnosis of the mesial and distal forms. Of course, in
mutilated cases allowance must be made for the possible
abnormal position of these teeth.
Angle's Classification. —
Of all the schemes alluded to
above, the Angle classification is the most widely accepted.
It proposes a division of all forms of malocclusion into three
classes as follows
Class I. Normal mesiodistal relation of the arches.
Class II. Distal relation of the lower arch.
Class III. Mesial relation of the lower arch.
In its essence, therefore, it is a classification based upon
the relations of the two dental arches (an exceedingly impor-
tant distinction), though its numerical terminology does
not indicate this.

Now, in a consideration of arch relation we base our

THE DIFFERENTIATION OF THE VARIOUS FORMS 89

differentiation upon normal closure, or occlusion, hence

the ending elusion may readily serve us in our terminology
for designating the various forms. To this ending we

Fig. 36

Normal and abnormal arch relation. A is diagrammatic of their normal relation, as

indicated by the plane a, b, c, and d; in B their relation in a bilateral mesioclusion is set
forth, the perpendicular b x indicating the normal. The line 6 y suggests their relation
in distoclusion.

prefix well-known anatomical terms, and thus get the fol-

lowing: Mesioclusion, when the lower arch is mesial in

its relation to the upper (Fig. 36) ; distoclusion, when it is
90 THE DIAGNOSIS OF MALOCCLUSION

distal to normal (Fig. 37). As stated above^ both sides of

an arch may be affected, when it is termed a bilateral

Fig. 37

Bilateral distoclusion complicated by liuguoversion of the upper central inciso'^s.

 FORMS 91
THE DIFFERENTIATION OF THE VARIOUS
one side is involved,
inrshrlusion or disforhmnn. Or, if only
or (Usindimon (Fig. 38).
we term it a iinihtfmil wcslocJn.von

Fig. 38

Unilateral distoclusion.
92 THE DIAGNOSIS OF MALOCCLUSION

In a consideration of 1000 cases of malocclusion, Angle

found 692 in which the mesiodistal relations of the arches
were normal, the main difficulty being a malposition of the
individual teeth, or an anomaly of arch form. In other
words, one or more teeth were in malalignment, hence mal-
occlusion, a condition recognizedby all writers and loosely
termed "irregularities." That there were several kinds of
malposition was generally known, but again it remained for
Angle to enumerate seven primary forms, and to call special
attention to their possible combinations. Unhappily, this
writer has become so enamored of the w^ord occlusion that
he makes it serve in this instance by prefixing anatomical
terms to it for the designation of these seven deviations.
The author firmly believes that it would be a distinct
advance if an ending denoting position were used instead,
because the spoken word should be measurably descriptive.
Again, having adopted the ending elusion as appropriate
for the designation of malrelation of the arches, it becomes
necessary to use another term to denote malposition of the
individual teeth. Hence the author suggests that the widely
used medical ending version (Lat. vertere, to turn, to change
position) be used to denote malposition of individual teeth.
This gives the following terms: Labioversion or huccoversion
to denote labial or buccal malposition; linguoversion, when
a tooth is lingual to normal; mesioversion, when mesial to
normal; distoversion, when distal to normal; torsoversion,

when rotated on its axis; swpr aversion, to denote elongation;

infr aversion, for depression (Fig. 28) ;
perversion, for impacted
teeth (Fig. 22); and transversion, for transpositions (Fig. 21).
Now, the mere fact that approximately 70 per cent, of all
forms of malocclusion exhibit neither extreme malformation
THE DIFFERENTIATION OF THE VARIOUS FORMS 93

of the jaws nor mesial or distal malrelation of the arches,

emphasizes the advantage of a separate term for this large

Fia. 39

Typical neutroclusion.
94 THE DIAGNOSIS OF MALOCCLUSION

class (Class I, Angle). The author/ therefore, suggested

that the word neutroclusion (Lat. neutro, in neither direction;

Fig. 40
THE DIFFERENTIATION OF THE VARIOUS FORMS 95

occlmio, to close) be used for the naming of this group

(Fig. 39).
Fig. 41

A, bilateral distoclusion complicated by extreme labioversion of the upper incisors;

B, bilateral distoclusion complicated by infraversion of the upper incisors.
 :

96 THE DIAGNOSIS OF MALOCCLUSION

SUMMARY
In confirming the diagnosis of a malocclusion we proceed
by excluding all possible conditions in the order of their
gravity. Thus dentofacial deformity, which is always
serious, is first considered. Owing to the fact that com-
it

prises a large field and involves many grave points, was

it

deemed best to treat it separately (Chapter VI). Next in

importance comes a consideration of malformation of the
jaws; then the relation of the arches, or the totality of their
alignment and occlusion; then the occlusion and alignment
of each tooth, which necessarily implies the form of each

arch; and such other anomalies as may be present.

Finally, the naming of these deformities should be governed
by the following rules
1. Jaw deformities so extreme as to be beyond the scope

of orthodontic treatment should receive first consideration.

Their accompanying malocclusions are merely symptoms.
2. Arch malrelations amenable to orthodontic treatment
are next in importance.
3. All cases of malocclusion accompanied by a neutral
relation of the arches are spoken of as neutroclusions.
4. The individual peculiarities of any given case are best
expressed by adding such qualifying phrases as "compli-
cated by labioversion of the upper incisors," or " infraversion
of the upper incisors," etc. (Figs. 40 and 41).
 CHAPTER VI

FACIAL DEFORMITIES DUE TO MALOCCLUSION

NORMAL VARIATIONS OF THE HEAD FORM

As intimated in Chapter I, a frequent attribute of mal-
occlusion is a marked inharmony of the facial lines. A
rational basis for conclusive deductions regarding these
deformities is a knowledge of the normal variations of
facial form. To a large extent all faces are similarly formed,
and their likenesses are patent to everyone; yet there exist
in every face certain lineaments of character which stamp
it with individuality. Indeed, in probably no other part
of the human form is the variability of features so evident.
The normal variations of organic beings have long been
a subject for careful study; and since Darwin's day with
renewed earnestness. It remained for Blumenbach,^ Cam-
per,2 and Prichard^ to first draw attention to the relationship
existing between the teeth and their osseous base and the
profile or facial lines of man. This phase of scientific inquiry

now forms an important division in anthropology, where, in

common with other elaborate systems and classifications, it
is termed anthropometry, the science of human measure-

ments. The comparative study of the variable morpho-

logical aspects of the skull comprises a subdivision termed
craniometry. When the measurements are made upon the

1 Gottingen, 1775. 2 Berlin, 1792. = London, 1836.

7
98 FACIAL DEFORMITIES DUE TO MALOCCLUSION

Fig. 42 Fia. 43

Fig. 44

Top view of skulls: Fig. 42, negro, index 70, dolichocephalic. Fig. 43, European, index
80, mesocephalic; Fig. 44, Samoyed, index 85, brachycephalic. (After Tyler.)
 NORMAL VARIATIONS OF THE HEAD FORM 99

living head it is termed cephalometry. Numerous methods

for measuring the features have been devised, though very
few have been sufficiently standardized to win universal
acceptance. Much of the development of this branch of
science Ave owe to the French anthropologist Broca.
Cephalic Index. — In comparing a number of skulls even
the beginner experiences little difficulty in detecting differ-
ences of shape. " The form of the head is for all racial pur-
poses best measured by what is technically known as the
cephalic index. This is simply the breadth of the head above
the ears expressed in percentage of its length from forehead
to back. Assuming that this breadth is 100, the mdth is

expressed as a fraction of it. As the head becomes pro-

portionately broader —that is, more fully rounded, viewed
—
from the top down this cephalic index increases. When
it rises above 80, the head is called br achy cephalic; when

it falls below 75, the term dolichocephalic is applied to it.

Indexes between 75 and 80 are characterized as 7neso-

cephalic."^ Figs. 42, 43, and 44 are diagrammatic of these
variations of form.
Other Systems of Measurement. —Among the other systems
proposed for the determination of differences of shape,
mention may be made of Camper's method for the measure-
ment 45 and 46), Flower's gnathic
of the facial angle (Figs.
index, and Turner's dental index.^ By means of the gnathic
index, which is used to determine the amount of projection
of the lewer part of the face, the races of mankind may be
divided into three groups, as follows: Orthognathous, when
below 98; mesognathous, when 98.1 to 103; prognathous.

1 Ripley, The Races of Europe, New York, 1899.

2 Tomes, Dental Anatomy, 5th ed., p. 517.
 Fia. 45

Fig. 46

Camper's measuremeDts of the facial angle.

 NORMAL VARIATIONS OF THE HEAD FORM 101

when above 103. With the dental index we determine "the

relation of the size of the teeth to that of the skull," and
get the three groups termed microdont, index 42;
mesodont,

index 43; and megadont, index 44 and above.

Fig. 47

Normal variation of the s\iinphysian angle.

Fig. 48

B
Noiraal variation of the symphysian angle.
 Via. 49

Normal variation of the symphysian angle.

Fig. 50

C 4m j ^^'•f

Normal variations of alignment of the upper teeth. (After Broca.)

 Fia 51

F"ia. 52

Fig. 63

Showing variations in the relative position of the lower third molar.

104 FACIAL DEFORMITIES DUE TO MALOCCLUSION

Still other differences of interest are the anthropological

varieties of the palate, termed by Turner dolichuranic,
mesuranic, and hrachyuranic; and the variations due to
the development of the muscles of mastication. The latter

are readily recognized in the changeable position of the

Fig. 54 Fig. 55

Normal variation of the profile Dental model of the case shown in Fig. 54.
taken from life.

temporal ridge; the differences in width of the ascending

rami of Europeans when compared with the aborigines; the
varying degrees of parallelism of the borders of the rami; and
the outward and inward everted angles of the lower jaw,
which affect the width of the lower part of the face. Other

and even more important facts of interest are the normal

 NORMAL VARIATIONS OF THE HEAD FORM 105

variations of the symphysian angle (Figs. 47, 48, and 49),

and the ethnological deviations observed by Broca in the

forms of the dental arches. Of the latter there are four
varieties, which he designated parabolic, hyperbolic, ellip-

tical, and U-shaped (Fig. 50).

Fig. 56 Fig. 57

^^1
106 FACIAL DEFORMITIES DUE TO MALOCCLUSION

bones, as well as the accessory sinuses of the nose, differ

and form.
also in their size
Summary. — In
measurements of the facial lines. Camper
his

discovered that in an Australian black they approached an

angle of 85 degrees; in a European, 95 degrees; and in the
beautiful forms of Greek art, 100 degrees or more. This

Fig. 58 Fia. 59

Normal variation of the Dental model of the case shown in Fig. 58.
profile taken from life.

variation is largely due to the backward sloping of the

symphysis, which in the lower races approaches the chinless

form of the anthropoid ape. The degree of prognathism, or

position of the denture in its relation to the skull as a whole,

must also be taken into consideration. These osseous varia-
tions affect all skulls in varying degree, and in Figs. 54, 56,
 NORMAL VARIATIONS OF THE HEAD FORM 107

and 58 we see three photographs which, though unlike in

general contour, are normal from a purely orthodontic stand-
point. The dental models of these three profiles are shown in
Figs. 55, 57, and 59, and it will be seen that in each instance
the teeth are in approximately normal occlusion.

Fig. 60

i
108 FACIAL DEFORMITIES DUE TO MALOCCLUSION

affected by orthodontic treatment. Some of the normal

variations in the arrangement of these parts have been
recognized by orthodontists.

Fig. 61

Neutroclusion complicated by labioversion of the upper and linguoversion of the

lower incisors. (Compare with Fig. 62.)

ABNORMAL VARIATIONS OF THE PROFILE

The various anomahes of dentition which may combine
in a malocclusion were outlined in Chapter V, and it now
becomes necessary to describe in detail the deformities of
the face resulting therefrom.
In Fig. 61 a photograph is shown of a dental model
exhibiting a pronounced labioversion of the upper incisors.
Obviously, such deformity must always affect the contour
 ABNORMAL VARIATIONS OF THE PROFILE 109

of the soft and yielding tissues of the Hps, particularly the

upper. It will be observed that the occlusion of the first

molars is normal, there being no arch malrelation, and it may,

therefore, be classified as a case of neutroclusion. The con-
sequent distortion of the facial lines is shown in Fig. 62.

A similar though frequently more] pronounced type of

deformity is shown in Fig. 63. This must not be confused

Fig. 62

Facial deformity resulting from the malocclusion shown in Fig. 61.

with the former, however, for upon closer examination it

will be seen that though we again have a labioversion of

the upper incisors, there exists in addition a bilateral disto-

clusion of the lower (Fig. 64). Any attempt at correction
of the facial deformity and of the labioversion of the upper
incisors would prove futile if it did not take into consider-
ation the distal malrelation of the lower arch.
Further complications in these types, especially in patients
110 FACIAL DEFORMITIES DUE TO MALOCCLUSION

beyond the developmental period, are an abnormal growth

of the lips, an arrest of development in the alveolar processes,
and malformations of the jaws. On the other hand, if

Fig. 63

Facial deformity resulting from tte malocclusion shown in Fig. 64.

Fig. 64

Bilateral distoclusion complicated by labioversion of the upper incisors.

(Compare -with Fig. 63.)
 ABNORMAL VARIATIONS OF THE PROFILE 111

correction of the malocclusion is instituted early, a restora-

tion of normal function and subsequent growth of the bony
structures will take care of the accompanying inequalities

of facial contour. This rarely, if ever, follows when treat-

ment is too long postponed. In Fig. 65 a profile is shown of

a girl, aged sixteen years, with such a deformity completely

established. Suffering from mouth breathing for a number
of years, the upper lip, by continual stretching, was arrested

Fig. 65

Permanent deformity of the upper lip resulting from postponement of treatment

of the malocclusion shown in Fig. 66. (Compare Fig. 25.)

in its development, and now remains too short and too

thin. The lower, on the other hand, found lodgement in
the space between the upper and lower incisors, and thus,
through abnormal function, overdeveloped (Fig. 66).
The reverse of this type of deformity is found in neutro-
clusions complicated by a linguoversion of the upper incisors;
in mesioclusions; in arrested development of the maxilla;
112 FACIAL DEFORMITIES DUE TO MALOCCLUSION

Fig. 66

Models of the case shown in Fig. 65.

Fig. 67

Facial deformity accompanying the malocclusion shown in Fig. 68.

 ABNORMAL VARIATIONS OF THE PROFILE 113

and in cases of macrognathism of the mandible. Figs. 67 and

68 show the casts and photographs of a lad, aged thirteen
years, where the lack of prominence of the upper lip is
very apparent. An extreme form of micrognathism of the
maxilla, with distoclusion of the upper arch and infraversion
of the anterior teeth, and the consequent facial deformity.

Fig. 68

Unilateral mesioclusion, resulting in deformity of the profile shown in Fig. 67.

are shown in Figs. 69 and 70. Though similar to the former

in outward appearance, the latter must not be considered
as belonging to the same group, or to the next and even
more serious type (Figs. 34 and 35). The latter is a case of
mandibular macrognathism, of which the accompanying
mesioclusion of the lower arch and mesioversion of the lower
teeth are but symptoms. To overlook the mandibular
114 FACIAL DEFORMITIES DUE TO MALOCCLUSION

Fig. 69

Maxillary micrognathism.

Fig. 70

Profile of case shown in Fig. 69.

 ABNORMAL VARIATIONS OF THE PROFILE 115

deformity in such a case is to utterly fail in the diagnosis.

Indeed, all dentofacial deformities, of whatever type, are
but symptoms of the underlying, and therefore more
fundamental, dental anomalies.

Fig. 71

Deformity due to curvature of the mandible.

The so-called "open bite" (Fig. 41, B) is a deformity

commonly associated with nasal obstruction, and may com-
plicate either neutroclusion, mesioclusion, or distoclusion.
Very rarely it may be due to a curvature of the body of
the mandible (Fig. 71). Attention must also be directed
to the fact that in the unilateral forms of distoclusion
116 FACIAL DEFORMITIES DUE TO MALOCCLUSION

and mesioclusion the same facial deformities may exist as

in the bilateral types,
though they are usually less severe.
Another type of deformity is that associated with supra-
version of the incisors, which may be symptomatic of neutro-
clusion or of distoclusion; and in all of these the outer contour
of the facial muscles involved, particularly of the lower lip.

Fig. 72

Neutroclusion aocompanied by the facial deformity shown in Fig. 73

appear so crowded that it suggests overdevelopment. But

this is usually more apparent than real, because after the
correction of the malocclusion they readily assume a normal
form. The author is convinced, moreover, that the really
seriQUs condition met with in many of these cases is a lack
of perpendicular development in the region of the symphysis.
In other words, the distance from the gingival line of a lower
 ABNORMAL VARIATIONS OF THE PROFILE 117

central incisor to the mental eminence of the chin is too

short. This condition is the source of much annoyance to
the operator during treatment, and extremely difficult to
permanently correct.
The normal variations of the symphysian angle have
already been referred to. Figs. 72 and 73 show a case where,
besides exhibiting considerable malocclusion of a type

Fig. 73

Showing extreme deficiency of the symphysian angle.

ordinarilydemanding a liberal expansion of both the upper

and lower arches, a compromise in treatment would seem
to be indicated. The receding chin, in this instance, is a
fundamental osseous condition wdiich must be reckoned
with, and which no amount of tooth movement at this late
period (the patient being sixteen) would ever correct.
118 FACIAL DEFORMITIES DUE TO MALOCCLUSION

ORTHODONTIC CONCEPTIONS AND IDEALS

The mere fact that orthodontics embraces methods for

the correction of deformities of the face predicates the
desirabihty of a standard, or criterion of judgment.

Fig. 75

Classical profile of Apollo. Measurements employed by artists.

(After Farrar.) (After Wiegall.)

"The upon him great

duties of the orthodontist force
responsibihties,and there is nothing in which the student
of orthodontia should be more keenly interested nor better
informed than in the study of the artistic proportions and
relations of the features of the human face; for each of
his efforts, whether he realizes it or not, makes for beauty
or ugliness, for harmony or, inharmony, for perfection or
 :

ORTHODONTIC CONCEPTIONS AND IDEALS 119

deformity."^ Furthermore, besides forming an important

phase of the difficult art of diagnosis, it involves us in "the
most remarkable problem of esthetics," viz., that of beauty

of form. Ignorance of these requirements has led numerous

operators into the unenviable position of having permanently
marred the beauty of an otherwise handsome face.

In the works of Kingsley, Farrar, Jackson, etc., the need

for some standard as an aid in diagnosis was plainly felt.

The classical profile of the Grecian mythological god

Apollo (Fig. 74) and the lines of division employed by
artists in the study of esthetics (Fig. 75) have been widely
used for this purpose. But not until Case^ and Angle^
developed their comprehensive systems did we approach
methods of tolerable accuracy. Unfortunately, a review of
the works of these two authors reveals the fact that their
conclusions are diametrically opposed to each other.
Case's Ideal. —A large experience and much careful obser-
vation have led Professor Case to formulate the following
principles
"The portion of the human face that it is possible to
change with dental regulating apparatus may be said to lie

between two diverging lines which arise at a point below the

ridge of the nose and curve downward to enclose the alse

and depressions on either side; thence laterally to encircle
a portion of the cheek, and downward to enclose the entire
chin (Fig. 76). This area may be termed the changeable
area in contradistinction t^^he more stable features, or
unchangeable area. For convenience of ready reference, the
features in that portion of the changeable area which are

1 Angle, Amer. Text-book of Oper. Dentistry, 3d ed., p. 694.

2 Dental Orthopedia, 1908.
5 Malocclusion of the Teeth, 7th ed., 1907.
 :

120 FACIAL DEFORMITIES DUE TO MALOCCLUSION

bounded laterally by the nasolabial lines may be divided

into four segments, as follows
"Segment 1. The end of the nose and the upper portion
of the upper lip, including the nasolabial depressions.
"Segment 2. The lower portion of the upper lip.

"Segment 3. The lower lip.

"Segment 4. The chin.

"These four segments are changeable in their relations
to each other, and also in their individual relation to
features in the unchangeable area."

Fig. 76

Unchangeable area

Changeable area "I

Method of measurement. (After Case.)

Dr. Case further maintains that the relations of these

areas to each other must be determined prior to treatment
by the trained eye and the deviations, if any,
of the operator,
noted. Following this the treatment must be planned so
as to produce the best possible exterior effects or contour
of these parts. In other words, the operator's ideal of facial
 ORTHODONTIC CONCEPTIONS AND IDEALS 121

form is the standard or criterion he would ha\e accepted.

