ORAL
DEFORMITIES
KINGSLEY
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DENTAL LIB.
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1888
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PAGAN
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UNIVERSITY OF MICHIGAN
PLURIBUS UNUM
SCIENTIA
OF THE
TUCOUR
PRA KAVIČK
SQUAERIS PENINSULAM AMOENAM
CIRCUMSPICE
WOOUUOLLOLOKOAJALEN
DENTAL
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DENTAL LIR
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523
K55
1883
A TREATISE
ON

ORAL DEFORMITIES
AS
A BRANCH OF MECHANICAL SURGERY.
BY
NORMAN W. KINGSLEY, M. D. S., D. D. S.,
PRESIDENT OF THE Board of CENSORS OF THE STATE OF NEW YORK, LATE DEAN OF
THE NEW YORK COLLEGE OF DENTISTRY AND PROFESSOR OF DENTAL ART AND
MECHANISM, MEMBER OF THE AMERICAN ACADEMY OF DENTAL SCIENCE,
OF THE ODONTOGRAPHIC SOCIETY OF PENNSYLVANIA, AND OF
THE ODONTOLOGICAL SOCIETY OF NEW YORK, ETC.
WITH OVER 350 ILLUSTRATIONS.
NEW YORK:
D. APPLETON AND COMPANY,
1, 3, AND 5 BOND STREET.
1888.
COPYRIGHT BY
NORMAN W. KINGSLEY.
1879.
PREFACE.
THIS work was begun ten years since, and in its substan-
tial features was ready for the press some time ago; publi-
cation was deferred in order to make the whole more scien-
tifically complete, but I realize that it is useless to wait until
a reversal of opinion on some topics is rendered impossible.
In the mean time, I have revised and rewritten the whole,
and have endeavored to make it the embodiment of the
latest knowledge upon the different subjects treated.
Since the act was passed by the New York Legislature
in 1868 creating a Board of Censors, I have been the mem-
ber of that Board upon whom devolved the duty of examin-
ing dentists upon these branches.
It has been exceptional that I found any one possessing
more than the most elementary knowledge, and the exami-
nations were necessarily wanting in desirable thoroughness
because there existed no source from which they could readi-
ly obtain the required knowledge; the meager and inade-
quate instruction of the text-books could only be augmented
by a tedious search through journals and voluminous society
transactions for scattered contributions to such literature.
Only upon the subject of Maxillary Fractures has there
been heretofore any approximation to completeness; even the
works of Hamilton and Heath, while containing all that the
iv
PREFACE.
general surgeon requires, are not of equal value to the spe-
cial surgeon or dentist.
In the department of Irregularities, a number of illustra-
tions have been introduced which the superficial reader may
regard as excessive or confusing, but each was found to pos-
sess some valuable principle, or was introduced to contrast
its complexity with simpler methods, and prevent "a waste-
ful expenditure of time in the contrivance of useless appa-
ratus."
A critical reader may detect here and there repetitions,
but I regarded the knowledge of so much importance in
another connection as to justify an occasional reiteration.
When I began practice in certain specialties herein
treated, there was almost no literature upon the subject, and
I was obliged to invent nearly every process which I used.
The appliances and the methods of treatment are therefore
to a large extent original with me; nevertheless, I have not
hesitated to adopt, from any source at my command, any and
all different methods which had anything in them to com-
mend them. Hamilton very truly says, "It is not in the
discovery and multiplication of mechanical expedients that
the surgeon of this day declares his superiority, so much as
in the skillful and judicious employment of those which are
already invented."
I have endeavored to treat these topics with such com-
prehensiveness that it will not be necessary for any one else
to go over the same ground until the progress of science
shall make these teachings obsolete.
It has been my desire to present this information in such
form that it shall interest and profit, not only the student
but the practitioner of dentistry and general surgery.
PREFACE.
▼
I doubt if any of my readers will ever be more pro-
foundly conscious of my shortcomings than myself.
To Dr. St. George Elliott, of 39 Upper Brook Street,
London, I am much indebted for valuable assistance in the
preparation of the chapters on Fractures. His large expe-
rience as an army surgeon and his subsequent dental practice
in North America, South America, and Japan, rendered him
eminently qualified for such a work.
The chapter on Anatomy and Physiology of Expression
is, to a considerable extent, an epitome of Sir Charles Bell's
work on that subject. I prepared such an article for publi-
cation a few years since, not knowing at the time that the
late Professor McQuillen had published a similar paper.
Upon a conference with him, and by his consent before his
death, I have adopted much of his language in my chapter
under that title.
NEW YORK, December, 1879.
If the knowledge herein contained and the plans pro-
posed for treatment shall prove beneficial to needy human-
ity, and save the practitioner the intensity of thought which
they have cost the author, I shall be more than satisfied.
NORMAN W. KINGSLEY.
CONTENTS.
PART I.
IRREGULARITIES OF THE TEETH.
CHAPTER I.
ETIOLOGY.
Normal Type of Jaws.—Definition of Abnormality.—Malposition from Pre-
mature Extraction of Temporary Teeth-from Slight Causes-from Pro-
longed Nursing-from Thumb-sucking.-Origin of Contracted Dental
Arches.-Influence of Heredity-of High or Selective Breeding.—Mixing
Diverse Types of Jaws.-Illustration of Second Dentition.-Teeth of
Giants and Dwarfs.-Effects of Civilization and Neural Disturbances.-
Causes of Irregularities of the Teeth.-Irregularities foretold.--Irregu-
larities prevented
CHAPTER II.
PAGE
CORRELATION OF IRREGULARITIES TO IDIOCY.
Dr. Down's Examination of Idiots.-Dr. Down's Use of Irregularities in Diag-
nosis.-Variety in the Normal Type of Jaws.-Author's Investigation of
the Jaws of Idiots.-Idiots in America.-Idiots in Great Britain.-Idiots
in France.-Jaws of Cretins.-Dental Arrangement of an Absolute Idiot.
-Usual Type of Idiots' Jaws.-Observations of Dr. J. W. White, Prof.
Stellwagen, and Prof. Pierce.-Down's Theories questioned.-Possible
Correlation of Irregularities to Idiocy
CHAPTER III.
DIAGNOSIS.
Factors of a Diagnosis.-Esthetic Considerations.-Retention of Every Tooth
in the Mouth unnecessary.-Correct Articulation of Teeth of More Impor-
tance than a Full Complement.-Retention or Extraction of Teeth dis-
cussed.-Diagnosis and Prognosis in Hereditary Cases.-Illustrations from
1
26
viii
CONTENTS.
Practice.-Study of External Features essential.-Extraction in Certain
Cases justified.-Effects upon the Nervous System.-Consideration of
Charity Patients.-Remuneration considered
40
CHAPTER IV.
PAGE
PHYSIOLOGY AND PATHOLOGY.
Teeth constantly changing Position through Life.-The Functions of Absorp-
tion and Reproduction.-The Philosophy of Movement in regulating
Teeth.-Alveolar Walls yielding without Absorption.-Age for correcting
Irregularities.-Possibilities in Adult Life.-Possibilities in Hereditary
Cases.-The Kind and Source of Pressure.-An Absurd Pathological Law.
-Critical Period in regulating Teeth.-Objection to the Relaxation of
Force.-Care of Regulating Apparatus
• 57
CHAPTER V.
MECHANICAL FORCES USED IN REGULATING TEETH.
Jack-Screws.-Dr. Dwinelle's Invention.-Various Methods of using Jack-
Screws.-Angell's Screws.-Farrar's Screws.-Wedges.-Elastics and their
Attachments.-Inclined Planes.-Levers.-Bands and Plates.-Ingenuity
and Ready Invention a Necessity
CHAPTER VI.
CHAPTER VII.
IMPRESSIONS AND MODELS..
Plaster versus Plastic Substances.-How to take Plaster Impressions.-Morale
and Demeanor.-Examples of Difficult Cases.-Best Method of making a
Model.-Study of Articulating Models
89
68
CASES FROM PRACTICE IN REGULATING TEETH.
Triangular Arch and its Simple Treatment.-Contracted Arch, Inherited De-
formity.-Contracted Arch altered by Thumb-sucking.-Discussion upon
the Origin of the Contracted Arch.-Case of Contracted Arch by C. S.
Tomes.-Triangular Arch corrected by "Jumping the Bite."-Remark-
able Case of Protruding Lower Jaw corrected by Wedges in Twenty Days.
-Remarkable Case of Protruding Upper Jaw.-Dr. George S. Allan's Case ;
Alteration at Condyles.-Extraction of a Lower Central Incisor.-Case of
General Disorder of Upper Teeth.-Two Similar Cases requiring Different
Treatment.-Discouraging Experiments in regulating Teeth.-Case of
General Disorder of Both Jaws.-Dr. McQuillen's Cases.-Dr. Flagg's
Cases. Dr. Richardson's Case.--Dr. Meredith White's Cases.-Dr. West-
cott's Cases.-An Absurd Method of regulating Teeth.-Discussion by
McQuillen and Stellwagen on Gilmour's Case.-Tomes's Cases.—Dr.
Angell's Cases
96
CONTENTS.
PART II.
PALATINE DEFECTS.
CHAPTER VIII.
CONGENITAL AND ACQUIRED PALATAL LESIONS.
Origin of Cleft Palate.-Harelip and Cleft Palate.-Evils of Cleft Palate.-
Surgery of Cleft Palate.-Failure of Staphyloraphy.-Mechanisın more
reliable than Surgery.-Contrasted Results in Congenital and Acquired
Lesions
PAGE
•
CHAPTER IX.
HISTORY OF OBTURATORS.
Ambroise Paré's Obturators.-Obturators of Guillemeau, Heister, Fauchard,
and Delabarre.-Snell's, Rowell's, Hullihen's, Buckingham's, J. D.
White's, McGrath's, and Suersen's Obturators for Congenital Cleft.-Case
from the Author's Practice.-Change from a Velum to an Obturator.
CHAPTER XI.
•
CHAPTER X.
APPLIANCES FOR ACQUIRED PALATAL LESIONS.
Treatment by Granulation.-Illustration of Extensive Absorption.-Apparatus
for Simple Perforations.-Impressions of Palate Perforations.-Artificial
Velum for Acquired Lesion.-Artificial Velum on the Snell-Scrcombe
Plan.-Immediate Effects upon Articulation
HISTORY OF ARTIFICIAL VELA.
Delabarre's Artificial Palate. -Snell's Palate.-Stearn's Palate. - Stearn's
Method of making a Palate.-Peculiar Characteristics of Stearn's Palate.
-Sercombe's Palate.-Parkinson's Palate.-History of the Author's Ap-
pliances.-The Author's Original Invention of Universal Application
•
ix
CHAPTER XII.
TREATMENT OF CONGENITAL FISSURE OF THE PALATE.
Essential Requisite of an Artificial Velum.-Mechanism of an Artificial Velum.
-Author's Latest Invention.-Its Simplicity, Originality, and Universal
Application.-Obturators and Palates combined.-Undoing a Staphylo-
raphic Operation .
203
215
248
259
278
X
CONTENTS.
CHAPTER XIII.
METHOD OF MAKING ARTIFICIAL PALATES.
Illustration of a Cleft Palate.-Taking Impressions of a Cleft Palate.-Detcc-
tion and Correction of Errors in Palate Impressions.-Impressions of the
Nasal Cavity.-Construction of an Artificial Velum.-Molds for an Arti-
ficial Velum.-Flasks for Palate-Molds.-Packing and vulcanizing Soft
Rubber
CHAPTER XIV.
INTRODUCTION AND USE OF ARTIFICIAL VELA.
Proper Position in the Pharynx.-Manner of Attachment.-Experience 11
wearing.—Durability of Rubber Vela.-Best Age for their Introduction.
-Benefits from their Usc.-Best Practice for improving the Speech.
—
p
CHAPTER XV.
BUCCAL AND NASAL PROTHESES,
Artificial Nose.-Artificial Ear.-Prothesis in Hereditary Syphilitic Case.-
Elevation of Sunken Noses.-Elevation of a Sunken Check.-Protheses
in Cases of Gunshot Wound.-Artificial Nose of Rose Pearl.-Artificial
Nose, Lip, and Obturator.-Artificial Nose and Lip, Gunshot Case.—Arti-
ficial Nose, Syphilitic Case.-Artificial Palate and Obturator, Author's
Case
PART III.
PAGE
MAXILLARY FRACTURES.
CHAPTER XVI.
LOCATION, DIAGNOSIS, ETC.
Fractures of the Upper Jaw, and Treatment.-Fractures of the Lower Jaw.
Location.-Direction.-Compound.-Comminuted.— Displacement.—Ne-
crosis.-Irregular Union.-Fibrous Union.-Non-Union.-False Joint.-
Diagnosis. Prognosis. -Treatment. - Ligatures.-Wire Suturc.-Wire
Splint.-Bandages.-Pasteboard Splints.-Objections to Bandages
CHAPTER XVII.
+
•
INTERDENTAL SPLINTS.
Gunning's, Bean's, Suersen's, Harrison Allen's, and Moon's Splints.-Splints
with External Clamps.-Chopart's, Desault's, Rutenick's, Bush's, Hill's,
Houzelot's, Malgaigne's, Lonsdale's, Hayward's, Moon's, and Bullock's
Splints.-Author's Interdental Splints and Method of making, Cases from
Practice.-A Splint for General Use
•
288
203
313
361
384
CONTENTS.
PART IV.
MECHANISM OF SPEECH.
CHAPTER XVIII.
SOUND.
PHYSICS OF
PAGE
Musical Sounds and Noises.-The Laws of Vibrations.-Composition of a
Clang. Philosophy of Resonance.-Anatomy, Physiology, and Function
of the Vocal Organs.-Influence of the Accessory Organs.-The Forma-
tion of Articulate Language.-The Origin and Explanation of Vowel
Sounds
CHAPTER XIX.
THE FORMATION OF VOWELS AND CONSONANTS.
Bristowe's Division of Vowels.-Prof. Tyndall's Description.-Illustrations
of their Mechanism.-French Nasal Vowels.-Experiments in Articula-
tion.-Points of Interruption in the Oral Stream.-The Formation of Con-
sonants.-Illustrations of their Mechanism.-New Classification and Table
of Consonants.-Some Experiments with Cleft-Palate People.-Compen-
sation for the Loss of the Palate.-Perfect Gutturals formed without a
Palate.-A Case where Articulate Speech was impossible.
PART V.
THE ESTHETICS OF DENTISTRY.
•
CHAPTER XX.
ART CULTURE REQUIRED IN DENTAL PROSTHETICS.
A Violation of Esthetics abhorrent.-Definitions of Fine Art and Mechanic
Art.-Ideal Arts and Mechanic Arts contrasted.-Characteristics of Sculp-
ture.-Prosthetic Dentistry as a Department of Sculpture.-Ideality in an
Artificial Denture.—" Taking the Bite."--Drawing an Ideal Head.-Com-
parison of Various Types.-Experiments in remodeling a Face.-Ideal
Types of Teeth.-Comparison of Skulls.-Profiles of Upper and Lower
Jaws.-Tricks and Devices in Artificial Dentures.-Criticism on Teeth as
now made.-The Culmination of Excellence
•
xi
CHAPTER XXI.
ANATOMY AND PHYSIOLOGY OF EXPRESSION.
A Knowledge of Physiognomy indispensable.-Expression dependent upon
Action of the Muscles.-Illustration of the Facial Muscles.-Description
412
424
465
xii
CONTENTS.
PAGE
and Function of Facial Muscles.-Illustration of the Pterygoidei.—The
Great Lines of Character in the Face.-Expression centering chiefly about
the Mouth.-Function of the Fifth and Seventh Pairs of Nerves.-Illus-
trations of Different Expressions.-Value of Teeth as a Means of Expres-
sion.-Effects of Civilization on Physiognomy .
€ 510
PART I.
IRREGULARITIES OF THE TEETH.
CHAPTER I.
ETIOLOGY.
IRREGULARITIES, either in the form of the arch or the
position of the teeth, are very uncommon in the deciduous
set. We have seldom seen an irregular arch in a child prior
to the eruption of the permanent teeth, unless associated
with and correlated to some other deformity. In a few
instances there has been observed a slight malposition of one
or more of the incisors, sometimes of congenital origin, and
sometimes the result of mischievous habits; as, for example,
the two centrals may be pulled forward by the prolonged use
of an artificial nipple, sucking the thumb, or other similar
habit.
Congenital deformities rarely amount to more than a
trifling displacement of one or two of the incisors; but, con-
sidering the temporary character of the deciduous teeth, and
more especially the incisors, no irregularity in their position
that we have ever seen can be regarded as of special impor-
tance, or as justifying any interference for its correction.
They are to be classed as mere freaks of nature, not asso-
ciated with nor indicating any other peculiarity in the child.
Nor do they prognosticate an irregularity in the development
of the second set. This important fact can not be too promi-
nently borne in mind. The deciduous dental arch is always
NORMAL TYPE OF THE DENTAL ARCH.
2
well formed, and the positions of the teeth are regular (mere
freaks of nature excepted). But from this perfectly sym-
metrical dental arch there develop with the growth of the
permanent set some of the most astounding abnormalities.
These peculiarities of the permanent teeth it is unneces-
sary to describe in detail. In the departure from symmetry
they assume almost every variety of position, so that it
would be almost impossible for the human mind 'to conceive
of an irregular arrangement which would not find its coun-
terpart in nature. These variations are recognizable by
every one of extended observation, and are deformities,
because they are a greater or less departure from a normal
standard. Such a standard can not, in the nature of things,
be one shape to which all must conform or be classed as de-
formed.
Symmetry and harmony do not imply uniformity; and
the dental arch may be developed up to the highest type of
perfection, and yet there exist as great a variety of form as
there would be in the faces of the aggregated beauties of
the world. Races, nations, and families are thus represented
without deformity.
The normal type of the dental arch I conceive to be a
regular line; the arch may be wider or narrower, varying
somewhat in individuals or races, but the line will be an
easy, graceful curve, without break or tendency to form an
angle. Within certain limits a narrow dental arch, as asso-
ciated with certain features, may become the very perfection
of beauty, while with another form of head and face the
widest development may be equally pleasing. That which
is recognized now as the standard or full measure of beauty,
as well as of utility, is not unlike that which existed in the
remotest historic ages, nor different from that which is now
exhibited among all communities not degenerated by luxury
or vice.
In 1864 Messrs. Cartwright and Coleman, of London,
made an examination of some two hundred ancient skulls in
WIDTH OF ANCIENT AND MODERN JAWS.
3
the crypt of Hythe Church, Kent. Those skulls, of which
there is no authentic history, further than that they had
been there for centuries, were apparently of both sexes and
all ages. The maxillæ presented in all instances unusually
well-developed alveolar arches. The teeth were remarkable
for regularity of position, only two deviations being noticed :
one upper canine shut within the lower jaw on occlusion,
and one bicuspid was turned upon its axis, and there might
have been other slight irregularities which were unnoticed;
but in no single instance was there anything seen approach-
ing to that which, under the term "contracted arch," so
commonly exists in the present day. The average width of
the dental arch in those skulls, from the outside of the first
molar to the corresponding point, was two and a half
inches.
In 1869 Mr. John R. Mummery, of London, contributed
to the Odontological Society of Great Britain the most
valuable paper on this subject which I have ever read. I
accord more importance to his personal examinations than I
do to the observations of any man not a practical dentist.
The statements of all others, even those of ethnologists,
being less precise and more general in their character, must
be accepted with some allowance. He examined all the
available skulls of ancient races, and of modern uncivilized
races, to the number of about three thousand, and tabulated
more than one half of them, which were classified as follows:
Ancient British, 203; Roman British, 143; Anglo-Saxon,
76; and ancient Egyptian, 36. Of modern uncivilized races :
North American, 145; Polynesian, 204; East Indian, 223;
African, 438; and Australian, 165.
From a careful analysis of the measurements given in
his tables, I find that the average width of the dental arch,
from first molar across to first molar, in the skulls of ancient
races, was a trifle less than two and three eighths inches; the
same measurement of the uncivilized moderns showed an
average width of a trifle above two and a half inches. The
4
DEFINITION OF ABNORMALITY.
narrowest measurement given by him of any skull of any
race is two and one eighth inches. The highest average of
any race is nearly two and three fourths inches, and these
belong to the New-Zealander, the Feejee-Islander, and the
Ashantees. The narrowest average was found among the
Hottentots and Bushmen of South Africa.
In these tables there is abundant evidence that the full
measure and type of both dental and maxillary arches has
been sustained among all races of simple habits in all ages.
Dr. Nichols, a dentist, who spent twelve years in the Rocky
Mountains and on the Pacific coast, during which period
he examined the mouths of thousands of Indians and Chi-
nese, informed me that he never saw an instance of irregu-
larity of the teeth in either of those races, with but one ex-
ception, and that a displaced canine in the mouth of a Chi-
nese woman. The jaws of both races are universally well
formed and amply developed. And this is also true of all
semi-barbarous and savage races of good physical organiza-
tion.
The standard of normality of the dental arch is a curved
line expanding as it approaches the ends, and the teeth all
standing on that line.
Abnormality will include such a shape of the arch as is
not in harmony with the surrounding features, all crowding
and twisting, and all departures from a regular line in the
positions of the teeth.
In classifying the causes of irregularities, they will be
placed under one of two heads-developmental or acci-
dental; the developmental operating prior to the eruption
of the crowns, and the accidental at the time of eruption or
subsequently.
Almost the only answer received by the dental student
as to the cause of these irregularities has been "premature
extraction of the deciduous teeth," and consequent contrac-
tion of the jaw; and this answer has been almost universally
accepted without a question as to its philosophy. A few
PREMATURE EXTRACTION.
20
5
facts have been correlated, and a conclusion arrived at as
unscientific as it is erroneous.
The premature extraction theory rests upon the suppo-
sition that the jawbone contracts upon the removal of the
deciduous teeth. The fact seems to have been entirely
ignored that the teeth and alveolar processes are a super-
structure of the jawbone, growing up on it, fulfilling their
destiny, and passing away, without disturbing the foundation
much more than an oak disturbs the planet upon which it
has been sustained. There is a period in the history of the
maxilla when it is itself an entity, and prior to hardly a trace
of the subsequent superincumbent structures; and in the
ordinary course of nature there comes a period at the other
end of life when equally all trace of dentition is gone, and
the maxillæ remain undestroyed entities.
While the proofs are conclusive that the jaws are devel-
oped independently of the teeth and alveolar processes, and
that no ordinary surgical interference with the teeth or pro-
cesses impedes or impairs that development, and while also
it may be true that all the primary teeth may be removed
long anterior to the period of eruption of the permanent
ones without retarding their development or impairing their
regularity, the doctrine may still be correct that the too
early extraction of some of the temporary teeth in connec-
tion with a tardy development of the maxilla will be likely
to result in a crowded and abnormal condition of their suc-
cessors. This result is not as likely to show itself with any
other teeth as with the canines.
In observing the order of eruption of the permanent set
in the regular economy of nature, it will be seen that for
every tooth of the deciduous set there is a permanent one
lying underneath it in process of formation, and that in due
time a deciduous tooth will loosen and fall out, and a per-
manent one will take its place.
With a normal growth of the maxillæ there will occur no
interference and no irregularity. The central incisors will
2
6
first appear; then the laterals; after that the bicuspids; and
lastly the canines. Each predecessor of a permanent tooth
will maintain its position until about the period of the emer-
gence of its successor. There will be no contraction of the
alveoli, because there will be no opportunity for it.
DISORDERED ERUPTION.
But take now a disturbed or tardy development of the
maxillæ instead of a normal condition, and observe the result.
Remove for any cause one after another of the temporary
set, or all at once, and the period of eruption will not be
interfered with, but the arrangement in the arch may be im-
paired. The centrals will find a place without difficulty-so
will the laterals; the bicuspids will be pretty certain to
have sufficient room, as their diameters are generally less
than their predecessors; but when these teeth are all fully
erupted, it will be found in a majority of cases at the
present day that the first bicuspid and the lateral are nearly
or quite in contact, filling the space destined for the perma-
nent canine, which must now emerge either anteriorly or
posteriorly to its true position, showing conclusively that, if
the alveolar arch had not contracted, the contiguous teeth
had encroached upon the space destined for the canine and
forced it out of position. In either case it is the unques-
tioned result of the too early removal of the deciduous ca-
nines; for no one will doubt that, had the temporary canines
been allowed to remain, they would have prevented contrac-
tion of the alveoli or an encroachment on their domain. It
may be argued that if the original direction of the canine
was correct, it would force itself between the lateral and
bicuspid, thus making way for itself; but this is against the
experience of nearly all observers, and very naturally so.
Admit the fact that from some cause or other the bicus-
pid and lateral come into contiguity, and from the tardiness
of the erupting canine it will find solid and unyielding roots
to contend with, which will necessarily force it out of the
dental arch.
Mr. Tomes relates a case in which he removed for cause
RETENTION OF THE TEMPORARY CANINES.
7
from a child all of the deciduous teeth prior to the eruption
of
any of their successors, so that for a time the gums were
edentulous; nevertheless, in due time the permanent teeth de-
veloped in perfect regularity of sequence and of symmetry.
While Mr. Tomes's report shows that no abnormality fol-
lowed the removal of all the teeth at once, such a result
is to be feared from such a practice, and most certainly will
ensue if there be not a coincident, independent, and ample
development of the maxilla. Cases are coming constantly
under our observation where from some cause the temporary
canines have been sacrificed, the space closed up, and the
permanent teeth malposed, with little hope of their ever
assuming unaided their rightful positions.
From this there can be but one deduction, which is that
whatever may be the inducement to remove any or all of the
deciduous teeth prior to their period of shedding, the canines
should be retained until there is ample evidence of the early
emergence of their permanent successors, unless the health or
comfort of the child would be sacrificed in so doing. But it
would be far better to remove one or all of the deciduous
teeth and take the risks of an irregularity in the permanent
ones, than submit the child to constant suffering and conse-
quent injury to its health by their retention.
How much of the malposition of the permanent teeth is
due to the prolonged presence of the temporaries is still an
unsettled point. Although absorption may be proved to be
an independent process, and in no wise connected always
with the progress of an erupting tooth, nevertheless the cases
are so common in which the absorbed portion of the decidu-
ous tooth corresponds accurately with the new crown as to
force upon us the conviction that it is influenced by it, and
therefore that if the permanent tooth had persisted in the
right direction, the deciduous tooth would have become dis-
placed.
The question naturally arises, Is the presence of the de-
ciduous teeth the cause or the effect of the irregularity? If
8
their presence be the cause of irregularities, then it is mani-
fest that in this generation of malposed teeth it is our duty
to anticipate the trouble, and at an early day remove them
before even it is possible for them to give a wrong direction
to their successors.
RESULTS FROM SLIGHT CAUSES.
With the present knowledge upon the subject, there is
no more evidence that the presence of the temporary tooth
caused the irregularity than that the position and tendency
of the permanent tooth was originally wrong. It is quite as
reasonable to adopt the latter view as to suppose that the
function of absorption was arrested and by that the tooth
was turned aside. Whether their presence be the cause or
the result of the malposition, this we know, that when a per-
manent tooth has erupted and its deciduous predecessor has
not been removed, the immediate extraction of such tooth
will go very far toward the complete correction of the de-
formity, thus showing that the apparent cause of the mal-
position of a single tooth is often the presence of a temporary
crown.
Even an unabsorbed spicula of a deciduous root will ap-
pear to cause a slight deviation in the inclination of a grow-
ing tooth, which, on coming in contact with its opponent of
the other jaw at an unnatural angle, will be sufficient to
cause the mal-occlusion of the entire dental economy.
A very trifling accident occurring at the period of erupt-
ing teeth will sometimes cause most serious results. The fall
of a child has produced a slight inversion of an erupting
central incisor, which, when further elongated, met the cut-
ting edge of the lower centrals. It was easier and more
natural for the child to throw the lower jaw forward and
catch outside the upper tooth than otherwise. Thus began
a habit which did not end until all the upper incisors were in
like manner caught and inverted, and finally the whole dental
articulation disorganized.
It would be impossible to describe and give the exact
operating cause of all irregularities which could be traced to
TRANSMITTED PECULIARITIES.
9
an accidental source; they could not be ascertained short of
a special anatomical examination of each individual case,
which is generally out of the question.
Many of the forms of irregularity are directly traceable
to inheritance, and are transmitted peculiarities. Probably in
a large proportion of cases where the irregularity in a dental
arch is confined to one or two teeth, the primary cause, so far
as that individual is concerned, is an hereditary family pecu-
liarity. The teeth of every person possess more or less indi-
viduality, and most of those peculiarities which stamp their
individuality are inherited. The form and color of teeth,
when not disturbed by abnormal influences, are derived
from the same source. Whenever we find any departure
from what we are apt to regard as the typal form of each
tooth, or any disproportion of size in their relations to each
other, we shall be likely to find them peculiarities of descent.
The number of such cases which come under the obser-
vation of the dentist shows the universality of the law, that
departures from a normal type are liable to be transmitted to
succeeding generations, and eventually the peculiarity be-
comes the fixed type of the family or race.
For example, we have seen two small teeth develop be-
tween the central incisor and the canine, neither of which
could be called a symmetrically formed lateral incisor, while
upon the other side of the median line a single lateral incisor
was well developed. This abnormality in a boy a dozen
years of age was inherited from the father, in whom exactly
the same kind of a deformity existed.
The transmission by inheritance of a predisposition to a
defect or a deformity, is the result of the same general law
of nature which gives the form and features of progenitors.
to their offspring. How far back in one's ancestry such
peculiarities could be traced before arriving at the initial
must be a matter of conjecture. The observations and the
data are too limited to form an opinion.
It is a wonderful subject for contemplation that, at some
10
INFLUENCE OF CORRECTION ON OFFSPRING.
remote period in the history of our progenitors, Nature de-
parted from her normal type, and a dwarfed lateral incisor,
a twisted canine, or an undeveloped bicuspid was the result;
and, following down the line of descent, we find precisely the
same peculiarity appearing and reappearing-not always
confined to the direct line, but continuing in the same
family, by passing to the children of the brother or sister,
and always presenting characteristics identical with the ante-
cedent type.
"There is an ingrafted tendency in all living
organized matter to reproduce itself."
It is yet to be determined whether the correction of the
irregularities of the dental organs exercises any influence upon
the offspring. I am of the opinion that such deformities,
even where transmitted for generations, may have the ten-
dency stamped out by being corrected immediately on their
development—that is, before the deformity has made its
fixed impression upon the individual. This we might rea-
sonably expect, because it would be assisting nature to return
to its normal type.
There is one form of irregularity which is sometimes due
to hereditary predisposition and sometimes to causes acting
after eruption. An undue prominence of the upper incisors
may be either congenital or acquired. The acquired origin
is almost always a habit of thumb-sucking or its equivalent.
It is not difficult, as a general thing, to make the distinc-
tion even without questioning the patient. In a protrusion
of congenital origin the jaw is generally pinched in the
bicuspid region, and the protrusion culminates in a pointed
or V-shaped position of the central incisors. When such
prominence has a mechanical or accidental origin, the whole
front of the arch will be found rounded out, and the teeth
pulled forward; and there will be likely to be more or less
space between each of the teeth anterior to the bicuspids.
A marked case of the latter class came into my hands
for treatment. It was an only child, a girl about thirteen
years old, brought by her mother. The protrusion of the
THUMB-SUCKING.
11
incisors was considerable, and the effect upon the upper lip
most marked, destroying the symmetry of the features. On
remarking half inquiringly, "I wonder what could have
caused that?" the mother replied with a somewhat shamed
face, "I suppose it was my allowing her to nurse until she
was nearly nine years old. I did not know it would hurt her
teeth."
An undue prominence of the superior incisors is said
to be not uncommon among idiots. And to such an extent
had it been observed among that class in connection with the
habit of thumb-sucking that Dr. Ballard, of London, adopted
the theory that the thumb-sucking preceded, and was the
cause of idiocy. A little further inquiry into the ancestry
of the patient, and a better knowledge of the development of
the dental organs, would have probably shown the fallacy of
this theory. Subsequently Mr. Charles Tomes presented his
hypothesis, attributing the deformity to a peculiarity in the
development of the maxillæ at a very early period of life,
and to mechanical causes operating upon the permanent teeth
at the time of their eruption.
The causes operating upon the development of the max-
illæ Mr. Tomes does not seem to regard in the light of a
transmitted tendency, but rather to forces having their origin
in the individual. The mechanical causes at work on the
crowns of the teeth at the period of their eruption, forcing
them inward, he believes to be the pressure of the cheek; for
he says: "It will generally be found that this malformation
is associated with greatly enlarged tonsils which necessitate
breathing being carried on with the mouth open. Now, as
every one can easily verify upon himself, the effect of the
mouth being held open is to increase the tension of the soft
parts about its angles, and the result of the increased pressure
is to bring about a bending inward at the corresponding
point, i. e., the bicuspid region; at the same time the me-
dian portion of the arch escapes the controlling pressure
which would have been exercised by closed lips, and the
+
12
effect of this is traceable in the excessive prominence of the
median pair of incisors, and also in their oblique position,
which makes them correspond with the form assumed by the
inner surface of the lips when the mouth is open."
My own observation has not shown this association of
enlarged tonsils with this kind of deformity so generally as
to enable me to accept Mr. Tomes's theory, even if I could
believe that the muscular contraction of the cheeks could
produce such results under such circumstances. Neither is
it quite conceivable that the pressure of the orbicularis oris
at the center, with the mouth open, would not exert a coun-
teracting influence upon the incisors, and thus restore the
equilibrium.
MR. TOMES'S THEORIES.
The pinched or V-shaped dental arch I believe to be
nearly always of congenital origin—that is, an inherited ten-
dency, favored in all probability by like circumstances with
those which initiated it in the ancestry; while the broad or
rounded form is often, if not always, due to mechanical
causes.
In referring to the same class of cases, Mr. John Tomes
says: "The deformity may result from excessive develop-
ment of the alveolar processes of the anterior part of the
upper jaw, but more commonly we shall find that the molar
teeth are unusually short, thereby allowing the incisor teeth
of the lower to press unduly upon the inclined lingual sur-
faces of the teeth of the upper jaw. The upper teeth, yield-
ing to the pressure, are forced outward, and are retained in
the malposition by the teeth which have led to the displace-
ment. If, in cases resulting from the latter cause, the inquiry
be extended to the condition of the lower jaw, it will be
found that with the short molar teeth we have a short alveo-
lar range and short rectangular ramus. This conformation is
probably the primary cause of the mischief."
Again he says: "The condition under consideration may
also arise from the tardy eruption of the molar teeth, leaving
the incisors to act for a time upon each other, as they do
MR. CARTWRIGHT'S HYPOTHESIS.
13
when from any cause the back teeth are lost. Then, again,
the incisors of the lower jaw may attain an unusual height,
or they may project in an unusual degree, and produce the
mischief. Or the result may be consequent upon a regular
linear arrangement of large teeth in a jaw having a small
alveolar base, in which case the teeth prior to their eruption
will assume an unusual anterior obliquity."
But we naturally ask, What was the cause of the "exces-
sive development," "the short molar teeth," "the short al-
veolar range," or "the short rectangular ramus"? The
explanation must be regarded as a description of antecedent
phenomena, rather than as a statement of the origin of the
deformity.
In a paper read before the Odontological Society in Lon-
don in 1864, Mr. Cartwright says: "Want of space in the
bones of the jaws may be defined as the true cause of irregu-
larity in the position of the teeth in the majority of in-
stances"; and follows this statement immediately with an
inquiry as "to a satisfactory explanation of this want of
capacity in the jaws of people of certain communities." He
further says:
"Irregularity is uncommon among many, if
not most, aboriginal peoples and tribes, and also the inhabi-
tants of particular districts and locations. Irregularity is
common in most highly civilized communities, and especially
so among the upper and middle classes, and it is more con-
stant among the inhabitants of towns than it is among the
inhabitants of agricultural districts."
Mr. Cartwright then offers the hypothesis that this abnor-
mality is due to a process of breeding, and brings forward
Mr. Darwin's statements that the bones and plumage of birds
become altered by such a process. He further supports his
position by the results of high breeding among animals,
which is maintained by constant and careful selection of
such as possess particular points and characteristics. For
instance, he says: "Take the horse and the ox, and consider
the points which make up a thoroughbred animal, the small
14
head and ears, the thin legs, small fetlocks and feet, the necks
and bodies finely and symmetrically proportioned, and then
the narrowness and comparative smallness of the maxillæ.
From the results obtained by high breeding in animals, they
might reasonably argue that small jaws might be a character-
istic of breed in certain conditions of life. If they com-
pared two types of human beings, represented by the upper
class in one case, and in the other case by a large class of
which the prize-fighter furnished an apt example, they would
find as a rule in the first: well-shaped lips, a small oral ori-
fice, high and capacious forehead, well-pronounced chin, ears
small, and neck long; the ankles, wrists, feet, and hands
small; with an expression in which the intellectual predomi-
nated over the animal"; while the other class, represented
by the prize-fighter, presented exactly the opposite character-
istics.
HIGH OR SELECTIVE BREEDING.
The hypothesis of Mr. Cartwright is not without reason;
and yet it is not altogether an explanation of the present
phenomena, for the laws which govern selective breeding in
animals do not apply to man in any condition in which he is
now found. These principles would, without doubt, produce
precisely similar results if applied under similar conditions.
Regard man as an animal only; dismiss all cognizance of
his intellect and his affections; mate him to the woman with
sole reference to the physical development of the race; and
it would take but a few generations to see disease and de-
formity swept from the face of the earth. But to call the
intermarriage of families, whose brains have been stimulated
to their highest capacity, and whose physical and nervous
systems have been deranged by the habits of modern civiliza-
tion—to call such a mixture high or "selective breeding,"
is a perversion of the term. If the application of these prin-
ciples produces a delicacy of form in the whole physique, we
should reasonably expect to find a corresponding delicacy
and refinement in the condition of the dental organs. That
the process of selective breeding should tend to or end in
RESULTS OF MIXING DIVERSE TYPES.
15
deformity, is manifestly inconsistent with its prime object,
which is the elimination of everything which tends to de-
generacy or deformity.
The characteristics pointed out by Mr. Cartwright in his
illustrations from animals are conspicuously æsthetic. We
can conceive of no such force acting uniformly upon the
whole physique, and producing such æsthetic results, without
its influencing equally the dental organs; and thus there
would be not only no irregularity or abnormality, but en-
hanced beauty-more symmetrically formed, more sym-
metrically arranged, and more symmetrically related dental
K
organs.
We are therefore irresistibly led to the rejection of the
theory of "high or selective breeding,"* in its true significa-
tion, as exerting any direct influence upon the malposition of
the permanent teeth; and while the facts noticed by Mr.
Cartwright are in consonance with other observers, we are
forced to the conclusion that such abnormalities are not a
necessary result of a higher civilization and refinement, and
that they are only coincident and correlated thereto.
There is a kind of breeding which does undoubtedly pro-
duce abnormalities of the kind under consideration. It is
a manifestation not uncommon in this country of mixed
nationalities, but it can hardly be called high or selective
breeding. The laws of inheritance, confirmed by common
observation, show how constant is the mingling in the off-
spring of the traits of character and the peculiar features of
two diverse races brought together in marriage. This mix-
ing, without blending or harmonizing, is productive of de-
formity in character and deformity in physique. Thus, so
far as the jaws and teeth are concerned, they may exist in
*It is more than probable that Mr. Cartwright uses the term "selective "
here in its broadest signification; meaning the mixing of peculiarities or types
which have a tendency to depart from normality, and not in its more restricted
and limited sense of combining only excellences, as the term when applied to
breeding is commonly understood.
CROWDED POSITION BEFORE ERUPTION.
16
each parent in perfect symmetry: in one parent the jaws
and teeth are large, in the other parent both jaws and teeth
are small; but each in its way is a normal development. If
now (and for this we can give no reason) the small jaw of
one parent and the large teeth of the other appear in the
offspring, deformity is sure to follow; and in any efforts
made thereafter toward correction these facts must be taken
into consideration.
G
In examining the maxillæ of a child between the ages of
four and seven years, with the external walls removed, so as
to expose the developing permanent teeth, we shall be struck
with the advanced stage of growth which the crowns have
attained, and with the crowded and jumbled condition in
which they are placed. Of such an exhibition the late Pro-
fessor McQuillen made the following remark: "When ex-
amining a series of jaws of different ages, arranged so as to
show deciduous and permanent teeth, it is not a matter of
surprise that there should be irregularity in the permanent
set; but, when observing their crowded and irregular ar-
rangement in the jaw prior to eruption, it is rather a mat-
ter of astonishment that they should ever assume a regular
and symmetrical appearance." In such specimens we see
that while there is no transposition of these crowns-each
one maintaining its individual locality-they nevertheless
stand in almost every variety of position. They will be seen
deflected within or without the line, twisted, lapping, and
sometimes completely overlapping one another.
In Fig. 1 the lower permanent central incisors have
recently erupted, showing the age to be about seven years.
Their predecessors are the only ones of the deciduous set
which have been removed. The general contiguity of the
temporary teeth shows that but little enlargement of the
dental arch had taken place, while the presence of the crowns
of all the permanent teeth (the third molars excepted) is an
ample illustration of the crowded confusion and disorder
which has been described. In the upper jaw the left central
17
incisor is partially twisted; both of the lateral incisors are
within the arch, and, if continued on the same line, would
shut within the lower jaw. The crowns of the canines over-
ride and are in front of the laterals and in contact with the
central incisors save by a thin partition of process. The first
bicuspids on each side are in close contiguity with the lat-
CROWDED POSITION DURING ERUPTION.
FIG. 1.

erals. The crowns of all the bicuspids are either twisted or
tipped in such a way as to show that some new direction
must be given to nearly every tooth, or irregularity of the
most pronounced character must ensue. The general con-
dition of the lower teeth is not dissimilar to that of the
upper ones, and this example is not an exceptional case.
These crowns, we also observe, are of their full diameter,
TEETII OF DWARFS AND GIANTS.
18
and are placed upon a maxilla which at this age has not de-
veloped sufficiently to allow them to range side by side upon
a true dental line; hence, they must remain in this crowded
and irregular condition until the maxilla itself has grown
large enough to allow the change.
It is now an established fact that the development of the
teeth and alveolar processes and the development of the jaws
are two distinct and independent operations. Maxilla will
go on in their growth until they have reached the measure
prescribed by the Creator, whether a tooth develops or not;
and likewise the teeth will grow into undiminished crowns
and erupt either in order or disorder, whether the maxillæ
increase or remain stunted.
I examined a few years since the mouth of the celebrated
dwarf "Tom Thumb." I found the teeth of a man in indi-
vidual size; but the maxillæ, in harmony with the rest of his
osseous system, was dwarfed. The result was what we should
naturally expect—a most marked malposition of the teeth;
so much so that he said he "had a double row of teeth all
around." And this is uniformly the case with dwarfs where
the whole physique is symmetrically dwarfed. The converse
is also true of giants, except in those cases where the extraor-
dinary stature is a characteristic of race.
T
To such an extent are these observations in accordance
with science, that it is quite possible to judge of the nature
of both these monstrosities, whether they be congenital, he-
reditary, or lusus naturæ. If, upon the examination of the
fully developed teeth of a giant, I found them large, regu-
lar, and in a well-formed arch, the whole in harmonious
relation to his other enlarged features, I should have little
hesitation in pronouncing him a congenital giant-a large
man by nature, and belonging to a family or race of giants.
If, on the other hand, I found the teeth the size of those
of a man of ordinary stature, and standing apart from
each other in an enlarged jaw, I should pronounce him the
result of forces which did not antedate his own existence,
19
but continued their power long after the development of
the teeth after their hereditary pattern had been completed.
And in like manner a dwarf belonging to a race of small
stature would not necessarily show irregularity or crowding
of the teeth, but would be expected to show a reduction in
size of the dental organs in consonance and in harmony with
the type of his race.
This is but a confirmation of the theory of the indepen-
dence of these organizations; the evidence from a variety of
sources going to show that the forces which preside over the
growth of the osseous system are separate and distinct from
those which originate and develop the dental organs, and
that while in a normal state both teeth and jaws would grow
in harmony, in an abnormal condition the teeth might be far
in advance of the growth of the jaws, or they might be
equally retarded. If the former, they must erupt in a
crowded condition; if the latter, they would, other things
being equal, be likely to be in line.
No one of extended observation will hesitate in believing
that there is a faculty or power at work, modifying mate-
rially the physique of the present generation, altogether in-
explicable by the too commonly asserted influencing power
of climate, hygiene, or diet.
"This change indicates the existence of less muscle, more
nerve; less physical vitality, more nervous energy; less
power of endurance, but more mental activity.
"This same change is also indicated in the anatomy and
physiology of the person. The framework of the body gen-
erally is not so large, is not so compact, nor so well propor-
tioned; the countenance is paler, the features are more
pointed and not so expressive of health, though more so of
intelligence. The texture or quality of organization is more
delicate and refined; the brain is becoming developed more
and more relatively, and too frequently at the expense of
the body; or, in other words, the nervous temperament, with
all its advantages and disadvantages, is becoming too pre-
INDEPENDENT GROWTH OF TEETH AND JAWS.
20
INFLUENCES OF CIVILIZATION.
dominant for other parts of the body. As one of the conse-
quences, we have more diseases of the brain and nervous sys-
tem, more sudden deaths from apoplexy, paralysis, and also
from diseases of the heart. No truth in vital statistics is
better established than the fact that large cities and a dense
population tend to diminish the physical energies of the body
and shorten human life. .
"The simple reason is, as we conceive, that their style of
living taxes the brain altogether too much; it develops a
great predominance of the nervous temperament at the sac-
rifice of other parts of the body, which by inheritance is
increased from generation to generation. The balance of
structure and harmony of function in organization is radically
changed, and carried to an intense development of nervous
tissue, which in its very nature is unfavorable to the preser-
vation of offspring.
"But it is in the accumulated, the intensified effect pro-
duced by the law of inheritance, that the most striking and
destructive results are to be witnessed." *
As the peculiarities of progenitors in mind, temperament,
and physique are by nature stamped upon their offspring,
we see a generation of children inheriting a tendency to a
nervous exaltation which very slight favoring circumstances
encourage and stimulate. This is unquestionably more no-
ticeable in the centers of luxury in this country than in
any other portion of the civilized globe. Fathers who are
under a mental strain to the very verge of insanity transmit
that exaltation to their offspring. Children are no longer
children, except in their immature physical development;
their emotions are under constant stimulus and excitement,
and, if there is not in all instances an absolute intellectual
precocity, there is relatively a mental and nervous develop-
ment far in advance of the physical. Hence, if the mental is
only up to the average of its years, we will find it associated
* Dr. Nathan Allen, of Lowell, Massachusetts.
EFFECTS OF NEURAL DISTURBANCES.
21
with anything but a robust physique; and the contrast re-
mains the same. One of the manifestations of this preco-
cious, emotional, and exquisitely developed nervous system
is its influence upon the development of the teeth, while the
physical system is following in tardy but vain efforts to keep
pace with it.
The conclusion, then, is this: Laying aside all cases that
may be due to an inherited tendency to follow or exaggerate
some given type, together with those which are manifestly
due to forces operating only after eruption, the primary
cause, so far as the individual is concerned, of any general
disturbance in the development of the permanent teeth,
showing itself particularly in their malposition, is directly
traceable to a lesion or innervation of the trigeminal nerve;
it is an interference, more or less prolonged, with one of the
prominent functions of that nerve, and operating at its origin.
While there may be no way to prove this by any examination,
microscopical or otherwise, while the nerve-center is under
this influence, it is nevertheless sufficiently proved by secon-
dary phenomena which could only have originated from such
a source. The function of the trigeminus, thus stimulated
or interrupted, is that which supports, regulates, and gov-
erns the nutrition of the tissues to which its terminal
branches are distributed.
That such a lesion or innervation would be likely to pro-
duce such a result is clearly foreshadowed in the following
statement made by the late Professor Anstie in one of his
lectures on the fifth nerve: "The nervous center in which
the trigeminus is implanted is, of all nervous centers, the one
which in the human subject is most liable to congenital im-
perfection of the kind which necessitates a break-down in
its governing functions at special crises in the development
of the organism."
No author on the causes of malposition of the teeth has
made this direct connection between the abnormality and a
disturbance of the nerve-center, during the formative and
3
22
MR. MUMMERY'S DEDUCTIONS.
eruptive period; but I find a large array of facts, confirmed
by my own observations, which point in my mind to this only
conclusion; and, although other observers of similar facts have
attempted in many instances an explanation of what they
saw, they have failed to refer them to any satisfactory pri-
mary cause.
In Mr. Mummery's paper, before referred to, in speaking
of diseases of the teeth, he says: "It is to be feared that a
large amount of dental disease is originated by overtaxing
the brain-action of children. According to the best author-
ities, the most rapid increase in the growth of the brain takes
place before seven years of age; and it must be remembered
that the crowns of all the permanent teeth, with the excep-
tion of the third molars, are simultaneously in the course of
development with this great advance in the size of the brain.
May we not, therefore, reasonably suppose that through the
diminished vitality consequent upon this diversion of the
formative energy from the teeth, by premature mental exer-
tion, these organs necessarily become degenerated, and that
this circumstance constitutes one great difference between
the teeth of the intellectual and those of the uncultivated
families of mankind?"
The argument from this universally recognized condition
is this: During the formative and eruptive periods of the
permanent teeth they are under the influence of an indepen-
dent and peculiar vital (nervous) force; this innervation
pushes on their development regardless of the more tardy
growth of the osseous system; being implanted in a crowded
position, in undeveloped maxillæ, they never have an oppor-
tunity to recover from it, and emerge in the same disordered
arrangements in which the crowns were formed. In these
positions, when fully erupted and surrounded by their alve-
olar walls, they become fixed regardless of any subsequent
growth of the jaw; for it is one of nature's laws that, when
the climax of development has been reached and the type is
complete, function ceases. Under such circumstances it
23
would not be expected that any or all organic changes in the
nerve-center would manifest the same results in detail; a dis-
turbance of function would produce general results, the de-
tails of which might vary in every case. That such a lesion
or innervation could only operate upon the permanent teeth
is easily seen, when it is remembered that, to produce any
marked effect upon the deciduous teeth, we should have to
go back to intra-uterine life for the period of its influence,
and before the child had an independent and sentient being.
ORIGIN OF INHARMONIOUS DEVELOPMENT.
This hypothesis does not find any contradiction in our
daily observation; for such a disturbance of nerve-function
might occur only for a limited period, and no other exhibi-
tion or evidence of it ever again appear.
The logical result of such reasoning would be that in
individuals and families of sluggish or feeble intellects and
phlegmatic temperaments, but with good physique, we should
find capacious jaws and teeth not crowded. If a precocious
or stimulated brain in infancy urges on and crowds the den-
tal organs in advance of the growth of the jaws, then a brain
of low caliber, or power, will be likely to have associated
with it a retarded dentition, but with abundance of room.
The grounds for such a conclusion are not merely theoreti
cal, but are the results of observations in private practice
for more than a quarter of a century in connection with in-
vestigations of different classes, nations, and races, ancient
and modern, including all ranks and conditions of life from
the highest order of intelligence down to the idiotic.
A perfect dental development is the result of well-bal-
anced physical and nervous systems, without hereditary taint.
The causes of irregularities we classify as developmental
and accidental; the developmental operating prior to the
eruption of the teeth, and the accidental subsequently.
Abnormalities of development having their origin in the
same individual are due to a disturbance of the trigeminal
nerve during the period in which the crowns of the perma-
nent teeth are forming and arranging themselves in the jaw
·
24
prior to eruption; or, when arising from causes antedating
the life of the individual, are traceable to an inherited ten-
dency, which tendency had its origin in a like disturbance in
one of the progenitors, and was subsequently transmitted;
or are the result of mixing different and distinctly marked
types of jaws and teeth by the progenitors.
This proposition may be stated in another form as fol-
lows: The cause of irregularities of the teeth other than acci-
dental lies in a want of development of the jaws commensu-
rate with the size of the teeth; and this want of relation is
sometimes due to a retarded growth of the jaw while the de-
velopment and eruption of the teeth is not retarded, and
sometimes due to the inheritance of large teeth out of all
proportion to the size of the inherited jaw.
In our view we do not call a feeble mind, a sluggish
brain, or a dull intellect a nerve-lesion or a brain-disturb-
ance; for it is abundantly proved that when this condition
is associated with an average physique, the development of
the dental organs is tardy, but in regular order.
We have before us, then, both the solution of the problem
and the evidence of most alarming symptoms in the physical
and mental condition of the inhabitants of the centers of
civilization.
There can be no question that the Creator intended that
there should be perfect harmony in the development of the
physical and nervous systems, and that where such harmony
exists we come nearest to the standard of a perfect organiza-
tion. This harmony of organization or true balance of the
two systems demands that in the earlier years of life the
brain and the nervous system be held in abeyance to the
physical.
The healthier mental organization is of slower growth.
If, therefore, we find that a certain mode of life destroys this
harmony, breaks up this balance, there will follow necessarily
deterioration and destruction of the race; and this is based
on a well-recognized physiological law: if the brain and the
CAUSES OF IRREGULARITIES.
IRREGULARITIES PREVENTED.
25
nervous system are in an undue state of activity, the drain
upon the sources of nutrition will be at the expense of the
physique.
No force operating on the brain can interrupt or alter the
type or inherited model of the dental arch, after the first
decade of life. All cerebral disturbances occurring during
that period, showing mental aberration, we should class under
the head of idiocy-imbecility. After that period, such
manifestations come more properly under the head of lu-
nacy-insanity which might degenerate into imbecility or
idiocy. Consequently, neither lunacy nor insanity, in the
ordinary acceptation of the terms, can have any direct bear-
ing upon the development of the dental organs; but such a
condition would be most potent of evil if transmitted to off-
spring.
I do not hesitate to place it upon record that the next
generation will see more of abnormality in dental develop-
ment, and an increase of nervous and cerebral diseases, and
that the two are correlated and spring from the same cause.
It is too late to stop it in those who have passed infancy,
but it is not too late to modify and partially remedy the evil
in those now being born, and those who may be begotten
hereafter.
To fathers and mothers surrounded by luxury and flat-
tered with the precocity of their infants, which they are
stimulating to the last degree, we say: Do not under peril
encourage this brilliancy, which is now so charming; let the
mind stagnate rather. For the first seven years of life give
concern only to his morals and to his physique. Nourish
him as you would nourish an animal from which you desired
the finest development, stimulating only his moral nature,
and his intellect will take care of itself. Thus, if he have no
hereditary taint, will be laid the foundation of a splendid
specimen of his race.
CHAPTER II.
CORRELATION OF IRREGULARITIES TO IDIOCY.
A FEW years since, Dr. Langdon Down, physician to the
Earlswood Asylum for Idiots near London, reported the re-
sults of his investigations into the dental development of
nearly a thousand feeble-minded youths who had come under
his observations. His examination satisfied him that there
was always narrowing between the posterior bicuspids of the
two sides and inordinate vaulting of the palate; the only
exceptions being certain macrocephalic idiots, in whom the
mouth like the rest of the cranium was extraordinarily large.
In a paper read before the Odontological Society of Great
Britain, he says:
"A marked character of the teeth of idiots is their irregu-
larity as to position. They are often crowded, so crowded as
to present their sides instead of their anterior surfaces. They
are often arranged on different planes. The canine teeth are
frequently unduly prominent, and a marked sulcus is some-
times seen between the incisors and canines, with prominence
of the incisors.
•
"Of the most significant value, however, is the condition
of the palate. I have made a very large number of careful
measurements of the mouths of the congenitally feeble-
minded and of intelligent persons of the same age, with the
result of indicating, with some few exceptions, a markedly
diminished width between the posterior bicuspids of the two
sides.
"One result, or rather one accompaniment, of this nar-
27
rowing, is the inordinate vaulting of the palate. The palate
assumes a roof-like form. The vaulting is not simply ap-
parent from the approximation of the two sides; it is abso-
lute, the line of junction between the palatal bones occupying
a higher plane. Often there is an antero-posterior sulcus
corresponding to the line of approximation of the two
bones.
THEORIES OF DR. DOWN AND MR. TOMES.
“An appeal to the condition of the mouth is an impor-
tant aid in determining whether the lesion on which the
mental weakness depends is of intra-uterine or post-uterine
origin. In the event of the mouth being abnormal, it indi-
cates a congenital origin; while if the mouth be well formed,
and the teeth in a healthy condition, it would lead to the
opinion that the calamity had occurred subsequently to em-
bryonic life."
Subsequently, Mr. Charles Tomes, in an essay "On the
Developmental Origin of the V-shaped Contracted Maxilla,"
based upon the investigations of Dr. Down, undertook to
trace the phenomena back to their origin and explain them.
Such opinions advanced by such distinguished authority
I should have accepted unhesitatingly, did not my own ex-
perience fail to endorse them; for during a period of twenty-
five years I had been noting and treating all forms of abnor-
malities, and the V-shaped or contracted arch was universally
associated with a higher order of intelligence. On the very
day of this writing, I examined the mouth of a lady in which
there were seen contracted and V-shaped arches in both upper
and lower jaws of most decided character. The lady was
one of unusually well-balanced mind and of a superior order
of intelligence. No ordinary observer could possibly associ-
ate any feebleness of intellect with the abnormality in the
person of this lady. Furthermore, in a large majority of the
contracted dental arches which have come under my obser-
vation and treatment, I do not believe that the maxilla were
affected.
In the widening of a dental and alveolar arch no pressure
28
VARIETY OF NORMAL TYPE.
brought upon teeth will perceptibly affect their osseous basal
structure. If the maxillæ were actually pinched, the widen-
ing of the dental arch would be likely to produce external
deformity.
Having some doubts of the correctness of the inferences
that had been drawn upon this subject, I undertook, a few
years since, a somewhat extended investigation to collect evi-
dence bearing upon the subject. In entering upon an inves-
tigation of this kind, with a view of demonstrating a fact in
science, it is of the utmost importance that there be no am-
biguity of language or terms.
I have heretofore spoken of the normal type of the den-
tal arch being a regular curved line. I wish now to state
that the absolutely perfectly regular line is very rarely found
in either ancient or modern skulls. To be more explicit, it
will be found that nearly every case which would be pro-
nounced regular by an expert on looking at it, will show
variations when put to a mathematical test. For instance, if
a piece of soft wire be bent around the outside of the circle
so as to touch every tooth, it will show places indicating that
certain teeth are either within or without the line, and yet
the deviations are so little as to be hardly observable by the
ordinary critic. Such deviations as this I do not class under
the head of irregularities, because they are no more out of
the limit of normality than are the varieties of feature in
different members of the same family. Furthermore, it is
not certain that they are in any sense developmental in their
origin; and if not, they can not be used as an argument in
an investigation into development.
My own opinion is that, with the exception of inherited
deformities, almost all cases of slight peculiarities of position
result from the accommodation of articulation with the op-
posing jaw.
We remember the anomalous position of the teeth before
eruption; if they continued to grow in the same direction,
great general disorder would be the result. That they ever
METHODS OF INVESTIGATION.
29
come perfectly into line, is due partly to the enlargement of
the jaw encouraging it, and partly from articulation with the
antagonizing teeth on occlusion. As it is only inclined sur-
faces that come in contact, we can readily see that a jaw
which has the full measure of natural tendency to regularity,
may thus show some deviations as the permanency of the
structure is attained. A peculiar rotary movement in masti-
cating, when teeth are erupting, may be sufficient to throw
a bicuspid ever so slightly out of position, which malposition
may be considerably increased or may be corrected by con-
tact with the opposite tooth on occlusion.
In my investigations I used pieces of thick cardboard
cut about two and a half inches square, which were inserted
in the mouth, the teeth closed, and with a pencil a line was
drawn around the circle and close to the teeth. In this
diagram both the size of the arch and its form were indi-
cated. Such an examination was made of hundreds of youth
above twelve years of age in our public schools, where I
found as great a variety of nationalities probably as I would
in any quarter of the globe. The investigation included the
inmates of the Asylum for Idiots on Randall's Island, and
subsequently some weeks were devoted to an investigation of
cretinism in Switzerland, and an examination of idiots found
in the various asylums and hospitals of Paris, and to a more
limited extent in Great Britain. The results were briefly as
follows:
In private practice I have seen a very large aggregate of
dental deformity, and in most instances associated with an
intellectual capacity above the average of mankind. These
abnormalities have not been confined to any prevailing type,
but have included nearly every possible variety of irregular
development. In the public schools, among the middle and
lower classes of society, I have found but a small percentage
of pronounced irregularity. Such as I have found was in
nearly every case among the brightest children of the schools.
Among the children of good physique and fair mental ca-
I
30
JAWS OF CRETINS.
pacity the development was on the whole regular and nor-
mal, a noticeable fact being that the jaws were generally
capacious and ample for the regularity of the teeth. In an
occasional instance there might be found a jaw of undue
capacity, and with separated and straggled teeth. One in-
stance of this kind was particularly marked, and, on making
inquiry of the principal as to the status of the scholar, I was
told that she was the dullest one in the school of over three
hundred, and, although of an age to justify an entrance into
the highest class, she could not rise above the lowest.
Among the cretins, capacious jaws were universal.
In the examination of idiots I endeavored to separate
those where the mental defect dated from birth from those
who in infancy showed the average mental capacity, and
who from accident or disease afterward degenerated into
imbeciles. No more reliance is to be placed upon an exami-
nation of the jaws and teeth of the latter class, in a question
of development, than upon an examination of the inmates of
an insane asylum.
Confining myself to congenital idiocy, I found only a
small percentage of pronounced irregularity in form of the
jaws or arrangement of the teeth, and that generally asso-
ciated with the lowest type of idiocy and the kind of which
mental improvement was the most hopeless. Associated
with deformities of the jaws were usually other abnormali
ties of physique showing a general constitutional disturb-
ance. Only among idiots drawn from the higher classes in
Great Britain were there found exceptions.
The examination of some two hundred inmates of the
asylum on Randall's Island did not show a single pronounced
case of V-shaped dental arch, such as is shown in Fig. 2. I
saw but very few cases of narrowed palatine arch; there were
but three or four of saddle-shaped palates, i. e., where the
sides of the palate approximated in the bicuspid region, such
as shown in Fig. 3.
There was but little irregularity in the positions of the
EXAMINATION OF IDIOTS.
31
teeth; very few teeth that were out of line, whatever that
line was. The little malposition that I saw was generally
FIG. 2.