It is presumed, of course, that this be a cultivated ideal,
carrying with it that fine discretionary ability to say when
teeth shall be extracted, or moved bodily, for the improve-
ment of facial balance. According to this author, the full
complement of teeth is not necessary in the treatment of
certain types of malocclusion; in some instances extraction
of one or more teeth is positively indicated.

Fig. 77

Shows the unrelatedness of beauty of form and beauty of elements.

(After Santayana.)

Theoretically, this is perhaps true, because "Beauty of

form cannot be reduced to beauty of elements. All marble
houses are not equally beautiful." Similarly, all profiles,
even though they are moulded over an ideal occlusion of
all the permanent teeth, are not equally beautiful. "All
ideal forms have an emotional tinge. Beauty of form is due
to expression, and all expression, ultimately, is something
else than beauty —some practical or moral good." For
example, "take the ten meaningless short lines in Fig. 77,
122 FACIAL DEFORMITIES DUE TO MALOCCLUSION

and arrange them in the given ways intended to represent

the human face; there appear at once notable different
esthetic values. Two of the forms are differently grotesque,
and one approximately beautiful. These effects are due to
the expression of the lines; not only because they make one
think of fair or ugly faces, but because, it may be said, these

faces would in realit}^ be fair or ugly according to their

expression, according to the vital and moral associations of

the different types. "^

—But according to Angle, "We must be able
Angle's Ideal.
to detect whether the features — that the forehead, the is,

nose, the chin, the — each individual face balance,

lips of
harmonize, or whether they are out of balance, out of har-
mony, and especially whether the mouth is in harmonious
relations with the other features, and if it is not, what is

necessary to place it in balance. The faculty of determin-

ing the proper balance of the features is a difficult one to
attain." Quoting Prof essor Wuerpel, he further says : "Only
one in two or three hundred art students ever succeed in
mastering it, and these only after much observation and
practice in sketching and modelling of faces. Unpromising
as this seems, it is doubtless correct; yet we have a rule for
determining the best balance of the features, or, at least,
the best balance of the mouth with the rest of the features,
that artists probably know nothing of, and one that for the
orthodontist is more unvarying and more reliable than even
the judgment of the favored few —a rule so invariable and
with so few exceptions that we may consider it a law, and
if it be not applicable in all cases, the exceptions will be
so very rare that they are hardly worth considering. It is,

1 Santayana, The Sense of Beauty.

 ORTHODONTIC CONCEPTIONS AND IDEALS 123

Fig. 7S

Shows the aiitlior'a method for estimating in advance the probable effet-t

of an orthodontic treatment. (Compare with Fig. 79.)

124 FACIAL DEFORMITIES DUE TO MALOCCLUSION

furthermore, a rule so plain and so simple that all can under-

stand and apply it. It is thai the best balance, the best harmony,
the best proportions of the mouth, in its relations to the other

features, require thai there shall be the full complement of teeth,

and that each tooth shall be made to occupy its normal position

—normal occlusion."
Fig. 79

Photographs of the patient before and after the use of the wax mould
shown in Fig. 78.

Expressed differently, Angle maintains that the outward

form of the changeable area of the face is dependent upon
the relative normality of the denture within; and that, as a
rule, it is best to establish normal occlusion (which implies
the presence of each tooth), and thus strike a balance which
is rarely wrong. Theoretically, this is not absolutely true;
and it can hardly be called a law, using the word in its

scientific sense. But many operators of wide experience are

practically unanimous in support of his contention, hence it
 ORTHODONTIC CONCEPTIONS AND IDEALS 125

has become a fundamental postulate in orthopedic practice.

In other words, it is true because it ought to be true, and
because the opposite practice of sacrificing teeth for the

Fia. 80

Method employed in distoclusiona. (Compare with Fig. 81.)

126 FACIAL DEFORMITIES DUE TO MALOCCLUSION

improvement of facial contour is rarely necessary, and

seldom advantageous. Indeed, the necessity for the extrac-
tion of one or more teeth is so infrequent that its practice
has become almost obsolete. This is particularly true in all

cases where the treatment is instituted during the develop-

mental period. The development of the surrounding osseous
structures subsequent to tooth movement is usually to be
expected in young patients; hence their profile must never
be considered as a fixed line (at least not immediately after
treatment), but one in which further changes will continue
to take place.
Fig. 81

Shows temporary effect upon the profile.

DIAGNOSTIC METHODS

In order to ascertain in advance the probable effect of

treatment upon the facial lines, the author has used the
following methods whenever ap])licable:
 DIAGNOSTIC METHODS 127

In cases of neutroclusion accompanied by linguoversion

of the incisors, a piece of softened wax is moulded over the

Fig. 82

Same method as in Fig. 80.

128 FACIAL DEFORMITIES DUE TO MALOCCLUSION

occluded models and trimmed to a form approaching the

future alignment of these teeth (Fig. 78). After it has
been allowed to cool it is placed in position in the mouth.
The patient is now asked to relax all tension of the lip
muscles, which allows the facial lines to assume the form
which the treatment will ultimately produce (Fig. 79).

FiQ. 83

Photographs of case shown in Fig. 82.

In distoclusion accompanied by labio version of the

upper incisors (Fig. 80, a) the patient is requested to bite

mesially, so as to bring the first molars into normal mesio-

distal relations. Fig. 81 clearly shows the effect upon the
facial lines, representing photographs of the patient with
the teeth in the positions shown in Fig. 80, a and b. Simi-
lar preliminary studies can be made of patients presenting
a distoclusion accompanied by linguoversion of the upper
incisors. The latter type frequently combines with supra-
 DIAGNOSTIC METHODS 129

version of the incisors and infraversion of the molars and

bicuspids, for which Dr. Case^ has suggested a temporary
"opening of the bite." If necessary, pieces of modelling
compound, or wax, are previously inserted to prevent
complete closure, and while in this position a study of
the profile can be made (Figs. 82 and 83).
In the more serious cases of facial deformity, e. g., those
due to mandibular macrognathism or to infraversion of the
incisors, these methods are inapplicable.

1 Dental Orthopedia, p. 323,

 CHAPTER VII
THE PROGNOSIS OF MALOCCLUSION

DEFINITION

The medical term prognosis is used to denote the probable

result of, or prospective recovery from, a disease or abnor-
mality. It is an opinion concerning the duration, course,
and termination of a disease and of the outcome of the
treatment. And while such judgments necessarily vary in
accordance with an operator's experience, they are, never-
theless, dependent upon conditions inherent in each case.
In orthodontic practice it frequently becomes necessary to
render an intelligent opinion in advance of treatment; and
it is well toremember that a favorable prognosis depends
largely upon an early diagnosis, when conditions are such
that a comparatively simple treatment will suffice. For-
merly was customary to postpone most treatments until
it

all of the permanent teeth had erupted, for it was believed

that nature would assist in the correction of the malocclusion,

and that most patients would "outgrow" the deformity.
Many bitter disappointments have taught us the error of
such advice, and strongly emphasize the fact that the severe
forms of malocclusion do not develop over night, but are of
slow growth. Hence it follows that years before even an
intelligent parent recognizes the impending deformity, the
alert diagnostician can advise ways and means for its
prevention.
 GENERAL CONSIDERATIONS 131

GENERAL CONSmERATIONS

Age and Health. —Age and health may be regarded as funda-

mental considerations in every prognosis. Thus a macrog-
nathic mandible, accompanied by mesioclusion of the lower
arch, might readily yield to treatment between the eighth
and tenth years. On the other hand, if such a condition is

neglected until the twentieth year the deformity might then

be so severe that orthodontic measures for its correction
would prove futile. Similarly, if treatment is attempted in

two cases of the same age and type, but with widely divergent
conditions of general and oral health, their response to treat-
ment might vary considerably. Let us suppose that in
one case immunity to caries had always existed; that the
patient's robust health permits the operator to carry the
treatment to a rapid and successful conclusion. In the
other, we find caries very progressive, and the oral secretions
markedly abnormal; the patient is hypersensitive and
enfeebled by prolonged illness. It is obvious that in the
latter, response to treatment will be extremely slow or
plainly doubtful, even though it be administered by the
same experienced hands. To be able to detect such differ-
ences in advance is often difficult, and the ability to do so
can only be acquired by a wide experience and much careful
observation.
Sex. — Dr. Guilford^ has pointed out that the question of
sex may and claims that "a robust
enter into a prognosis,
boy can undergo an operation that in a tender girl might
result in nervous shock or even greater physical harm."
He rightly maintains that a "loss of general health could

' Orthodontia, 4th ed., p. 41,

132 THE PROGNOSIS OF MALOCCLUSION

never compensate for an improvement of the dental organs,

however great." Other writers assert that sex is of httle
consequence, and they are unwilHng to accept a comparison
between a "robust boy" and a "tender girl," because there
are many robust girls who make better patients than tender
boys. However, it appears self-evident that the advent
of puberty in females, with its frequent disturbances of
bodily equilibrium, requires the exercise of more than
ordinary care and attention; all of which emphasizes the
necessity for early treatment.
Furthermore, the methods of today are such that, when
properly administered, they do not act as a hardship on the
patient. It is unfortunate, therefore, that the cry of an
ignorant laity should raise an echo in the profession, leading
to a denunciation of orthodontics, and the claim that its

treatments seriously undermine the health of many indi-

viduals. Dr. Ketcham^ and others have gathered data in
refutation of these false assertions, and have found that
practically all patients gained in weight during the entire
period of orthodontic treatment; many of them improved
rapidly in their studies at school, and few failed to respond
favorably to treatment. This ought not to cause surprise
when we consider that most parents are sufficiently careful
not to demand orthodontic services for their sick children.
A well-meant, though misdirected, enthusiasm has
prompted some operators to ignore entirely the factors of
age and sex, and to accept cases of advanced years. Most
of these patients are women who suddenly desire amends
in facial expression, but with expectations entirely beyond
the achievable. Though a carefully executed orthodontic

1 Dental Cosmos, September, 1910.

 SPECIAL CONSIDERATIONS 133

operation usually improves the facial lines, there are many

instances where the results could hardly be called beautiful,
and for which the operator is in no wise responsible. Let
the beginner beware, therefore, of all mature cases with a
doubtful prognosis; especially in the cases of married women,
with the ever-present possibility of an intervening preg-
nancy. The latter constitutes an exceedingly unfavorable
condition, rendering post-treatment maintenance extremely
doubtful, if not impossible.

SPECIAL CONSIDERATIONS

One of the most important factors entering into a prognosis

is that of cause, the ignoring of which has led to many
failures. The removal of the cause, whenever possible, is

the first Of course, in a great

step in successful treatment.
many instances (owing to our limited knowledge of this
subject) we are unable to proceed in this manner; but this
makes it all the more imperative to do so in all cases where
the cause is readily recognized. By way of illustration, let

us consider the case shown in Figs. 84 and 85, exhibiting

abnormal breathing. This symptom connotes nasal obstruc-
tion, which usually stands in causal relation to the mal-
occlusion. Its presence and neglect in early childhood
invariably leads to malocclusion of the permanent teeth,
and in all cases associated with mouth breathing the com-
petent treatment of the abnormal nasal conditions should
be insisted upon. (Compare with Fig. 4:1, A, which is from
a patient of similar type at the age of sixteen.)
Owing to the mechanical aspects of dentition, the self-
correction of most forms of malocclusion is an impossibility.
134 THE PROGNOSIS OF MALOCCLUSION
Fig. 84

Facial deformity in a lad of eight years suffering from nasal obstruction.

Fig. 85

Denture of case shown in Fig. 84.

 SPECIAL CONSIDERATIONS 135

Nature and time rarely exercise a corrective influence upon

them. To the usual c^uestions, then, which parents so
frequently ask in first consultation, a negative answer is

uniformly best. The accompanying facial deformities, which

are often the immediate reason for their inquiries, grow
steadily worse. Fig. 86 shows the models of a lad, aged

Fia. 86

Incipient unilateral distoclusion at eighth year.

eight years, whose parents found it convenient to heed the

advise of an ignorant dentist: " He'll outgrow that in a few
years. I wouldn't advise any treatment now." These and
many similar assertions are soothing to a father's purse.
During the few minutes boy occupied the author's
this

operating chair, and while his remarks on the urgent neces-

sity for treatment were slowly and emphatically expressed.
 FiQ. 87

Same case as Fig. 86 at age of fourteen.

Fig. 88

Facial deformity accompanying case shown in Fig. 87.

 SPECIAL CONSIDERATIONS 137

the impressions from which these models were made were

taken. Under pressure, probably, of the conflicting social
and economic tendencies of our age, this lad and his parent
disappeared from the immediate scene. Six years elapsed
before their return, during which time the models rested
peacefully in their place in the cabinet. x4nother dentist is

now caring for this family's dental ills, and their return to
the author's office is not an unusual or unexpected incident.
Fig. 87 shows the same denture at the age of fourteen, and
Fig. 88 the pronounced deformity of the face which time
and nature, unaided, had wrought. The history of many
similar maldevelopments could here be introduced; they are
all too common, even in this day. But multiplication is
unnecessary. Every fact gleaned from a study of the process
of dentition substantiates the orthodontic axiom that mal-
occlusion and its accompanying deformities are yrogressive,
not static. In short, the prognosis of malocclusion is equally
as unfavorable as of caries of the enamel; the evil conse-
quences are equally certain. The old adage, "An ounce of
prevention, etc.," is decidedly apropos in a consideration
of malocclusion of the teeth.
The one great lesson, then, which recent orthodontic
progress teaches is that all forms of malocclusion develop
slowly; that during childhood they are ever in process of
development. To appreciate this evolution of types, to
detect them in their incipiency, and to divert the underlying
forces into channels of normality —this is the highest mission
of orthodontics. But there is another lesson which must be
more widely taught than formerly, and which has been too
much neglected, namely, the important relation a normal
denture bears to health. In earlier periods orthodontic
efforts were appreciated mainly for their esthetic conse-
138 THE PROGNOSIS OF MALOCCLUSION

quences; the desire for an improvement of facial harmony

was the prime motive in most instances. More recently
we have come to a realization of the fact that a normal
denture implies normal occlusion, without which its efficiency

is greatly reduced.
The recent experiences of many practitioners have led us
to a keener appreciation of the "golden age for treatment,"
by which we mean that time in an individual's life when the
change from the temporary to permanent dentition takes
place. This covers the period from the sixth to the four-
teenth year. In rare instances (those cases which early
exhibit a tendency toward extreme malformation of the
jaws) it has been found advisable to begin treatment prior
to the sixth year. And in most cases of mesioclusion or disto-
clusion it is best to institute treatment as soon as it can be
diagnosed, i. e., immediately after the eruption of the four
first permanent molars.
The establishment of the alveoli and the complete cal-

cification of the roots of the teeth; the development of

the temporomandibular articulation; the lengthening of the
rami and the development of the body of the mandible —
all these are considerations which must be reckoned with.

CLINICAL SUMMARY

A brief study of the various forms readily establishes the

conclusion that in their earliest stages all are comparatively
simple. Figs. 89 and 90 show two cases of distoclusion;

one aged nine years, the other fourteen. In Fig. 89 it will

be noticed how the linguoversion of the upper central

incisors prevents a normal mesiodistal relation of the lower
 Fig. 89

Incipient bilateral distoclusion at nine years.

Fig. 90

Same type of malocclusion at fourteen years.

140 THE PROGNOSIS OF MALOCCLUSION

arch; the tendency is toward an arrest of development of

the mandible. Note further how the molars are thereby

prevented from coming into normal occlusion. A moment's
comparison establishes the inference that the older case
(Fig, 90) passed through a similar stage.

Fig. 91

Bilateral mesioclusion at eleven years.

That the history of mesioclusion is similar is equally

certain is shown by a comparison of models in Figs. 91 and

92. Fig. 91 is made from the denture of a boy, aged eleven

years, while Fig. 92 is from an adult, aged twenty-eight
years. It is inconceivable how neglect could prove beneficial
to Fig. 91; it is the surest way toward a multiphcation of
difficulties. If the influences of abnormal function, of the
 CLINICAL SUMMARY 141

impacts during use, are considered, it becomes evident that

the omission of treatment constitutes a "penny-wise and
pound-foolish policy." How an intelligent dentist, intrusted
with the care of the mouths of growing children, could permit
such abnormal developments under his very eyes and not
remonstrate against them is incomprehensible. The probable

Fig. 92

Mandibular macrognathism at twenty-eight years.

result of treatment for Fig. 91 is exceedingly favorable; the

correction of the mandibular macrognathism of Fig. 92
lies beyond the domain of orthodontics. (See Chapter
XVIII.)
In the next illustration (Fig. 93) we note a distoversion
of the upper centrals in a girl, aged eight years, due to an
142 THE PROGNOSIS OF MALOCCLUSION

abnormal frenum labium, and another (Fig. 94) at the

age of twelve. Four years of neglect have again demon-
strated their evil consequences. The diastema between the

Fig. 93

Denture of a girl, aged eight years.

Fia. 94

^^
 CLINICAL SUMMARY 143

centrals caused an encroachment upon the lateral spaces,

and when the latter finally appeared they readily erupted
lingual to normal. A further study of many similar cases
might here be introduced, but the lesson from each would
be substantially the same. To the question then. Is early
treatment always advisable? the uniform reply is Yes.
Should postponement of treatment be desirable in a given
case, the operator should be accorded the privilege of the
decision.
As to treatment, MacDowelP has suggested a classification
of cases into three groups, as follows:
The possible: all cases between the ages of eight and
fourteen.
The probable: mesioclusions and distoclusions after the
age of fourteen.
The impossible: most cases beyond the age of sixteen.
Skilful orthodontists regard this as a very conservative
classification, because a wide experience enables them to
considerably extend the age limit of each group. But the
beginner will find it a valuable guide, it being the part of
wisdom to err on the side of safety.

1 Orthodontia,. xvii.
 CHAPTER VIII
THE EVOLUTION OF METHODS
METHODS OF THE PAST
Scientific progress during the last half century has so
altered our conceptions regarding the theory of life and the
growth of society, that we are forced to re-write history
and adapt it to the evolutionary philosophy (Pearson^).
Present-day standards require history to be more than
antiquarian; the real profit in tracing the development of
an art must rest in something else than a mere knowledge
of what has happened must dwell
in chronological order; it

in an understanding of the principles that have promoted

the developments of the past, in the meaning of certain
events. This advance in our conceptions is due to the
epoch-making labors of Darwin, "who made all reasoning
since his day follow his method."
Now, in tracing the evolution of orthodontics the aim
should be to view its development from the standpoint of
this new and higher perspective. In no other division of its

subject matter is this more desirable than in the methods

of treatment. Not that the tracing of its remedial measures
constitutes the whole of its history; the evolution of the
science and the history of its theoretical foundations are
equally important. But a greater unanimity of opinion

1 The Grammar of Science.

 METHODS OF THE PAST 145

regarding these fundamentals has always existed. Indeed,

the principles of the science are readily traced; in these
fields a greater harmony prevails than a first survey seems to
justify. Not so with the art. The steep aclivity up which
we have so slowly traveled measures a progress not without
interest or strife. The desire for supremacy on the part
of several of our leaders has added its bitterness as well as
charm.
The delineation of the methods of treatment is difiicult

not only because they have been as varied as could well be

imagined, but because they comprise an overwhelming mass
of trivial details. Formerly, the dentist only occasionally
dabbled in matters orthodontic, and thus failed to grasp
the principles underlying the technical details of treatment.
Prior to diagnostic systems each case constituted a class
by itself, so that the designing and constructing of a mechan-
ism for treatment often taxed to the utmost the inventive
capacities of the practitioner. Thus the birth of the new
order was painfully prolonged, and the rudiments of present-
day methods unwittingly obscured.
But in 1878 Dr. Farrar, of New York (see page 27),
prophesied lines of advance which have since been followed
with increasing advantage and favor. The import of his
prediction was not readily grasped, though it stipulated
the standardization of appliances and their being carried in
stock by dealers. Indeed, this ideal is not yet fully achieved,
though its influence thus far has been nothing short of
revolutionary. It has forever relegated appliance manufac-
ture where it rightfully belongs, has freed the mind of the
operator of many petty details, and furnished the necessary
leisure for the investigation of more important matters.
Viewed in this wise, it is not difficult to imagine the
10
146 THE EVOLUTION OF METHODS

probable present status of a department like operative

dentistry had not the manufacturer long ago come to the

Fig. 95

Fauchard's metallic alignment band (1728). (After Pfa£E.)