confined to the six front teeth; of these six, the lateral in-
cisors were more generally at fault, being inverted, everted,
FIG. 3.

or twisted. It was not a common thing to find the canines
out of line. Many of the malposed cases were those where
3
CAPACIOUS JAWS OF IDIOTS.
32
the teeth were still erupting, and did not show such abnormal
position that I would have felt justified in interfering if the
patient had been brought to me for treatment. There was
every reason to hope that when fully developed they would
appear in good position. There were also many cases of re-
tarded dentition.
There was no more irregularity, decay, loss of teeth, or
neglect, than I have seen in the same number of youths
picked up from the street. The prevailing impression was,
that I had seen an unusual number of well-developed jaws;
they would average larger than the fully developed jaws of
the average of my patients; and that they were above the
average for density and probable durability.
The dental arch was generally a broad and regular curve;
the variations from this, but within the range of normality,
were a smaller circle, anterior to the bicuspids, and straighter
lines behind them. The lower jaw corresponded with the
form of the upper in nearly every case, and therefore the
articulation was almost always good. There were three or
four cases (those with saddle-shaped palates) where there
was a narrowed or somewhat pinched condition of each side
against the first molar, with which the lower jaw did not cor-
respond, and the lower teeth articulated there outside the
upper ones. Associated with the last-named peculiarity,
there were four or five where the superior incisors appeared
tipped up, as in the so-called thumb-sucking cases, and which
it is quite possible were caused by sucking habits; in some
of them a vertical gap, of from one quarter to three eighths
of an inch, between the incisors of both jaws when the teeth
were closed, was observed. There were several cases where
the arch was well curved upon the right side, but the left
side showed a variation from that curve and a depression of
the line. There were more cases where the arch was de-
pressed on only one side than upon both. I did not see a
single case in which there was any abnormality of size or
shape of the jaws before the eruption of the permanent teeth.
DISORGANIZATION IN ABSOLUTE IDIOCY.
FIG. 4.
33

I was informed that a very considerable number of these
patients are of Hebrew extraction. The others are made up
from nearly all civilized nationalities.
FIG. 5.

From conversations with those in charge of the educa-
tion of the idiots, I was able to note the intellectual status
of the patient and the corresponding condition of the dental
34
JAWS OF AN ABSOLUTE IDIOT.
organs. It was thus I discovered that, in those cases where
there was a fair physical constitution and development, the
intellect in a progressive state, and considerable hopes enter-
tained of mental improvement, the jaws and teeth were in a
normal condition. As the scale descended until we arrived
at that melancholy condition of absolute idiocy upon which
all improvement was hopeless, I found jaws and teeth, and
in a measure the whole physical condition, degenerate. Thus
did I see the extremes and the gradations, beginning with a
sluggish or feeble mind, in a fair organization with well-
developed jaws, descending in regular sequences through all
the grades of imbecility to unconditional vacuity, associated
with corresponding disorganization and degeneracy of the
teeth, jaws, and whole physical system.
The accompanying cuts represent casts illustrating these
extremes in the dental development of idiots. Both these
subjects were found in the asylum on Randall's Island, and
both are congenital idiots.
Figs. 4 and 5 show the form of jaws and arrangement of
teeth in the mouth of John Rowse, an idiot of the lowest
type and incapable of improvement. He was born in 1843,
weighs now seventy-two pounds, and is four feet seven and
a half inches high.
Figs. 6 and 7 represent the jaws of a boy fourteen years
of age, of full average height and good physical organization.
The record shows him to be "disorderly and wild; incapable
of improvement under special training."
The examination of between three and four hundred of
the inmates of the Paris asylums showed substantially the
same results as that in this country.
I also visited Dr. Down's private asylum near London,
and together we made a careful examination of every inmate
of the institution, with a result not so widely different as I
had supposed must exist. There was, to be sure, a larger
percentage of irregularities of the teeth than I had before
observed. About five per cent. might be said to be pro-
USUAL TYPE OF IDIOTS' JAWS.
nounced cases of narrowed or V-shaped arches, and another
five to ten per cent. might be said to have more or less ten-
C
20
FIG. 6.
35

dency in that direction; but of the more positive cases I did
not see one so marked as I have seen and treated in private
FIG. 7.

WWW of
practice, and associated with full intellectual development.
Of the total number, I could not pronounce one half, or
36
fifty per cent., as showing an irregularity of dental develop-
ment out of the range of normality, or that might not have
arisen from accidental causes operating on the crowns of the
teeth after eruption, and therefore only incidentally con-
nected with idiocy and in nowise correlated thereto. In
this way only is to be accounted for the difference of
opinion which existed between us upon many cases which
seemed to him an unduly high vault to the palate, narrowed
arch, or irregularity, but which to my eye came clearly within
the limit of normality. Nevertheless, there was no mistaking
the fact that there was a larger percentage of the kind of
deformities which he had described than I had found in any
other collection of idiots. This type of idiocy seemed to be
the result of a long line of hereditary transmission occurring
in the higher walks of life, brought about by various causes;
showing itself first in an overwrought nervous system and
a stimulated mental activity transmitted to children in an
exaggerated form; showing also coincidently in the chil-
dren irregular dental development, and the evils further
increased by transmission, and finally ending in a complete
break-down of mental power.
By a comparison of my observations of idiots with those
of all ranks and conditions in life, as represented in our
public schools, I found that, taking the idiots as a class and
comparing them with the lower orders of society as found in
this country, there were no more irregularities in the one than
in the other. In both cases did I find that amply developed
jaws and teeth were the rule, and narrow, pinched, and
V-shaped maxillæ and dental arches were the exception.
And this was equally true of the idiots in France and of the
cretins in Switzerland, among whom I did not see a single
case of narrowed arch or high-vaulted palate.
In Dr. James W. White's report of a visit which he
made to the Pennsylvania Training School for Feeble-
Minded Children he says: "In the mouths of some of
the inmates-especially those whose mental development
TYPE SEEN IN GREAT BRITAIN.
1
37
was little above zero-there were teeth which, for size,
regularity, density, and perfection of form, would answer
as models. There were also teeth which were faulty in
every respect and relation; but on the whole we had to
admit they were about an average lot, neither better nor
worse than those of the same number of similarly neglected
people of ordinary intelligence."
Professor Stellwagen, of the Philadelphia Dental College,
visited the same institution, and says: "I examined the
mouths of ninety-seven males and eighty-seven females,
making in all one hundred and eighty-four patients. Among
these there was a very small percentage that, had they been
presented to me in my office, would have warranted inter-
ference in any manner as regards the regularity of the
teeth. . . . The jaws were unusually large as compared
with the same number of jaws in the mouths of intelligent
children-such as would seek the services of the dentist."
TYPE SEEN IN AMERICA.
Professor C. N. Pierce, of the Pennsylvania Dental Col-
lege, says: "While traveling through the Tyrol of Southern
Austria, and Lombardy, Italy, I had the opportunity of see-
ing a large number of cretins-disgusting, jabbering idiots
as they were, unable to articulate a word distinctly. By the
aid of a few small coins I obtained a hasty glance at the oral
cavity, which, though not critical or satisfactory, was suf-
ficient to satisfy me of an unusually large development of
both superior and inferior maxillæ, with an abundance of
room for the teeth. Opportunities have also not unfre-
quently offered for viewing the mouths of negroes, where
mental growth was far below the average, with a decidedly
retreating forehead; in such the jaws were invariably large,
the teeth far from crowded, and quite projecting. In my
regular practice, cases have not unfrequently occurred where
one or two in a family would have what might be termed
straggling teeth, or teeth standing alone with an unusually
wide space between them; while with other members the
reverse condition would predominate. In the former the
4
38
IRREGULARITIES IN DIAGNOSIS OF IDIOCY.
mental condition was always far below the latter, being a
marked reversion to a lower order of development.
""
In these apparent contradictions between Dr. Down and
other observers, it is difficult to form an opinion which will
reconcile the differences; and it might be just as well to
leave it as it is, were it not for the startling conclusion
to which Dr. Down comes and its bearing upon the wel-
fare of the community. In his essay he says: "It was in
my inquiry into the condition of the teeth and mouth espe-
cially, that I arrived at the conclusion that, in by far the
larger number of instances, I was able to indicate the period
at which the depressed condition commenced, and to predict
in some degree the amount of improvement which phys-
ical, intellectual, and moral training might possibly effect.
In children where idiocy is accidental, arising from causes
operating after uterine life, there is but slight deviation
from a normal condition in the state of the mouth and
teeth; while it is in those whose malady is congenital, espe-
cially where arising from causes operating at a very early
period of embryonic life, that the deviation of the mouth
and its appendages from a normal condition is most pro-
nounced."
The bearing of this opinion may not seem at first of much
consequence, but it becomes of the utmost importance when
applied, as it has been by Dr. Down, in determining the
mental capacity of an heir to manage his estates. In such a
case the contracted condition of the mouth was the deciding
point of evidence, in the opinion of Dr. Down, that the
patient was a congenital idiot.
We do not believe that any irregularity in the position of
the dental organs is any evidence per se of idiocy in the
individual. The cases are so common where such deformi-
ties are found associated with the highest order of intel-
ligence that, if we are to draw any inference from that
condition in the abstract, we should say that it was more
likely to indicate a precocity of mental development, with a
POSSIBLE CORRELATION OF IRREGULARITIES TO IDIOCY. 39
stimulated emotional nature in the child, and possibly a more
brilliant intellect in the adult. There are so many cases
where the proof is incontestable that the idiocy is of con-
genital origin and where the dental development is perfect,
that we can also reasonably say that the regularity of the
dental organs showed conclusively that there had been no
lesion or cerebral disturbance (in the true sense) after birth,
but that the teeth grew in accordance with physiological
laws under a low order of intellect.
We do not see any connection between these phenomena
and causes acting especially "at a very early period of em-
bryonic life," when we consider that the deciduous teeth are
well arranged, and that it is only after they pass away that
abnormality appears; also, as it is only at the very latest
period of embryonic life that even the germs of the perma-
nent teeth are found, it is difficult to conceive the connection
or correlation. If the cause antedates the birth of the child,
we should seek for its origin not during intra-uterine life, but
in a like deformity existing in the parents or ancestry, which
may appear exaggerated in the child under favoring circum-
stances. An inherited taint, disturbance, lesion, predisposi-
tion, or tendency to idiocy (of which these irregularities may
be a symptom, but not a proof) may show itself in a preco-
cious mental development in one instance, and be the pre-
cursor of insanity in the same individual, or appear as idiocy
in posterity.
CHAPTER III.
DIAGNOSIS.
MUCII of the success in treating irregularities will depend
upon a correct diagnosis and prognosis.
This is one of the most difficult problems in the practice
of dentistry, and its proper performance must take into con-
sideration the efficiency of the masticating apparatus, the
enunciation of the voice, the organism of the teeth, the rav-
ages of decay, the family type, and the relation of the features;
the constitution, temperament, and systemic condition of the
patient; the sex, age, and social status; the causes of displace-
ment, whether accidental, congenital, or hereditary; the
means and appliances for correction; the time, trouble, and
skill required of the operator, and the time, annoyance, and
endurance of the patient; the risk of inflammation and of
destruction of pulps; and, finally, the character and perma-
nency of the change wrought.
It is not a question of the ability to bring one or more
teeth into the line of a regular dental arch, so much as it is,
Will the result, when obtained, be permanent and justify
the means used? For example, a bicuspid or a canine in a
person of mature years may be turned upon its axis to the
extent of a quarter of a circle; the mechanical difficulty in
returning it to its place being in some instances very serious,
involving much time, ingenious appliances, and often the
perforation of the enamel for a pin to obtain an attachment,
and the result being no probable gain to its masticating
an
PERFECT UNIFORMITY UNNATURAL.
41
power nor its preservation, and so little benefit to the appear-
ance as to be of doubtful expediency.
Cases are constantly coming before our observation where
most remarkable achievements are within the scope of scien-
tific skill, but where a conservative view would not justify
the means required to produce such a result. Neither can
it be asserted incontrovertibly that all irregularities in the
position of teeth are deformities, and require our interposi-
tion. A fine æsthetic taste may maintain that there are mul-
titudinous departures from a normal type where neither the
utility nor the beauty of these organs, nor the symmetry of
surrounding features, is seriously affected by the malposi-
tion.
Nowhere in developmental nature will we find mathe-
matical uniformity in size, shape, or position. The trees of
the forest take every conceivable form within the limits of
their type. No two leaves are precisely alike. The two
sides, even, of every leaf differ in outline. Every human
figure differs from every other human figure; face from face
-even the two sides of the same face are not mechanically
mated. Variation from mathematical precision in nature is
universal, and any appearance of absolute regularity always
suggests the interference of man.
The eye soon tires of the stiffness and formality of un-
broken uniformity, and is only permanently pleased with the
beauty which comes from graceful variation. If it were pos-
sible to bring all dental arches to one standard of arrange-
ment, deformities of facial expression would probably be
more common than now. An apt illustration of such a
result is found in the limited variety in form of the artificial
teeth in the market, and the still more limited skill in ar-
ranging and adapting them for service; consequently, there
are seen all over the country prevailing patterns of teeth
made in rows, devoid of grace, and inserted indiscriminately
in the mouths of the beautiful and the mouths of the
ugly.
1
42
RETENTION OF EVERY TOOTH UNNECESSARY.
Esthetically considered it can hardly be claimed that a
dental arch with all the teeth in contact is positively more
beautiful than one where slight spaces occur, while expe-
rience is uniform in showing that in this age of degen-
erate teeth their durability is much enhanced by separa-
tion.
An erroneous teaching has maintained that the full num-
ber of teeth must be retained in the mouth, regardless of
their organization, the progress of decay, the limited capa-
city of the arch, or the external features.
G
Two arguments are advanced to support such a judgment:
First, that a certain number of teeth are developed by nature,
and therefore every one must be preserved. Such an opinion
might be of some force if we were passing judgment upon a
normal condition of the human race, but, as the condition we
are considering is wholly abnormal, the argument is of little
value. A second argument in favor of the retention of all
the natural teeth is, that the alveolar arch and the associated
maxilla will become contracted, narrowed, pinched, as the
result of such loss, consequently the articulation of the teeth
broken up and the efficiency of the masticating organs im-
paired.
An experience of sufficient length to determine results
has shown very conclusively that the retention of every tooth
in the mouth is not necessary to the efficiency of the masti-
cating apparatus, is not required to maintain the contour of
the jaw, and the loss of certain teeth produces no visible ex-
ternal effects.
I have heard the statement gravely made in an association
of dentists that the extraction of the first permanent molar
produced such an effect upon the facial features as to be al-
ways perceptible, and that in a community where such dental
practice was common the individuals who had lost their first
molar teeth could be readily distinguished in an assemblage
from those who had not. Such an absurd statement would
be hardly worth repeating except to show how the imagina-
CORRECT ARTICULATION OF PARAMOUNT IMPORTANCE. 43
tion overleaped all reason. It comes within our daily ob-
servation that one half the masticating power of the den-
tal apparatus is not utilized, it being the exception that
patients use equally both sides of the mouth, and this
without any apparent detriment to digestion or general
health.
The articulation of masticating organs is of much more
importance than their number, and a limited number of
grinding teeth fitting closely on occlusion will be of far
greater benefit to the individual than a mouthful of teeth
with the articulation disturbed.
It requires a profounder knowledge than most of us pos-
sess to decide always upon the wisdom of extraction, and
when such conviction is settled the judgment may be equally
at a loss as to the choice of teeth to be removed.
It is a disputed point as to which of the teeth behind the
six front can be best spared from the mouth; the arguments
being principally for or against the retention of the first per-
manent or sixth-year molar.
There are so many considerations to be taken into account
that it is hardly possible to lay down any rule of universal
application. If the sixth-year molars are badly decayed, their
removal would be indicated. If they were sound, and also
the bicuspids, there might be no greater reason for their
removal than either of the bicuspids. In fact, sound molars.
in the jaw are of more value as masticating organs than
equally sound bicuspids.
Narrowing the decision to the bicuspids, there can be no
general reason given for selecting one in preference to the
other for appearance' sake. The two teeth are so nearly alike
that they might change places without detection; and, there-
fore, if the mechanical difficulties in treating an irregularity
were lessened by the choice of one, that would be sufficient
to determine the course.
As a general rule, extraction of any teeth from a pinched
or V-shaped jaw before it is widened would be likely to prove
44
bad practice. Certainly the extraction of any teeth from the
sides of the jaw in such cases for the purpose of correcting
or improving the condition without immediate subsequent
steps being instituted to widen the arch would be most un-
scientific and detrimental.
BAD PRACTICE ILLUSTRATED.
The following case, taken from Tomes's "Dental Sur-
gery," illustrates the want of foresight in such a proceeding.
FIG. 8.

Mana
Fig. 8" shows a case in which the V-shaped conformation was
attended with unusual contraction in the neighborhood of
the bicuspids and first permanent molar teeth. On the left
side both of the bicuspids were removed, and in the right
the second bicuspid (and lateral) was extracted without any
advantage being gained as regards the contracted condition
of the palate."
Such a case may be likened to an arch where the stones
have become loosened and displaced, but, still impinging upon
each other, the integrity of the arch is maintained. Remove
now any one of the stones, and the whole collapses in abso-
lute ruin.
There are many cases where the utility of the dental ap-
paratus would not be seriously impaired by the extraction of
one or more teeth, even in the forward part of the mouth.
For example, there are cases of a very regular arch and good
EXTRACTION OR RETENTION IN DOUBTFUL CASES. 45
articulation with the lower teeth, but with both laterals en-
tirely within the line, the canines being on the line with all
the other teeth nearly or quite in contact, and the occlusion
good. Such cases sometimes occur from the development of
large teeth, out of all proportion to the size of the maxilla
and to the facial features, and where the expansion of the
arch sufficient to admit them into line without the removal
of any teeth would result in increasing the size of the jaw to
a deformity. In such cases the considerations are purely
æsthetic; the usefulness of the masticating apparatus would
not be affected.
Whether the correction shall be reduced to the simple
surgical operation of removing the laterals, or whether it is
better to extract one of the side teeth and introduce mechani-
cal appliances with all their attendant objections, can not be
decided in the abstract, and can only be determined by the
operator, whose judgment must take cognizance of considera-
tions before referred to.
Such cases, in my own practice, have been treated both
ways, and often with the feeling that the greatest benefit to
the patient might possibly have been derived from the other
course.
In extensive deformities of inherited origin the extent of
the correction must be governed much by the probable effect
upon the external features, for there can be but little justifi-
cation for creating a deformity of one feature in the process
of correcting a deformity in features less exposed.
When the abnormality can be clearly traced to the parents
or ancestry, the course of treatment may be varied from what
it would be if caused by influences operating subsequent to
birth.
In a transmitted tendency arising from the mixing of
inharmonious types, as the small jaw of one parent with the
large teeth of the other, resulting in a crowded condition, it
is very doubtful if the arch can be made regular without the
extraction of some of the teeth.
"
46
EXTRACTION UNJUSTIFIABLE.
Again, a transmitted deformity may show itself in teeth
which may not be too large for their proper relation to the
facial bones and features, but may be placed upon a maxilla
too narrow for a symmetrical dental arch, showing itself in a
narrowed palate in the upper jaw and often associated with
a lower jaw abnormally wide.
The attempt to widen the upper arch in such a case to
the extent of establishing its proper relation to the lower
teeth would probably end in failure, or if successful in get-
ting the proper enlargement, might result as in the former
case in producing deformity of the external features.
If extraction is indicated, as it might be in a case of in-
herited origin where unduly large teeth were crowded upon
a small maxilla, the selection of the tooth or teeth to be sacri-
ficed would be less difficult after a close observation of all
the articulating surfaces on occlusion.
While in many cases there may be very grave doubts
about the removal of teeth for regulating purposes, there are
others where extraction can not possibly be beneficial and
when to do so would be little short of a crime.
For example, there came to me for consultation a lady
belonging to a well-known family in this country, bringing
her daughter, about fourteen years of age, with a full mouth
and moderately prominent teeth in both jaws. The teeth
were regular in the arch and the articulation was good, and
the only criticism would be upon the prominence of the teeth
and the consequent expression of the mouth.
The arrangement presented to my mind every evidence
of an inherited characteristic.
The desire of both mother and daughter was to have the
undue prominence reduced. My diagnosis of the inherited
character of the presentation was sustained by my memory
of her uncle and her grandfather, whom I had met, the ex-
pression of whose mouths was identical with the young lady's
before me, although the father of the young lady was unlike
the other members of the family in this respect.
47
I declined to interfere, on the ground that whatever I
might accomplish would be but temporary. The tendency of
the jaw would be continually toward the inherited type, and
ten years from this time the mouth would probably present
the same expression as if nothing had been done. But in
that mouth was exhibited the egregious blunder of a dentist
who had extracted from the lower jaw the first permanent
molars on each side, both teeth being perfectly sound, and
all the teeth articulating most accurately with those of the
upper jaw, all of which were also sound. The explanation
of the dentist was that he did it to allow the ten teeth for-
ward of the space thus made to fall back, and thus reduce the
FIG. 9. (Case I.
ILLUSTRATION OF BAD PRACTICE.

3
prominence of the mouth. The fallacy and absurdity of such
an expectation needs no comment. With a view to illustrate
this subject further, some cases from practice are here intro-
duced. Fig. 9 represents the teeth of a young lady thirteen
years of age. The features externally were regular except-
ing an undue prominence of the upper lip over the canines;
the articulation of the teeth was not defective; the arch in
both jaws was of sufficient capacity for distinct enunciation,
and the teeth in the upper jaw were nearly in contact, but
between the lateral incisor and first molar on each side there
was but one tooth, viz., a bicuspid-the other bicuspid and
the canines were crowded out.
48
EXTRACTION JUSTIFIABLE.
At the period at which this model was taken no history
of the missing bicuspid could be obtained. The patient was
uncertain about teeth which had been previously extracted,
and there was no external evidence of the teeth being unde-
veloped. Believing, from a careful observation of all the
appearances, that the bicuspids were hidden in the jaw, and
could not emerge with the teeth crowded as they were, the
first molar on each side was taken out to make room, and
because they were defective. An apparatus was applied and
the canines were brought into line, the first bicuspid being
crowded back to make room. In a few weeks the missing
bicuspids made their appearance in the gaps of the extracted
FIG. 10. (Case II.)

molars, and at this day the arch is full of sound teeth in reg-
ular order and close contact.
Fig. 10 represents the mouth of a young lady of fifteen.
The arch is capacious, and the articulation of the masti-
cating teeth would have been good but for the fact that she
had worn some badly-adapted regulating plates before she
came into my hands, which had permitted the last molars to
elongate.
The six front teeth in both jaws were crowded and
irregular, and the lower lip had an undue prominence. My
study of the case brought the conclusion that, if the lower
teeth were all brought into line, the arch would be enlarged
1
EXTRACTION NECESSARY.
49
and the deformity of the lower lip increased; if, added to
that, the upper teeth were all advanced over the lower ones,
the mouth would be made very ugly. The treatment left
the upper teeth without change except to bring the laterals
into line, and the prominence and irregularity of the lower
teeth were corrected by the extraction of the right central
incisor and bringing the others into line. The result was a
perfectly even row of teeth, and no one would notice the
loss of the incisor except by a studied observation.
My third example (Fig. 11) is that of a young lady of
small stature and spare face. The model shows large teeth,
FIG. 11. (Case III.)

MH
INTA
B
a narrowed arch, but with good articulation. But on the
upper jaw the canines are crowded completely out of line,
while on the lower jaw there is a generally jumbled position
of all the front teeth. Believing that both the narrowed
arch and the crowded state of the teeth were abnormal con-
ditions, the superior arch was expanded sufficiently to bring
the teeth into line. It then became apparent that while one
deformity had been removed a new one had been created.
The expanded dental arch was a disfigurement. It was out
of harmony with the external features. The mouth, when
opened, gave the appearance of "too much teeth." The
50 SIMILAR CASES REQUIRING DIFFERENT TREATMENT.
continuation of that treatment was abandoned; a bicuspid
was taken out on each side, and the irregular teeth were
brought on to substantially the same line as before treat-
ment. The articulation of the masticating surfaces was pre-
served, and the expression of her mouth followed her family
type.
My fourth illustration (Fig. 12) shows a very irregular ar-
rangement of the six front teeth of the upper jaw, involving
also four others. The irregularity of the six front teeth is
manifest at a glance; but the bicuspids were also malposed,
being inside the proper articulation of the lower teeth.
FIG. 12. (Case IV.)

Face
✩✩✩
TANGENT OF THEM WITH THE
No teeth were extracted here for regulating purposes;
the first molars were removed because they were badly
decayed, their pulps exposed and diseased. Appliances
were used, and in exactly eight weeks from the commence-
ment of the work all the teeth were brought into perfectly
regular arrangement.
My fifth example (Fig. 13) shows a condition so nearly like
the last that only a long experience and a deep insight into
the future could have suggested a different treatment. Such
a judgment I did not possess. The case called No. 4 was
that of a miss about thirteen years of age. The case now
under consideration was that of a lad of the same age. The
·
ILLUSTRATION OF QUESTIONABLE TREATMENT.
course of treatment attempted was substantially the same;
varied, however, continually, as the means employed failed
to produce the full result expected. I gave this case my
undivided consideration, but, instead of producing a satis-
factory result in eight weeks' time, it was more than eighteen
months before I ceased giving it active attention. In the
mean time I had been on the verge of sacrificing the very
organs I was attempting to preserve. I had seen both lateral
incisors loosen and elongate more than half the length of
their crowns—so loose that I feared they would drop out—
and their preservation was so apparently impossible that I
suffered in advance all the mortification of a failure; but
ORGAN
FIG. 13. (Case V.)
51

they were retained and driven back to their position by
appliances, and ultimately the result was a regular arch, all
the teeth in line without elongation or loss of vitality. But
I am firmly convinced that what I ought to have done in the
beginning was to have extracted the lateral incisors, when
the canines would have dropped into line without extraneous
aid.
My sixth and last illustration (Fig. 14) is the case of an-
other miss of about the same age. This presentation is en-
tirely unlike any of the preceding ones. The upper incisors
are exceedingly prominent, while the lower jaw is excessive-
ly retreating or under-hung. This discrepancy in the rela
CASE OF UNDER-HUNG JAW.
52
tion of the jaws is seen in the model of the case, Fig. 14, and
also in a cast of the profile, Fig. 15. This case was brought
FIG. 14. (Case V1.)

1/11/
to me by a gentleman of excellent attainments in our pro-
fession, and I made an appointment to examine the patient
FIG. 15.
"