Fig. 96

Schange's appliance (1840). (After Pfaff.)

rescue. The wonder of it, then, is not how little, but how
much the past has achieved. Truly, a sincere review of the
 METHODS OF THE PAST u:

work of the pioneers and pathfinders awakens the deepest

reverence; their labors must ever be regarded as indispen-
sable stepping stones. Though they are now^ fading from
twilight into dusk, let us not forget that they ushered in
that golden dawn which made the present possible.
F'ig. 95 shows an appliance used by Fauchard (1728), and
exhibits the principle of our present-day alignment wire.
Fig. 96shows an appliance designed by Schange (1840), and
embodies the essentials of mechanisms in use today. A

Fig. 97

Flagg's round alignment wire (1865). (After Pfaff.)

similar, though greatly simplified, apparatus is shown in

Fig. 97, being a design by Flagg (1865). It represents the
round alignment wire, with flattened ends anchored to the
molars, and serves as a goal toward which the malposed
teeth are moved by means A comparative
of ligatures.
study of other elements might easily be here introduced,
though a sufficient number have been shown to demonstrate
their gradual evolution. Some systematists have studiously
avoided such comparative study, and utilized well-chosen
contrasts to their own advantage.
148 THE EVOLUTION OF METHODS

RISE OF THE SYSTEMS

Following the epoch-making labors of Farrar, the intro-

duction of stock appliances was inevitable. The wholesale
construction of standard mechanisms with interchangeable
parts, to be placed upon the market for sale, was now

Fig. 98

Farrar's "labial bow" and clamp bands.

Fig. 99

Patrick's appliance.

demanded. Naturally, many of the earlier efforts in this

direction were very incomplete and unsatisfactory, and in
untrained hands often proved a failure. They were usually
brought forth in the shape of a "system," and represented
the more commonly used methods of their author.
 RISE OF THE SYSTEMS 149

In 1876, in response to these demands, Dr. Farrar offered

duplicates of many of the appliances he had nsed in his
practice (Fig. 98). For a time they enjoyed an extended
sale, but were soon displaced by devices of simpler design,
notably those by Patrick in the early 80's (Fig. 99). A
study of this ilhistration reveals the principle of the align-
ment wire anchored to the molars by means of adjustable

bands with buccal tubes.

Fig. 100

Angle appliance of 1887.

In 1887 Angle introduced a system which embodied

sundry of these old principles, though greatly simplified
by a reduction of parts (Fig. 100).
Among the many other methods brought forward during
this unusually productive period were the systems of Jack-

son, Case, Lukens (Fig. 101), and Knapp.

150 THE EVOLUTION OF METHODS

Recent adverse criticism has created considerable ill

feeling in opposition to these so-called systems, which could

easilyhave been avoided had their originators adhered to
the principles of historical method. Their tacit claims of

Fig. 101

Lukens' appliance.

having suddenly, and by original methods, revolutionized

the art and brought it to an approximate finality, are
directly traceable to the wilful omission of the work of

many predecessors.
In Chapter I attention was called to their achievements,
to their influences toward the simplification of methods;
 LINES OF ADVANCE 151

and so the struggle which they themselves engendered may

be regarded as a passing cloud —for systems are wholly
foreign to the democracy of science. Hence the thought
that they must finally die, that upon their shattered dreams
of finality a greater and grander art will rise, is encouraging,

and not at all dispiriting. Indeed, this forward movement

has now^ begun.

LINES OF ADVANCE

The comprehension of the importance of a differential

diagnosis, the designing of a definite treatment for all cases
belonging to a given class, and the simplification and mastery
of the technical details of every such definite treatment, may
be said to constitute the core of what has been termed the
new movement in orthodontic practice.
The systems (particularly the efforts of Angle) have been
largely responsible for promoting this advance in our
progress. And though they were unbecomingly dogmatic,
they possessed the saving grace of showing the wide range
of applicability of a limitednumber of very simple mechan-
isms. Hence the burden of their claims w^as, after all, a
very laudable one; by insisting on the mastery of a few essen-
tials and their manifold combinations, orthodontics made a

progress hitherto unattainable. In fine, to be a master in

the application and use of a few appliances, rather than
the slave of many, is a worthy lesson the sj^stematists have
tried to teach. Ever dawn of this tendency toward
since the
simplicity and the unification of methods, orthodontics
has witnessed a wholesome elimination of many unneces-
sary^ and impractical procedures. Though this process of
elimination still continues, at the present writing it is very
152 THE EVOLUTION OF METHODS

evident that certain mechanisms (those embodying advanced

principles of design) are tending rapidly toward universal
acceptance.

DETAILS OF DESIGN

Fig. 102 is diagrammatic of a modern appliance, combin-

ing many of the essential elements in use today. These
elements may briefly be summarized as follows: The plain
band {B), anchor band {D), alignment wire {F), ligatures
(C and A), and a number of minor miscellaneous accessories

Fig. 102

Modern appliance. (After Angle.)

not shown in the illustration. By the skilful and judicious

combination of these elements we are enabled to treat most
cases of malocclusion. Only rarely are we obliged to employ
other and more complicated appliances.
From the earliest times, several of the noble metals, viz.,

gold, platinum, silver, and their alloj^s, have been used in

the construction of regulating appliances. In recent years
base metal alloys like German silver have been widely
employed. Iron, steel, nickel, aluminum bronze, and
 DETAILS OF DESIGN 153

vulcanite ru])ber have all been recommended. German

silver, ho\ve\-er, possesses many of the virtues which should
be embodied in an appliance, such as temper, adaptability
when annealed, inexpensiveness, etc. On the other hand,
Pullen^ and Grieves^ have recently called attention to its
shortcomings, which are as follows: Discoloration and
disintegration, and, occasionally, the formation of metallic
stains upon the tooth surfaces.
Alloys of iridium and platinum, and of gold and platinum,
are therefore preferred b}' many operators, because they
are not affected by the acid fluids of the oral cavity, or by
any of the medicaments employed in practice (such as
hydrogen peroxide, solutions of silver nitrate, tincture of
iodine, etc.).
When attention was first called to the corrosion of German
silver, its advocates proclaimed this a virtue, believing the
consequent liberation of metallic salts had a favorable
prophjdactic influence, promoting an immunity to caries of
the enamel. Grieves,^ on the other hand, has shown that
the amount of metallic salts thus set free and swallowed
by the patient frequently proves deleterious by unfavorably
affecting, the physiological action of the ptyalin and enzymes.
He claims zinc is the most objectionable of all the metals
which enter into alloys used for appliances.
The introduction of aluminum bronze into dentistry by
Sauer, and its recent revival for regulating appliances by
Treymann,* resulting in the so-called "non-corrosive"
appliances, will doubtless lead to the discovery of base-
metal alloys with virtues equal to those of the noble metal
group. The latter, however, possess all of the requisite
qualifications except that of cost.

' Proc. Amer. Soc. Orthodontists, vol. vii. ^ ibid., vols, viii and ix.
3 Log. cit. * Vierteljahr. f. Zahnhk., July, 1909.
 CHAPTER IX
PRINCIPAL ELEMENTS OF MODERN MECHANISMS
BANDS

The Plain Band. —The individual movement of malposed

teeth and the correction of arch form constituted the sum
total of orthodontic efforts for many decades. Only recently
have the possibilities of arch movement been developed.
Even in those earlier stages of progress was the need plainly
felt for some form of attachment to the teeth to be moved.
Owing to the unfavorable forms of many of the teeth, the use

Fig. 103

The plain band.

of simple ligatures often proved inadequate for the move-

ments required. To gain secure attachment at the point
of attack, regardless of the kind of mechanism employed,
is the first requisite of successful therapy. Hence the plain,
band was invented (Fig. 103). It consists of a ribbon of
metal 36 to 38 gauge, accurately adapted to the crown of
the tooth for which it is designed, after which its free ends
 BANDS 155

are united by solder (S) to form a contiiiiioiis band, or

ferrule.

As early as 1815 Delabarre^ suggested the use of metallic

caps, or crowns, for the teeth to be moved, and to which
the various attachments were soldered. In 1848 Jos.
Linderer^ advocated ribbons of metal for the same purpose.
These had perforations in their ends, through which ligatures
were passed, making them adjustable as to size (Fig. 104).

Fig. 104

Linderer's adjustable band on the canine. (After Pfaff.)

Magill and Gilmer have been credited with the honor of

introducing the plain band as used today, and of advocating
its secure attachment by means of cement. While many

1 Odontologische Beobachtungen, Paris, 1815.

« Handbucli der Zahnheilk., Berlin, 1848.
156 PRINCIPAL ELEMENTS OF MODERN MECHANISMS

minor tooth movements are ])ossible witliout its use, it is

evident that the plain band with its various attachments

will always occupy a prominent place in the technique. A
detailed consideration of these various attachments and
their uses will be found in the chapters on treatment.
The Anchor Band. —This essential element of an appliance
has passed through many stages, all of which can readily
be grouped under the two divisions of adjustahle and non-
adjustable. The non-adjustable designs were the first to be
used, and were variously described as crowns, cribs, clasps,
and ferrules. They w-ere constructed bj' the operator, and
prior to the introduction of cement were very insecure in

their anchorage, besides promoting caries of the enamel.

The ferrule design, which, in reality, w^as a plain band,

proved the most efficacious of these, and still continues in
use. With the introduction of the adjustable form of anchor
band, was claimed that an accurate adjustment was more
it

readily obtained. Owing to the fact that anchorage is

usually applied to the molars, the crowns of which are less
accessible than those of the anterior teeth, the adjustable
designs readily met with great favor. Furthermore, the wide
use of stock appliances aided materially in their adoption.
As stated, Linderer was probably the first to use an
adjustable band. A decided advance in design is shown in
Fig. 105, which was introduced by Schange in 1841.^ He
adopted the principle of the threaded bar, or screw, for
adjusting the size of the band. Later, in the hands of
Farrar, it passed through various stages (Fig. 106). The
screw-block on the buccal surface was modified by Patrick
(Fig. 107) and Angle (Fig. 108) into the tube in use today.

1 Precis sur le redressement des denta, Paris, 1841.

 BANDS 157

Even this tube, which provides anchorage for the ahgnment

wire, has been modified in design by Knapp, Kemple, Otto-
lengui, and others. An ingenious modification is shown in the
design by Lukens (Fig. 109), in which the tube is threaded

Fig. 105

Schange'a adjustable band on the central.

Fig. 106 Fig. 107 Fig. 108

Farrar's adjustable anchor Patrick's adjustable Angle's adjustable anchor

band for molars. anchor band. band.

on its outer surface and thus made to serve as the screw-

post, which does away with the attachment of the latter

on the Hngual surface.

Fig. 110 shows the so-called all-closing, or continuous
158 PRINCIPAL ELEMENTS OF MODERN MECHANISMS

form suggested by Barnes. This feature is widely used

today, because it constitutes an additional precaution
against caries of the enamel. The recent introduction of
the "seamless band" has been favorably received, especially

Fig. 109 Fig. 110

Lukens' adjustable anchor band. All closing or continuous band. (After Barnes.)

for the treatment of young patients. The advantage of a

smooth lingual surface, as emphasized by Lukens, has
prompted manufacturers to furnish seamless bands in such
a variety of sizes that an accurate fit is readily obtained in
most instances (Fig. 111).

Fig. Ill

Seamless ferrules, from which non-adjustable anchor bands can be constructed.

The use of lingual extension wires, as advocated by

Hawley,^ for the buccal movement of teeth mesial to the
first molars (Fig. 112), mairks another step in advance.

' Proc. Amer. Soc. Orthodontists.

 THE ALIGNMENT WIRE 159

Pullen has recently suggested a modification of this principle

by extending the screw-post (Fig. 113).

Fia. 112

Lingual extension wires. (After Hawley.)

Fig. 113

Showing continuation of the clamping bolt. (After Pullen.)

THE ALIGNMENT WIRE

According to Farrar, this element was used in the earliest

times, when it was made of wood or strips of bamboo.
Fauchard was probably the first to apply it in the shape of a
metal strip, as shown in Fig. 95. jNIany of the mechanisms
employed by Fox, Schange, Carabelli, Harris, Patrick,
Farrar, and others embodied this element, when it was
called the Jabial bow. In the design by Flagg (Fig. 97) it
is seen in its simplest form. Farrar and Patrick employed
it frequently, and developed many of its attachments.
160 PRINCIPAL ELEMENTS OF MODERN MECHANISMS

Fig. 114 shows the attachment of spurs for preventing the

slipping of ligatures, as advocated by Farrar.^ This detail
has recently been improved by Lourie, whose spur-cutting
pliers for this purpose are excellent (Fig. 115).
Angle's conclusive demonstrations regarding its wide
range of applicability mark an epoch of no small moment
in the treatment of malocclusion. Through we
his efforts
have learned that this simple wire establishes a line of

Fig. 114

Farrar's spur attachments to the alignment wire to prevent ligatures from

slipping.

alignment for the correction of arch form in advance of

tooth movement; that itserves as a working basis for most
of the individual tooth movements; that it may be utilized
both for expansion and contraction of the dental arch; that
it is the most efficient means, when properly manipulated,
for arch movement; and finally, in the first stages of reten-
tion, it serves as an excellent retaining device.
The plain form, with threaded ends and nuts, answers
every purpose in most cases, and Nos. 16 and 18 gauge
represent the sizes in general use. Occasionally, in patients
above ten years of age, the dental arch may be so contracted

' Irregularities, 1888.

 THE ALIGNMENT WIRE 161

that lateral expansion in the region of the canines can be

more readily accomplished by the use of a divided wire
(Fig. 116), a design advocated by Bethel and Pullen.

Fig. 115

Lourie spur-cutting pliers.

11
162 PRINCIPAL ELEMENTS OF MODERN MECHANISMS

An attachment of great value (Fig, 117) is that known as

a tube hook. The tube fits the wire accurately, and is attached

Fig. 116

Di\dded alignment wire. (After Bethel and Pullen.)

by means of solder in the region of the canines. This hook

engages elastic bands, the uses of which are fully described in
the chapters on Treatment.

Fig. 117

Intermaxillary tube hook. (After Angle.)

LIGATURES AND ELASTICS

The use of ligatures for tooth movement have been advo-

cated from time immemorial. In the works of Fauchard,
Bourdet, Jourdain, Linderer, etc., we find illustrations show-
ing the manner of their application. Silk and linen threads
were first emploj'ed for this purpose, as well as wires of
iron, gold, and silver.^ Angle, in connection with his appli-

• Pfaff, Lehrbuch.
 MISCELLANEOUS ACCESSORIES lt)3

ances of German silver, advocated the use of soft brass

wire, ranging in size from 25 to 30 gauge. On the other hand,

many operators now prefer the so-called silk grass line,
recommended by Hawley.^ This revival of the silk ligature
isprompted largely by the present use of the noble metals,
the rapid oxidation of which the brass wires promote; and
by the tendency toward earlier treatment, when the force
required is considerably less.

The use of elastic rubber bands was advocated by Fox

in 1814, who employed them in his practice. Lachaise,
Tucker, Kingsley, and others continued their use to the
present. While they are still largely employed for the
various movements of individual teeth, their greatest value
is in connection with arch movement. Case, Lourie, Baker,
and Angle have recently developed this important detail
of treatment, the importance of which can hardly be over-
estimated. (See Chapters XVI and XVII.)

MISCELLANEOUS ACCESSORIES

Among the countless mechanisms that have been designed

for the treatment of malocclusion, there have been very few,
indeed, which have achieved survival. As intimated in
Chapter VIII, only rarely are we obliged to use appliances
other than those which can be constructed out of the elements
enumerated above. And in these rare instances a very few
additional elements will suffice, such as the lever, the skull
cap for extramaxillary or occipital anchorage, the "Case
contom-ing apparatus" for the bodily movement of teeth,
etc. The use of these can best be described in the chapters

on Treatment.
' Proc. Ainer. Soc. Orthodontists,
 CHAPTER X
PRINCIPLES OF APPLICATION

In the application of every appliance we are forced to

comply with certain fundamental mechanical requirements.
The main points to be considered in this connection are:
(a) The teeth to be moved (or the points of attack), (6) the

forces employed (or the means by which movement is

affected), and (c) the utilizable resistances (or anchorage

of the means). Pullen'^ has defined anchorage as "the
resistance selected as a base from which force is to be
delivered for the movement of teeth." Korbitz^ has very
aptly stated that "The art and difficulty of orthodontic
technique does not consist in the production of the acting
forces, but of the advantageous utilization of the resistances
present." Continuing he says: "In the masticating appa-
ratus there is no fixed point from which we are able to act
upon the individual teeth. The production of a move-
ment always requires a point of anchorage; the forces
employed act with the same power upon this point of
anchorage as upon the point to be moved."

FORMS OF ANCHORAGE
The resistances utilized in the movement of teeth may
be classified as follows:

• Operative Dentistry, Johnson. ^ Kvjrsus der Orthodontic.

 .

FORMS OF ANCHORAGE 165

(a) As to method, into stationary and reciprocal.

(6) As to source, into intraviaxiUary, inter maxiUary, and

extramaxillary
Stationary Anchorage. —This term is a merely relative
one, since there is no absolutely fixed point in the dental

Fig. 118

Exemplifies stationary and reciprocal anchorage.

arches. It may be described as a rigid resistance at "the

point of departure," which may be due to the greater size
and more abundant osseous support of the tooth utilized,
to themanner of attachment of the appliance, or to the
direction of the force employed.
The appliance shown in Fig. 118 is intended to effect a
166 PRINCIPLES OF APPLICATION

mesial movement of the first bicuspid. This is accomphshed

by the use of a hgature attached to the ahgnment wire.
The latter is anchored to the molar by means of an anchor
band. If the nut on the wire is brought to bear upon the
mesial end of the tube, the molar exemplifies stationary
anchorage. Besides being larger, and offering greater resist-
ance than the first bicuspid, it has the additional support
of the second molar. The cuspid has not yet erupted,
and hence the resistance mesial to the first bicuspid will
yield. On the other hand, if the crown of the first bicuspid

were inclined distally, and the first molar were unsup-

ported by the second, the tendency for a distal movement
of the first molar might readily assert itself.

Reciprocal Anchorage. —A further study of the case reveals

a labioversion of the central incisors. The aim will be to
move these lingually, which can easily be accomplished if

the nut is released at the mesial end of the tube. By so

doing, the alignment wire will glide distally within the tube
upon the labial surfaces of the incisors at the
until it bears
points a The load imposed by the tension of the ligature
a.

from the bicuspid is now shared by the incisors, whose

combined resistance is less than that of the molars. Hence
we no longer have stationary anchorage; the incisors,
like the bicuspid, will yield under this stress. We term
this reciprocal anchorage, by which means the force is

utihzed at both "the point of attack" and "the point of

departure."
"In reciprocal anchorage the reciprocity of the resistance
points is never quite perfect. This is due to the diversity
of the resistances and to the variety of the deviations."
(Korbitz.)
If we release the nut prior to ligating the bicuspid, and
 FORMS OF ANCHORAGE 167

then subsequently tighten it, we can utiHze both forms

simultaneously. Indeed, this is the aim in most instances.

The use of stationary anchorage per se is very limited, and

rarely as satisfactory as the reciprocal form. Furthermore,
if the anchor teeth are not carefully guarded, they rarely
remain stationary.
Intramaxillary Anchorage. — Many of the required tooth

movements can readily be performed by the use of anchor

bands and the alignment wire in combination with ligatures.

Fig. 119

Reciprocal anchorage.

Previous to its insertion within the buccal tubes, it is bent

to that ideal form we wish ultimately to establish. The teeth
in each lateral half are then forced into normal alignment
by ligation, and by the alternate and simultaneous use of

stationary and reciprocal anchorage. Occasionally we seek

the necessary resistance on the opposite side of the dental
arch, as shown in Fig. 119. The two upper cuspids being
similarly malposed, we resort to the most direct method of

the jack-screw. This is a good example of reciprocal anchor-

age, resulting in the simultaneous movement of the cuspids.
168 PRINCIPLES OF APPLICATION

In all cases where the resistances selected are in the same

dental arch as the teeth to be moved the term intramaxillary
anchorage is applied.
Intermaxillary Anchorage. —There are many forms of mal-
occlusion which cannot be so readily disposed of, and for

which we are forced to seek anchorage in the opposing jaw.

Whenever we employ an anchorage thus located, we term

it intermaxillary anchorage. This is also used in both the
stationary and reciprocal forms.

Fig. 120

Direct intermaxillary anchorage. (After Angle.)