try, not stand on to f
and form a plan of treatment. After a careful study, I
came to the conclusion to extract a tooth on each side of the
SUMMARY OF ARGUMENTS.
53
upper jaw previous to the reduction of the anterior promi-
nence. The necessities of such a removal were clear in my
own mind, and the step was delayed only as a matter of con-
venience. In the mean time I made the models here illus-
trated, and continued my study of the subject from the
models. The result of which was that I saw that extraction
was not indicated, that it could do no good, but, if done,
would produce positive harm. What was required was a
little widening of the arch, a flattening of the superior in-
cisors, and a "jumping of the bite"; and the extraction of a
tooth could in no wise contribute to such a result.
These six examples illustrate the following points, viz.:
Every case of considerable irregularity of the teeth shows
peculiarities which make it differ from every other one of
similar aspect.
A diagnosis and a prognosis can not be made without
giving the case more study and more reflection than has usu-
ally been deemed necessary.
An opinion formed by the most experienced observer on
a cursory examination may be changed upon a more careful
study of the features, the family type, and the model of the
teeth. I desire to call especial attention to this point, that a
correct opinion can rarely be formed from the models alone.
I am constantly called upon to indicate a line of treatment
for a patient whom I have never seen, and the only basis
given me being some very crude models sent by mail with
little or no explanation.
It is not always advisable to attempt to change the ex-
pression of a mouth where the condition is an inherited
peculiarity, a part of the family type, and where the change
would involve very prolonged effort, possible breaking up of
a good articulation of masticating organs, and with the
knowledge that nature will be constantly making an effort
to return to the hereditary type.
In patients who have by inheritance small features
and small jaws with large teeth, and a tendency to over-
5
SUMMARY OF ARGUMENTS.
54
lap or to be crowded out of line, the extraction of a pair
of teeth is indicated rather than the enlargement of the
arch.
Cases are of frequent occurrence, which show that a
pair of any of the teeth in the mouth may be removed
to correct an irregularity, excepting the canines of both
jaws and the superior central incisors. It would be an
inconceivable case which would justify the extraction of
the superior central incisors; but the upper lateral in-
cisors and any pair of the lower incisors may be removed,
in certain cases, without serious detriment to the appear-
ance of the mouth.
It is not necessary to the contour, symmetry, or harmony
of the features that every one of the masticating organs
should be retained in the mouth.
In the treatment of irregularities, the comfort and per-
manent good of the patient are secured in larger measure by
not moving organs that are not themselves offending mem-
bers.
It is often better to extract a malposed tooth than disturb
a whole arch to bring it into line. In such cases as are rep-
resented by my fourth and fifth examples, other things
being equal, the question of sex should make a factor of the
prognosis. The fourth illustration was of the mouth of a
young lady with regular, handsome features. The extrac-
tion of both the canines or both the laterals from the upper
jaw would have left the arch full of teeth, but the defi-
ciency would likely have been observed, and would have
marred her beauty all her life. In the fifth example we find
a lad likely to grow up with strongly-marked features and,
quite possibly, a hirsute covering, which might hide the
mouth completely. The articulation of the masticating
organs being good, the dental arch being broad enough for
distinct enunciation of speech, there remains but slight ob-
jection to the removal of the lateral incisors; and, when the
alternative is the risk to all the teeth involved in bringing
UPON DIAGNOSIS.
55
them into line, the weight of the argument is in favor of
removal.
A consideration not to be lost sight of is the tax upon the
nervous system. With appliances carefully and skillfully
adapted, and with proper vigilance in their attention, the
strain upon the nervous system need not be serious, and
need not be sufficient in itself to decide against treatment;
but, in connection with other considerations, it may become
an important factor.
Of minor importance, and yet not without weight, is the
condition in life of the patient.
In a purely scientific view the social standing of the
patient can have no weight, but in a conservative view the
present and probable future position of the patient in society
must necessarily influence the treatment. If of a low order
in both social scale and intellect, associated as it generally is
with a total lack of appreciation of the benefit conferred,
and with but little hope of advancement in either direc-
tion, the æsthetic considerations would be of little impor-
tance.
The utilitarian would naturally be the chief object. The
children of a charity hospital may be largely benefited by a
limited and comparatively inexpensive treatment, while such
a course would not be justified if applied to the daughters
of refinement and exalted social position.
And lastly comes a consideration which neither the pur-
poses of science nor the philanthropic and humanitarian
view entitles to enter into a diagnosis of the case, but
which, as society is now organized, can not in all cases be
ignored.
What may be of the greatest benefit to the patient, with-
out reference to the time and skill required of the operator,
may be one thing; how much of that time and skill he shall·
give without adequate remuneration becomes a question of
casuistry, and is a very different thing.
It is rightfully somewhat within the power of the patient
4
56
or those acting for him, to elect whether the more extended
treatment with the finer æsthetic results shall be undertaken,
with the consequent remunerative fee, or whether a more
limited benefit be accepted, and with less tax upon the
charitable disposition of the operator. Patients are not apt.
to value that which has been obtained at little expense, and
while in one view it is the duty of every honorable prac-
titioner to render in all cases only his most skillful service
without regard to fee, yet it will be often found that such
service was entirely unappreciated, and, considering all
things, not of sufficient importance to the patient to justify
the effort the chief benefit derived being an increase of the
practitioner's experience.
The remarks of the late Dr. Westcott, which will be
found on page 184, are worthy of careful attention.
REMUNERATION CONSIDERED.
CHAPTER IV.
PHYSIOLOGY AND PATHOLOGY.
THE movement of teeth in correcting irregularities is
based on an anatomical and a physiological fact. The ana-
tomical, that the teeth are placed upon the maxillæ surrounded
by vascular, elastic, bony processes, which are easily moved,
absorbed, and reproduced; the roots penetrating but little
into the true maxillæ, and in their movement affecting the
maxillæ but slightly if at all.
The physiological fact being that bone will yield or be-
come absorbed under certain influences, and also be repro-
duced.
That teeth can be moved and become firm in their new
positions, and that they are moved frequently at nearly all
periods of life, is a matter of common observation.
Teeth which have been used as supports for a plate with
clasps are very often, through the bad adaptation of the plate,
or through the strain arising from mastication on the artifi-
cial teeth, drawn away from their original places, and assume
and become firm in new positions.
In like manner we frequently find, where scattered teeth
are extracted from both jaws, the remaining ones change
position and assume new relations on occlusion.
So, from one cause or another, there is more or less
change of position going on through life, and not inconsistent
with their healthy retention in the jaw nor their firmness.
In moving teeth the power used creates a pressure which
produces absorption.
58
FUNCTION OF ABSORPTION AND REPRODUCTION.
The function of reproduction is nature's means of coming
to the rescue and restoring lost parts.
In correcting irregularities it is not probable that there is
any lateral movement at the apex of the root.
In that re-
spect it is virtually a fixed point. The tooth may be driven
up into its socket under pressure or elongated under strain,
but rarely, if ever, do we find evidence of lateral movement
at the apex. The greatest motion is at the cutting or grind-
ing ends, and the least at the apices.
The only exceptions I have ever seen or thought I saw
were where, in consequence of loss of front teeth, the molars
have seemed to travel bodily forward without tipping.
The function of absorption and reproduction may or may
not go on coincidently, simultaneously, and with equal ra-
pidity.
That bone will become absorbed under pressure, and that
bone must be deposited to fill up the socket of a displaced
tooth before it will become fixed in its new position, is used
as an argument that such a state exists always as a con-
sequence of change in the position of a tooth, and that the
success of the movement is dependent upon both these func-
tions. In a slow movement this is probably the case, in a
rapid movement it is doubtful.
To account for certain results which have been accom-
plished by this theory alone, we must believe that the func-
tion of reproduction goes on with greater rapidity than has
ever been proved.
For example, the superior dental arch has been fre-
quently enlarged to a considerable degree within a very
few days.
If the enlargement depended solely upon absorption and
reproduction, it would necessitate an entire change of sub-
stance in the external alveolar walls, as the movement has
often been sufficient to displace the process entirely; but we
see the bony covering remains intact, neither impaired nor
perceptibly diminished. By its integrity the vital connec-
M
•
MOVEMENT NOT DEPENDENT UPON ABSORPTION.
59
tion and condition of the teeth were maintained until nature
filled up the sockets behind them.
In a case now under observation, it is but forty-eight
hours (at the present writing) since I applied a fixture across
the roof of the mouth of a miss of thirteen years, for the
purpose of widening the dental arch.
It has already, by careful measurement, accomplished that
result to the extent of half the diameter of the bicuspids.
The patient says there has been no tenderness sufficient
to disturb her sleep nor interfere with her mastication.
No one for a moment will suppose that, coincident with
that outward movement, there has been an absorption of the
external alveolar wall to the extent that the movement in-
dicates.
If the movement is due alone to absorption, then repro-
duction must be equally rapid, as the external alveolar walls
bear all the evidence of undiminished integrity.
Nor is it altogether explained by the theory of Mr. Tomes
that the pressure has lifted the teeth partially from their
sockets, and, owing to the conical form of their roots, they
have simply moved against the farther wall. This hypoth-
esis may account for a limited lateral movement, but if
there were elongation we should discover it in soreness or
otherwise on the occlusion of the teeth. The circumstances
are analogous to the separation of teeth with wedges prepara-
tory to filling proximal cavities, which is performed every
day by dentists and at all ages.
In such cases any elongation of the teeth acted upon
would be immediately noticed.
Patients are very susceptible to the most trifling elonga-
tion, as is daily evidenced in finishing off fillings which are
inserted upon grinding surfaces, the removal of the diameter
of a hair often being perceptibly noticed.
If, therefore, this lateral movement of the teeth were to
be attributed to their being lifted from their sockets, its
effects would be shown in every case where the teeth were
60 MOVEMENT DEPENDENT UPON ELASTICITY OF THE ALVEOLI,
spread for filling, where there were antagonizing teeth; but,
so far from this being the case, we often find by the com-
plaints of patients that the soreness is not confined to the
teeth in contact with the wedge, but is distributed to several
contiguous teeth; very often the patient saying that a tooth
two or three removes from the wedge is the most painful.
Furthermore, the slight interference with the natural oc-
clusion of the masticating surfaces while the wedge is in the
mouth, is fully accounted for by a purely lateral movement
which breaks up temporarily their perfect articulation.
In a reverse movement, as for example the contraction of
the superior dental arch, we find no such rapid progress is
made as in an outward movement, for the reason that the
large body of bone resists the pressure as against both expan-
sion and compression.
It is probable that in the last-named movement we make
progress no faster than the bone is absorbed, and here we
get another proof that the function of absorption progresses
more rapidly than that of reproduction; for, while we may be
but a few weeks in carrying a tooth to a certain position, we
find it is as many months before deposition of new bone has
made it solid in its new location.
The enlargement of the arch can be accomplished with
great rapidity and with perfect safety; so rapidly as to pre-
clude the idea that the external walls of process are broken
down by absorption to permit it, and the only conclusion is
that the vascularity of the alveoli permits an elasticity which
allows the teeth to be moved outwardly, carrying the exter-
nal processes along with them.
This process is not necessarily absorbed at any subsequent
period, simply because pressure has been brought against it.
It has not been stretched beyond its powers of elasticity, no
sequestrum has been formed, and it will remain the same
process and continue to perform its functions until deposition
of new bone shall have filled up to it and the whole become
solid.
G
AS WELL AS UPON ABSORPTION.
61
Nevertheless there must be a limit to the rapid move-
ment of teeth outwardly, lest destruction of the process
ensue.
In the movement of the anterior teeth of the lower jaw
it is not probable that absorption plays any more important
part, either in expanding or contracting the arch. The pro-
cesses are so thin upon both external and internal surfaces
that they would be likely to yield before they became ab-
sorbed, and therefore the principal action would be one of
reproduction of bone to make them solid.
The movement of a single incisor or canine of the lower
jaw can be made inward or outward with much the same
readiness, save only that in an inward movement the tooth is
apt to bind on an adjoining tooth, and thus retard it. The
resistance of the internal and external alveolar wall is much
the same.
It has been maintained by some that teeth can not be
moved with safety faster than bone can be absorbed or repro-
duced, but an extended experience has shown that in the out-
ward movement of the superior arch and in the movement
in either direction of the anterior teeth of the lower jaw, the
idea is fallacious.
The functions of absorption and reproduction vary, how-
ever, very much at different ages and under different sys-
temic conditions, but are most active during the formative
period of the tissues, so that operations undertaken in youth
with impunity could not be carried out at other periods of
life without bringing the vitality of the organs acted upon
into jeopardy.
It may be assumed as a rule that as soon after eruption as
it becomes certain that an irregular denture is inevitable,
there is no longer justification for delay, and that after that
period every year increases the difficulties, both mechanical
and pathological, and prejudices the stability of the dental
apparatus. Consequently, if at the age of eight years one of
the superior centrals has locked within the lower teeth, im-
62
THE AGE FOR CORRECTING IRREGULARITIES.
mediate interference is demanded; there can be no good rea-
sons under ordinary circumstances for delay.
Every week strengthens the partially formed root in its
unnatural position, and the occlusion of the lower teeth will
prevent it by any possibility from ever assuming its true
place unaided. It might be argued in favor of a postpone-
ment of action that some of the other teeth may develop ir-
regularly at a subsequent period, and the necessity might
again arise for aid; but the answer to this is, that there is less
liability for the others to come in crowded if the front ones
are in line, and again it is impossible to foretell irregularities
that may need appliances for correction.
In some of the illustrations given in this work, it will be
seen that the author has not hesitated to undertake treatment
of very extensive irregularities, even while teeth were emerg-
ing from the gums.
It is not uncommon for parents to be unobservant of the
irregular condition of their children's teeth until the erup-
tion of the canines which so often appear high up on the
gum, and give the appearance of tusks.
If it is clear to the dentist that mechanical interference
is inevitable, it is better generally to begin as soon as they
have emerged sufficiently to get a bearing upon their surfaces.
The movement of teeth is comparatively easy at this age
and for one or two years following, but at seventeen, eigh-
teen, and nineteen, the action is slower, growing more and
more difficult, and in cases where a considerable number of
teeth are to be moved the results become more and more
doubtful with advancing years.
It is less so with one or two teeth, and there need be but
little apprehension of the results in such cases up to the
period of full maturity, particularly if the antagonizing teeth
would favor the change when made.
For example, a lady over forty years of age applied to
me for artificial teeth in place of the two central incisors and
the left lateral of the upper jaw. The right lateral was
63
remaining, in good condition and position, but the right
canine was very far within the arch and articulating inside
of the lower teeth-in fact, with a decided inclination to-
ward the roof of the mouth. As she was now compelled to
resort to artificial teeth, it was her desire that this life-long
deformity of the malposition of the canine should be cor-
rected by extraction, and its place supplied by an artificial
crown. As the tooth was a thoroughly sound one and the
mouth in a healthy condition, I proposed the experiment of
bringing it out into line; and, if sacrificed in the attempt,
neither the comfort nor the appearance of the patient would
be jeopardized. A plate of vulcanite was made, to which
were attached the required artificial teeth. This plate ac-
complished the double purpose of a support for the artificial
teeth, and a regulating plate, by the attachment of a jack-
screw, with the conical end resting in a little pit on the
lingual surface of the misplaced canine. In one week the
canine was forced outside of its articulation with the lower
teeth and into its true dental line. There was no more sore-
ness than is common in wedging teeth for filling. There
was no more elongation, and no subsequent loss of vitality.
A new plate of gold was made, which served as a retain-
ing plate and for the support of the artificial teeth. The
canine tooth became in time perfectly firm, and five years
afterward showed no evidence of change.
EXAMPLE FROM ADULT LIFE.
It may be regarded as a settled fact that there is hardly
any limit to the age when the movement of teeth might not
succeed. Such success must depend on favoring circum-
stances. It is a common occurrence at all ages, but particu-
larly with people of advanced age, to see teeth changing and
assuming new positions, as the result of the loss of adjoining
or occluding teeth, or by the attachment of artificial teeth.
In any case, movement will go on until the force has spent
its power, or until the resistance is equal to the power. The
occlusion of the teeth is a most potent factor in determining
the stability in a new position. If the occlusion of the teeth
1
TIME FOR WEARING RETAINING PLATES.
64
will be such as to favor the retention of moved teeth in their
new position, then considerable movement may be attempted
at almost any age at which it might be desired, and with an
expectation of success; but if, on the other hand, the occlu-
sion would be bad, with a tendency to drive them to their
former position, then all efforts at regulating would be folly
at any age.
Teeth could only be retained in a changed position, under
such circumstances, by constantly wearing fixtures which
would jeopardize their durability and permanency. The
wearing of retaining plates, as well as all other fixtures,
upon the teeth is undesirable in itself and objectionable;
they are an evil, necessary in some cases, but to be avoided
as much as possible. Nevertheless, the fruits of a skillful
and successful effort in regulating teeth must not be lost by
neglecting to retain them in place until they not only become
firm, but the tendency to return to their former position has
been seemingly overcome.
The length of time which it is necessary to wear such
fixtures must vary with each case, to be governed by the
judgment of the operator, bearing in mind a few general
principles.
The number of teeth moved, the distance, the occlusion,
the age of the patient, and the cause of the malposition,
whether hereditary or otherwise, are all factors in forming
an opinion. For example, if it be a central incisor shutting
inside of the lower arch which is brought outside in a patient
eight to ten years of age, a few days even may be all that is
necessary to wear anything to retain it, even if the occlusion
of the lower teeth be not all-sufficient, which it would be in
most cases. The same case in a much older person might
require a retaining fixture for some weeks. The younger
the patient and the fewer the teeth moved, the shorter time
will fixtures be required. The older the patient and the
larger the number of teeth to be moved, the longer time
must they be held by some means external to themselves;
THE KIND OF PRESSURE PREFERABLE.
65
and, in cases of hereditary irregularities, including nearly all
the teeth, where the correction has not been undertaken very
early, it will be safer to hold them for a long period, even
to two or three years. In hereditary cases of extensive char-
acter, which have been delayed until at or near maturity, we
can never feel certain but that the original tendency to mal-
position, so long unbroken, will reassert itself at any time
that we abandon retaining fixtures.
Different opinions are held as to the kind of pressure
most in accordance with physiological action; some main-
taining that the pressure must be constant and uninter-
rupted, while others claim that interrupted pressure will
produce the most beneficent result. I doubt if either can
be shown to be the best in all cases. The resilience of elas-
tic rubber represents the usual means of obtaining constant
pressure, while the movement of a jack-screw describes the
interrupted. Irritation and inflammation will sometimes fol-
low from very slight pressure, and again will not follow
where very high pressure is used. It would be difficult to
make a test of the different methods with any accuracy, as
the coincident but unknown factors might not be the same.
A moderate degree of soreness for a short time after the first
application of pressure is to be expected, but is likely to pass
away within a day or two without injurious results, if the
pressure be constant and not too great. When circulation
on the side of resistance is stopped by pressure, the pain
ceases.
0
A recent writer has claimed that there is an exact limit
to the distance to which teeth can be moved in a given time
without injurious action, and places it at to of an
inch in every twelve hours. It is hardly necessary to show
the absurdity of placing physiological or pathological action
under a mathematical law, no matter how broad.
So far as pressure itself is concerned, it is immaterial
whence it is derived. The same weight, force, or power will
produce the same result. It is only a matter of convenience
66
A CRITICAL PERIOD IN REGULATING TEETH.
what source shall be employed. The only difference of
opinion can be upon the point as to whether constant or
interrupted pressure is preferable.
The care of a patient wearing regulating fixtures must be
based on general principles, and adapted in some degree to
the peculiarities of the patient. With the same kind of
a fixture, other things being apparently equal, one will re-
quire much more personal attention than others. Some are
quite capable of managing an apparatus entirely themselves,
reporting only occasionally to the dentist, while others may
need the almost daily attention of the dentist, especially in
the beginning. No rules can, therefore, be given applicable
to all. In a general way it may be stated that for the first
few days the patient should be seen daily, and after that the
intervals may be gradually lengthened to a week or more.
In complicated cases there often comes a critical period
after the teeth have become loosened under pressure and
considerable distance yet to be attained, when, if they are not
watched with exceeding care, some tooth or teeth may be
sacrificed to the movement. Under such circumstances it is
not safe to allow any prolonged absence on the part of the
patient. He should be instructed, in the event of any
marked change in the movement, either laterally or of
elongation, to report immediately. If there is an undue
movement, the pressure must be relaxed, and only sufficient
strain put on to keep the ground gained.
As a rule, it is objectionable to take away all force from
moving teeth until the completion of the movement. In-
flammation that might be a necessary concomitant to the
movement, and not such as to be prejudicial to the teeth or
surrounding tissues, would be likely to be considerably in-
creased by a complete relaxation of force.
So far as is possible, such apparatus should be made as
can be readily removed, and thorough cleanliness insisted.
upon. Inflammation to the extent of ulceration will quickly
ensue from an ill-adapted appliance, or from a properly
67
adapted one if not kept clean. The accumulation and reten-
tion of foreign matter under such circumstances is one of
the most potent agents for evil. Antiseptic and astringent
washes may be applied as occasion demands.
But by far the greatest evil is to be apprehended from
badly-fitting apparatus. The importance of more care and
more skill than are usually exhibited can not be too strongly
insisted upon.
ANTISEPTIC CARE.
Wherever it is proper that a regulating plate should
touch a tooth, it should be made to fit the neck of the tooth
accurately; otherwise, in a short time will be developed a
spongy growth of the gum which would not have taken
place if the apparatus had been properly adjusted. When-
ever irritation of the gums is discovered arising from this
cause, the remedy, which lies principally and many times
wholly in the removal of the cause, should be immediate,
even if it should involve remaking the apparatus.
CHAPTER V.
FORCES.
THE treatment of irregularities of the teeth is almost en-
tirely mechanical, but is lifted above the plane of ordinary
mechanics because it has to do with vital organs, and thus
becomes an important branch of mechanical surgery.
To the anatomical, physiological, and pathological knowl-
edge required of the operator, there must be added a knowl-
edge of mechanics and a clearness of perception and ingenu-
ity to apply it. Precisely the same ability is required as
would be demanded of a mechanical engineer in the construc-
tion of a machine for a given purpose. He is to apply,
directly, one of the mechanical powers, or to invent a com-
bination of those powers, as shall best answer the purpose.
Levers, pulleys, inclined planes, wedges, and screws are all at
his command; and it is quite as impossible to describe an
apparatus, such as would be applicable to every case, as it
would be to anticipate the future and describe every inven-
tion that the fertile mind of man may make for his comfort
or convenience. It is impossible for one to overcome a com-
plicated case of irregularity who has not a comprehension of
each and all the above-named powers, singly and in combina-
tion with each other.
As an illustration: There came to me a dentist, with his
patient, for consultation. The fixture was very nicely made,
and had been in the mouth for some days, but with no ob-
servable change. As I had previously suggested the kind
of appliance to be used, the question very properly followed,
69
why it did not work. It needed but a single glance to see
that its force was working against itself, and this fact was
unrecognized by the operator. All that was required was to
change the bearings of the ligature, using the same appliance,
and within forty-eight hours there was a perceptible move-
ment of the teeth.
SCREWS.
Every case of complicated irregularity requires a variation
in the application of forces necessary to produce the result.
No complex case that I have ever seen could be corrected by
following the exact steps of any preceding case, which might
have been, to all appearances, precisely like it. Consequently
no plan of treatment, however detailed in description or pro-
fuse in illustration, can be of much benefit to the reader who
has not a knowledge of mechanical powers and a ready ability
to apply them, or to combine and apply such as are best
adapted to the end.
Regulating appliances call into requisition the power to
be derived from screws, wedges, levers, inclined planes, and
elasticity.
SCREWS.
The screw is one of the most valuable adjuncts at our
command in regulating teeth. On its first introduction it
seemed a cumbersome apparatus, taking up valuable room in
the mouth, interfering with mastication and articulation,
irregular in its movements, requiring constant attention, and
liable to injure the teeth by impinging and wearing upon
them. It was a common idea that the pressure on the teeth,
for their safety, must be moderate, uniform, and uninter-
rupted, and the action of a screw could be neither uniform
nor uninterrupted. But experience has demonstrated its
safety and its wonderful adaptability. By it a narrow arch
of the most refractory character can be made to yield, and
with it almost every movement we desire can be accom-
plished. It is not recommended for universal use, but, if we
were deprived of every other mechanical power, we could do
6
70
nearly all things in regulating by the aid of a screw. The
jack-screw of the present day is a delicate and strong instru-
ment of steel, with provision made to prevent oxidation.
This contrivance was first used in dentistry by Dr. William
H. Dwinelle, to whose ingenuity, skill, and various attain-
ments, during a period of forty years, the profession is largely
indebted for its rapid advancement. His discovery of a sim-
ple means to avoid oxidation rendered a screw of steel ad-
missible, and thus overcame the instability of screws which
theretofore he had made of gold. The form used by Dr.
Dwinelle is shown in Fig. 16 and again in Fig. 20. The ap-
plication of jack-screws in the author's practice is illustrated
in the following cuts.
FIRST USE OF JACK-SCREWS.
FIG. 16.

Hain
It is seldom desirable to use the screw alone; metallic
bearings upon and in contact with the teeth are generally
objectionable. An excellent plan is, to make a plate reach-
ing across the mouth and bearing against the offending teeth.
The jack-screw is placed in a straight line across from or near
the extremes of the plate, the plate being made light enough
in the center or slit up a certain distance to allow it to
straighten under pressure. By this method the pressure can
be distributed among all the teeth on one side, and concen-
trated upon one tooth upon the other side if desired. Such
an arrangement is shown in Fig. 16. Before jack-screws
were made by the instrument-makers and placed on sale,
those which I required were made in my own laboratory,
DIFFERENT APPLICATIONS OF JACK-SCREWS.
71
and especially adapted to the case under treatment, and even
now the plan then followed would be found advantageous.
Fig. 17 shows the employment of two screws upon the
upper jaw. The plate was of vulcanite, and the screws have
no other nut than the plate itself. The plate was vulcanized
FIG. 17.

Cali
around the screws, thus making the thread very perfect.
This plate was used to drive out a very stubborn canine, and
also to twist a central incisor.
FIG. 18.

Fig. 18 shows another combination of plate and screw,
and adapted to the lower jaw. In this case a piece of gold
was inserted to form the nut of the screw, as shown in the
engraving. This apparatus was used to force out two bicus-
pids, the first of which was considerably within the line,
and the second one less so. Its action can readily be com-
DIFFERENT APPLICATIONS OF JACK-SCREWS.
prehended from the cut. The force of the screw here is
distributed to all the teeth on one side, and concentrated on
the bicuspids on the other. Fig. 19 is an illustration of the
same principle applied to both sides of the lower jaw, and
was used in a case where the inferior dental arch was nar-
rowed and the canines pushed outside the line. Elastic
72
FIG. 19.

ME
straps were attached to the extremities of the plate, as seen
in the engraving, and drawn forward over the canines, which
came into line as soon as the arch was widened. The spread-
ing of the lower jaw is ordinarily much more difficult than
of the upper, and such appliances as Figs. 18 and 19 possess
peculiar advantages in utilizing the extraordinary power of
the screw, when the presence of the tongue would make a
screw bearing directly on the teeth inadmissible.
The jack-screws which have been placed on the market
are very neat and effective instruments. There are three
kinds represented in the following cuts-Figs. 20, 21, and
22. That shown in Fig. 20 was first introduced, and is
FIG. 20.
the kind which I have always used in conjunction with
plates. That represented in Fig. 21 shows a crutch at each
end, and the screws turning in opposite directions. This
73
plan would, undoubtedly, be advantageous in the case of two
teeth directly opposite each other, both of which required
moving the same distance and offered the same resistance-
conditions which are rarely found. While this pattern will
evidently fulfill all the requirements of the former, I have
a
DIFFERENT FORMS OF JACK-SCREWS.
FIG. 21.
2
3
b
never used it in the special cases for which it seems to have
been invented.
ALIME
I never use jack-screws except in conjunction with a
plate, for two reasons: First, I never find occasion to move
equally the teeth upon which such a screw would rest; and,
secondly, a vulcanite plate gives not only the facility of dis-
tributing and concentrating pressure at will, but the bear-
ing of the vulcanite on the teeth is less injurious than the
metal.
FIG. 23.
1
The screw in Fig. 22 is a later invention, and is substan-
tially a combination of both the other forms, being an in-
tended improvement upon the first pattern by adding a
revolving crutch to the end of the screw.
کے نظر
FIG. 22.


3
QQUA

2
In 1860 Dr. E. H. Angell, of San Francisco, communi-
cated to the “Medical Press" his method of treating certain
cases of irregularity. For widening the dental arch he em-
ployed a screw such as is represented in Fig. 23. The collars
DR. ANGELL'S ARRANGEMENT.
74
at the extremities were made of gold and lined with pure
gold, so as not to be injurious to the enamel of the teeth.
The portions marked 1 and 2 in the diagram are made of
tubes with a screw-thread cut upon the inside; 3 represents
the shaft of sixteen-carat gold, No. 13 Stubbs's gauge, made
square at the middle to be readily turned with a wrench,
ONE
DIME
CHUA
FIG. 24.

NGUE:
2
1
Gi
*ITH FA!**
and the screw-threads upon the shaft turn in opposite direc-
tions. The wrench was made by cutting a slot in a silver
dime, as shown in the next illustration. For moving teeth
along the line of the arch he used a variation of the
screw, as shown in Fig. 24. The application of this ap-
paratus is shown in a report of one of his cases, to be found
on p. 200.
This method of using screws is substantially the same as
that which has latterly appeared in several numbers of the
FIG. 25.
ttt


"Dental Cosmos," under the ostentatious title of "Regu-
lation made easy."
""
Fig. 25 shows another form of the application of screws
to regulating, which was introduced by Dr. Farrar. These
seem better adapted to the rotation of single teeth than any-
thing else, and for that purpose will probably be found as
useful as any other means.
:
WEDGES.
75
WEDGES.
Wedges are also an important source of power. They
are not new to the dentist, and have proved of great benefit
to him in various ways; but it is doubtful if their value in
treating irregularities has ever been realized, although they
have often been resorted to, and results claimed for them
which were mechanical impossibilities.
For instance, a dentist living in a distant city had a
patient under treatment, where the six front teeth of the
upper jaw shut within the lower teeth. He fitted accurately
a rubber plate all over the roof of the mouth, covering the
grinding surfaces of all the teeth behind the canines, and
lying close against the inclined lingual surfaces of the offend-
ing six teeth. Against each of the front teeth he made a
slot in the rubber plate, into which was inserted a wedge—
the wedge of course impinging on the teeth, with the ex-
pectation of driving them forward. These wedges were
changed daily and thicker ones inserted. This treatment
was carried on for several weeks, when the patient, being
obliged to visit New York, was referred to me. I found
between the incisors and the plate behind considerable space,
which, the young lady stated, represented the distance which
the teeth had moved. Believing that it was an impossibility
for teeth to move with just such an appliance, I removed all
the wedges, and replacing the plate, found that the teeth had
not moved a hair's breadth, but fell into the depressions of
the plate as nicely as when it was first made.
In this case there was no recognition of the power of the
inclined plane to oppose and overcome all that was expected
of such a fixture. In similar cases, and by the proper ad-
justment of wedges, they can be made to do more in the
same length of time than all screws, pulleys, levers, or
inclined planes combined.
A
Such an application of wedges is illustrated in Fig. 26.
The full report of the case will be found on page 127.
76
ELASTICS.
The principle is identical with the function of the key-
stone of an arch. Drive in the keystone or a wedge between
each of the separate stones, and the arch is necessarily en-
FIG. 26.

larged, and will continue to be enlarged so long as a wider
keystone is admissible, and there is a support which pre-
vents the whole arch from tumbling in ruin to the center.
་
ELASTICS.
There is no mechanical force used in regulating teeth of
such wide application as that derived from elasticity—that
inherent property possessed by certain bodies of returning
to their former shape when bent or strained.
The jack-screw can be regarded as first in importance
only because it possesses greater power; but its application
is limited. The force of elasticity is readily obtained and
applied, and has been in use by mankind from the earliest
dawn of the arts. This power has rendered effective alike
the simplest and the most complex machinery. The bow of
primitive warfare and the chronometer of civilization are
777
equally dependent upon elasticity for their results; and,
whether derived from the springing of metal or the resili-
ence of rubber, it forms the most convenient and valuable
aid in regulating teeth which is at our command.
APPLICATION OF ELASTICS.
Elastic ligatures cut from small rubber tubing can be
applied in a multitude of cases. The dental arch may be
widened or contracted, the teeth elongated, shortened, or
made to rotate in their sockets, by their judicious use. It is
but necessary to obtain a fixed point for the attachment of
the ligature, and, with the other end stretched over the
FIG. 27.