In the case shown in Fig. 120 we observe a lingual per-

version of the right upper cuspid. After removing the
superimposed gum tissue and providing an attachment to
the cuspid, we can force its eruption by means of a small
elastic-rubber ring anchored to the lower bicuspid and
cuspid. This constitutes the simplest and most direct form
of intermaxillary anchorage after the manner indicated by
Anglei in 1891.
Fig. 121 shows a similar case complicated by a mesio-
version of the right upper bicuspids and molars, and linguo-
version of the permanent canine due to prolonged retention

1 Dental Cosmos, September, 1891.

 FORMS OF ANCHORAGE 169

of its temporary predecessor. Hence the first step in the

treatment is a distal movement of loiciispids and molars.
This cannot be accomplished in the ordinary manner; the
resistance offered by the incisors to the mesial is not equal
to the task. Nor would an anchorage point on the opposite
side of the same dental arch be of any value. We therefore
search for the necessary resistance in the opposing arch, as
suggested by Lourie^ (Fig. 122). In this instance we secure

Fig. 121

Case requiring the use of intermaxillary anchorage for its correction.

stationary anchorage in the lower by ligating several of the

anterior teeth to the alignment arch and so adjusting the
nut that comes into contact with the mesial ends of the
it

buccal tube. In the upper arch the nut is adjusted so that

the alignment wire does not touch the labial and buccal
surfaces of the teeth mesial to the molars. Hence the

1 Amer. See. Orthodontists, 1902.

170 PRINCIPLES OF APPLICATION

combined resistances of the lower teeth, by means of the

elastic bands, is thrown against the upper molar, forcing it
distally. After sufficient distal movement of the molars has
been gained, the attachment is changed to the bicuspids and
these in turn moved distally.

Fig 122

^^/!!j;niiJ!Ji))j)i))i!im)jnTTT.

^/;w/mwwwwnwwwj777r.

Mechanism employed for intermaxillary anchorage.

Recent advances in the use of intermaxillary anchorage

have so enlarged its field of application that it has become
the most valuable of all. The wide range of its applicability
constitutes one of the most important steps in orthodontic
progress; without it, the correction of arch malrelation would
be extremely difficult, if not impossible. (See Chapters XVI
and XVII.)
Extramaxillary Anchorage. —Prior to the perfection of
intermaxillary anchorage, many of the pronounced forms of
malocclusion (such as mesioclusion and distoclusion) were
treated by means of occipital anchorage. This was obtained
by the wearing of a cap, or network with frame, adjusted
to the back of the head, to which the chin cap or cross-bar
was attached by means of heavy elastics (Figs. 123 and
124). This form constitutes the best type of stationary
anchorage, but unfortunately is under the patient's control.
It is extremely annoying and conspicuous, and is now
 FORMS OF ANCHORAGE
Fig. 123

Extramaxillarj anchorage ( '^fter Angle.)

'
Fig. 124

Extramaxillary anchorage. (After Angle.)

172 PRINCIPLES OF APPLICATION

rarely employed, owing to the recent advances in the use of

intermaxillary anchorage.
To the beginner, a discussion of the problems of anchor-
agemay seem as a mass of trivial reflections in reality, they
;

constitute some of the hardest lessons to be learned. A

mastery of these principles enables one to accomplish truly
remarkable results with the very simplest mechanisms.
Ignorance, on the other hand, yields consequences quite
unexpected. An exhaustive study of the principles of
anchorage, theoretical as well as practical, is therefore
advisable. "They must be transfused into our flesh and
blood, so that we may employ them automatically in our
practice; just as we use the multiplication table in calcu-
lation." (Korbitz.)
 CHAPTER XI
DETAILS OF APPLICATION

In preceding chapters many of the preHminaries for

treatment were described. The next step is a detailed
consideration of the plan of treatment, which should always
be carefully worked out beforehand and in accordance with
a definite routine. An operator must always be mindful
of the many necessary details, and then firmly resolve to
carry them out.

BANDS

The Anchor Band. —As intimated in Chapter X, a compli-

ance with fundamental mechanical principles is imperative;
hence the anchorage of the appliance should receive first

consideration. In view of the fact that this is provided

in most instances by the use of anchor bands, the details
of their application are important. A very limited experi-
ence readily emphasizes the fact that the first permanent
molars are preferable to any other teeth in the arch for
purposes of anchorage, owing to their large size and early
calcification. Only in rare instances, owing to the absence
of these teeth, are we compelled to utilize the second molars
or bicuspids.
After a decision has been reached as to the teeth to be
utilized, the selection of an anchor band should be made.
The author prefers an all-closing adjustable band, as shown
in Fig. 110. Prior to its insertion it is contoured to approxi-
174 DETAILS OF APPLICATION

mate the form of the tooth upon which it is to be placed.

It is frequently necessary to bend the screw-post on the
lingual side, so that it closely embraces the tooth to the
mesial. In case the second molars have erupted, and lateral
expansion in this region is indicated, it may be advisable
to place the band so that the bolt will point in a distal
direction (compare Fig. 118). The protrusion of the screw-
post into the oral space toward the tongue is never necessary
if care is exercised in the adjustment. The mesial portion
of the band should always be forced well up under the gum,

Fig. 125

Shows correct adaptation of anchor band to a molar. (After Angle.)

and the distal slightly burnished over the distal marginal

ridge to prevent displacement.^ The tubes being soldered
parallel with the borders of the band, this manner of adjust-
ment will effect a proper occlusogingival alignment of the
buccal tubes (Fig. 125).
In very young patients (owing to a superabundance of
gum tissue), and in cases of infra version of the molars, it is

best to use a seamless band. This is first adjusted without

a tube, which latter is soldered on subsequently.
All anchor bands should be of the proper size and accu-
rately adjusted, and they should invariably be set with

1 Angle, Malocclusion of the Teeth,

 BANDS 175

cement. Cementation is always deferred until the second

sitting, Avhen the anchor teeth are again thoroughly cleansed
with pumice and washed with alcohol, the saliva excluded
by means of cotton rolls, and dryness maintained.
The Plain Band. —The next step is to determine which
teeth will require plain bands, and the various attachments
for each band. The form of a tooth and its required move-
ments will usually settle this. For most patients the adap-
tation of the band metal is readily accomplished; but if

firmly established contact points interfere with the adapta-

tion, it is best to separate the teeth by means of a separator,
or by the insertion of tape, for twenty-four hours.

Fig. 126

Double end burnisher (Woodson No. 3).

After all the bands in one arch are thus prepared, they
are laid to one side, and the anchor bands of that arch are
adjusted. The patient is now dismissed, and during the
interim prior to a subsequent ^•isit the plain bands are
constructed and finished. Upon the patient's return each
band so constructed is placed upon the tooth for which it was
prepared. This can usually be effected with the fingers and
one or two gentle blows from a mallet on a band driver. A
more accurate fit can now be obtained by frequent burnishing
with the double end instrument shown in Fig. 126.
The bands are now remo\'ed without changing their form,
and placed upon the operating table. Their inner surfaces
are cleansed with alcohol, and the operating table prepared
176 DETAILS OF APPLICATION

for cementing them into place. The teeth to be banded are

again thoroughly cleaned with powdered pumice, and a
polishing point in the dental engine, after which they are
isolated with a napkin or cotton roll. After washing the
tooth with alcohol and drying with compressed air, the
inner surface of the band is lined with a coat of cement and
placed in position. The final adjustment is best accomplished
with a band driver and mallet and the burnisher. The
surplus cement is now removed and the exclusion of moisture
continued until the remaining cement has thoroughly
hardened.
In cases where there is considerable crowding, and where
two or more adjoining teeth all require bands, the double
thickness of metal in each interproximal space will occa-
sionally interfere with their ready insertion. A good plan
in such instances is to adjust the bands without cement,
and to dismiss the patient for twenty-four hours, after which
sufficient separation will have been gained.
All bands should fit accurately, and all attachments
should be well soldered and highly polished.

THE ALIGNMENT WIRE

Following the adjustment of the plain and anchor bands,

an alignment wire is adapted to complete the appliance.
The sizes in common use are of 16 and 18 gauge, and they
are furnished sufficiently long for all cases. They are
shaped to an ideal form by the manufacturer, and must,
therefore, be bent to conform to the requirements of a
given case and cut to exact length. This preliminary adap-
tation can partly be executed on the model, and partly by
trial insertions in the mouth.
 THE ALIGNMENT WIRE 111

During the adjustment of the anchor bands the subse-

quent insertion of the wire within the tubes must be kept

Fia. 127

Properly shaped alignment wire.

FiQ. 128

Improperly shaped alignment wire.

ill mind. In other words, the two buccal tubes on opposite

sides of the dental arch should occupy a common plane,
12
178 DETAILS OF APPLICATION

with the mesial ends of the tubes pointing shghtly toward

the gingival. Viewed in their buccal, or horizontal, aspects,
the threaded ends of the wire appear as in Fig. 127. The
careless adjustment of the buccal tubes and of the align-
ment wire will result in the improperly shaped appliance
shown in Fig. 128.^
Occasionally, it is permissible to bend the wire mesial to
the nuts (Fig. 129), or in the region of the cuspids (Fig.
130), to effect the proper alignment in the incisal area. In

Fig. 129

Bending the wire immediately mesial to the buccal tubes to gain correct
alignment.

Fig. 130

Bending the wire in the region of the cuspids.

cases where intermaxillary anchorage is employed, it is

best to avoid this, and to procure correct alignment by

resoldering the anchor tubes.
Viewed from an occlusal aspect, the free ends of the
alignment wire must again receive careful attention. A
proper relation to the dental arch can readily be secured by
bending with a pair of clasp pliers, and by repeated trials

of one end within a tube, as shown in Figs. 131 and 132.

By means of the pliers we can produce an expansion or con-

1 Korbitz, Kursus der Orthodontie.

 THE ALIGNMENT WIRE 179

traction of the wire, in whole or in part, depending on their

position and manner of appHcation.^ (Figs. 133 and 134.)

Fig. 131

Fig. 132

Shows the adaptation of the ends of the wire.

After a correct adaptation has been effected, the wire is

inserted in both tubes and allowed to remain in a merely

passive state, our first aim being to accustom the patient
to its presence within the mouth. In cases where it mast
encircle an extreme labioversion of one or more teeth it may
be necessary to give it a decidedly abnormal form, to avoid

1 Korbitz, Kursus dor Orthodontic.

180 DETAILS OF APPLICATION
Fig. 133

Producing an expanding action over its entire length.

Fig. 134

Restricting the expanding action; by reversing the beaks of the pliers a contracting
action can be obtained.
 LIGATURES AND ELASTICS 181

undue prominence. Only subsequently, after considerable

movement of the adjoining teeth, do we give it that ideal
form we wish to establish.

LIGATURES AND ELASTICS

Many movements of the teeth are accomplished by the

use of ligatures. As previously stated, the silk grass line
(which comes in three sizes, heavy, medium, and light)
is widely used for this purpose. Occasionally, owing to the
position and form of a tooth (particularly lower cuspids),
a wire ligature more effective. These are usually from 25
is

to 30 gauge thick, and made of soft, annealed brass.

All ligatures should be of generous length, to permit
of a firm grasp while applying them. Wire ligatures are
tightened by twisting, and silk ligatures by tying in a surgical
knot. The more important ways of using a ligature are
shown Owing to the absorption
in Fig. 102. of moisture,
the silk ligature continues in its tension for a considerable
period, often a week or more. The spring of the alignment
wire also aids in prolonging their action. Wire ligatures
can be tightened by additional twisting, thus obviating
their frequent renewal.
Elastic rubber bands are widely used in present-day
practice, particularly in intermaxillary anchorage. Occa-
sionally, they are of value in intramaxillary anchorage, e. g.,

in rotation of a bicuspid (Fig. 163). A liberal supply should

always be kept in stock, varying in size from an "election
ring" to those made from |-inch pure rubber tubing. The
former are used principally in the treatment of mesioclusion
and distoclusion, for reenforcement of anchorage, and for
reduction of extreme labioversion of the upper incisors. The
182 DETAILS OF APPLICATION

small sizes are employed for direct intermaxillary anchorage

for the correction of infraversion (Fig. 120). In the latter
method they are usually limited to the hours of sleep, while
in the former they can be worn constantly. The patient
should be taught the manner of their application, and
provided with a sufficient number for frequent renewal.
Owing to the fact that their action is constant, they require
careful supervision to prevent undue displacement of the

anchor teeth, as well as the teeth to be moved.

 CHAPTER XII
PRINCIPLES OF RETENTION

TISSUE CHANGES CAUSED BY TOOTH MOVEMENT

During tooth movement a number of very important
changes are produced in the tissues of attachment. All
authorities are agreed that the immediate result of the
application of force is a compression of the fibers of the
pericementum on the side toward which a tooth is moved,
and a stretching of those on the opposite side. In the first

stages following pressure a feeling of pain is frequently

induced, due to mechanical irritation of the nerves in this
membrane. This speedily ceases if the pressure is constant,
and is followed by hyperemia. Latei, an absorption of
the resisting alveolar plates is produced by osteoclasts,
or "bone-destroying" cells, which make their appearance.
The mechanism of this process of destruction is not yet
fully understood, though many theories have been advanced
as to the probable cause of the molecular dissolution of
the osseous support.
Some observers have maintained that in many instances
a bending of the alveolar plates (and even fracture) takes
place;and occasionally an opening of the maxillary suture
has been induced by rapid lateral expansion of the upper
arch for young patients.^
The manifold functions of the pericementum exercise an
exceedingly favorable influence during these serious stages

'See Proc. Amer. Soc. Orthodontists, 1911.

184 PRINCIPLES OF RETENTION

of destruction and the repair which follows. The deposition

of bone on the side from which a tooth is moved is controlled
by osteoblasts, or "bone-building" cells, but is far less rapid
than absorption and tooth movement.

DEFINITION

Owing to the fact, then, that the osseous support of the

teeth is more or less destroyed by the process of absorption,

and the subsequent formation of new bone considerably

prolonged, it leaves them suspended by their soft, peri-
cemental attachments in greatly enlarged sockets. The
length of this period' of inadequate maintenance varies in
different individuals, during which time the fibers of the
pericementum tend to force the teeth back to their former
abnormal positions. This necessitates the application of
mechanisms for the purpose of retaining the teeth in their
new positions until this tendency has subsided and socket
repair has been completed. Retention may, therefore, be
defined "as the maintenance of sufficient antagonism to the
forces tending to cause the return of a corrected malocclusion
to its original condition, to insure permanency of the normal
relationships of occlusion which have been established."
(Puhen.i)
Other factors besides that of age which may influence the
time required and the ultimate success of retention, are the
general and oral health of the individual, the kind and extent
of movement accomplished, the detection and removal of
causative factors, and the occlusal contact established.
Pathological conditions of the pericementum militate

1 Items of Interest, April, 1907.

 DEFINITION 185

against successful retention. Nasal obstruction, i)ernicious

habits,and other causative factors, when present, must
always be removed or corrected. And Walkhoff^ long ago
pointed out that "the placing of the teeth into normal
articulation (occlusion) is a fundamental postulate in the
treatment of malocclusion, insuring permanent results."
Or, as Angle^ puts it, "It cannot be too strongly insisted
upon that the permanency of the teeth in their new positions
cannot be hoped for, regardless of the length of time the
retaining devices have been worn, unless such occlusion
has been established as will enable the inclined planes of
the cusps to ultimately act in perfect harmony for mutual
support."
In designing a retaining appliance it is imperative that
we study the probable movement of each individual tooth
in its tendency toward its original position. This can
only be done by comparing the original models with the
ideal that has been established. In the words of Angle, the
underlying principle of design should be "to antagonize the
movement of the teeth only in the direction of their tendencies.
Very slight antagonism is required, hut its exercise must he
constant."
The time required for successful retention varies from
three weeks to three years, and in rare instances it is neces-
sary to resort to permanent retention. All uncemented
contact points of a retention appliance should be reduced
to the minimum, to prevent caries of the enamel, and all

bands securely cemented to the teeth to which they are

attached.

1 Die Unregelmassigkeiten in den Zahnstellungen, Leipzig, 1S91, p. 37.

2 Malocclusion of the Teeth, 1907, p. 263.
186 PRINCIPLES OF RETENTION

MAINTENANCE OF TOOTH POSITION

Innumerable mechanisms for retention have been sug-

gested, dating back to the ferrule, or plain band, used by
Disarabode in 1823. The appliances in use today are the
result of countless efforts, and they have passed through
many modifications. There can no longer be any doubt,
however, that plain bands and their many combinations,
as suggested by Farrar, Guilford, Case, Angle, and others,
constitute the best and most widely used designs.

Plain band with two spurs for maintaining a corrected torsoversion. (After Angle.)

Fig. 135 shows a band (F) upon an upper lateral which

has been rotated. After accurate adaptation the band is

removed and one or two spurs {G) are attached with solder,
as may be indicated. The spurs should be of sufficient
length to engage the adjoining teeth (though not too long)
after which the appliance is polished and set with cement.
In most cases of malocclusion the treatment involves the
movement of several adjoining teeth, hence the retainer
should be planned so as to include as many as possible,
thereby gaining simpHcity of design. Figs. 136, 137, and
138 illustrate designs by Angle in which this principle has
been carried out. They consist of plain bands united by
 MAINTENANCE OF ARCH FORM 187

connecting wires, the dotted lines indicating the preexisting

malocckisions.

Fig. 13G Fig. 137

Fig. 138

Showing advantageous combinations of the plain band with connecting wires.

(After Angle.)

MAINTENANCE OF ARCH FORM

The treatment of malocchision invariably implies the cor-

rection of arch form, and in all cases where this is extensive
the posterior teeth are necessarily involved. Not infrequently
this includes the buccal movement of bicuspids and molars,
whose subsequent lingual tendencies must therefore be
counteracted. In 1873 Farrar^ introduced vulcanite plates
for this purpose,which have been in use ever since (Fig. 139).
Such plates have passed through a variety of designs, and many
convenient attachments to them have been recommended.
But as Guilf ord^ says :
" Their use is open to certain objections.
All plates, used either for correction or retention, must be re-

moved at frequent intervals for cleansing. The very necessity

for their removal affords opportunity for the patient to

Irregularities, i, 366.
Orthodontia, 4th edition, p. 129.
188 PRINCIPLES OF RETENTION

remove them at other times, and possibly forget or wilfully

neglect to reinsert them for a longer or shorter period, thus

causing delay in the reparative process."

Fig. 139

Kf ;,

I'' '3

Vulcanite plate advocated for maintenance of arch form in the posterior teeth.

Fig. 140

Retention apparatus embracing the entire arch.

Owing to their unreliability, they have therefore been

largely discardedand replaced by non-removable appliances.
For maintaining the corrected arch form the lingual extension
wires advocated by Case, Watson, and Lourie have found
general favor. Fig. 140 shows the author's modification,
and consists of two molar bands and an 18- or 20-gauge
 MAINTENANCE OF ARCH RELATION 189

iridioplatinum wire constructed in three sections. Section

a accurately follows the arc described by the six anterior
teeth, and its ends are extended into the interproximal
spaces distal to the cuspids. Sections h and c connect this
with the anchor bands. The bands on the cuspids are
provided with spurs to prevent displacement of the wire,
but are not attached to it. These bands are cemented into
place prior to inserting the remaining apparatus. This
appliance permits of many modifications, which will be
referred to in the chapters on Treatment.

MAINTENANCE OF ARCH RELATION

The correction of arch malrelation (mesio-and distoclusion),
without resorting to the extraction of permanent teeth, prob-
ably dates back to Catalan's planum indinatum and Kingsley's
hite-plate for "jumping the bite." Recent advances in the

Fig. 141 .
Fig. 142

Antagonizing spur retainers. (After Angle.)

treatment of these deviations necessitated improvements in

the methods of retention. The principle of this inclined plane

in the form of antagonizing spurs (Figs. 141 and 142) has been
advocated by Angle for this purpose. This method imposes
a severe strain upon the anchor teeth, and frequently results
in their displacement. ]\Iany operators have sought to
avoid this, and now place chief reliance in a continuation of
190 PRINCIPLES OF RETENTION

the intermaxillary anchorage used in correction, though in a

weakened and modified form.^
Fig. 143 shows an appliance designed for this purpose in a
case of bilateral distoclusion. Each arch is provided with
an appliance for themaintenance of the corrected arch
form. On the upper, canine bands with delicate hooks of
20-gauge iridioplatinum wire are provided for the attach-
ment of light elastic rings. The latter are stretched to

hooks on the buccal surfaces of the lower molar bands, and

Fia. 143

Showing the continuation of the intermaxillary elastic for the maintenance of

a corrected distoclusion. (After Pullen.)

are worn at night. During the last stages of retention the

elastics are worn on alternate nights.

In mesioclusions the attachments are placed on the lower
cuspid and upper molar bands, and the stretching of the
elastics is reversed. In unilateral deviations the elastic is

worn only on the side originalh' abnormal. For further

designs and their modification the reader is referred to
the chapters on Treatment.

I
See Watson, Proc. Amer. Soc. Orthodontists, 1908; Rogers, Ibid., 1909 and 1910.
 PART II

THE METHODS OF TREATMENT

CHAPTER XIII
TREATMENT OF MALPOSITION OF THE TEETH
Technically, every treatment of malocclusion embraces
two or more of the following rudimentary principles: The
correction of (a) tooth position, (b) arch form, (c) arch
relation, and, conjointly, of jaw and face deformity. It has
already been pointed out that a tooth may occupy any one
of nine possible malpositions and their various combina-
tions, and we now approach the technical details of their
treatment.

LABIOVERSION AND BUCCOVERSION

The term labioversion is used to denote labially malposed

incisors and cuspids, and huccomrsion for buccal malpositions
of the bicuspids and molars. These two terms are here
grouped together because their treatment is similar, imply-
ing a lingual (or inward) mo\'ement in each instance. For-
merly, the use of special apparatus for the treatment of
these deviations was considered a necessity (Figs. 144 and
145); but it rarely happens that only one tooth is in mal-
192 TREATMENT OF MALPOSITION OF THE TEETH
occlusion. A careful study of occlusal relation usually leads
to the discovery of malposition in adjoining and opposing
teeth. Furthermore, the wide range of applicability of the
alignment wire and its accessories (by utilizing the various
forms of anchorage) has rendered it possible to carry out

Fig. 144

Discarded methods for the correction of labioversion.

most lingual movements without resorting to the use of

special mechanisms. In fact, it is our constant aim to avoid
special appliances, and to design new uses for those already

employed.
Happily, in most instances the teeth immediately mesial
and distal to a labioversion are in linguo version. The
 LABIOVERSION AND BUCCOVERSION 193

undue prominence of a labioversion may thus be advan-

tageous, permitting the vise of reciprocal anchorage. In
adjusting the ahgnment wire for a case as shown in Fig. 146,
it invariably fails to come in contact with the labial and

buccal eminences of the teeth adjoining the cuspid. The

labial mo\ements of the lateral incisor and first bicuspid are
accomplished by ligation to the wire, which is so adjusted
as to come in contact with the labial ridge of the cuspid.
By previously releasing the nut mesial to the buccal tube, it

will be permitted to rest passively, and glide "inwardly,"

within the tube. The upon the lateral and
force exerted
upon the cuspid, producing
bicuspid will be equally delivered
a lingual movement in the latter. In attempting a move-
ment of this kind, it should always be remembered that the
necessary mesiodistal spaces for each tooth must be within
the range of possibility. Considerable expansion of the
dental arch is, therefore, frequently indicated, and clearly
impossible if we employ a mechanism as shown in Fig. 144.
The extraction of the first bicuspid for the accommodation
of the cuspid, as shown in Fig. 145, is rarely if ever considered
justifiable.

Frequently, in crowded arches, the complete labial move-

ment of the incisor and buccal movement of the bicuspid
will not progress uniformly with the final adjustment of the
cuspid, in which e^'ent we resort to the use of the rubber
wedge (Fig. 147). The ligatures employed for the lateral
and bicuspid, and the nut in front of the buccal tube, will
provide stationary anchorage for the alignment wire, and
thus aftord the necessary resistance for the rubber. This is

a very effective method for accomplishing lingual movements

in cuspids, and through reciprocal action, labial movements
of the adjoining teeth. A further utilization of this principle
13
194 TREATMENT OF MALPOSITION OF THE TEETH
is shown in Fig. 148, for the correction of buccoversion of
a second bicuspid and hnguo version of a first bicuspid.
The use of intermaxillary anchorage for the reduction of
labioversion of the incisors in neutroclusion and distoclusion
is described in subsequent chapters.

Fig. 146 Fig. 147

Illustrates the use of reciprocal Intensifying the pressure by means of the

anchorage. rubber wedge.
Fig. 148

Advantageous utilization of reciprocal anchorage.

is comparatively rare, and can,

Buccoversion of the molars
in most instances, be corrected by utilizing the spring
temper of the alignment wire. By reversing the beaks of the
pliers shown in Figs. 133 and 134, a contraction of the arch

can be effected.
 LINGUOVERSION 195

LINGUOVERSION

This is a very common form of malposition, and the

methods for its correction are numerous. One of the most
powerful and satisfactory methods at our command is-

illustrated in Fig. 119. However, such instances are ex-

tremely rare; linguoversion is usually associated with labio-
version of the adjoining teeth. Hence the alignment wire,
by means of which we can accomplish all of the various

movements, is to be preferred.
As previously intimated, outward movements can readily
be accomplished simultaneously with lingual or inward move-
ments. The tension of a ligature employed for this purpose
may likewise be increased if used in combination with the
rubber wedge, as shown in Fig. 149. The reciprocal form

Fig. 149

Correction of linguoversion.

of anchorage should be employed whenever possible, for if it

is neglected at the outset the difficulties occasioned by the

adjoining labio- or bucco versions are increased. For example,
let us assume that we neglect such an opportunity in the
case shown in Fig. 150, and attempt to correct the linguo-
version of the lateral incisors by utilizing the stationary
anchorage of the molars. Now, a more detailed considera-
tion of the case reveals the labioversion of the central
incisors. But suppose we had completed the labial move-
196 TREATMENT OF MALPOSITION OF THE TEETH
ments of the laterals before realizing this fact; it at once
becomes clear that the reduction of the labioversion of the
centrals has become more difficult. Hence, if we are mind-
ful of our advantages in advance, we can, by releasing the

nuts mesial to the buccal tubes (thus allowing the alignment

wire to rest upon the labial surfaces of the centrals), utilize
reciprocal anchorage.
Fig. 150

Reciprocal anchorage for correction of linguoversion and labioversion.

The buccal movement of molars is readily accomplished

by utilizing the spring temper of the alignment wire (see
Figs. 133 and 134). Such movements may be required on
one side of either the upper or lower, or on both sides, and
in both upper and lower arches simultaneously. But in
either event the movement must be carefully guarded to
prevent undue speed. Should it proceed too rapidly, it
may be counteracted by reducing the expansion pressure
 LINGUOVERSION 197

of the wire by reversing the phers, and by resorting to direct

intermaxillary anchorage, as shown in Fig. 151.

To prevent undue tipping of the incisors during kibial
movements, it frequently becomes necessary to adapt the
ahgnment wire close to the gingival line, as shown in Fig.

153. In extreme cases a modification of the Case contouring

apparatus, as suggested by Korbitz,^ can be employed (Fig.
154). Again, unfavorable tipping may assert itself in rapid

Fig. 151 Fig. 152

Intermaxillary anchorage used as an Increased stretch of the rubber in corn-

auxiliary in case of unexpected displace- bination with alignment wires for the
ment of the anchor teeth. correction of linguoversion and buccover-
sion of molars. (After Reoch.)

buccal movements of the molars, and thus cause extremely

undesirable difficulties of occlusion. To avoid the use of
the direct intermaxillary anchorage already referred to
(which is annoying to the patient), and in anticipation of
such undesirable movements, we may employ the square
tubing on the molar bands, as suggested by Kemple.- Vari-
ous other forms of molar anchorage for this purpose have

' Kursus der Orthodontia. ^ Proc. Amer. Soc. Orthodontists, 1909.

198 TREATMENT OF MALPOSITION OF THE TEETH
been suggested by Barnes, Hawley, and Ottolengui.^ These
latter forms may all be advantageously employed for the

Fig. 153

High adjustment of the aUgnment wire to prevent tipping of the incisors

during labial movements.

Fig. 154

Korbitz's modification of Case's contouring apparatus.

bodily buccal movement of the molars, thereby inducing

desirable lateral development in the osseous structures,

whenever that is indicated.

DISTOVERSION

The correction of a distoversion implies a mesial move-

ment within the line of the arch. One of the simplest

' Proc. Amer, Soc. Orthodontists, 1909.

 DISTOVERSION 199

instances of this kind is shown in Fig. 155, ilhistrating the

method of correctingtwo upper centrals in distoversion as

a result of an abnormal frenum labium. The silk ligature,
owing to its prolonged tension in a moist environment, is
admirably adapted for this purpose. Occasionally, it may
be advantageous to construct a plain band for each incisor.

FiQ. 155

For mesial movement of the central incisors.

Fig. 156

For mesial movement of the central incisors. (After Lukens.)

with a labial spur (Fig. 156) for the attachment of a wire

ligature, which is applied in the form of a figure eight.
Such ligatures should be about one foot long, permitting a
firm grasp with the hands while twisting their knots. The
silk ligature already referred to may occasionally be carried
beyond the centrals and include the laterals and cuspids.
200 TREATMENT OF MALPOSITION OF THE TEETH
Small spaces between the six anterior teeth in either jaw
may readil}-^ be closed in this manner. The skilful use of

the silk ligature is an important detail of treatment, even

though it be difficult to master.
In all cases where the separation between the centrals is

very marked the use of a ligature is contraindicated. Its

hinge-like attachment favors tipping instead of bodily
movement. The latter can be accomplished by substituting
the screw bolt anchored to bands by means of tubes, as
shown in Fig. 157.

Fig. 157

For bodily mesial movement of the central incisors. (After Lukens.)

The mesial movement of bicuspids may also be affected

by ligatures in combination with notches on the arch (Fig.
118). After all mesial movements anterior to the molars
have been accomplished, during which the anchorage was
may be released and the
provided by these teeth, the nuts
molars moved mesially if indicated. This is usually best
accomplished by means of intermaxillary anchorage (Fig. 122
for lowers, and Fig. 230 for uppers).
 MESIOVERSION 201

MESIOVERSION

Though rarely met with in incisors, and only occasionally

in cuspids, it is frequently found affecting bicuspids and
molars. When it extends to the anchor teeth the difficulties

of treatment are considerably increased. A single anterior

tooth, such as a central or lateral, may usually be moved
distally by ligation to a wire provided with a spur in a
suitable location. Cuspids only slightl}' in mesioversion
(which are almost invariably associated with linguoversion
of the lateral incisors) are readily reduced by means of the
rubber wedge (Fig. 147). The rubber must, in such instances,
be applied toward the mesiolabial angle. In extreme mesio-
version of a cuspid the latter method would prove inade-
quate, hence we are occasionally compelled to employ the
traction screw (Figs. 158 and 159).

Fig. 158 Fig, 159

Angle's method for effecting a distal movement of the canine.

Not infrequentl}-, owing to a premature loss of deciduous

cuspids and first molars, the first bicuspids erupt mesial to
normal. In all cases where other treatment is in progress
during such a period, the author uses the method shown in
Fig. 160. The illustration shows an arm extended from the
alignment wire which is moved distally by means of a nut.
The arm is made from an ordinary tube hook and prevented
 —

202 TREATMENT OF MALPOSITION OF THE TEETH

from dropping occliisally, or being forced gingivally, by
flattening the alignment wire with a file along its lingual
surface and subsequently adapting the tube to it. This
appliance is also applicable in the correction of distoversion.
Mesioversion of a first permanent molar may, in rare
instances, be corrected by utilizing all of the anterior teeth
for anchorage, e. g., where the second deciduous molar was

Fig. 160

Author's method for correcting mesioversions and distoversions of bicuspids.

lost prematurely. The combined resistance of the anterior

teeth, after secure ligation to the alignment wire, may thus
be pitted against the first molar by turning distally the nut
in front of the tube. Finally, the distal movement of the

anchor teeth can be accomplished by use of intermaxillary

anchorage —
as in mesioclusion, and in cases of distoclusion
and in rare instances by means of extramaxillary anchorage.
These are described in subsequent chapters.
 CHAPTER XIV
TREATMENT OF MALPOSITION (Continued)

TORSOVERSION

This is a very common form of malposition, and its

treatment dates back to Delabarre^ (1815), who used a

and Linderer (1834) and Schange
lever for its correction,
(1841), who accomplished the same end with the ligature.
The lever was also employed by Linderer, and has recently
been revived, in a somewhat modified form, by Angle.^
Its use is, however, rarely indicated, because it possesses a
distinct disadvantage in that it causes an outward move-
ment, as well as rotary action.^ Furthermore, the mere
fact that we rarely have to deal with malposition of only one
tooth compels us to employ other mechanisms; hence the
alignment wire, with its limitless possibilities, again merits
our attention.
On the other hand, the principle of the le\'er is still worthy
of our consideration, especially in a restricted or localized
sense. It is well known that a corrected torsoversion is

hard to maintain in a normal and it is in such

relation,

instances that the modified lever plays an important role.

The retainer of a torsoversion frequently embodies a spur
of wire, which can be pressed into service should a tendency

1 Pfaff,Lehrbuch der Orthodontie.

2 Proc. Int. Med. Congress, Washington, 18S7.
3 See Korbitz, Kursus der Orthodontie.
204 TREATMENT OF MALPOSITION
toward a former malposition assert itself. Fig. 161 shows an
application of this principle during the retention period.
Korbitz^ has recently suggested a modification of it for the
treatment of a simple torso version, provided the necessary
space can be gained by the purely local action (Fig. 162).
He maintains that the rubber elastic shown in the illustration
exerts the necessary sideward, or separating, action. The
tube attachment of the lever provides a hinge-joint, which
permits the rotary movement.

Fig. 161 Fig. 162

For effecting slight rotary movements. Hinge appliance for rotation. (After
Korbitz.)

The roots of bicuspids present oblong forms on cross-

section, and offer considerable resistance to a rotary move-
ment. It occasionally becomes necessary, therefore, to
apply extreme measures to accomplish the desired results.

Fig. 163 shows a case of this kind from the collection of Dr.
Lukens, and exhibits the pushing action of a jack-screw
on the buccal side, and the pulling action of a rubber ring
on the lingual.

' See Korbitz, Kursus der Orthodontie.

 TOKSOVERSION 205

In rare instances, the molars will require rotation, and, if

confined to the anchor teeth, this can readily be accom-

plished with the ends of the alignment arch (Figs. 131 and
132). Should the second molar be in torsoversion, the
draught of an elastic ring can be called into service after
the manner suggested by Korbitz^ (Fig. 164).

Fig. 163

Forcible correction of torsoversion of a bicuspid. (After Lukens.)

The rotation of incisors, cuspids, and bicuspids can

generally be affected by means of the ligature, and we now
pass to the details of its application. Fig. 165 shows the

Kursus der Orthodontic.

206 TREATMENT OF MALPOSITION
application of a silk ligature for the correction of a simple
torsoversion in an upper central incisor, the ligature being
applied in the form of a loop. Fig. 166 shows the applica-

FiG. 164

Correction of torsoversion in the second molar. (After Korbitz.)

Fig. 165

The silk ligature applied for correction of torsoversion in an upper central.

Fig. 166

The silk ligature applied for reciprocal action in correcting lower centrals in
torsoversion. (After Korbitz.)

tion of a silk ligature to the lower central incisors. In all

cases where the lower centrals are of sufficient length and

of favorable form, this method will prove efficacious.
 TORSOVERSION 207

Both upper and lower cuspids, owing to their unfavorable

form, usually require the use of bands and spurs to prevent
the ligatures from slipping and from becoming disengaged.

Fig. 167

For torsoversion in upper cuspids.

Fig. 168

For torsoversion in bicuspids.

208 TREATMENT OF MALPOSITION
two ways of treatment for torsoversion
Fig. 167 illustrates
in upper cuspids, by means of a ligature in combination
with the rubber wedge. The wire ligature is preferable to
the silk ligature in the rotation of cuspids, and can be
rendered more certain and prolonged in its action when
combined with the rubber.
The rotation of a bicuspid is shown in Fig. 168. In A,
the rotation is accomplished by means of a ligature in com-
bination with the rubber wedge; in B, a buccal movement
is also indicated, hence the ligature only is used. The
rubber wedge is not only inapphcable in such a case, but
contraindicated in the first stages.

INFRAVERSION

As suggested by Korbitz,^ this form of malposition may

be either relative or absolute. A tooth is relatively too short
when its crown is fully exposed and alveolar development
has been arrested. A tooth is absolutely too short when
its crown is not fully exposed and alveolar development
apparently normal.
Fig. 169

For absolute infraversion in a central incisor.

The correction of infraversion is usually accomplished

with the alignment wire and stationary, reciprocal, or
intermaxillary anchorage. Fig. 169 shows a case of absolute
infraversion of an upper central which is being elongated by

1 Kursus der Ortbodontie.

 INFRAVERSION 209

means of the ligature fastened to the ahgnment wire. Tlie

adjoining teeth are securely ligatured to the wire, after
which the ligature to the malposed central is applied high
toward the neck, and then to the wire. The silk ligature
is preferable in such instances, and should invariably be
passed above the cervical ridge of enamel. In lateral incisors
and cuspids it frequently becomes necessary to adjust bands
with spurs to prevent the ligatures from slipping.
In cases of relative infraversion, as, for instance, in the
so-called "open bite," the spring temper of the alignment
wire is utilized. The wire is inserted in such a manner that

Fig. 170

For relative infraversion of the incisors.

it approaches the incisal edges of the teeth to be elongated,

and during the process of ligation is held well toward the
gingival line, antil the ligatures of all the teeth to be elon-
gated have been attached. Upon being released, its tendency
will be toward its original position, thus forcing the elonga-
tion of the teeth fastened to it (Fig. 170). It must not be
overlooked, however, that such action might also cause a
mesial tilting of the molars; hence a more secure form of
stationary anchorage is shown in
occasionally indicated, as
the illustration. An additional anchor band is provided for
the second bicuspid, and the buccal tube soldered to both.
Such precaution renders the anchorage more secure.
14
210 TREATMENT OF MALPOSITION
Intermaxillary anchorage may be used in either its

stationary or reciprocal form, depending upon the require-

ments of the case. If the teeth of one arch only are to be
elongated, the alignment wire in the opposing jaw is securely
attached to many teeth; and only to two or four in the arch
to be treated. On the other hand, in cases Adhere the teeth
of both arches are to be lengthened, we can advantageously
employ reciprocal intermaxillary anchorage (Fig, 171).

Fig. 171

miiiiiiiiiimiiiiinmmimiiiimiiiin'f^

^iiiwinmimnuiimiiwiimiirnip^l

Direct intermaxillary anchorage for infraversion.

The elongation of molars can also be effected by means of

intermaxillary anchorage, either by direct stationary, or
the reciprocal form. (Compare Figs. 173 and 200.)

SUPRA VERSION

Though supraversion is by many regarded as a common

form of malposition, other writers maintain that it is

extremely rare. The latter assert that supraversion is more

apparent than real; that, in most instances, we have to deal
with infraversion in more remote places in the arches. For
example, the cases shown in Figs. 37 and 38 are said to
exhibit only an apparent supraversion of the incisors; the
 SUPRAVERSION 211

real difficulty —so

some writers believe — is an infraversion
of the bicuspids and molars.^
The correction of supraversion is extremely difficult, and'
can only be executed to a very limited extent. Occasionally,
such action can be procured with the alignment wire and
ligatures, as shown in Fig. 172. The wire is inserted into

Fig. 172

Ligature applied for reduction of supraversion in upper centrals.

Fig. 173

^^nnzmznznzL

The reduction of supraversion in lower incisors intensified by means of inter-

maxillary elastics.

buccal tubes whose mesial ends point gingivally. It is thus

brought close to the gingival line, and the ligature, being

passed around the teeth toward their incisal edges, is tied

while the wire is pulled incisally. Its spring causes it to
return toward the gingival line, thus carrying the attached
teeth with it.

Lower incisors can be shortened in similar fashion; and

' Rogers, Items of Interest, January, 1911.

212 TREATMENT OF MALPOSITION
where the intermaxillary anchorage is employed simulta-
neously (which is frequently the case in distoclusion) the
action can be intensified (Fig. 173).
The opposite application of the intermaxillary, e. g., in
mesioclusion, can also be utilized, though mesioclusions
rarely present supraversion of the upper incisors. It is

important to remember that in the application of a ligature

for a shortening action, we must adjust it well toward the
incisal edge, i. e., above the neck; and that such action is not
obtainable in bicuspids. Owing to their unfavorable forms,
being cone-like, they invariably require the use of bands
with spurs, to prevent the slipping of ligatures.