MILLELETS
offending tooth, the result is but a question of time. By a
little ingenuity, a single ligature may be made to move
several teeth into line, when they stand alternately, one
without and one within the arch, and even to twist one
or more in the sockets at the same time. One of the most
useful applications of the ligature is in contracting the arch,
as in cases where the incisors are too prominent. In some
cases it may be only necessary to place a cap over the in-
cisors, and stretch the ligature from the cap and secure it to
the extreme back teeth. In most cases, however, it will
prove less a cause of irritation to the gums along where it
78
passes to adapt a plate over the roof of the mouth, extend-
ing behind the molars, and secure the posterior ends of the
ligature to the plate rather than to the teeth.
DIFFERENT USES OF ELASTICS.
An admirable illustration of what can be done in this
way is shown by Fig. 27. All the teeth in this case were
brought into a symmetrical curve, the front teeth being
carried back and the sides expanded by this fixture alone,
in the short space of seven weeks. A variation of such
an appliance, but involving the same principle, is shown
с
FIG. 28.

in Fig. 28. The band across the face of the incisors was
kept from slipping against the gums by hooks over the
cutting edges of the teeth. The horseshoe-shaped slot in
the plate shows a ready means of attaching the elastic,
or it may be tied with thread, as indicated in the engrav-
ing.
To enlarge the arch to any extent by the use of elastic
ligatures involves a point of attachment external to the arch;
and, as this can only be done by a fixture under the lip or
cheek, it is not so desirable a method as the use of a jack-
screw or wedges. Elastic ligatures are invaluable, however,
in conjunction with a retaining plate, to gently hold the teeth
in their newly acquired positions.
The following engravings will illustrate some of the ap-
plications of elasticity.
79
Fig. 29 shows a combination of vulcanite and gold wire
for bringing into line certain irregular teeth upon the lower
jaw.
DIFFERENT METHODS OF USING ELASTICS.
It was a former practice, in a case like this, to use the
wire band independent of the plate, the ends being tied with
silk or twine ligatures to the molar or bicuspid teeth; but
experience showed that the ligatures were apt to irritate the
gums, besides giving much trouble whenever the fixture was
removed for cleansing, by the difficulty of re-tying; conse-
quently the wire was carried over the teeth, selecting such
a gap when the jaws were closed as was most favorable,
witter or of hand
FIG. 29.

and the ends of the wire anchored in vulcanite. In this
way perfect facility in removing and replacing was ob-
tained.
Another advantage derived from fixing the wire in a
vulcanite frame is the steadiness with which the wire is kept
in relation to the teeth.
In drawing teeth toward a wire, rubber elastics exert a
constant tendency to force the wire into some position where
the elastics will not remain on the teeth, particularly the
incisors and canines. There is often apparently but one po-
sition in which the wire can be made to act as the anchorage
for the elastics, and this position can not always be obtained
VARIOUS APPARATUS.
80
where the wire is only sustained by tying the ends to adja-
cent teeth. It will therefore be found to be far less trouble
in the end, to both operator and patient, to have the wire
secured to a vulcanite frame, carefully adjusted to a position
which will exert the most efficiency.
Two methods of attachment for the elastics are indicated
in the engraving: with those on the right a single band of
the rubber passes over the tooth; those on the left show
rings cut from this same size tubing, but being doubled, and
both ends of the loop being carried over the tooth, the power
is much increased.
Fig. 30 shows another method of attachment for elastic
rings. This fixture was used in a case where the canine
FIG. 30.
༽

teeth on the lower jaw stood outside the line, and the arch
behind was somewhat narrowed. Both the first permanent
molars had been removed because of decay, and the appli-
ance here represented drew the canines into position and
widened the arch. Hooks of gold wire were inserted in the
vulcanite to attach the elastic bands more readily, and waxed
silk or linen twine drew the bands forward and inside of the
bicuspids, and tied them to the canines; thus the resilience
of the rubber, from being attached to the plate in the posi-
RUBBER TUBING AND LINEN TWINE.
81
tion here indicated, was made to perform contrary move-
ments of the teeth.
Fig. 31 illustrates other forms of attachment, as also a
moderate degree of elasticity to be obtained from the shrink-
age of linen fiber when wet.
FIG. 31.
-
It is frequently the case that the rapidity of movement
obtained from rubber endangers the vitality of the tooth.
More harm would be likely to follow the abandonment of
pressure than its continuance, but it is wiser to reduce the
strain to the minimum until tone has returned to the tissues.
In such cases a piece of linen twine in place of the rubber,

tied tightly, will retain all the advancement and add some-
what gently to it. In fact, in the earlier days of treating
irregularities, and before the introduction of rubber, this
kind of ligature was much depended upon.
Fig. 32 shows other attachments of elastic under peculiar
circumstances. This fixture was made to correct a bad ar-
rangement of the four inferior incisors, and prior to the
shedding of either the molars or the canines. The regulating
of the incisors necessitated attachments of a firmer character
than could be obtained from the loosening temporary teeth,
besides the danger of removing the canines prematurely if
strain was applied to them. Consequently the apparatus was
made with wire, passing over the arch between the canines
82
and temporary molars, terminating in hooks, as seen in the
illustration, marked A A. The elastic ligature could thus
have an independent attachment outside as well as within the
arch, and movements in almost any direction could be ob-
tained.
INCLINED PLANES.
FIG. 32.
b

A
Such fixtures possess the decided advantage of being
managed by the patient. Any intelligent child could remove
and replace such appliances for cleansing purposes, and avoid
unnecessary visits to the dentist.
INCLINED PLANES.
The inclined plane was one of the first mechanical forces.
adopted for regulating teeth, and was much recommended in
the earlier text-books. Its application is probably well known.
It consists simply of a plate adapted to the jaw, opposing by
a sliding surface the offending teeth. For example: The
incisors of the upper jaw may be shutting inside the lower
teeth. To correct the deformity, an inclined plane may be
made of any of the materials which are used as a base for
artificial teeth, accurately adapted to the incisors of the lower
jaw, with a process extending upward and backward so that
it shall impinge upon the lingual surfaces of the offending
superior incisors at every occlusion of the jaws.
Such an appliance is shown in Fig. 33, letter A. The
objections to this mode as a sole reliance are many. It will
be observed that there can be no movement expected of the
misplaced teeth unless there is a forcible occlusion of the
83
jaws, the result being that it almost always defeats its own
objects; even when a movement takes place, it is only after
a tedious and prolonged wearing of the fixture. The teeth
will not be held impinging on the incline except by a con-
stant effort of the will. The length of time required is also
a serious objection. The masticating teeth, being held apart
for a long time, will be pretty certain to elongate, and the
proper articulation of the teeth be destroyed. To avoid this,
it has been recommended to build up blocks or gags on the
molar teeth which can be used in mastication. These objec-
tions, among others, condemn the principle as unreliable for
general use, but as an accessory to other fixtures it may often
prove a valuable adjunct.
INCLINED PLANES FOR LOWER JAW.
FIG. 33.
A

B
In Fig. 33, letters A and B show a combination of an in-
clined plane with elastic ligatures, which was used to correct
an irregularity of both upper and lower incisors, and the
same apparatus was used as a retaining plate when the
change in position was completed. The case was one where
the superior incisors shut within the inferior ones in the
mouth of a lad of fourteen. The fault was in both jaws.
The lower teeth were too prominent and the upper ones too
retreating. Advancing the upper ones until they covered
the lower ones would have made the mouth too full, and
the reverse would have been the result if the lower ones had
been retracted behind the upper ones. Both sets being at
84
fault, both were operated upon. The fixture was made to
be worn on the lower teeth, and it will be observed that the
incline seems to stand unnecessarily forward of the receptacle
for the lower teeth. When first adjusted, the lower incisors
were flush with the front edge of the incline, and the upper
incisors caught on the upper front surface. The fixture was
cut away freely behind the lower incisors, to permit of the
inward movement, and a narrow gold band was carried across
the front as seen in the engraving, letter B. Elastic straps
were drawn between the teeth connecting the two, and the
lower teeth were drawn back simultaneously with the ad-
vancing movement of the upper ones.
INCLINED PLANES FOR UPPER JAW.
FIG. 31.

A
Fig. 34 shows another application of an inclined plane
somewhat out of the ordinary course.
It was adapted to the inside of the superior dental arch,
and the inclined surface marked A projected below and
caught the inferior incisors.
The object was, not to protrude the lower teeth, but to
change or jump the bite in the case of an excessively retreat-
ing lower jaw.
In the engraving the appliance is shown bottom up, to
exhibit more clearly the attachment of some elastic ligatures
which were caught on a hook in the roof of the plate, and
were drawn out through corresponding openings, and con-
LEVERS.
85
nected with a gold bar worn across the front of the superior
incisors to reduce their prominence.
The fixture was worn constantly, and in a few months
produced the desired result. The objection urged against
the use of an incline, because the time required had a ten-
dency to alter the articulation of the teeth, was in this case
an argument in its favor, and an advantage, because a new
articulation was desired, and the incline, as adapted, offered
no opposition to the antagonism of the teeth.
The principle of the inclined plane is always operating in
the mouth, and may often be taken advantage of beneficially,
while at other times it will tax our ingenuity to the utmost
to overcome its powerful influence. In the case of the supe-
rior incisors shutting within the lower, after they have been
brought forward so as to barely catch over the lower ones,
then the principle of the inclined plane becomes available in
completing the operation.
The points of the lower teeth, catching within the upper
ones, strike their natural inclined surfaces, and nature may
be relied upon for the rest.
In moving the bicuspid teeth of the upper jaw, either
outward or backward, all that is accomplished by fixtures
may be entirely overcome by the articulation of the lower
teeth forming an inclined plane, and thus acting upon the
upper ones to return them to their former places.
Levers do not come into such universal application as do
some other powers; the principal objection being, that the
limited space of the mouth does not permit their unrestricted
movement.
Levers may be used to advantage in revolving teeth in
their sockets; and for this purpose a band around the tooth
is necessary, which will not slip, and the lever may be at-
tached to the band. Force may be brought against the long
arm of the lever by ligatures connected with convenient teeth.
Such an appliance will pretty surely accomplish the result,
but it can generally be obtained with a less cumbrous fixture.
7
86
METHOD OF USING LEVERS.
Levers may often be advantageously used on the outside.
of the arch, to press gently against some offending tooth, and
thus drive it into its desired position.
Such an apparatus is shown in Fig. 35. The lever,
marked D, was made of moderately stiff gold wire, anchored
in a vulcanite plate in a case where the first permanent molars
had been extracted. The lever in this instance was required
quite as much to get an attachment for elastic ligatures as to
press in the outstanding canine. If the canine had been the
only tooth out of place, it could readily have been brought
in with a strap attached to the vulcanite; but several of the
incisors needed moving and twisting. By getting an attach-
ment at the end of the lever, a variety of work could be
C
FIG. 35.
C

B
accomplished, according to the connection with the vulcanite.
For example: If the elastic were brought between the two
centrals and tied at A, the action would tend to move out one
tooth and depress the other. If the point of attachment
were changed to B, the influence would be changed; and so
again if transferred to C.
In like manner, if carried between the lateral and central
or lateral and canine, there would be a difference in the force
exerted according to the point of attachment.
Fig. 36 illustrates a method of reducing one or more
teeth to a regular line by means of a wire or bow going
around the outside, and acting partly as a lever and partly
by the force of elasticity. The engraving sufficiently ex-
plains the action. The plate is of vulcanite, and an elastic
87
loop acts to contract the circle by drawing the ends of the
wire together. Such an appliance would act only on the
teeth, but in the following illustration, Fig. 37, a similar
GOLD BANDS AND VULCANITE.
FIG. 36.

principle is used in a case of maxillary fissure connected with
a fissure of the palate.
There was a wide gap between the lateral incisor and the
FIG. 37.

canine tooth, and the opening extended through the alveolar
arch and into the nasal passage.
It was desired to bring the maxillæ into contact, and a
88
fixture like the last would only act upon the teeth, tending
to give them a wrong inclination. This fixture was made to
embrace the gum as well as the teeth with the wire running
through the length of the vulcanite to give both stability,
and the terminal hooks were drawn toward each other when
in situ, with silver wire wound around and twisted with a
pair of pliers. In the process of twisting, the gap was seen
to perceptibly close and ultimately came together and united.
The application of these principles to the movement of
teeth is one of the most responsible duties the dentist is
called upon to perform.
READY INVENTION A NECESSITY.
Each and every one of these mechanical powers can be
made to do our bidding; and, equally, each one of them may
become a formidable engine of disaster.
When applied in the mouth they should have constant
watchfulness and care. Not one of them but in the hands
of empirics would cause the destruction of those valuable
organs they can be made to conserve.
To any one who has become deeply interested by expe-
rience with these cases, there is a fascination about them
which will lead him to new experiments in the treatment of
almost every case.
In fact, success depends quite as much on ready invention
of means to meet any emergency as upon the exercise of any
knowledge, or the use of any appliances already proved.
CHAPTER VI.
IMPRESSIONS AND MODELS.
In all complicated cases of irregularity, impressions and
models are a preliminary necessity in making suitable appli-
ances for correction; and in a majority of cases correct
models of both upper and lower jaws, properly articulated,
are a valuable aid in making a diagnosis of the case. The
positions of the teeth, within or without the line, their in-
clination, rotation, and articulation, can be much more closely
studied from models than in the mouth. Often it will be
seen that an opinion formed upon the observation of the
living structures may be an erroneous one when the models
are closely studied.
The probable effect of the change of position in the side
teeth can not always be prognosticated by looking at them in
the mouth; but by observing accurately how they articulate
in a model, and carefully noting the inclination of the oc-
cluding surfaces and the tendency of the same surfaces if the
proposed change were made, a much better opinion can be
formed of the propriety of movement. Nothing is more
injudicious than the moving of teeth into a position which
can not be maintained by the articulation of the opposing
jaw; and nothing is more powerful in carrying moved teeth -
back to their former state than the continued action of in-
clined surfaces in ordinary mastication, favoring such return.
A proper knowledge of the case requires models and im-
pressions, and such models are better taken in plaster of
Paris than in any other known substance. While the merits
PLASTER VERSUS PLASTIC SUBSTANCES.
90
of plaster are generally conceded, there is also a feeling that
it is especially or only adapted to mouths denuded of teeth,
and that its use where teeth are scattered or straggled is in-
applicable. Experience proves the reverse of this to be the
fact. Plastic substances, such as wax, gutta-percha, etc., are
only adapted to simple surfaces; and in no case where there
are intricate, devious, or tortuous details can they be relied
upon. Their very nature—namely, their plasticity—is what
condemns them; and the opposite characteristics of plaster-
namely, hard, rigid, unyielding, brittle-are those which make
it peculiarly applicable for impressions in all difficult cases.
That it will adapt itself accurately to all the details of form
and irregularity, and will break with a clean, sharp, well-
defined fracture on removal, are the peculiar qualities which
stamp its superiority.
Therefore it is that the most difficult cases are those
which require plaster, and in the more simple ones there is
nothing as a rule to make plastic substances a necessity.
An objection has been made to plaster on account of the
difficulties attending its use; but, with an experience far less
than is required to become proficient in most skillful manip-
ulations, it will be found the most simple and accommo-
dating of substances. This false notion has led to innumera-
ble inventions of steps preliminary to the use of the plaster.
A variety of cups or trays have been constructed especially
designed for plaster, but the proper use of the material does
not justify any such especial inventions. The common form
of tray made of britannia, which can be changed in shape
somewhat by bending, equally applicable for wax, is the most
simple as well as the best that has been introduced for taking
impressions of all cases except those of most extraordinary
oral deformities. Neither is the preliminary operation of
taking an impression in wax, cutting out a portion of the
wax and supplementing with plaster, or any other preliminary
device, at all necessary. A simple cup of an approximate
form, and only large enough to inclose the parts from which
HOW TO TAKE PLASTER IMPRESSIONS.
91
an impression is required, is all that is necessary. To put
the plaster in such a tray, carry it steadily to its place, and
remove it at the proper moment, constitutes the whole pro-
ceeding.
But while the process is a very direct and a very simple
one, success will come only from a careful attention to the
details. The plaster must be fine and strong, and set with
moderate rapidity. The so-called "dentists' plaster" in the
market has not proved in the author's experience to possess
any advantages. The quality known among the manufac-
turers as "superfine" is far preferable. When in proper
condition—that is, where it has not become deteriorated by
long exposure to a damp atmosphere-it possesses all the
desirable qualities for impressions, models, and general use.
For ordinary use it sets with all the rapidity that proper
manipulation will permit, while this property can be much
accelerated by the addition of a little salt.
The details of taking an impression of a case of irregular-
ity can be best met in substantially the following manner:
Select a cup which shall just inclose all the teeth required
to be shown, and bend it to the general conformation of the
dental arch. If it is an old cup which has been often used,
it is preferable, as the roughened surface facilitates adherence
of the plaster; if a new one, the inner surface should be
made quite rough, so that the cup will not be liable to come
away, leaving the plaster in the mouth.
A common stoneware coffee-cup is the most suitable ves-
sel for mixing the plaster in, and a small table-knife the most
suitable instrument. Fill the cup about one third full of
tepid water (tepid water, only because it is pleasanter to the
mouth; not hot water, because that affects the time of setting),
and throw in a pinch of salt, the quantity necessary being
determined by a little experience in working that particular
quality of plaster. Shake into the water all the plaster that
will readily sink under the surface, stir the mass until it is
observed that it is becoming stiffer, and place it in the tray
92
CONDITIONS OF SUCCESS.
as soon as it is stiff enough not to run out. Avoid placing
too much in the tray. Pile it up more particularly in the
center for an upper jaw; the sides will take care of them-
selves. Carry it gently and steadily to its place, holding it
firmly, with the left hand passed around the head and the
fingers supporting and sustaining the tray, while the right
hand is left free to note the process of crystallization going
on in the cup. Stir up the remaining plaster in the cup into
an irregular form, and test the solidity of the mass by trying
those forms. Keep the plaster in the mouth until that re-
maining in the cup will fracture under trial. If under pres-
sure the form mashes, delay; but the moment it will fracture,
remove the impression from the mouth. If the case be an
intricate one, it will be found broken into many fragments,
and the remains sticking to the teeth in various places.
These fragments can now be removed at leisure.
In the restoration of the impression from these pieces
there will be found no more difficulty than in putting to-
gether a dissected map of a continent. By no possible con-
tingency is it likely that a fragment can be misplaced. These
pieces can be retained in place by a little melted wax, rosin,
shellac, or any other convenient substance, dropped upon the
outside of the fracture, avoiding anything upon the surface
to be represented in the model, as its perfection of form
would be thereby destroyed.
Much of the success in taking a difficult impression de-
pends upon the morale existing between the patient and
operator. It is not desirable that the patient be impressed
with any idea of the importance of the proceeding, nor that
any coöperation on his part other than submission be required.
On the part of the operator there should be that quiet de-
meanor, that freedom from nervousness and excitability,
which inspires confidence in the patient and betokens a mas-
tery of the manipulations. Much of the failure in operations
of this kind has resulted from a magnified fear of the patient
that a formidable operation was to be undertaken, attended
EXAMPLES OF DIFFICULT IMPRESSIONS.
93
with choking and much other suffering, and requiring all
his self-control. To dissipate such alarm by quiet words
and demeanor is the first step to success. If the patient
manifests any symptom of gagging or choking, let the head
be pitched well forward, and the request made to breathe
through the nose, when all unpleasant symptoms will be
likely to pass.
In taking an impression of the lower teeth, the same prin-
ciples are to be followed. The plaster when ready for intro-
duction to the mouth will be found stiff enough to remain in
the tray while it is carried to the mouth and deftly turned
bottom upward and inserted. In other respects the proce-
dure will be the same as for the upper jaw.
As illustrating the capabilities of plaster for impressions
of somewhat inaccessible places, the following occurred in my
practice some years ago: A distinguished surgeon of this
city was treating a patient where the posterior border of the
soft palate had united with the wall of the pharynx, closing
entirely the passage to the nares, and precluding all respira-
tion through the nose. He had dissected off the palate, but
found great difficulty in keeping it away so as to prevent re-
union. In this emergency he conceived the idea of an elastic
rubber chimney adapted to the posterior nares, and which
could be drawn in by being compressed and passing through
the new-made opening behind the palate. The expansion, it
was calculated, would hold off the palate, while the opening
through would permit a free passage of air. I was applied
to, and immediately saw the necessity of acquiring some
knowledge of the exact form of the cavity above the open-
ing. The passage had contracted to the size of the little fin-
ger, while the cavity above must be much larger. An im-
pression of that cavity was obtained in the following manner:
a stout piece of twine was passed with a bougie through one
of the nostrils, and carried back until it appeared below the
palate; it was then seized and brought out of the mouth, and
the ends were tied. We then had a revolving band to which
BEST METHOD OF MAKING A MODEL.
94
was secured a small piece of compressed sponge, as large as
would pass the opening. This compressed sponge was then
dipped in a thin mixture of plaster, and the cord drawn out
of the nostrils until the sponge passed into the posterior nares.
It was left there until the plaster had hardened, when by a
reverse action of the cord it was withdrawn, the elasticity of
the velum permitting it to come away. In this manner a
most accurate impression of the posterior nares followed the
expansion of the compressed sponge and the fixedness of the
setting plaster. From this, of course, an accurate model of
the parts was obtainable. As a further illustration of the
adaptabilities of plaster for impressions the reader is referred
to the details of a case described on pages 322 and 333.
To obtain the finest casting from a plaster impression re-
quires always that the impression should be soaked full of
water, thus driving out all air and preventing all porosity of
surface in the cast. A lather of soap spread over the surface
of the impression and then well washed off, is the best and
only treatment the impression requires to give the finest cast.
When the plaster is introduced, the first should be in a small
quantity and gently insinuated into all the intricacies; other-
wise a globule of air may be covered in the cusp of a tooth
and result in a defect. To facilitate the separation of the
cast from the impression, it is desirable that the two masses
be of different colors. The merest trifle of some pigment
thrown into the cup when the plaster is mixing for either is
sufficient to make a contrast, the other being white. One of
the most convenient pigments for this purpose, as well as one
which gives pleasing color, is Venetian red or Spanish brown;
and, being of little commercial value, its cost is of no conse-
quence.
In the treatment of any considerable case of irregularity
even when confined to the upper jaw, it is preferable to ob-
tain impressions of both jaws, and make a study of the case
from articulated models. Thus only can it be decided which
of the mechanical powers or what combination of them will
95
be most likely to produce the result. From a study of the
models, in conjunction with observations of the physiognomy,
a more definite conclusion can be arrived at as to the wisdom
of extracting any teeth. In doubtful cases I have sometimes
cut off the teeth from the plaster model, dispensing with
one or more, and, rearranging the remainder, have thus
formed a better idea of the probable result of extraction and
a movement of the natural teeth.
STUDY OF THE MODELS.
In some instances this has been the only method by
which I could determine with any degree of certainty what
would be the result of my interference. I would therefore
recommend, especially to young practitioners, that this plan
be pursued in all cases of doubt.
This course is particularly applicable to such cases as are
described on pages 154 and 156. In certain instances in my
own practice it has been with much gratification that I have
seen the natural teeth assume, under treatment, the exact
position of which the altered plaster model was a type.
CHAPTER VII.
IRREGULARITIES.-CASES FROM PRACTICE.
THE case here illustrated is that of a miss twelve years of
age. The second permanent molars had not erupted. The
canines had erupted, but had not attained their full growth.
The patient's stature was equal to the average of her age, and
there was no want of symmetry to indicate a tardy or defec-
tive development of the maxillæ. The superior central inci-
FIG. 38.

sors were a full half inch in advance of the inferiors at the
mesial line. Fig. 38 shows this relation.
The treatment consisted of a plate of vulcanite adapted
to the roof of the mouth, as seen in Fig. 39. A hook of
gold was inserted in the plate against each molar, and a little
T-shaped catch was made of gold to pass between the centrals.
Before introducing the plate, a rubber ring cut from tubing
SIMPLE TREATMENT OF A V-SHAPED ARCH.
97
was secured to one of the hooks at the back of the plate,
passed through a loop made in the stem of the T, and caught
upon the hook on the opposite side. The plate was then ad-
justed to the roof of the mouth, and the T brought forward;
its stem, being quite thin, was passed between the centrals,
FIG. 39.

and the cross-bar caught on their labial surfaces, as shown in
Fig. 39. This was the only treatment the case received, and
in seven weeks the result was as is shown in Fig. 40. The
incisor teeth were brought back in contact with those of the
inferior jaw, and the contrast in the form of the dental arch
is strikingly shown on comparison of Figs. 39 and 40. At
the end of the period above stated, a simple retaining plate
was introduced, resting against the palatal surfaces of the
incisors, which were held in firm contact with it by a slight
rubber ligature. This retaining plate was worn a number of
months, after which it was abandoned, and the teeth remained
stationary in their newly acquired position.
A natural inquiry follows as to what became of the lower
teeth during this process. The answer is, that the bicuspids
and molars both articulated well with their antagonists before
the treatment, and this articulation was not interfered with
V-SHAPED ARCH OR "V-SHAPED MAXILLA.'
98
so rapidly nor so extensively but that the lower teeth ulti-
mately followed into a new position by mere force of occlu-
sion; and, by the time the retaining plate was abandoned,
both dental arches had assumed a new and permanent shape.
This case illustrates how great a work can be accomplished
by very simple means, and yet this kind of an appliance
might not be of any benefit in any other case except one ex-
actly like the above. This case would naturally be termed
one of a "V-shaped maxilla"; but it was not a V-shaped
maxilla. I doubt very much if the maxilla were concerned
at all in the disturbance. I came to this conclusion before
FIG. 40.