PERVERSION AND TRANS VERSION

These two forms are, fortunately, extremely rare (par-

ticularly the latter), and our means for their correction even
more limited than in the case of supraversion. For trans-
version there are, practically, no methods at our command;
though theoretically, transplantation suggests itself. Per-
version, on the other hand, is so often combined with linguo-
or labioversion that it is frequently operable. Fig. 120
shows the most common form met with, and one of the

best methods yet devised for its correction.

 CHAPTER XV
TREATMENT OF NEUTROCLUSION
SIMPLE NEUTROCLUSION

As intimated in Chapter XIII, the treatment of a mal-

occlusion may embrace the correction of (a) tooth position,
(b) arch form, (c) arch relation, and, conjointly, jaw and
face deformity; and though each of these details is worthy
of separate consideration, it is obvious that the goal can best
be reached by the establishment of normal occlusion. This
implies that each case be considered in its entirety, that all

its various problems receive contemporaneous treatment.

Hence we pass to a consideration of the various types.
As elsewhere noted, most malocclusions develop slowly;
in their early stages all are comparatively simple. We shall

begin, therefore, with a few of the simpler forms.

Case A. —A robust girl, aged eight years (Figs. 174 and
175); the illustrations presenting side and occlusal views
before and after treatment. The history of the case is

entirely negative; the temporary teeth have never been

by caries, having received regular
affected dental attention.
The mother of the patient believes in exercising every
precaution, and has had the nose and throat examined by a
rhinologist, who found them normal. Infancy was unevent-
ful, being free from any of the serious infectious diseases
of that period of life. The family history is also negative,
both parents having normal dentures; hence the question
of cause remains obscure.
214 TREATMENT OF NEUTROCLUSION
Formerly it was common practice to postpone treatment
in such cases until after the eruption of bicuspids and
cuspids, for it was deemed impracticable, if not unwise, to

Fig. 174

Right and left views of denture before and after treatment. (Compare with
Fig. 175.)

move their temporary predecessors. A moment's com-

parison of the models readily establishes the conclusion that
it is good practice to administer treatment thus early. It
is, of course, true that the denture of this child will require
 SIMPLE NEUTROCLUSION 215

further observation, and probably treatment, depending on

the subsequent normal or abnormal eruption of the now
unerupted teeth. But it is obvious that the enlargement
of the dental arches has greatly increased the probability
of their normal eruption. And further, it must be equally
clear that the malocclusion already existing in the incisors
wdll never correct itself, no matter how long the treatment
is postponed.
216 TREATMENT OF NEUTROCLUSION
engage silk ligatures tied to the alignment wires. The move-
ment of the right upper central incisor was also effected with
a silk ligature, which was renewed at weekly intervals. The
entire treatment consumed less than four months.
Maintenance of the corrected condition is now being
provided by an appliance on the lower arch similar in design
to that shown in Fig. 140, though it is anchored to the
second temporary molars. Bands with spurs for the pre-

FiG. 176

Modification of appliance as advocated by Korbitz.

vention of anterior displacement were placed upon the

lateral incisors, instead of the canines as illustrated. In the
upper arch maintenance is largely providedby the occlusion
of the lower, and by a plain band with spurs upon the left
central after the manner indicated in Fig. 135,
An ingenious and very excellent modification of this plan
of treatment has recently been advocated by Korbitz'

1 Zeitschr. f. Zahnarztl. Orthopadie, September, 1910; Deutsch. Monatssch. f. Zahn-

heilk., November, 1910.
 SIMPLE NEUTROCLUSION 217

(Fig. 176). He uses the hinge-joint at (a), which is procured

by soldering an IS-gauge tube to the free end of the clamping
bolt, which thus removes all possibility of rotation of the
molars. He further advocates anchorage of the mesial end
218 TREATMENT OF NEUTROCLUSION
maintaining the newly established arch width. The buccal
movement of the temporary teeth is accomplished with an
elastic rubber band attached to a hook on the gingivolabial
border of the canine band, then passes over a tube hook on
the alignment wire, and on to the anchor band, all as shown
in the illustration. The form given to the alignment wire
controls the ultimate form of the dental arch.

Fig. 178

Occlusal views of case shown in Fig.- 177.

Case B.—An anemic girl, aged nine years (Figs. 177 and
178), who related a history which gave no clue as to the
probable cause. Indeed, such local arrests of development
as the denture of this child exhibits are difficult to account
for. The linguoversion of the incisors could hardly be the
result of premature loss of the temporary cuspids; the mouth
presented an unusually healthy condition in every other
respect, being immune to caries. Though the canines have
 SIMPLE NEUTROCLUSION 219

been exfoliated, it would be interesting to learn the cause

of their early loss, which might then serve as causa prima.
The plan of treatment was, in many respects, similar to
that outlined for Case A, though the incisors were differently
malposed and necessitated a slight change in the details.
It isevident that both arches required expansion, and that
all incisors be moved labially. The upper incisors are also
in distoversion, with wide spaces between them.

Fig. 179

Maintenance appliances used for the case shown in Figs. 177 and 178.

The appliance consisted of four molar anchor bands with

extension wires, two IS-gauge alignment wires, and four plain
bands with spurs for the lateral incisors. The expansion of
220 TREATMENT OF NEUTROCLUSION

each arch is very noticeable in the after treatment models,

and resulted in gaining the necessary spaces for the cuspids.
Maintenance of the corrected condition was provided by
the appliance shown in Fig. 179. The bands upon the lateral

Fig. 180

Side views of case, aged eleven years, before and after treatment.

incisors are thesame as those used for movement; and the

anchor bands upon the molars are reduced in parts by
removal of the buccal tubes and clamping bolts, after which
 SIMPLE NEUTROCLUSION 221

the free lapping ends are united with solder to form a con-
tinuous band of exact size.

Case C. —A boy, aged eleven years (Figs. 180 and 181),

who has suffered much from dental caries, and to whom
mastication has for years been both difficult and painful.
His mother related an operation for hypertrophy of the
tonsils performed during his ninth year. Thus it is very

Fig. 181

Occlusal views of case shown in Fig. ISO.

probable that the arrest of development in the upper arch

is a result of the ailments just enumerated.
The treatment was again similar in plan to that described
for Cases A and B, though the lower canines were also

involved. Hence they are included in the treatment by

providing them with, spurred bands as already described.
]\Iost of the temporary teeth remaining are so badly decayed
that their immediate removal is indicated. By means of
222 TREATMENT OF NEUTROCLUSION

the anchor bands, 16-gauge alignment wires and ligatures,

with all of which the reader is now somewhat familiar,

expansion of both arches was achieved as shown in the

models.
Fig. 182

Facial relations before and after treatment of case shown in Figs. 180 and 181.

Maintenance was provided for the upper arch by an

appliance as shown in Fig. 179, and for the lower by"one like
Fig. 140.
 SIMPLE NEUTROCLUSION 223

Fig. 182 shows the facial relations before and after treat-
ment.
Case D. —A boy, aged nine years (Figs. 183 and 184),
slightly below the average in height. Inquiry into his

Fig. 183

Side views before and after treatment of case, aged nine years. Note the
lingual relation of the entire right upper lateral half.

history revealed the fact that his persistent mouth breathing

and noticeable facial deformity had led his mother to con-
sult a rhinologist, who removed an adenoid and enlarged
224 TREATMENT OF NEUTROCLUSION
tonsils about six months previously. His father, whom he
resembles in facial expression, hair, and eye color, has a
malocclusion of the same type, which is comparatively rare.
The arches are in normal mesiodistal relation, though the
entire right upper lateral half is lingual to the lower. The
lower arch is of ideal form, and was not involved in the

Fig. 184

Front and occlusal views of case shown in Fig. 183.

treatment. But the upper arch presents a feature that is

interesting in its anchorage requirements. Only one lateral
half requires a buccal movement, though the expanding
action of the alignment wire acts with equal pressure (as
ordinarily applied) upon both sides. Let us briefly consider
its various methods of application, and of this controlled
action in particular. Fig. 185 is diagrammatic of the action
 SIMPLE NEUTROCLUSION 225

of the alignment wire in the various ways in which it is

ordinarily appHed. In a the dotted hnes indicate its expan-

sive power toward the buccal in each lateral half, when
introduced with that intent. Under such circumstances it
also tends to glide distally within the tubes, resulting in a
lingual movement of the incisors, as shown by the arrows,
unless such action is prevented by contact of the nuts against

FiQ. 185

Shows the action of the alignment wire in its various applications.

the mesial ends of the buccal tubes. If applied for con-

traction of the arch, as in b, its tendency in the incisal area

will be in a labial direction, as indicated in the drawing.

In c the distribution of the load on the molars imposed by

the tension on the bicuspids is shown.
The case under discussion requires that the bilateral
buccal action of the alignment wire as shown in a, Fig. 185,
15
226 TREATMENT OF NEUTROCLUSION
be rendered unilateral. This can readily be accomplished
if the anchorage of the wire in the tube on the normal side
is changed to complete stationary form. By soldering a
buccal tube to the left anchor band, as shown in Fig. 186,
and by providing it with a lingual extension wire as already
described, the resistance was so increased as to effectually
overcome the expanding action of the wire on the normal
side. Its effect, therefore, was to move the right molar
buccally, w^hich occurred within a month's time. The
expansion action of the wire was now slightly reduced by
bending with the pliers, and after re-insertion the second
temporary molar was attached. The buccal movement of
this tooth, and of its neighbors to the mesial, was accom-
plished by means of ligatures.

FiQ. 186

Maintenance was easily provided by an appliance con-

sisting oftwo molar anchor bands with lingual connecting
wire, as shown in Fig. 179, though its anterior section was
held in place by spurred bands upon the centrals. These
bands were also united with solder at their mesial contact
points, thus combining their resistance and providing
maintenance for the corrected infraversion of the right
central.

COMPLEX NEUTROCLUSION

Cases belonging to this group differ from the foregoing

only in their minor symptoms, being identical in the funda-
 COMPLEX NEUTROCLUSION 227

mental characteristic, viz., the normal mesiodistal relation

of the lower arch to the upper. They are usually older,
however, consequently more teeth are involved, and their
228 TREATMENT OF NEUTROCLUSION
Case "E.— Neutroclusion complicated by pronounced linguo-
version of the upper incisors and infraversion of the upper
cuspids. A strong, healthy girl, aged thirteen years (Figs. 187
and 188), whose non-resonant voice and marred facial

expression before treatment (Fig. 189) were symptomatic of

arrest of development of the intermaxillary bone and nasal
passages, was requested to consult a rhinologist. The exami-
 COMPLEX NEUTROCLUSION 229

and lower cuspids; and two 16-gauge alignment wires.

incisors
The molar bands were of a design as shown in Fig. 113.

Fig. 189

Facial relations before and after treatment of case shown in Figs. 187 and 188.

The adjustment of the entire appliance consumed six short

semiweekly visits, after which tension was applied. The

alignment wires were given a slight expansive spring; the
230 TREATMENT OF NEUTROCLUSION

extension wires were fastened to the alignment wire after

the manner indicated in Fig. 112, and hgatures appHed to
the lower incisors and two upper centrals. After a period
of three weeks considerable movement had been gained,
which in a measure liberated the interlocked upper laterals.
Ligatures were now applied to these teeth, as well as to the
lower cuspids. After another period of four weeks sufficient
movement had been accomplished to permit of a more
favorable adjustment of the upper alignment wire. By
careful bending after the manner indicated in Fig. 130, it

was possible to carry it sufficiently to the gingival line, so

that it embraced the seemingly prominent canines. Its
length was so adjusted that it rested firmly upon their labial

eminences, thus relieving the strain upon the upper molars,

and aiding materially in reducing the developing supra-
version of the upper laterals, which was now asserting itself.

It may be worthy of mention to state that the second upper

temporary molars were extracted during the patient's
second visit, which resulted in the immediate eruption of

their successors.
Maintenance has been sustained by an appliance for the

upper arch, as shown in Fig. 179 (upper diagram), and for

the lower as shown in Fig. 140. The improved facial lines
resulting from the treatment are shown in Fig. 189.
Case F. — Neutroclusion complicated by extreme lahioversion
of the upper incisors. A boy, aged nine years (Figs. 190 and
191), addicted to the habit of sucking his lower lip. Several
acute attacks of rhinitis a year previous had led the mother
to consult a rhinologist, who failed to detect any lymphoid
hyperplasia in the nasopharynx. And though the deformity
is typical of an adenoid child, we are thus forced to conclude
that the habit already alluded to is the sole cause of the
 COMPLEX NEUTROCLUSION 231

malocclusion. The facial deformity in this instance was

very marked, presenting an enlarged lower lip.

Treatment was executed by the use of appliances identical

with those employed for the previous cases, with addition

Fig. 190

Side views of Case F, before and after treatment.

of two tube hooks on the upper alignment wire. These

were soldered at points opposite the interproximal spaces
between laterals and cuspids. Rubber elastics were anchored
232 TREATMENT OF NEUTROCLUSION
after the manner indicated in Fig. 122, after which the
nuts on the upper ahgnment wire were released. This action
resulted in a lingual movement of the upper incisors. In
the meantime the lower arch was liberally expanded over its

entire length, and the upper temporary cuspids and molars

moved buccally.
Fig. 191

Occlusal views of case shown in Fig. 190.

Post-treatment maintenance is being effectually supplied

by an appliance similar to that shown in Fig. 127, which
provides for a continuation of the intermaxillary elastics.
There being no permanent cuspids to anchor to in the upper
arch, the hooks were in the nature of an extended arm from
the two central bands (Fig. 214).
Case G. — Neutroclusion complicated by labioversion of
2, I
1, 2, and perversion of 1 \ . A girl, aged twelve years
 COMPLEX NEUTROCLUSION 233

(Figs. 192 and 193), whose "prominent" upper incisors and

consequent facial deformity led her parents to a consultation.
They also felt certain that the delayed eruption of the right
upper central was abnormal. A hard mass could plainly
be felt at this point, Fig. 192, which gave assurance to
the belief that the tooth was impacted. The father then

Fig. 192

Side and front views of Case G, before and after treatment.

related the following history: He had a similar "space"

on his left upper side, and during his seventeenth year two
teeth erupted simultaneously, one considerably lingual to
normal. Upon examination, his left central was found
in labioversion, and he stated that the "extra tooth" was
234 TREATMENT OF NEUTROCLUSION

extracted shortly after its appearance. The mother presented

a normal denture. Models of the father's teeth were now
constructed, and a radiograph ajdvised for the daughter,
with the result shown in Fig. 12. This clearly revealed the
presence of a supernumerary tooth, though on the opposite
side to that of the father. After the construction of his
models he was asked to locate, as nearly as possible, the
 COMPLEX NEUTROCLUSION 235

with tha,t provided for Case F, except that it included the

extraction of all remaining temporary teeth, which the age
of the patient justified. After several weeks of treatment
the impacted tooth made its appearance. This was treated
by means of a plain band and ligature as soon as it had
erupted sufficiently, and thus brought in normal alignment.

Fig. 19i

Retaining appliance which was modified for use in Case G.

Maintenance was effectually provided by the appliances

shown in Fig. 194, omitting the band upon the central
incisor. The right central was maintained in its corrected
position by means of a w4re ligature tied around the lingual
connecting wire. The hooks upon the upper canine and lower
molar bands, for use with elastic rubbers, were also dis-
236 TREATMENT OF NEUTROCLUSION

pensed with. The facial deformity and its correction are

shown in Fig. 195.

Fig. 195

A
 COMPLEX NEUTROCLUSION 237

hypertrophy of the tonsils, for which treatment by a

rhinologist was requested. Their removal having been
executed, the malocclusion was corrected by simultaneous
expansion of both arches.

Fig. 196

Neutroclusion complicated by supra-linguoversion of the incisors, before

and after treatment, Case H.

The appliances for treatment consisted of four anchor

bands and two 16-gauge alignment wires applied as in Fig.
112 for the upper, and Fig. 167 for the lower. The right
lower first and second bicuspids were provided with plain
bands and spurs for their rotation, as in Fig. 168. The
lower canines were similarly banded. The upper incisors
238 TREATMENT OF NEUTROCLUSION

were carried labially by means of silk ligatures without

banding.
In the lower arch the four incisors were first attached.
After considerable labial movement the cuspids were
included, with rotary action. Subsequently the bicuspids
were ligated to the wire. The anchor bands had been so
adjusted that their clamping bolts embraced the second

Fig. 197
 COMPLEX NEUTROCLUSION 239

the lower as illustrated in Fig. 140, with a hook attached

to the buccal surface of the left lower molar band for the

Fig. 198

Facial relations before and after treatment in Case H.

intermaxillary elastic, and the union of the two bands on the

right lower bicuspids. These bands were united with solder
at their points of contact, and then reset with cement.
240 TREATMENT OF NEUTROCLUSION

In the upper arch an appliance like Fig. 194 (upper diagram)

was applied, with the exception that the spur on the right

Fig. 199

Front views of the models of Case H, before and after treatment.

upper cuspid band was dispensed with. Similarly, the

incisor band shown in the drawing was prepared for the
right central, instead of the left.
 COMPLEX NEUTROCLUSION 241

The vast improvement in his facial expression and general

well-being is clearly shown in the photographs in Fig. 198.
The correction of the occlusal plane, which had been totally
destroyed in the anterior region of the arches by the marked
"overbite," is shown in Fig. 199. This was only partly
affected by the manner of application of the ligatures to the
upper incisors (see Fig. 172); and by the action of the align-
ment wire on the lower (see Fig. 173). The most effective
aid for the removal of such deviations is shown in Fig. 200,
which promotes an elongation of the posterior teeth.

Fig. 200

m\w.v\\\\\\^\^i-o.vw'avav,m'j^
Q;

v=
Intermaxillary anchorage modified to effect elongation of the molars.

Case I. — Neutroclusion complicated hy extreme infraversion

of the incisors, cuspids, and first bicuspids. A girl, aged
sixteen years (Figs. 201 and 202), who was referred by a
rhihologist after having been operated on for adenoids.
It is extremely doubtful, however, whether they had any
causal relation to the malocclusion. The arches are too
symmetrical to indicate nasal involvement. Examination
revealed an unusually large tongue, and the patient admitted
being addicted to the habit of nursing same.
Aside from the elongation required for all the teeth
involved, the arches need slight alteration in form by widen-
16
242 TREATMENT OF NEUTROCLUSION

ing in the region of the cuspids, and a rotation of the lower

centrals, which are in torso version. The infra version is,

moreover, too extensive to warrant an attempt at correction

Fig. 201

Side views before and after treatment of Case I.

by using only the spring of the alignment wire. Such an

attempt would surely result in displacement of the molar
teeth (see Fig. 170). Hence the use of direct intermaxillary
anchorage (Fig. 171) was resorted to. The incisors and
 COMPLEX NEUTROCLUSION 243

canines were provided with bands spurred as in Fig. 203.

These afforded secure adjustment for the ahgnment wires,
and were carefully prepared and set with cement, so that
they were all on the same plane. The intermaxillary elastics
were worn constantly during the hours of sleep and during
as many of the waking hours as was compatible with the
patient's necessary comforts.

Fig. 202
244 TREATMENT OF NEUTROCLUSION

Maintenance has now been effectually provided by appli-

ances of a design as shown in Fig. 140. Small hooks, con-

structed of 20-gauge wire, were soldered to the labiogingival
borders of the canine bands, to which light elastics were
applied at night, and subsequently on alternate nights. In

Fig. 203

Shows band used for anchorage of the aUgnment wires in treating Case I.

addition, the central incisors were provided with plain bands

with spurs on their lingual surfaces, so placed as to overlap
the lingual connecting wire. These bands were also united

with solder before cementing into position, thus adding

strength to the upper, and retaining the lower corrected
torso versions.
 CHAPTER XVI
TREATMENT OF DISTOCLUSION
BILATERAL DISTOCLUSION

The distinguishing characteristic of this type of deformity

is a bilateral distal relation of the lower arch when the teeth
are brought into occlusion. This may be due (a) to disto-

version of the lower teeth, (b) to arrest of development of

the mandible, or (c) to a posterior development of the glenoid
fossse, resulting in a posterior position of the lower jaw.^ The
various minor peculiarities which usually complicate cases
belonging to this class are practically identical with those
of complex neutroclusion.

Bilateral Distoclusion. Complicated by Extreme Labioversion of

the Upper Incisors

CaseJ. —
A delicate and timid boy, aged eight years (Figs.
204 and 205) who had adenoids removed during his fifth year
,

by a rhinologist. He has, from infancy, been troubled with

rhinitis and mouth breathing which the above-mentioned

operation and continued nasal treatment failed to cure. He

had recently been placed under the care of another rhinolo-
gist, who immediately recognized the extreme dentofacial
deformity and the utter futility of nasal treatment unassisted
by orthodontic treatment. The facial deformity and arrest
of development of the mandible at this time are clearly

' Federspiel, Proc. Amer. Soc. Orthodontists, 1911.

246 TREATMENT OF DISTOCLUSION

shown in Fig. 84. The narrowing of the upper arch (which is

symptomatic of such an abnormal nasal condition) is shown

in the upper occlusal view of Fig. 205 (left upper corner).

Fia. 204

Side views before and after treatment of Case J.

The plan of treatment adopted in this case was after the

method suggested by Angle, for which an appliance com-
posed of the following elements was used: Four molar
anchor bands with buccal tubes and lingual extension wires,
as previously described, were anchored to the first permanent
 BILATERAL DISTOCLUSION 247

molars; two 16-gauge alignment wires with tube hooks for

the upper; four plain bands with spurs on the distogingival
borders of their lingual surfaces for the upper incisors. The
lower incisors were tied to the alignment wire with silk

ligatures. The lingual extension wires were similarly fastened

to the alignment wire for the expansion of the lower arch.

Fig. 205

Occlusal views of Case J.

This apparatus furnished the source of anchorage for inter-

maxillary elastics attached to the tube hooks on the upper
wire (see Fig. 122).
In the early stages of treatment only the lingual wires
were tied to the upper alignment wire, to promote buccal
movement of the upper temporary teeth. The nuts mesial
to the buccal tubes were so adjusted that the alignment wire
248 TREATMENT OF DISTOCLUSION

on the upper arch failed in contact with the labial surfaces

of the incisors. Hence the pressure of the intermaxillary
elastics was upon the upper first permanent
entirely exerted
molars, resulting in their full distal movement. This being
accomplished, the nuts were released and the alignment
wire allowed to rest upon the incisors, which resulted in a
reduction of their labioversion. Finally, ligatures were

Fig. 206

Facial relations of Case J after four months of treatment. (Compare with Fig. 84.)

passed from the lingual spurs on their bands to the align-

ment wire Such ligation in the
to effect their rotation.
earlier stages must always be dispensed with, to avoid
undue elongation.
The treatment up to the time of maintenance occupied
a period of four months. The occlusion of the teeth at this
time shown in the illustrations already referred to, and the
is

vast improvement in facial balance is set forth in Fig. 206.

 BILATERAL DISTOCLUSION 249

It may be of interest to note that mouth breathing ceased

entirely during the second month of orthodontic treatment.
Maintenance is being successfully accomplished by an
appliance similar to that shown in Fig, 179, though the
following minor alterations were necessitated by the disto-
clusion. The lower molar bands were provided with small
hooks constructed of 20-gauge iridioplatinum wire attached
to their mesiobuccal angles, close to the gingival margin.
The two bands upon the upper lateral incisors were connected
with a labial wire of the same gauge, which was bent into
hook form at each end, immediately distal to the canine
embrasure. During the first month of retention, delicate
elastics were worn continuously. Subsequently their use
was limited to the, hours of sleep, and in the last half of
the first year to the sleeping hours on alternate nights
only.
The entire appliance was now removed and the teeth
thoroughly cleansed, after which it was reset. The latter
precaution was for a twofold purpose; partly to maintain
the form of the arches, but more especially to exert a con-
trolling influence on the erupting bicuspids. In this stage
of retention the lingual wire is of inestimable value. The
growth in the mandible during the last year has been very
marked.
Case K. —A strong boy, aged twelve years (Figs. 207 and
208), whose history does not relate nasal treatment. Nor
did an examination by a rhinologist reveal any pathological
nasal condition, though he is a confirmed mouth breather.
It will be noted, too, that the occlusal views of the pre-
treatment models (Fig. 208) exhibit rather symmetrical
arches with very little arrest of development. The facial

deformity is not nearly as severe as in Case J. There can be

250 TREATMENT OF DlSTOCLUSlON

no doubt that this deformity was easily recognizable during

his sixth year, possibly earlier, though on this point his
parents are not certain. Such malocclusions are frequently

Fig. 207

Side views before and after treatment of Case K.

attributed to nasal obstruction, and explained on the

hypothesis that adenoid vegetations were undoubtedly a
contributing cause during childhood, and that their resorp-
tion (which is known to occasionally take place) has removed
 BILATERAL DlSTOCLUSION 251

every trace of them. But that is purely an hypothesis and

difficult of conclusive demonstration.
Furthermore, this boy provides the following interesting
family history: His father is dark haired, of English descent,
presents an extreme bilateral distoclusion of a type under
consideration, and a very decided dolichocephalic head
form. In short, his is a typical adenoid face. His mother.

Fig. 208

Occlusal views of Case K.

on the other hand (whom he strongly resembles in com-

plexion, hair and eye color, as well as in tooth form), is of
Celtic extraction, of the reddish blonde type, with freckled
with prominent malar bones, brachycephalic head form,
skin,
and prognathous denture (though normal in occlusion).
Hence the temptation to blame heredity for the deformity,
to speak of it as an inherited disharmonism. But this would
 .

252 TREATMENT OF DISTOCLUSION

again be purely an hypothesis and equally difhcult of veri-

fication.

Treatment was similar to that described for Case J,

though the lingual extension wires were dispensed with in

the upper arch. The molar anchor bands were adjusted
with their clamping bolts pointing distally. After the
normal mesiodistal relations between the molars had been
established by means of the intermaxillary elastics, the
upper molar bands were removed and bands placed upon
the second bicuspids. The first bicuspids were attached
to these with wire ligatures. After their distal movement,
the nuts were released and pressure brought to bear upon
the upper incisors. In the meantime the lower arch was
gradually enlarged for the accommodation of the left

canine.
An interesting feature of the case was a porcelain crown
upon the left upper central incisor, but which did not become
the seat of any discomfort. There being no torsoversion
present in any of the upper incisors, plain bands were
contraindicated
The retention appliance was identical in design to that
described for. Case J. The bands shown in the after treat-
ment models of the illustrations were substituted for same
at the close of the period of retention.
Case L. —A youth aged nineteen years (Figs. 209 and 210),
showing complete distoclusion as a result of postponement of
treatment. Note the extreme narrow upper arch, and the
pronounced labio version of the upper incisors. This case
is a fine exhibition of the axiom set forth in the chapter on
Prognosis, that nature and time rarely exert a corrective
influence on a malocclusion.
The improvements in the occlusion of the teeth shown in
 BILATERAL DISTOCLUSION 253

the illustrations were accomplished in the short period of

four months. The case is one of the first the author ever
attempted to treat, and as he now reflects over his seeming
achievement, he is quite convinced that a radical change
in the temporomandibular articulation, viz., the mounting

Fig. 209

Side views before and after treatment of Case L.

of the condyles on the eminentia articularis, was largely

responsible for the results.
The treatment was identical to the plan already described,
though retention was provided with vulcanite plates with
labial wires. The effect upon the facial lines is shown in
254 TREATMENT OF DISTOCLUSION
Fig. 210

Occlusal views of Case L.

Fig. 211

r'

Profile of Case L, before and after treatment.

 BILATERAL DISTOCLUSION 255

Fig. 211. The corrected condition was readily maintained

for two years, during which time the patient was under the
author's care. Since then he has lost all trace of him, and
he regrets that the ultimate results are not now available.

Fio. 212

Side views of Case M.

Such extreme deformities form interesting studies from

various points of view. First, they recall the inclined plane
of Catalan and Kingsley for "jumping the bite;" second,
they emphasize the many recent criticisms directed against
256 TREATMENT OF DISTOCLUSION

that plan of treatment; third, they forcibly impress one with

the necessity for early treatment, since they offer convincing
proof that neglect frequently results in jaw deformity, after
which the accompanying malocclusions are but symptoms.
(See Chapter XVIII.)

Bilateral Distoclusion Complicated by Linguoversion of the

Upper Incisors

Case M. —A girl, aged ten years (Figs. 212 and 213), with
negative history. The facial deformity was marked, and
of a type as illustrated in Fig. 83. The prognosis of cases

Fig. 213

Occlusal views of Case M. (The lower models should be transposed.)

belonging to this group has previously been emphasized,

the tendency being toward an arrest of development in the
mandible (see Fig. 89). Postponement of treatment would
unquestionably result in an aggravation of the deformity.
 BILATERAL DISTOCLUSION 257

Treatment was instituted by means of anchor bands,

alignment wires, plain bands for the upper incisors, and
intermaxillary elastics. The details of application are in
many respects similar to those described for the former
group, though thereis need for less widening of the arches.

Furthermore, the upper centrals require a labial movement,

which can easily be accomplished by reciprocal anchorage
in combination with the lingual movement of the adjoining
laterals (see Fig. 147).
Fia. 214

Retaining device for the upper arch of Case M, providing for a continuance
of the intermaxillary elastics. (After Rogers.)

As pointed out by Angle, the loss of occlusion of the

anterior teeth permits their elevation, so that the treatment
should aim at a reduction of their supra version. But in

view of the fact that such action is extremely diflficult to

obtain, and a growth of the mandible especially desirable,
the plan illustrated in Fig. 200 (resulting in an elongation
of the molars) has been widely accepted.
Such continued action of the intermaxillary elastics is

now provided for in the retaining appliance (Fig. 214). The

17
258 TREATMENT OF DISTOCLUSION

bands upon the centrals are united and attached to the

lingual wire, which extends to the molar bands, thus pro-
viding for maintenance of arch form. In addition, an
inclined plane of metal is provided, and so adjusted that the

Fig. 215

Side views, before and after treatment, of Case N.

"bite" will remain open to the desired height (section a-a).

On the labial surfaces of the incisor bands extended hooks
are provided for the fastening of the elastics, which are also
attached to hooks on the upper and lower molar bands. In
 BILATERAL DISTOCLUSION 259

the lower arch the appliance usually follows the design

illustrated in Figs. 140 and 179, depending on whether the
canines have, or have not, erupted.
Case N. —A girl, aged thirteen years, the daughter of a
physician, with negative history (Figs. 215 and 216). The
etiology in such cases is still obscure they are in
; all probabil-
ity due to intrinsic factors which we have failed to recog-

FiG. 216

Occlusal views, before and after treatment, of Case N.

nize. The normal nasal and lip function accompanying

this type naturally implies facial deformities less severe
than in the group complicated by labioversion of the upper
incisors and nasal obstruction. A well-developed mental
eminence in this case especially precluded the possibility
of severe facial deformity (Fig. 217).

The details of treatment were practically the same ag

260 TREATMENT OF DISTOCLUSION

for the former case, except that the laterals were carried
labially with the centrals, and the rubber wedge for reciprocal
action applied to the canines. The bicuspids were carried

Fia. 217

Facial relations, before and after treatment, of Case N.

slightly buccally, and distal movement of the upper and

mesial movement of the lower molars affected by inter-
maxillary elastics.
 BILATERAL DISTOCLUSION 261

For maintenance after tooth movement, an appliance as

shown in Fig. 140 was apphed to the lower arch, with the
addition of hooks to the buccal surfaces of the molar bands.
In the upper arch a plain band upon each lateral was con-
nected with a wire on the labial extending distally beyond

Fio, 218

Side views, before and after treatment, of Case O.

the labial eminences of the canines and ending in a hook,

for the reception of intermaxillary elastics anchored to the
lower molars. These were worn during the sleeping hours for
a period of six months, then on alternate nights only for the
remainder of a year, after which all appliances were removed.
262 TREATMENT OF DISTOCLUSION

Case O. —A boy, aged fourteen years (Figs. 218 and 219),

who presents an extreme deformity. An unusual feature of
the case is the arrest of development of the arches, with
linguo version of the upper molars and bicuspids. This
rarely is so severe in cases with linguo version of the incisors.
 BILATERAL DISTOCLUSION 263

version. The various details were carried out as follows:

Molar anchor bands were fitted to the lower first molars
and bands adapted to the lower canines, with spurs on the
distogingival borders of their lingual surfaces. The clamp-
ing bolts on the anchor bands were allowed to point distally,
thus embracing the second molars (Fig. 167). After all the
lower teeth were tied to the lower alignment wire, and
expansion of the lower arch thus prepared for, the upper
molar anchor bands with buccal tubes were similarly placed.
An alignment wire with tube hooks opposite the upper
canines was now inserted as high, gingivally, as the canines
would permit, though not encircling them, and the nuts
so adjusted that it failed to rest upon the incisors. The
application of intermaxillary elastics from lower molar
tubes to upper hooks (first one for each side, then two),
caused a distal movement of the upper molars. The expand-
ing action of the alignment wire produced their buccal
movement, the clamping bolts carrying the second molars.
This occupied a period of two months. The upper molar
bands were now removed, and similar bands placed upon
the upper second bicuspids, with their clamping bolts
pointing mesially to embrace the first bicuspids. The latter
were tied to the anchor bands by means of wire ligatures,
gauge 26. The upper alignment wire was reinserted and its

adjustment so controlled that it encircled the canines and

rested firmly on their labial eminences. The incisors were
now attached with silk ligatures as in Fig. 165, and the
action of the intermaxillary elastics resumed until the rela-
tions shown in the after-treatment models were established.
The lower arch was provided with an appliance as in
Fig. 140,though the clamping bolts on the molar bands were
retained. Hooks were also soldered to the buccal surfaces
264 TREATMENT OF DISTOCLVSION
after the buccal tubes were detached, as previously described.
In the upper arch an appliance similar to that in Fig. 179
(upper diagram) was adjusted. The anchor bands origin-
ally used on the upper first molars were employed, and their
clamping bolts pointing in a distal direction allowed to
remain. The two upon the laterals were con-
plain bands
nected wdth a labial wire bent into hook form at each end,
and of sufficient length to embrace the canines. The main-
tenance of the corrected arch form was thus provided for,
as well as the arch relation by continued use of the inter-
maxillary elastics.
Fig. 220

Modification of intermaxillary force for correction of labio-infraversion compli-

cating distoclusion.

Bilateral Distoclusion, Complicated by Labio-infraversion of

the Upper Incisors

This type of malocclusion is exceedingly rare. Fig. 41, B,

shows the right view of a case from the author's practice,
being a girl, aged nine years. The central incisors began
erupting during the seventh year, but the pernicious habit
of tongue-sucking prevented them from assuming a normal
length. The patient was also affiicted with hypertrophy
of the tonsils and inferior turbinates. In the treatment,
 UNILATERAL DISTOCLUSION 265

the ligation of the incisors is not only immediately desir-

able (which was contraindicated in the cases previously
described), but should even be intensified by the appli-
cation of the elastics as in Fig. 220.

Fig. 221

Side views, before and after treatment, of Case P.

UNILATERAL DISTOCLUSION

As its name implies, cases belonging to this group

present a distal relation of the lower on one side only,
266 TREATMENT OF DISTOCLUSION

the other side being as in neutroclusion. The compli-

cations are similar to those affecting the bilateral types.

Unilateral Distoclusion, Complicated by Labioversion of the

Upper Incisors

Case P. —A boy, aged twelve years (Figs. 221 and 222),

who had an operation for adenoids performed during his
tenth year, and who is still under treatment for chronic
rhinitis. The distal closure of the lower is readily seen in

Fig. 222

Occlusal views, before and after treatment, of Case P.

the right view of the pre-treatment models, as are also

the other minor complications with which the reader has
become familiar through a consideration of the bilateral
type. These are enumerated by Angle as follows:
briefly

Narrowing of the upper arch, elongation of the upper

 UNILATERAL DISTOCLUSION 267

incisors, abnormal nasal and lip function, and distortion

of the facial lines, (Compare with Figs. 204 and 205).

Fia. 223

Facial relations, before and after treatment, of Case P.

The first requirement of the treatment which naturally

suggests itself is the mesiodistal shifting of the right lower
and upper first molars, by means of reciprocal intermaxillary
268 TREATMENT OF DlSTOCLUSlON

anchorage. Following this should come the widening of

the arches, especially in the bicuspid region, as well as
a correction of their mesiodistal relation on the affected

Fig. 224

^^HHHHBnRv-vrTKc^n..^... —
_;.;....
 UNILATERAL DISTOCLUSION 269

intermaxillary force during the sleeping hours was provided

only for the right, or previously abnormal side. Fig. 223
shows the marked improvement in the facial relation.

Unilateral Distoclusion, Complicated by Linguo-supraversion of

the Upper Incisors

Case Q. — A young miss, aged sixteen years (Figs. 224 and

225), with negative history, presenting normal nasal and
lip function, and hut slight distortion of the facial lines.
270 TREATMENT OF DISTOCLUSION

Fig. 226

Modified application of intermaxillary anchorage for median line deviations.

(After Reoch.)

Fig. 227

Modification for simpler devi9,tioq3. (After Angle.)

 UNILATERAL DISTOCLUSION 271

left side was effected. The left upper canine, having pre-
viously been provided with a plain band with a spur upon
its lingual surface, at its mesiogingival angle, was likewise
moved into normal position in the arch.
The corrected torsoversion in the upper central incisors
was maintained with two plain bands united by solder at
their mesial contact points. The band upon the left upper
canine was replaced after a hook had been attached to the
distogingival angle of its labial surface. The left lower
molar band was provided with a similar hook on its buccal
surface after the buccal tube was detached, and an elastic
was then applied to them nightly. This was continued for
some eight months, after which they were removed, with
the occlusion improved to a normal relation.
In extreme cases of unilateral distoclusion pronounced
deviations of the median line frequently exist. To over-
come such marked deviations, particularly in older patients,
the application of an elastic on the normal side, as in Fig.
226, may at times be indicated. In less severe cases, but
which do not yield after continued application of the elastic
on the normal side, and in cases of neutroclusion and
unilateral mesioclusion which may present such deviations,
the application of an elastic as in Fig. 227 is indicated.
 CHAPTER XVII
TREATMENT OF MESIOCLUSION

BILATERAL MESIOCLUSION

It will be recalled that the cases comprising this group

are characterized by a bilateral mesial relation of the lower

arch. This may be due to (a) mesio version of the lower

teeth, (h) to a forward position of the mandible and its

articular fossae, or (c) to an overdevelopment of the bone,

either in its body or ascending rami, or both. And though
very little is definitely known regarding their etiology beyond
the factor proposed by Case (see page 71), all observers
agree that deformities of this type begin at an early age.
Not infrequently arrest of development of the maxilla, as
well as various versions of a number of the teeth, are found
as complications. Extreme conditions in patients of ad-

vanced years are more properly classified as presenting

mandibular deformities, the alleviation of which lies beyond
the scope of orthodontics (see Chapter XVIII).
The accompanying facial deformities are often pro-
nounced, and naturally the reverse of those aggravating
distoclusions. Some of the milder forms resemble those of
neutroclusions complicated by linguoversion of the upper
incisors (compare Figs. 182 and 236).
Case R. —A girl, aged ten years (Figs. 228 and 229),
afflicted with hypertrophy of the tonsils, gave a history of
 BILATERAL MESIOCLVSION 273

chronic "sore throat." She was referred to a rhinologist

for removal of the enlarged tonsils and such treatment of

the nose and throat as to him seemed necessary. The

improvement of the voice and breathing which followed

Fig. 228

Side views of Case R.

was marked. Attention is also directed to the premature

loss of the lower first permanent molars, which occurred
during her sixth year. These were affected by extensive
caries and consequent pulp exposure, but their extraction

was a serious blunder, and not only failed to correct the

18
274 TREATMENT OF MESIOCLUSION

deformity, but undoubtedly aggravated it by compelling

mastication with the anterior teeth.
 —

BILATERAL MESIOCLUSION 275

bands and alignment wire after the manner already described.

In the lower a decided modijQcation was necessitated by the
absence of the permanent first molars. Hence the canines
were provided with plain bands with lingual seam, which
were then united by a labial wire soldered to their gingival
margins and terminating in a well-formed hook at each end.
The latter offered anchorage for the intermaxillary elastics

Fig. 231

'^.^M
Facial relations of Case R, before and after treatment.

stretched from the buccal tubes of the upper molar bands.

The author's first aim was to induce development of the
upper arch and to restore occlusion of the anterior teeth
to bring them under the control of normal influences. Semi-
weekly visits extending over a month's time readily accom-
plished this, with a change in the profile as shown in Fig. 231.