11.
commencing treatment; but, even if I had not, I think the
sequel proved that it was a deformity entirely independent
of the maxillæ, and confined to the alveolar and dental arches.
It was a V-shaped or triangular dental arch—an arch in
which the sides from the base to the center were not curved
as they should be, but nearly on a straight line. I believe,
therefore, that the apices of the roots were in the maxillæ
upon their normal curved line; the crowns of the incisors
thrown beyond the line, and the side teeth drawn within it.
Had it been otherwise, I do not believe that force alone, on
the center, like pressure made on the keystone of an arch,
would have produced the desired bulging at the sides. An
99
essential element of the treatment, however, was the plate
across the roof, which effectually prevented any tendency for
the arch to collapse while the pressure was exerted.
The term "V-shaped maxilla" is very likely to be mis-
applied, and is an unfortunate term in any case. In those
writings where it has attracted the most attention, it does not
seem to be a "V"-shaped maxilla which was under discus-
sion, but rather a saddle-shaped palatine arch—one in which
the sides of the dental arch presented an appearance of hav-
ing been pinched together, and in which the triangular form
of the V was not applicable to either the dental arch, the
palatine arch, or the maxillæ. This criticism is made because
the case under discussion would be classed by many under
that general term, and its origin most likely referable to the
MR. TOMES'S EXPLANATION OF THEIR ORIGIN.
same cause.
As to its cause, I have no knowledge sufficient to prove
its hereditary character. I do not believe it to have been the
result of “thumb-sucking" nor "fruitless sucking" of any
kind. It was not associated with "enlarged tonsils," nor did
the patient habitually keep the mouth open for breathing,
and thus (as it has been claimed) have the sides of the arch
unduly pressed upon.
Mr. Tomes has advanced the latter hypothesis for similar
cases, but it does not offer to my mind a sufficient explana-
tion, as I should regard the retracting power of the orbicu-
laris, and all the other muscles merging in it, as equal in their
influence over the positions of the teeth to those muscles
acting more posteriorly. With a contracting muscular power
distributed all around the circumference of the dental arch,
I can not see how, as the result of that power, the arch should
sink in at its sides and bulge forward.
The following case presents an appearance similar to the
one just described, but which, if it had been treated by the
same means only, would have ended in failure. The patient
1
CASE OF V-SHAPE OF HEREDITARY ORIGIN.
100
was a young lady about seventeen years of age. Fig. 41
shows the profile view of both jaws, with the teeth in con-
tact and the advanced position of the superior incisors, to-
oo ou oo you que true va
FIG. 41.

gether with the articulation of the bicuspids and molars
within those of the lower jaw. Fig. 42 exhibits the pointed
character of the dental arch, and the irregularity in the posi-
tion of the teeth along the line. This twisted, pinched, and
FIG. 42.

tipped-up condition of the incisors, but especially the cen-
trals, gave a peculiar expression to the upper lip, distorting
the facial profile, and destroying the symmetry of what
METHOD OF TREATMENT.
101
was otherwise a more than usually intelligent and comely
face.
A comparison of Fig. 42 with Fig. 39 will be necessary
to a full understanding of the different treatment demanded.
In the former case the line from the proximal edges of the
central incisors to the posterior teeth on each side is nearly
straight; the variation from a straight line is a slight but
regular curve outward. The teeth stand nearly in contact
with each other; so nearly, that within a very few days after
pressure was applied they all met. The bearing of the teeth
upon each other was then practically the same as would be
that of the separate stones forming an arch, and any change
of shape in the arch, as the result of pressure upon one point,
must be in an outward direction.
A reference now to Fig. 42 will disclose the difference.
All of the teeth anterior to the molars are so related to each
other that pressure on one point would cause the arch to col-
lapse. Even if a plate had bridged the palate and come in
contact with the teeth at the sides, so as to prevent a collapse,
no force upon the center as they now stand would have car-
ried those teeth outward. A fixture operating like the T on
page 97 would not have affected the bicuspids and molars,
but would have drawn the middle incisors toward the center
in the same twisted condition, and would have moved the
laterals and canines irregularly apart. The widening of the
arch, therefore, which is of primary importance, must be
effected by other means.
The correction of the deformity necessitated three sepa-
rate stages and three distinct operations, as follows: First, the
widening of the arch; second, the twisting of the central in-
cisors; and, third, the reduction of the V to a proper curve.
The widening was produced by a jack-screw, that most
effective of all known agencies wherever it is applicable.
Its mode of adjustment is very fairly shown in Fig. 42. A
plate of vulcanite was made as there represented, so thin and
elastic along the center that it would straighten under mod-
8
WIDENING THE ARCH WITH A JACK-SCREW.
102
erate force, and so stiff where it came in contact with the
teeth that it would not yield. The attachment of the jack-
screw is made after the vulcanite plate is finished, and is
readily accomplished by carefully cutting a little mortise in
the plate on one side, and allowing the point of the screw to
rest in a pit on the opposite side. Care must be exercised
that the mortise be so nicely cut as to prevent that end of the
screw from twisting, and also that neither of the holes passes
through the plate. The power of the screw may be distrib-
uted ad libitum to different points, and in a greater or less
degree, according to its location in the plate. In the present
instance it was desirable to move the molar teeth but slightly,
the first bicuspids considerably, and the second bicuspids on
a line with the others. The screw was placed against the
first bicuspids, or rather against the gum above the bicuspids;
the principal object of so placing it was to give as much free-
dom to the tongue as convenient. It was applied on the 19th
of April, and the screw turned until a firm pressure was felt.
Slight turns of the screw were made daily or oftener, by the
patient herself, for a period of twelve days, when it was
found that the first bicuspids on each side had each moved
more than half their diameters, and that all the teeth on both
sides were articulating outside their corresponding ones of
the lower jaw. This increase of width is very well shown
in Fig. 43, although the vulcanite plate, as here described,
came in contact only with the bicuspids and molars, and the
jack-screw operated directly upon those teeth. Nevertheless
the six front teeth were affected by the movement, and the
canines were wider apart as the result of the treatment.
This was owing undoubtedly to the position of the screw
being so high upon the plate that the surrounding processes,
as well as the teeth, were involved in the movement. During
this period the plate and screw were worn night and day, but
were removed daily for cleansing. There was very little
soreness-none to cause complaint by the patient, and not
enough to seriously interfere with mastication.
103
On the 2d day of May, thirteen days after its adjust-
ment, the teeth at the sides being in the position desired,
the screw was removed and the second stage of the treatment
was commenced, which was the twisting of the central inci-
sors and disengaging them from the lock and overlap of the
laterals. This apparently trifling operation is often one of
the most difficult to accomplish. An almost infinite variety
of methods have been resorted to with more or less success,
and the same method often in what seemed the same presen-
tation, but with a very different result. In this instance a
TWISTING INCISORS WITH ELASTICS.
2
FIG. 43.

||||||||||||
TRE
vulcanite plate was required to retain the teeth in their spread
condition, and its presence was made available for attach-
ments for elastic ligatures. The plate was adapted to the
palatal surfaces of all the teeth, as seen in Fig. 43. A little
hook or catch of gold wire was inserted opposite the canine
teeth, and a little staple or loop of the same wire at the apex
of the plate between the centrals. Previous to insertion and
adaptation, a ring of rubber cut from tubing was caught over
one hook, passed through the loop at the apex, and caught on
to the other hook. The plate was then introduced into the
mouth, and the elastic strap drawn over each lateral incisor,
FLATTENING THE INCISORS.
104
as seen in the engraving. A little reflection will recognize
the philosophy of its action. The tendency of the elastic
ligature to contract to a straight line operates only on the
inverted corners of the centrals. Its action would be equally
upon the laterals, were it not that they are in contact with
the plate and can not be displaced. The real and only ac-
tion, therefore, is between the outer surface of the lateral
and the gold loop at the apex. The tendency of the rubber
to straighten between these two points twists and throws out
the inverted edge of the centrals. It accomplished the de-
sired work, but very slowly as compared with the preceding
movement; for it was not until the 24th of June, a period of
more than seven weeks, that the third and last stage was en-
tered upon.
In passing, let me remark that there was no effort made
in this case to produce a given result in the shortest possible
time consistent with safety. A great work had already been
accomplished in a limited time in the widening of the alve-
olar arch. That condition was being sustained by the plate,
and becoming settled and firm. It was better, when the
time was not limited, to take the next step in conjunction
with that retaining plate, and by a slower process, than to
adopt a much more rapid one, which would involve a more
complex appliance and more constant attention on the part
of the operator.
The form of the arch when the third stage of treatment
was entered upon was much the same as that shown in Fig.
39; that is, a V-shaped arch with the teeth regularly placed
along the line, each side the middle; and the reduction of
this V-shape to a proper curve was brought about by the
same kind of an appliance. The third plate answered the
same purpose as the second in retaining the side teeth in
their widened position, and differed from the second in bear-
ing so upon the central incisors as to prevent their returning
to their former twisted position, and in having attached to
it catches, ligature, and T, precisely the same as shown in
ľ
RETAINING PLATE WITH GOLD BAND.
105
Fig. 39. There is, however, this difference to be borne in
mind: When it was applied, the vulcanite plate came in con-
tact with the lingual surfaces of the front teeth, and was cut
away from time to time as the teeth were brought in contact
with it. This course was adopted for two reasons: First,
the former condition of the front teeth being twisted, there
was danger, if left too free, of returning to that position, and
thus destroying the lateral pressure upon the adjoining teeth;
and, second, the summer vacation came on, and the patient
could be seldom seen. For this last reason the reduction
FIG. 44.

progressed slowly, and this fixture was used for five months,
accomplishing the double purpose of carrying back the teeth
against the plate, and retaining them there until the plate
was still further cut away.
The desired curve being attained, the final retaining
plate, as seen in Fig. 44, was substituted. Other forms of a
retaining plate would have secured the same results, but this
one was adopted because of its simplicity as well as effective-
It was a simple plate of vulcanite with a small gold
wire imbedded in it, and passing to the outside of the six
front teeth, through a small gap between the cusps of the
ness.
106 INHERITED DEFORMITY ALTERED BY THUMB-SUCKING.
canine and bicuspid on each side. If the articulation of the
teeth of both jaws had been such, on occlusion, as to shut up
this gap, then this kind of a retaining plate could not have
been used.
There were many points in connection with the above-
described case, of the utmost interest to those engaged in
treating irregularities. They involve the origin of the de-
formity and the æsthetic results obtained by the treatment.
I believe now that it would have been better to extract
one tooth from each side of the mouth; but these matters
are referred to elsewhere.
The following case is introduced in connection with the
one last described, because it involves points of unusual in-
terest; including the origin of the deformity, difference in
the aspect, and difference in the method of correction. The
patient was an elder sister of the preceding. The points of
similarity in the two cases were, that the incisor teeth pro-
jected and the palatine arch was narrow; but the shape of
the dental or alveolar arch was entirely different.
FIG. 45.

Fig. 45 shows the profile view-the incisors tipped up
and projecting, one central lapping over the other, and all
the teeth back of the canines articulating inside the corre-
sponding lower ones. Fig 46, when compared with Fig. 42,
FORM OF THE ARCH BEFORE TREATMENT.
107
shows how the arch differed in form from that of the younger
sister. The effect upon the facial expression was as unlike as
was the form of the jaws. In the younger sister the upper lip
was pinched, and pushed forward in the center; in the present
case, of the elder, the whole breadth of the upper lip was ad-
vanced and decidedly curled up, the teeth being nearly always
exposed. Evidently the first æsthetic consideration was the
reduction of this prominent dental arch; and, as the teeth
were all in close contact, this could only be done by the re-
moval of some of the teeth, or by expanding the palatine
FIG. 46.

Tam
arch. Practically, then, the widening at the sides became
the first step in the process of correction.
A vulcanite plate and a jack-screw, such as described on
page 102, and here shown in Fig. 46, was introduced. It dif
fered from the afore-mentioned one in some respects, as fol-
lows: The second molars were so wide apart already that it
was desirable to avoid spreading them. The vulcanite plate
therefore clasped and embraced them. The pressure of the
jack-screw was desired equally against the two bicuspids and
the first molar on each side; it was therefore placed midway,
i. e., above and against the second bicuspid; and to avoid
UNEXPECTED RESULTS OF TREATMENT.
108
the second molar being influenced by it, the plate was sawed
down with a watch-spring saw nearly to the middle just be-
hind the first molar, as seen in the engraving. This fixture
was adjusted on the 26th of February and worn for thirty
days, the screw being tightened from day to day by the pa-
tient; but she presented herself at the office frequently for
inspection.
FIG. 47.

During this process it became evident that the continu-
ance of this expansion would create a deformity of more im-
portance than the first one. The movement of the side teeth
developed the fact unquestionably that the apices of their
roots were based upon a maxilla so narrow that the further
widening of the arch would have presented the palatine sur-
face of the upper teeth to the grinding surface of the lower
The divergence of the crowns was such that had the
expansion been continued until the prominence in front
could be reduced, it would have broken up the articulation
of the teeth, thrown the jaws wider apart, and increased
the gap between the upper and lower incisors. The width
already gained was equal to more than half the diameter
ones.
EXTRACTION NECESSARY.
109
of the teeth operated upon; but, as it was far from suffi-
cient to allow the front teeth to come back, there was but
one alternative, namely, the extraction of a tooth on each
side.
As the patient had reached maturity, and the teeth were
all equally sound, the removal of the first bicuspid was de-
cided upon as simplifying materially the subsequent steps.
On the 3d of April these teeth were extracted and a new
regulating plate adjusted, which is shown in Fig. 47. This
appliance is not unlike the retaining plate made for the
sister, and described on page 105. Its object being the re-
duction of the six front teeth, it effected that result as fol-
lows:
The plate was accurately adjusted to fit and catch be-
tween the bicuspids and molars. The gold wire in front
was elastic and springy. It was bent so as to impinge upon
the incisors, then caught in front of them, pulled back, and
sprung into its place. As fast as the reduction was accom-
plished, the wire was bent at the sides where the teeth had
been extracted and also contracted. So far as any variety of
fixture was concerned, this, in fact, completed the treatment.
This same appliance, or one like it to all intents and pur-
poses, became the retaining plate, which was worn from one
to two years.
Fig. 48 shows the form of the arch at the conclusion. It
was rounded very symmetrically, and the space formerly occu-
pied by the first bicuspids was nearly closed up. The third mo-
lars made their appearance. The articulation with the lower
teeth is good, and not likely to break up the present arrange-
ment.
While it was, without doubt, quite possible to have
so enlarged the arch as to admit the full number of teeth
into a symmetrical line, I am fully satisfied that it would
have created a deformity equal to the one I was reduc-
ing.
One point in this case of considerable importance was the
110
DISCREPANCY BETWEEN JAWS.
apparent want of correspondence in the size of the superior
and inferior maxillæ. It will be borne in mind that any at-
tempt to widen the palatine arch sufficient for the cusps of
the upper teeth to articulate naturally outside the cusps of
the lower ones would have ended in failure. From this it
may be inferred that the superior maxilla was too narrow
and the inferior too wide for such a correspondence; but a
careful observation of the external features did not disclose
FIG. 48.

any discrepancy. Had it been in reality a deformity of the
jawbones, there would have been a want of symmetry in the
face; but the face was regular in its outline, with no evi-
dence of pinching across the middle, nor of undue width at
its base. The want of correspondence was therefore due en-
tirely to the dental development. The dental arch of the
lower jaw was of unusual width, and this was owing, in all
probability, partly to the malocclusion of the upper teeth,
and partly to causes to be mentioned hereafter. The false
articulation in this case operated not only on the upper ones,
so as to narrow the arch, but also in a reverse direction on
the lower arch, to widen it. There is no doubt but that a
EFFECTS OF THUMB-SUCKING.
111
true articulation of both jaws could have been attained by
narrowing the lower dental arch, but this was not altogether
feasible, nor did the surrounding circumstances justify an at-
tempt.
An inquiry into the origin of the irregular dental devel-
opment of these sisters convinces me that the primary dis-
position, so far as they were concerned, was hereditary. I
saw no evidence of this, however, in either of the parents,
whose teeth were well developed and regular, and had no
suspicion of the inherited character until after the regulation
was accomplished, when I met a sister of the mother, and
was impressed not only with a strong general likeness to her
nieces, but with a dental irregularity of the same general
character, viz., narrow upper jaw and protruding incisors;
in fact, the expression of the mouth was identical with that
of one of the young ladies before treatment. But this dis-
covery did not account for the marked differences in the
dental arrangement of the sisters.
A further inquiry revealed the fact that the elder sister
(Figs. 45, 46) was an immoderate thumb-sucker during all the
earlier years of her life; in fact, according to her own state-
ment, continuing the practice until after she was ten years of
age; while the younger one had never contracted such a
habit. With this knowledge the solution of the problem
was not difficult. A tendency to a contraction across the
palatine arch was hereditary; the protrusion of the incisors
was the result of that contraction, and also hereditary. The
younger sister had preserved that inherited character, modi-
fied only by accidental circumstances, during the eruption
and growth of the teeth. But the thumb-sucking habit of
the elder sister had changed entirely the inherited form.
The constant presence of the thumb had retained the ad-
vanced position of the centrals, and had also brought for-
ward and rounded out all the six front teeth, while at the
same time this influence upon the lower jaw would have
been likely to force back the front teeth and expand the
T
L
112
ORIGIN OF THE V-SHAPED ARCH.
sides. It was thus, in all probability, both the malocclusion
and the thumb-sucking which produced the unusual width of
the inferior dental arch.
It has been asserted by some observers that these narrow
dental arches are the result of enlarged tonsils, compelling a
constantly opened mouth for respiration; but in neither of
these cases was there any enlargement of the tonsils, nor any
unusual tendency to keeping the mouth open.
It has also been maintained that these same V-shaped
or pinched arches are associated with abnormally high pala-
tine vaults, and that the same characteristics are peculiar to
congenital idiots; but there is not the least evidence of a
mental development below the average in either of the cases
under consideration, but rather the contrary-an intelligence
and refinement belonging only to the higher classes of so-
ciety.
Nor have I ever seen any evidence that this class of cases
have a congenital origin in any other sense than the inherited
tendency. There is certainly no evidence of such deformity
prior to the eruption of the second set. I have examined a
large number of children in looking for a pinched or con-
tracted dental arch, and, unless associated with some other
deformity, have never seen one. I have no reason, there-
fore, for believing that any considerable percentage of these
cases which come to notice later in life have a congenital ori-
gin. I was confirmed in this view by an examination into
the condition of two younger brothers of the two sisters
whose cases we have been considering.
Fig. 49 shows the upper jaw of the elder of the brothers,
then eleven years of age. Both deciduous molars on the left
side remained; on the right side one had been removed, and
the first bicuspid was emerging from the gum; the second
deciduous molar remained. The incisors, as seen in the cast,
were permanent, and the canines were developing normally,
one of them being through the gum, and the other nearly so.
The reader will observe that the incisors had already assumed
113
the V-shape which characterized those of the sisters! They
were half an inch in advance of the incisors of the lower
jaw. As will be seen, there is no want of space shown as
an explanation of their prominence; there is room enough in
the arch for all the teeth that are there or are coming; never-
theless, the arch is abnormally shaped, and will require sooner
or later appliances for its reduction. The lad has never con-
tracted the thumb-sucking habit, and his mental and physical
development are good. If the assumption were correct in re-
gard to the inherited origin of the deformity in the two elder
FAMILY CHARACTERISTICS.
FIG. 49.

sisters, we need look no further for the cause of a like ar-
rangement in the teeth of the brother. Reflection would
also lead us to expect such a development in other members
of the same family, on arriving at the proper age. But an
examination of the mouth of another sister, now about four-
teen years of age, shows a perfectly regular and symmetrical
dental arch. A younger boy of about six years shows only
the deciduous teeth and permanent molars of that age, and
all regularly developed, with no symptoms of a tendency to
a contraction of the arch to a V-shape.
From these observations, as well as others, I come to the
conclusion that an irregular dental development can not be
114
DEFORMITIES CAN NOT BE PROGNOSTICATED.
prognosticated, even with a strong hereditary tendency, and
particularly that form which assumes the V-shape. Neither
is this shape any evidence of idiocy or of any tendency to
idiocy in that individual.
In this connection I am impressed with the untenable
ground taken by Dr. Barker at a meeting of the Alumni of
the Pennsylvania College of Dental Surgery, as reported in
the "Dental Cosmos " for May, 1874: "Dr. Barker brought
before the association a patient who had a strong heredi-
tary tendency to a large projecting superior maxilla, and he
said: This tendency I overcame by extracting two per-
fectly sound six-year molars. There would be no such
thing as irregularity if the dentist could get the child young
enough.'
999
Professor Truman asked, "Was the protrusion mentioned
an existing fact, or was it only anticipated?"
Dr. Barker replies that the tendency was anticipated, and
Professor Truman most justly adds: "As there was no irregu-
larity to treat in this case, I can not discover any justifiable
reason for the removal of the first permanent molars. In
this patient the articulation of the anterior teeth is perfect,
while the proper articulation of the bicuspids has been de-
stroyed by the extraction. The masticating surfaces of these
teeth strike directly upon each other, producing, in my judg-
ment, a serious irregularity."
These observations of Professor Truman on the results of
an attempt to correct a protruding jaw which had not yet
developed, together with the impossibility of foretelling what
will be the results of an hereditary tendency, show the folly
of any such experiments. In the case of the family referred
to in this chapter, two daughters developed narrow arches
and protruding jaws through an hereditary taint; the third
child was passed entirely; the fourth is unquestionably fol-
lowing abnormally; and the fifth is too young to form a de-
cision as to the permanent teeth.
•
115
Figs. 50 and 51 show the models of a case I have now
under treatment. The patient is of German birth, fifteen
CASE OF SADDLE-SHAPE PALATE.
FIG. 50.

20
years of
age, and above the average in height. She is fair of
face and comely in appearance, and there is no external indi-
cation of the internal deformity. The natural contour of the
cheeks is not disturbed. It is evidently confined to the alve-
FIG. 51.

Coor
olar processes and the teeth. I have seen other members of
the family, and as yet discover no signs of hereditary trans-
116
TOMES'S CASE OF CONTRACTED MAXILLA.
mission. It is not associated with enlarged tonsils; the ton-
sils are not quite up to the average size. In intelligence she
is equal if not superior to the average of the class in society
to which she belongs.
The teeth, it will be observed, are very irregularly placed;
the second deciduous molars are remaining, and the second
bicuspids have not erupted in the upper jaw. I think the
palatine arch is the narrowest that I ever saw in an adult, not
otherwise deformed. The width between the remaining de-
ciduous molars across the arch is exactly one half inch, while
in length the jaw would indicate a size above the average.
The lower jaw articulates with the upper, but in such a way
as to leave more room for the tongue below than above.
G
I propose to widen these jaws to the extent that harmony
with the other features demands, and to that end have ex-
tracted the deciduous molar of the right side, and inserted a
vulcanite plate with a jackscrew reaching from side to side,
as illustrated in former chapters. The progress thus far has
been both rapid and satisfactory, but no attempt is being
made to accomplish it against time.
The following description of a case of V-shaped con-
tracted maxilla, in which there was a wide separation be-
tween the upper and lower front teeth, was communicated
by Mr. Charles S. Tomes, of London: *
"Mouths in which the back teeth alone antagonize, and
the upper and lower front teeth fall short of meeting one
another, are not very uncommon; though, inasmuch as this
deformity is often regarded as irremediable, or as necessitat-
ing a course of treatment so protracted as to be practically
prohibited, this case may possess some interest on account of
its having been brought to a successful issue within a very
moderate period. Before the patient came under my care
an attempt had been made to correct the irregularity of the
upper teeth among themselves with some degree of success,
*"Monthly Review of Dental Surgery."
BAD RESULTS FROM EXTRACTION.
117
as I learn, from a model taken at the outset, that originally
the lateral incisors stood within and the canines outside the
line of the other teeth. With the view, I suppose, of allow-
ing the canines to fall in, the first upper bicuspids had been
extracted on each side a plan of treatment which, in the
long run, led to unfortunate results; for although the canines
assumed a position of comparative regularity as far as the
teeth on either side of them were concerned, they did so at
the expense of sinking in altogether inside the arch of the
lower teeth.
16
16
16
"When first seen by me the characteristics of the mouth
were as follows: The upper jaw presented the ordinary form
of a V-shaped maxilla, the central incisors meeting one an-
other at an angle, their mesial edges being greatly everted
and overlapping one another, and the palate being excessively
deep and narrow. When the mouth was closed to the ut-
most extent possible, a gap of of an inch intervened
between the edges of the upper and lower central incisors,
of between the right laterals and the canines, and of
between the left laterals, while the left canines occupied a
position (relatively to one another) too irregular to admit of
exact measurement. Behind the canines the upper and lower
teeth came in contact with one another, but their disposition
was very irregular. Thus the second upper bicuspid (the
first having been previously removed, as has been already
mentioned) bit inside the corresponding lower tooth; while
of all the teeth in the upper jaw the second molars were the
only ones which preserved their normal relations by biting
outside the corresponding lower teeth. It was therefore
necessary to move outward the central and lateral incisors,
the canines, and the second bicuspids on both sides.
"The first stage in the treatment was to expand the arch
of the upper teeth, so that they would, had it been possible
to close the mouth fully, have passed outside the lower teeth.
The first upper molars, being excessively carious, and often
painful, were extracted, and a vulcanite plate was then in-
9
1
METHOD OF TREATMENT.
118
serted, which forced the bicuspids outward by means of
wooden wedges, while at the same time it disengaged them
from the cusps of the lower teeth by means of gold caps
fitted over the second molars so as to prop the mouth open.
It should be added that the removal of the first molars did
not enable the front teeth to be approximated any more
closely than before.
FIG. 52.

Wow?
פורט
Model of the mouth before the treatment was commenced.
"As soon as the bicuspids had passed out, so as to bite
outside the lower teeth, this plate was abandoned in favor
of one with a stout gold wire passing outside the incisors,
canines, and bicuspids, and being attached to the vulcanite
plate in the spaces left by the extraction of the first molars.
To this band, which had been rendered elastic by hammer-
ing, the central and lateral incisors and canines of both sides.
were firmly attached by silk ligatures, the band being pressed
inward toward the teeth by the finger of an assistant, while
each ligature was being tied. The effect of this was to
* "Were another similar case to present itself, I should adopt a modification
of this plan, shown to me by my friend Mr. S. J. Hutchinson. In place of
attaching the belt to the band by ligature of silk, an elastic band is passed
behind the neck of the tooth, brought forward and passed round the gold band,
then backward again, passing once more on either side of the tooth acted on,
and the ring then secured by being hooked over a small stud on the vulcanite,
immediately behind the neck of the tooth."
APPARATUS TO DRAW THE JAWS TOGETHER.
119
draw the teeth outward rapidly, and to make the front of the
arch rounded in the place of having the angular form charac-
teristic of the V-shaped jaw, so that the upper teeth assumed
a perfectly regular position among themselves.
"As soon as the upper teeth had been drawn outward so
that the arch was wide enough to allow of their passing out-
side the lower teeth, pressure was brought to bear in order
to close the front part of the mouth by means of a simple
arrangement of elastic bands. A circular air-cushion was
FIG. 53.

BASEMENT PARTENERIAT HERERE THANASA
Apparatus used to draw the jaws together. The band passing over the top of the head is
placed too far back in the woodcut,
adapted to the chin and connected by strong pieces of elastic
with a cloth band passing over the top of the head; the
whole was kept in place by two pairs of ribbons which were
tied at the back of the head. At first some little trouble was
experienced, owing to the skin of the chin becoming tender
under the heavy pressure; but this was combated by the use
of spirit lotions, and by putting slightly oiled lint between
the air-pad and the skin. This apparatus was worn constantly
at night, and also during a considerable part of the day, the
RESULTS OF THE TREATMENT.
120
teeth being kept from falling back into their former positions
by a light retaining plate. At the time when this apparatus
was first adjusted the only teeth which came into contact
were the upper and lower second molars and second bicus-
pids.
"For a few weeks no very marked effect was produced
save slight pain in the region of the temporo-maxillary artic-
ulation; but after that the gap between the upper and lower
incisors diminished each week by an amount that could be
measured, and at the expiration of six months from the com-
mencement of treatment (the elastic bandage having been
worn for about four months), not only had the gap entirely
closed, but the upper central incisors had been made to over-
FIG. 54.