This result was so gratifying that the author felt confident

the complete control of the deformity was now assured.
276 TREATMENT OF MESIOCLUSION

Hence the upper appliance was removed and a retainer

after the design shown in Fig. 179 (upper diagram) sub-
stituted. The molar bands were provided with buccal hooks
pointing in a distal direction, thus offering attachment for
continued use of the elastics.

Fig. 232

Side views of Case S, showing the progress attained during three and one-half
months.

The case was now dismissed, with the request for monthly
visits. At the close of the first year the post-treatment
 BILATERAL MESIOCLUSION 277

models shown in the half-tones were constructed, and further

treatment is now in progress. The eruption of the second
molars has taken place, as will be noted, and treatment
of the remaining versions rendered less difficult.

Fig. 233

Occlusal views of Case S.

Case S. —A girl, aged ten years (Figs. 232 and 233), who

had hypertrophied tonsils removed during her sixth year.

Orthodontic treatment was postponed for one year with the
hope that the left upper first permanent molar would make
its appearance. But not until the tenth year did this
occur (see left view in right upper corner of Fig. 232).
Treatment was begun February, 1911, and the left upper
temporary molar used for anchorage, this tooth being still
very firm. The second models shown in the illustrations

were made in May (current year) just prior to the patient's

departure for an extended trip.
278 TREATMENT OF MESIOCLUSWN

A gratifying change in the progress of the first molar is

noticeable; in fact, the eruption has so far progressed that

the temporary retaining device was anchored to it. The
eruption of the upper canines and first premolars was pro-

FiG. 234

Side views, before and after treatment, of Case T.

moted by the extraction of their temporary predecessors

immediately after the first models were made.
The maintenance provided is similar to that for Case R,
though the upper left lateral band has a spur of 20-gauge
 BILATERAL MEStOCLVSION 279

wire attached to its labial surface which extends over the

erupting canine. The labial wire on the lower arch is

attached to bands upon the lateral incisors, and extends

distally to embrace the erupting canines. The use of inter-
maxillary elastics has been advised during the entire vaca-
tion period to promote growth, as well as maintenance, of the
established relations. A resumption of treatment for a short
m ^R^A'TMEN'T OF MJESIOCLU'SWK

Maintenance was provided by an appliance as shown

in Fig. 194, omitting the band upon the upper central
incisor and reversing the attachment of the hooks for

Fig. 236

Facial relations, before and after treatment, of Case T.

reversal of the intermaxillary elastics. In other words,

the lower canines and upper molar bands were utilized
for anchorage of the rubbers.
 UNILATERAL MESIOCLUSION 281

UNILATERAL MESIOCLUSION

As its name implies, this type of malocclusion presents

mesial closure of the lower arch on one side only, the relation

Fio. 237

Side views, before and after treatment, of Case U.

being neutral upon the other. Its possible combination

with a unilateral distoclusion — mesiodistoclusion — consti-
tutes what Angle has designated as Class IV.
282 TREATMENT OF MESIOCLUSION

Unilateral mesioclusions are extremely rare, and their

accompanying complications are usually less pronounced
than in the bilateral types. The etiology is even more
obscure, though the treatment is decidedly easier, and
rarely, if ever, beyond orthodontic technique.
 UNILATERAL MESIOCLUSION 283

tion between successive generations," and though we know

infinitely more about it than formerly, we have not yet
succeeded in "measuring and weighing" such resemblances.
Treatment consisted in the application of molar anchor
bands and alignment wires for the development of each
arch and for the application of an elastic on the left side
as in Fig. 230. The upper incisors and lower canines were

Fig. 239

Profile of Case U after treatment. (Compare with Fig. 67.)

provided with plane spurred bands for the more secure

attachment of their ligatures and to effect rotation, as well

as labialmovement, of the incisors.

Maintenance was procured by an appliance like that
shown in Fig. 140 for the lower, and Fig. 179 (upper diagram)
for the upper. The improvement in the facial balance can
readily be noted by comparing Fig. 239 with Fig. 67,
 CHAPTER XVIII
TREATMENT OF MALFORMATIONS OF THE JAWS

Though the achievements of orthodontics are truly

wonderful, it is well that we recognize its limitations.
Indeed, its methods are now conceded to be inadequate for
the treatment of those extreme deformities which involve
the jaws, and to which the reader's attention has already
been called. Fortunately, the skill of the oral surgeon
frequently offers much hope to those afflicted with these
very distressing disfigurements.
In view of the fact that malocclusion of the teeth invari-
ably accompanies such deformities and frequently stands in
causal relation to them (thus demanding the cooperation
of the orthodontist), it seems eminently appropriate to
close the volume with a brief review of recent advances in
this field. But the remedial measures about to be described
are entirely of a surgical nature, which precludes a detailed
discussion of their technique. Moreover, the author con-
fidently believes that no definite set of rules can be laid
down for guidance; such decision must rest entirely with the
surgeon. However, it is of the utmost importance that
the operator carefully consider the degree of deformity, the
anesthetic, the most suitable operation for a given case,
the best method for postoperative immobilization of the
parts, etc. In the latter phase, the orthodontist can
frequently render invaluable service.
 :

TREATMENT OF MALFORMATIONS OF THE JAWS 285

Oral deformities requiring surgical interference were

partly enumerated in Chapter V as follows:
1. Macrognathism, overdevelopment of a jaw.
2. Micrognathism, arrested development of a jaw.
These may be more specifically designated according to
their location by the addition of such prefixes as man-
dibular, maxillary, and bimaxillary, and by combinations
of them. To this list (as was then intimated) must be
added all those deformities with which the oral surgeon
has to deal. The latter include:
3. Malposition of the mandible.
4. Curvature of the mandible.
5. Congenital deformities, such as clefts of the palate,
agnathism, polygnathism, etc.

6. Deformities due to abnormal extraneous influences,

such as blows, burns, fractures, etc.

7. Deformities resulting from disease —fibroma, ankylosis,

etc.

The most pertinent of these are mandibular macrogna-

thism, micrognathism, curvature, and malposition.
The historical development of the surgical measures
proposed for the alleviation of these deformities was briefly
set forth by Babcock^ in a paper read before the ninth
annual meeting of the American Society of Orthodontists
held in Cleveland, October, 1909, from which the following
is a quotation
"As to the history of what has been done in these opera-
tions on the jaw, a brief summary may be permitted. It
is, indeed, surprising how few operations have been done.
Starting in 1S4S, Dr. S. P. Hullihen,^ of Wheeling, W. Ya.,

' Items of Interest, June, 1910.

2 Amer. Jour. Dental Science, 1849, p. 157.
286 TREATMENT OF MALFORMATIONS OF THE JAWS

did the pioneer operation for an elongated jaw, with prog-

nathism. We name him with a great deal of pride.
should
He had to do with a patient who had been under the care
of some of the best surgeons in New York, only to meet with
failure and rather an increase of the deformity. Anesthesia

was not generally available, the germ theory and antiseptics

were not understood, hemostatic forceps had not been
invented, and much in the way of surgical technique was
yet to be evolved, but this man had the hardihood to go
ahead and do a series of very extensive operations upon
this girl's jaw and neck, which resulted in a remarkable
improvement, if not a complete restoration. The case was
that of a girl, aged twenty years, who fifteen years before
had been so badly burned over the neck that the jaw was
pulled down upon the chest, and there had been produced
an elongation of the mandible, a protrusion of the lower
incisors, and marked e version of the lower lip.
"With a small saw V-shaped sections were resected from
each side of the jaw, the section upon the left side including
the bicuspids. The V-shaped sections extended two-thirds
of the way through the bone, the apices being below (Fig.
240). From the apices the saw was turned horizontally
forward, completing the section, and leaving the upper
two-thirds of the anterior portion of the mandible attached
With the removal of the
to the soft tissues of the lip only.
two V-shaped sections of bone the mobilized portion of the
jaw could be pushed back into place, securing an occlusion
of the incisors (Fig. 241). From an impression taken in soft
wax a silver plate was then struck up, which, when applied,
held the section of the jaw in proper position. Union rapidly
occurred, and Dr. Hullihen then boldly proceeded to correct
the defect in the neck. A large flap of skin from the shoulder
TREATMENT OF MALFORMATIONS OF THE JAWS 287

and arm was transplanted to the neck, enabling the head to

be raised, and finally by two further operations the everted
and deformed lower lip was made sightly and useful. All
of these operations are said to have been successful.

Fig. 210

Diagram showing type of deformity in HuIIihen'a case, the dotted lines indicating
the lines of bone section and the triangular segments of bone to be removed. (After
Babcock.)

Fig. 241

Diagram of Hullihen's case, showing his method of correction. (After Babcock.)

"Nearly fifty years elapsed before bilateral resection of

the mandible was again suggested. In 1896 Dr. R. Otto-
lengui/ in discussing the subject, suggested the feasibility
of such a procedure, and the following year Dr. James W.

» Dental Cosmos, 1897, p. 143.

288 TREATMENT OF MALFORMATIONS OF THE JAWS

Whipple/ of St. Louisj referred to Dr. Edward H. Angle

a patient, a young man, with a progressive type of prog-
nathism. After studying this patient. Dr. Angle advised
a bilateral resection of the elongated portions of the jaw,
between the first molar and second bicuspid on the right side,

and the first and second bicuspid on the left side, the sections

Fig. 242

Profiles of patient before and after double resection of the mandible. (After Ballin.)

removed differing from those removed by Hullihen, inas-

much as the removed segments passed through the entire
depth of the body of the jaw. This operation was not
performed by Dr. Angle, and the patient finally came under
the care of a surgeon. Dr. V. P. Blair, who resected a quadri-

1 Dental Cosmos, 189S, p. 552.

TREATMENT OF MALFORMATIONS OF THE JAWS 2S9

lateral sectionfrom each side of the jaw, brought the teetli

into occlusion, wired them in place, and then found great

Fia. 213

Dental models before and after operation; the lines a and b indicate section
removed. (After Ballin )
19
290 TREATMENT OF MALFORMATIONS OF THE JAWS

difficulty in holding all the fragments of the jaw in occlusion.

However, after nine quite troublesome weeks from suppura-
tion and some necrosis, bony union and a very creditable

Fig. 244

Typical deformity, with dotted lines indicating the various possible sections.
Section made from b to d. (After Babcock.)

result were obtained.^ The publication of this operation

led to a few similar operations, which in some cases were

I Dental Cosmos, August, 1906.

TREATMENT OF MALFORMATIONS OF THE JAWS 291

followed by necrosis, one patient in New Orleans losing

the mandible from this cause. Although this operation is

Fig. 245

Shows possible correction after sections a-6 or a-e. (After Babcock.)

performed through incisions from below the jaw, the two

compound fractures into the mouth which are produced
are so objectionable that a preliminary extraction of teeth,
292 TREATMENT OF MALFORMATIONS OF THE JAWS

to be followed later by submucous resection of the bone,

has been advised."^
The operation has also been performed by von Bergmann,
Ballin^ (see Figs. 242 and 243), Babcock, Cathcart, and
others. The difficulties encountered by these pioneers has
led to improvements in method. Figs. 244, 245, and 246
show a skull exhibiting a typical deformity, with dotted
lines and cuts drawn upon the ramus to indicate several

Fig. 246

Correction according to section d-c. (After Babcock.)

possibleways for resection, all of which are far enough

removed from the body of the bone to exclude any possible
involvement of the teeth. From these it can readily be
seen that a correction of the deformities above referred to
are quite within the range of surgery, and that they offer
the only feasible plan for a cure.
Dr. Blair^ reports an original method of transplantation

1 See Blair, Dental Era, April, 1907.

2 Proc. Amer. Soc. Orthodontists, seventh annual report.
3 Jour. Amer. Med. Assoc, July 17, 1909, pp. 178 to 183,
TREATMENT OF MALFORMATIONS OF THE JAWS 293

FiQ. 247

Profile of Dr. Blair's patient prior to operation.

Fig. 248

Profile of Dr. Blah's patient after double

resection and transplantation of

costal cartilage.
294 TREATMENT OF MALFORMATIONS OF THE JAWS

of the curved part of the eighth costal cartilage, with its

perichondrium, to the mental eminence of a chin in a patient
suffering from mandibular micrognathism. This was for
improvement of the facial lines, which a bilateral transverse
section of the rami had previously failed to entirely correct.
The vast improvement of the profile is clearly shown in
Figs. 247 and 248.
For a further elucidation of the subject the reader is
referred to the original monographs enumerated above.
 INDEX

Appliances, Patrick's, 148

Schange's, 146
Abnormal frenum labium, 58, 61 Arch form, correction of, 191
Accidents causing malocclusion, 74 maintenance of, 187
Acquired malocclusions. See Eti- Artificial nursing as a cause of
ology. malocclusion, 77
Adenoids, 69 Asymmetry of the jaws, 63
Age best for treatment, 138
Alignment, definition of, 81
variations of, 105
wire, 147, 159, 160, 161, 176, 224,
Bands, anchor, 156
225
application of,173
Aluminum bronze for appliances,
attachments to, 157
153
introduction of, 156
Alveolar process, changes in, 183
kinds of, 156
Alveolitis as a cause of malocclu-
uses of, 156
sion, 75
plain, 154
Anchorage, definition of, 164
application of, 175
extramaxillary, 170
introduction of, 154, 155
intermaxillary, 168
uses of, 154
intramaxillary, 167
retaining, 186
reciprocal, 166
Beauty of form, definition of, 121
stationary, 165
Buccoversion, definition of, 92
Angle's appliances, 149
treatment of, 191
classification of malocclusion, 88
system, 149
Anomalies of eruption, 84
of form, 58
of the jaws, 84 Caries, prevention of, 36
of number, 56 treatment of, 38
of position, 63 Case contouring appliance, 163
of structure, 84
' modification of, 197
of the tongue, 65 Cells of construction and destruc-
Appliances, 152 tion, 183
Angle's, 149 Cephalic index, 99
Case's, 163 Civilization as a cause of malocclu-
Farrar's, 148 sion, 78
Fauchard's, 146 Cleansing of the teeth, 36
Flagg's, 147 Cleft palate as a cause of malocclu-
metals used for, 152 sion, 61
296 INDEX
G
Deciduous teeth, premature loss German silver for appliances, 153
66
of, texts. See Literature.
prolonged retention of, 67 Gilmer plain band, 155
Dental index, 99 Gnathic index, 99
Dentition, anomalies of, 84 Gold for appliances, 152, 153
Diagnosis, definition of, 83
methods of, 83
nomenclature of, 83
rules governing, 96 Habits causing malocclusion, 71
Diseases causing malocclusion, 65 Health as a factor in treatment,
Disharmonisms, causes of, 78 131
Distoclusion, definition of, 89 Hereditary transmission, 53, 282
post-treatment maintenance of, Hyperplastic formation of connec-
189 tive tissue, 77
treatment of, 245
Distoversion, definition of, 92
post-treatment maintenance of,
186 Impressions for models, 47
treatment of, 198 Infraversion, definition of, 92
Disuse of teeth, 77 treatment of, 208
Intermaxillary anchorage, 168
E Intramaxillary anchorage, 167
Iridioplatinum for appliances, 152
Early treatment, reasons for, 130,
137
Elastic rubber bands, 163, 181
Etiology of malocclusion, 52 Jackscrew for reciprocal anchor-
definition of, 52 age, 167
extrinsic factors, 66 for torsoyersion, 205
intrinsic factors, 55 Jaws, asymmetry of, 63
unknown factors, 77 deformities of, 87
Examination of mouth, 32 prevention of, 85
Extraction of teeth, 40 treatment of malformations of,
evils of, 41 284
rules governing, 41

Kingsley's inclined plane, 255

Facial angle, 99 Oral Deformities, 21
deformities, 97 Knapp's system, 149
diagnosis, 126
harmony, 119, 122
models, 48
photographs, 49 Labioversion, definition of, 92
Farrar's appliances, 148, 149 post-treatment maintenance of,

Fauchard's appliances, 146 187

Flagg's appliances, 147 treatment of, 192
Forces, anchorage of, 164 Lever for treatment of malocclu-
Frenum labium, abnormal, 58 sion, 163, 203
causes of, 61 Ligatures, 162
 INDEX 29-

Ligatures, application of, 181 Neutroclusion defined, 94

Linguoversion, definition of, 92 treatment of, 213
post-treatment maintenance of, Noble metals used for appUances,
187 153
treatment of, 195 Nomenclature of orthodontics, 19
Lip-biting as a cause of malocclu- Non-occlusion defined, 81
sion, 73
Literature of orthodontics, 20
American, 21 O
English, 22
French, 22 Obstetrical deformity, 74
German, 22 Occipital anchorage, 170
Spanish, 22 Occlusion defined, 81
importance of, 124, 138, 184,
185
M Oral hygiene, 37
Orthodontics defined, 17
Macrognathism defined, 87
journals of, 23
Magill, plain band, 155 literature of, 20
Malalignment defined, 81 nomenclature of, 19
Malformation of jaws, 85 postgraduate study in, 26
treatment of, 284 practice of, 23
Malocclusion defined, 81 societies of, 23
differentiation of, 85 specialization in, 24
Malposition defined, 81 synonyms of, 17
kinds of, 92 technique of, 26
treatment of, 191 Osteoblasts, 184
Malrelation of the arches defined,
85
treatment of. See Distoclusion
and mesioclusion.
Mechanical formation of denture,
Pain, relief of, 35
77 Palatal index, 104
Megadont defined, 101
Patrick's appliances, 148
Mesioclusion defined, 89 system, 149
treatment of, 272 Pericemental affections, 75
Mesioversion defined, 92 Pericementum, fibers and functions
treatment of, 201 of, 183
Mesodont defined, 101 Perversion defined, 92
Mesognathous defined, 99 treatment of, 212
Microdont defined, 101 Photographs, 49
Micrognathism defined, 87 Plaster models, 46
Models, facial, 48 Platinum, uses of, 152, 153
46
plaster, Predisposition, 53, 54
uses 47
of,
Premature loss of teeth, 66
Mouth, examination of, 32
Preparation of mouth for treat-
ment, 31
N Profile, abnormal variations of,
108
Nasal obstruction, 67 normal variations of, 99
consequences and symptoms Prognathous defined, 99
of, 69 Prognosis defined, 130
298 INDEX
Prolonged retention of temporary Tissue changes caused by treat-
teeth, 67 ment, 183
Pulpless teeth requiring move- Tongue-sucking as a cause of mal-
ment, 39 occlusion, 73
Tonsils, hypertrophy of, 69
R Torsoversion defined, 92
treatment of, 203
Race admixture as a cause of Transversion defined, 92
malocclusion, 78 treatment of, 212
Radiographs, 50 Traumatism, 74
Reciprocal anchorage, 166 Treatment of buccoversion, 191
Records of treatment, 42 of distoclusion, 245
Resorption in tooth movement, 183 of distoversion, 198
Retaining appliances, 186, 187, of infraversion, 208
188, 189 of labioversion, 191
Retention defined, 184 of linguoversion, 195
of arch form, 187 of malformation of the jaws, 284
relation, 189 of mesioclusion, 272
of tooth position, 186 of mesioversion, 201
time required for, 185 of neutroocclusion, 213
Rotation of teeth. See Torso- of perversion, 212
version. records, 42
Rubber elastic bands, 163, 181 of supraversion, 210
vulcanite plates forretention, 187 of torsoversion, 203
of transversion, 212
Tube hooks, 162
S Tubes, buccal, 174, 178
Turbinates, hypertrophy of, 69
Schange's appliance, 146
Sex, consideration of, in treatment,
131
Skiagraphs. See Radiographs.
Skull cap, 163, 170, 171
Supraversion defined, 92 Variations of alignment, 102
treatment of, 210 of the facial angle, 106
Symphysis, variations of, 105 of the head form, 97
Systems of treatment, 28 of lower third molars, 105
Angle's, 149 Vulcanite plates, uses of, 187
Case's, 149
Farrar's, 149
introduction of, 148
Jackson's, 149 W
Knapp's, 149
Lukens', 149 Wire alignment, 147, 159, 160,
Patrick's, 149 161, 176, 224, 225
ligatures, 162, 181

Technique of orthodontics, 26
Thumb-sucking as a cause of mal-
occlusion, 71 X-RAYS. See Radiographs.
 COLUMBIA UNIVERSITY
This book is due on the date indicated below, or at the

expiration of a definite period after tlie date of borrowing,

as provided by the j:ule8TtifrtMe\TLi»*aJ-y ^r .by special ar-
rangemei|J pT