#hit
Jilk
Model of the mouth after the lapse of six months.
lap the lower to the extent of of an inch, while, as may be
16
seen in Fig. 54, the laterals and the canines also overlap and
antagonize. It will be noticed that the closure is more per-
fect on the left than on the right side, on which latter the
gap was originally much the widest; and as the apparatus has
now been worn more or less for an additional three months
without effecting any further appreciable change, it is prob-
able that this will not be rectified. Not only has the pa- .
tient's appearance been very greatly improved by the closure
of the mouth, but the power of mastication, which before
treatment was necessarily very imperfect, has been most ma-
terially improved.
PATHOLOGICAL INQUIRY.
121
"The patient's age (seventeen), the number of teeth which
had to be moved, and the extent of the deformity, combined
to render the prospect of success remote, and it was only at
her own urgent desire that I undertook to treat the case at
all, feeling very doubtful of its ultimate issue; while the
success which has attended the treatment is mainly due to
the indomitable perseverance of the patient herself, who
fully understood what was being attempted at each particular
time, and furthered my endeavors in every way.
"A point of much interest which arises in considering
this case is, was the closure of the front teeth effected by an
elongation of the ascending ramus of the jaw, or by the
antagonizing teeth (i. e., the bicuspid and second molars)
being depressed, and, so to speak, forced down farther into
their sockets? I am inclined to think that the latter is the
true explanation, for not only did these teeth become tender
during the treatment, but the rapidity with which the closure
was effected when once it had commenced (each week show-
ing a very sensible improvement) almost precludes the possi
bility of its having been due to elongation of the rami, which
must necessarily have been a slow process."
In carefully reading the foregoing description, I am in
doubt about there having been a deformity of the maxilla.
Mr. Tomes calls it a "V-shaped contracted maxilla," but
gives no evidence that the maxilla was in any way con-
tracted. The changes resulting from the extraction of the
first upper bicuspids are only alveolar changes. If it were a
contracted maxilla, the spreading of the crowns of the teeth
at that age would have probably resulted as in the case of
my own, described on p. 108. I am inclined to think that
the contraction was confined entirely to the dental and alve-.
olar arches, and Mr. Tomes's closing sentence leads me also
to the further opinion that the maxillæ were not affected at
all by the treatment.
The following drawings are from models of a dental
1
T
122 PROTRUDING UPPER AND RETREATING LOWER JAW.
arch in the mouth of a miss thirteen years of age. An
examination of the cast taken before any treatment was com-
menced (see Fig. 55) shows a pointed arch, which should
not be confounded with the protruding arch of an upper
jaw, in which the six front teeth all stand forward on a
broad and flattened curve. It has been supposed that the
type shown in this model is the result of thumb-sucking, or
some other like and equally pernicious habit, but it is a mis-
apprehension of the facts. I have never seen a case of thumb-
sucking that produced the V-shaped arch, and the case de-
FIG. 55.

NE
scribed on p. 106 shows an example of undoubted hereditary
tendency to a V-shape, but which the habit of thumb-sucking
obliterated, and instead thereof the anterior portion of the
arch was widened and correspondingly fiattened, while the
sides, being held by the articulation of the lower teeth,
remained unchanged. In the present case the deformity of
the upper jaw was not in itself nearly so pronounced as in
many other cases, but the effect produced upon the external
features was very marked. In Fig. 56 is seen the profile of
both jaws with the articulation of the teeth. So great a dis-
LOWER JAW MAINLY IN FAULT.
123
crepancy between the incisors of the upper jaw and the
incisors of the lower jaw in the mouth of a child whose
features were otherwise regular, produced an incongruity
amounting to marked deformity. A study of the profile
did not show that the upper lip was so much in advance of
a regular outline as that the lower lip, chin, and lower jaw
were all receding and seemingly out of place. Neverthe-
less, the occlusion of the teeth showed that their grinding
surfaces articulated admirably with their antagonistic neigh-
bors.
The dental arch of the lower jaw was well formed, was
not contracted at the sides, but was round and of normal
FIG. 56.
A
development, and in this respect was unlike any lower jaw
that I remember to have seen associated with a pinched.
upper arch where the grinding surfaces articulated so accu-
rately. In all cases which I have heretofore observed of
a well-shaped lower arch associated with a pointed upper
one, the articulation was not good; the lower bicuspids and
molars articulated outside the cusps of their superior antago-
nists. I was puzzled over this anomalous state until the
plaster models were made (as represented in Fig. 56), when,
with a better opportunity of studying the articulation, I dis-
covered that the lower teeth were articulating one tooth be-
hind their normal place in the upper jaw; that is, the first
bicuspid of the lower jaw was shutting between the bicus-
་

CORRECTED BY "JUMPING THE BITE."
124
pids of the upper jaw, while in all cases normal occlusion
requires that the lower bicuspids should shut in advance of
their correspondents above. In the plaster models I was
able to see the perfection of articulation in this state of
malocclusion, and also to see that the movement to shut the
lower jaw farther forward showed the upper jaw too narrow
to receive it. Thus was obtained a clear insight into the
cause of the deformity.
The tendency to a pointed arch was inherited from the
child's father, but with him it was of so slight a character as
not to amount to a deformity. This peculiarity was more
marked in the child, for, as I have elsewhere shown, the
causes which produce an irregularity in development will, if
transmitted, exaggerate the peculiarity. And so in this case
the V-shape of the upper jaw was more marked in the child
than in the father, but not sufficient to produce such a de-
formity of external feature if the lower jaw had persisted in
shutting forward in its normal place, and of course outside
in the bicuspid and molar region, as in most other similar
cases.
The remedy evidently lay in the widening of the upper
jaw until the lower would be received in its forward and
natural place; and resolved itself, therefore, into three ele-
ments, viz.: widening the upper arch so that the lower
teeth could not articulate as they had been accustomed to;
secondly, compelling a new articulation in an advanced po-
sition (this action I have called in other places "jumping
the bite"); and, thirdly, flattening the pointed and project-
ing appearance of the incisors.
The appliance used was of the simplest possible character,
and is shown in Fig. 57. It was a thin plate of vulcanite
covering the roof of the mouth, fitting closely to the necks
of all the teeth except the central incisors, and sprung into
place. Two slots, as seen in the engraving, were cut through
the plate as a convenient means of attaching two rubber
rings cut from small elastic tubing. A piece of stout thread
REGULATION ACCOMPLISHED IN THREE WEEKS. 125
was passed through both rubber rings; the plate was intro-
duced in the mouth, and the thread drawn forward between
the central incisors and tied over a little cross-bar lying hori-
zontally about the middle of the crowns, at their proximal
edges; this cross-bar was the unburned end of a match-stick,
and less than an eighth of an inch long. The engraving
shows the rubber rings only under about half tension; in
use they were drawn clear up to the lingual surfaces of the
centrals, but of course the tension depended much upon the
size of the rubber tubing and the strength of the rubber.
At the time of the introduction of this appliance I inserted
thin wedges of rubber between the teeth on each side in the
FIG. 57.

three spaces between the canine and molar. How much
these wedges contributed to the correction of the deformity
I am uncertain, as after two or three days I became fearful
that they might operate disadvantageously, and removed
them. The sole appliance, then, depended upon for correc-
tion, was the vulcanite plate, as seen in Fig. 57.
Two weeks from the same hour at which I attached the
apparatus I took the casts which are represented in Figs. 58
and 59. At the end of another week I introduced the final
retaining plate, and pronounced my work at an end. The
articulation of the lower teeth in their new-found places was
nearly as perfect as in the former condition, and in process.
of time will, by accommodation, become quite so.
It is now
.
126
PHILOSOPHY OF THE MOVEMENT.
impossible for the teeth to shut in their former and abnor-
mal places. It needs no words to describe the change in the
external features; the casts shown in the engravings suf-
FIG. 58.

ficiently indicate how the profile was changed within three
weeks, from a marked deformity to an equally marked and
pleasing regularity.
To an unreflecting mind the results accomplished by so
simple an appliance may seem incomprehensible, but they
FIG. 59.

are the logical sequence of the application of well-known
laws. The power here applied to the median line was of
the same character as the placing of a load of sufficient
1
REMARKABLE CASE OF PROTRUDING LOWER JAW. 127
weight upon an arch to crush it. As the arch flattens in the
center under the weight, it must bulge at the sides until the
whole collapses in ruin. But before the disorganization of
our dental arch arrives, we apply our retaining plate, which
in this case was like the regulating plate, but with the rings
nearer to the front, which were drawn over each central,
simply to hold them from springing forward, and all the
other teeth were locked by them.
On the 19th of January, 1871, the treatment of the fol-
lowing-described case of irregularity was commenced:
The patient was a young lady fourteen years of age.
The occlusion of the jaws showed that the entire row of
FIG. 60.

lower teeth shut outside the upper ones.
This is fairly rep-
resented in Fig. 60. The external features showed-1. That
the lower jaw was not too large, being neither too wide nor
too long. This determination was easily arrived at by a
comparison of the extreme lower part of the face with the
CORRECTED IN TWENTY DAYS.
128
upper part of the face and head. 2. The same course of
reasoning showed that, relatively, the upper alveolar border
and row of teeth were contracted so much as to produce
limited external deformity. To a casual observer, the chin
and lower lip were too full. To a more accurate observer,
the upper lip, cheeks, and nose were depressed. I suggested
that immediate attention would correct what otherwise would
become an increasing deformity through life.
The casts represented in Fig. 60 were taken, and the first
fixture applied, as before stated, January 19th. Six days
FIG. 61.

afterward the incisor teeth of the upper jaw were overlap-
ping the lower incisors. On that same day, namely, January
25th, I gave a clinic, under the auspices of the District Den-
tal Society of New York, on the subject of "Treatment of
Irregularities," and took an impression and made a cast of
this case, exhibiting it there as a part of my demonstration,
to prove the rapidity with which teeth could safely be moved
into certain positions.
Within twenty days from the time the power was first
applied to the teeth, the entire upper row was articulating
outside of the lower ones, substantially as shown in Fig. 61.
129
A retaining plate was adapted to the upper jaw, such as is
shown in Fig. 62, which was worn, with some unimportant
modifications, for several months. The result was a most
marked change in the profile, and in the relation of the ex-
ternal features. The individual features being naturally
well formed and symmetrical, the change in their relations
produced a face of more than usual beauty.
The treatment consisted solely of wedges inserted be-
tween the teeth, as shown in Fig. 62, in conjunction with
REGULATION BY WEDGES ALONE.
FIG. 62.

the retaining plate, Fig. 63. Wedges were inserted between
all the teeth, as shown in Fig. 62, and worn from the first.
These wedges were of elastic rubber, and used of such thick-
ness only as would exert a gentle pressure. The retaining
plate answered a twofold purpose: it kept the teeth from the
possible contingency of any one of them moving toward the
center of the mouth; and, secondly—which was of equal im-
portance-points of the retaining plate were allowed to pass
between all the teeth, which kept each wedge from slipping
up into and irritating the gum. The patient was watched
PHILOSOPHY OF THEIR ACTION.
130
daily so long as the wedges were acting. When by reason
of their want of thickness they ceased to act, new ones, but
slightly thicker, were substituted. There was no more dis-
comfort to the patient undergoing this process than is com-
monly experienced in the wedging of one or two teeth in the
mouth for the purpose of getting space for filling. There
was no soreness which called out complaint from the patient.
There was no favoring diet, nor was there any provision
made for masticating while the teeth were in transit. The
teeth in their new position and articulation, as seen in Fig.
61, have remained stationary now for a period of eight years.
FIG. 63.

Not only is the external face improved, but a longevity is
guaranteed to these teeth by their isolation which could not
have been obtained by any other means.
The foregoing account is not designed to prove what is
sometimes possible, or what trials nature may undergo and
still survive; but it is set forth as an illustration of a princi-
ple in the treatment of irregularities which has never before
been published.* In the above there is nothing but a recog-
nition of pure mechanical principles in dental practice. The
wedge is a mechanical power. Its application here is identi-
cal with its use by the architect as a keystone in building his
arch. Its action and results are the same as if the hoops of
* First published in the "Dental Cosmos," January, 1872.
BAD CASE OF PROTRUDING UPPER INCISORS.
131
a barrel were loosened and a wedge driven between each
stave. The circumference of the barrel would enlarge so
long as the staves were prevented from twisting, in which
case the whole thing would collapse into a wreck.
In 1861 my attention was called to the mouth of a child
nine years of age, whose teeth were erupting and growing
unlike those of other members of her family. The father
and mother both had regular dentures. The mother in par-
ticular had a most intelligent face, with regular, handsome
features, and large, beautiful teeth. An older sister had fully
FIG. 64.

developed teeth in both jaws, all regular, and of the type
of the mother. In the child the incisors were protruding,
and the whole upper jaw gave the appearance of being ex-
cessively large. (See Fig. 64.) The teeth of the lower jaw
were normal. I could see no reason for this peculiarity. It
was not inherited from either father or mother, nor from the
grandmother, whom I also saw, nor did they know of a like
deformity in any of the relatives.
of the relatives. It was not the result of
thumb-sucking, nor, so far as I could learn, of any other
evil habit.
I did nothing at the time, thinking it possible that the
APPARATUS FOR TREATMENT.
132
action of the upper lip might have a tendency to depress
them as they advanced. I watched the case for four years
before I decided to act. During this time they had con-
tinued to grow worse, and were throwing out the upper lip
so that it was with much difficulty that the lips could be
brought together and the mouth closed. The surrounding
features were developing after the symmetry of the mother's.
The permanent teeth of that age (thirteen) had all made their
appearance, and the mouth was deformed without hope of
improvement in the course of nature. The teeth behind the
canines were all in contact and articulated well with those of
the lower jaw, but the incisors were spread and straggled,
and the crowns had the appearance of being of extraordinary
length.
As interference need be no longer postponed, I made
a frame of gold, covering the cutting edges of the incisors
and lapping on to the canines, and a plate of vulcanite
adapted to the roof of the mouth, such as described in
former chapters, and cut away in front to provide for the
retrocession of those teeth. Ligatures cut from rubber
tubing were attached to the posterior part of the vulcanite
plate, one on each side, and drawn forward and caught on
projecting spurs of the gold frame. This apparatus, which
can be easily understood from the description, was worn
for a short time, when two discoveries were made: First,
the arch in front was by this means contracted until the
teeth came in contact, but was not sufficiently reduced.
With the teeth all now in close contact, there was no hope
of further reduction without the removal of a tooth, and
the first bicuspid on each side was consequently extracted.
Secondly, the backward movement showed an apparent
elongation of the incisors. I do not think it was an actual
elongation, but an appearance arising from crowns of an
already extraordinary length becoming more perceptible as
they came into a vertical line. It became evident that any
further pressure in the same direction would eventually carry
SKULL-CAP BRACE AND ELASTICS.
133
the teeth down so as to touch the gum of the lower jaw, thus
completely hiding the lower incisors and producing a deform-
ity but little preferable to the first.
In this emergency I conceived the attempt to shorten
the crowns of the upper teeth by driving them up into the
jaw.
I continued the apparatus as before described within the
mouth, and added to the gold frame a stud or post about half
an inch in length, soldered to it opposite the canines, and
coming out of each corner of the mouth. This apparatus,
FIG. 65.

M
LA M
when in position, is shown in Fig. 65. The arms extending
upward, passing outside the cheeks, were made of strips of
brass, and were connected by elastic ligatures with a skull-
cap, as shown in Fig. 66. This skull-cap was made of
leather, and the whole apparatus was very easily applied
as follows: The vulcanite plate was inserted in the mouth,
and the rubber ligatures brought forward and caught as be-
fore described, the skull-cap placed on the head, and strong
elastic straps were caught over buttons or hooks on the cap,
and like buttons or hooks on the cheek-arms. The action
will be understood by observing Fig. 66. The outside pres-
10
134
sure was forcing the teeth up into the jaw, while the pressure
inside was carrying them in a direct line backward. This
apparatus did not interfere with the comfort of the patient
in any respect other than the appearance, and was worn con-
stantly for a period of three months; after that, during the
night, and somewhat during the day, for an additional two
months. The result was, that the six front teeth were car-
ried back so that the canines came in contact with the second
bicuspids, and the incisors were driven up into their sockets
;
INCISORS SHORTENED IN THEIR SOCKETS.
།
PR.
FIG. 66.

one fourth of the length of their crowns, and the family ex-
pression of the mouth and face restored. The result is shown
in Fig. 67.
So far as I am aware, this was the first effort ever made
to shorten teeth by retracting them within the jaw where
they had become elongated through natural or develop-
mental causes. This occurred in 1866, and was reported
at the May meeting in that year of the New York Dental
Society, and published in the "Dental Cosmos."
PHYSIOLOGICAL AND PATHOLOGICAL ACTION.
135
The success in this case involved absorption of the walls
of the socket, and is not to be confounded with some cases
which I have seen since reported, where a tooth had become
elongated by accident (as, for instance, the presence of a rub-
ber ring around the neck of the tooth), and pressure was
used to restore it. In the latter case it is probable that
neither deposition nor absorption of bone took place.
My attention was recently called to an instance in Dr.
Thayer's practice, in Brooklyn, where the pathological condi-
tion was like my own case. In regulating several upper teeth
FIG. 67.

Wlles
for a young lady, he had occasion to turn one of the central
incisors. After the teeth were all brought into line he made
a retaining plate with a band in front. The patient neglect-
ed to report herself, and went out of town, being gone for
several weeks; during which time the bearing upon the
afore-mentioned incisor became such as to drive it up into
the jaw, and when discovered by Dr. Thayer was shorter by
one half the length of the crown than its adjacent neigh-
bors.
Fidelity to history requires that I should report the dis-
astrous results that followed neglect and inattention to my
instructions in the case above described and illustrated. Im-
mediately on obtaining the desired results in appearance, I
made and applied a retaining plate, which, if worn, would
136
keep the teeth in their newly acquired positions. Being
over-persuaded, I foolishly gave my consent to an immediate
trip to Europe, the patient to return to me in four months.
My parting instructions were that the retaining plate must
be worn constantly. On board ship the plate was removed
during sea-sickness, and no attempt made to replace it until
they arrived on the other side the Atlantic, when it was found
that it could not be inserted, the teeth having changed posi-
tion. A number of weeks elapsed before any one was con-
sulted, and in the mean time they had gone all astray. A
year and a half afterward the patient returned to this coun-
try, and reported herself to me. The teeth were then, if
anything, more disorderly than before I made any attempt
with them; and I declined to further interfere, partly from
discouragement, and partly from a doubt as to the expe-
diency of breaking up the structures a second time, and at
this more advanced age. And the last condition of that
patient was worse than the first.
DISASTROUS RESULTS OF NEGLECT.
In April, 1878, Dr. George S. Allan brought a little girl
to me for consultation in regard to a marked protrusion of
the lower jaw. The deformity was entirely in the under
jaw, which, as usual in such cases of abnormal width, pro-
jected so that the lower arch extended outside the upper
throughout its whole circuit. As the irregularity appertained
to the jaw itself, and not to the arrangement of the teeth, it
was decided to operate upon the jaw alone, and to bring
about a correct articulation of the teeth as a sequence. At a
meeting of the Odontological Society of New York in No-
vember following, Dr. Allan reported the progress of this
case, from which I quote as follows:
"My first plan was to construct two dental splints or
plates of rubber, one each for the upper and lower jaws,
having a protuberance on each in the nature of an inclined
plane, which would act, during closure of the jaws, to force
DR. GEORGE S. ALLAN'S CASE.
137
the lower one backward. But I did not persevere in this
direction, for I soon found that it would be of little use.
Then, directing the child to continue wearing the upper
plate, I set to work to make an apparatus that would pull the
lower jaw back, keeping the upper splint alone in place. As
you will see from the photograph taken at the time she was
wearing this apparatus, it consists of two parts. For the
lower part I made a brass plate to fit the chin, having arms
FIG. 68.

with hooked ends reaching to a point just below the point of
the chin. These arms were arranged in such a way that the
distance between them could be altered at will by simply
pressing them apart or together. The upper part consisted
of a simple network going over the head and having two
hooks on each side, one hook being above and the other below
the ear. When this apparatus was completed and in use,
there were four ligatures of ordinary elastic rubber, pulling
}
SKULL-CAP AND REGULATING APPARATUS.
138
in such a way as to force the lower jaw almost directly back-
ward. I relied upon the elastics attached to the lower arms
to do the main work. The upper elastics were simply used
to keep the mouth closed so that the lower elastics would not
pull it open, the upper elastics being made just strong enough
so that the child, in the natural operations of eating and
talking, would not have to strain the muscles of the mouth
to keep the jaw open. The work proceeded very rapidly,
much more so than I had expected, so that at the end of two
months, instead of six (as I had told the mother of the child
it would take), the irregularity was almost entirely cured.
At about the end of the first month there came a stop, and
for two weeks I could not get the jaw to move one particle,
which puzzled me very much. The mother said the child
wore the apparatus regularly, day and night, and she knew
of no reason why the work should not go on. I had the
child brought down to the office in the morning, and kept
her there all day watching her; and I found that when she
was busy at reading or play she would push the network on
the head back so that the elastics did not pull. Thus that
puzzle was solved. I then directed the mother to watch her
carefully, and keep the band of the network well on the fore-
head, and also more carefully directed the young miss her-
self, and warned her that she would lose all that had been
done if she was not more careful in the future. After this
the work went on steadily to completion. In a little over
two months the under teeth were completely inside of the
upper. The cast I hold in my hand represents the condition
of the teeth when I commenced operations, and this one
shows the condition of the teeth at the present time. In my
absence during the summer the child wore the elastics only
during the night, and on my return I found that the jaw had
pushed out a very little, not enough to throw the upper teeth
within the lower teeth as formerly, but so that the left upper
incisor was just touching the tip of the lower one. I had
the apparatus reapplied, and this slight relapse soon disap-
NEW ARTICULATION PRODUCED AT THE CONDYLES. 139
peared. I see no reason why, in all such cases, either this
or similar methods of procedure should not be adopted. If
taken at this age, or even when the child is older, I can not
see why success should not attend the efforts of the dentist.
I was puzzled at first to understand how I had obtained so
great an amount of recession in the lower jaw; but on care-
fully examining the skull and position of the parts at the
child's age, the proper solution of the problem soon presented
itself. The jaw at that period of life is completely devel-
oped and hardened. When a child is one year old the union
between the two lateral halves of the jaw takes place, and at
eight years the jaw is solid. Consequently any efforts that
may be made will not affect the jawbone itself. The only
way in which the change can be made is by pushing back the
condyles of the jaw into the glenoid cavity. Allow me just
here to show you the skull of a child about five years of age.
The articulation between the glenoid cavity and the condyle
is peculiar, in that there is a double synovial membrane be-
tween which there is a cartilaginous bursa. This cartilage
gives way and absorption takes place at the posterior side of
the condyles, with filling in of the anterior, so that the whole
operation consists in pushing the condyles of the lower jaw
into the glenoid cavity of the temporal bone. Until the ar-
ticulation has again receded by the natural protrusion of the
teeth, I suppose the child will have to wear the apparatus
more or less. I had it taken off to bring here this evening.
I should certainly in any similar case presented hereafter,
even at twelve or thirteen years of age, before attempting
any other procedure, try this first and thoroughly."
Fig. 69 shows the arrangement and articulation of the
teeth of a miss of about fifteen years, as she was presented
to me. It will be observed that both lower canines shut
outside the upper lateral incisors. So also does the right
lower central close outside the upper central. All the six
FOLLY OF USING A GAG.
140
front teeth of both upper and lower jaws were in an irregular
condition, the lower ones being more marked.
A brief history of the case showed that at some former
period the superior incisors were all shutting inside the lower
ones, and the patient, then living in a distant city, had been
under treatment and the superior arch expanded until the
present condition was reached. During this process the
plate used in the expansion of the arch was made to cover
the grinding surfaces of the upper teeth, and mastication
went on between the lower teeth and this plate. When the
patient fell into my hands, there was a retaining plate on the
upper jaw, which in like manner covered the grinding sur-
FIG. 69.

faces of the teeth. I have always publicly and in practice
disapproved of such a gag, as not only unnecessary but pro-
ductive of positive harm. This case illustrates the harm,
for when I removed that plate it showed that the normal
articulation of the teeth had so long been interfered with
that the teeth would now touch only in a few points, these
points being the extreme molars and the incisors, which were
the only teeth that were free to develop, not being held back
by the plate. When this so-called retaining plate was out of
the mouth and the jaws in contact, there were spaces at the
sides where the teeth did not meet each other by nearly a
sixteenth of an inch.
141
There comes now a diagnosis of the case which can not
be made from a study of models, but requires a personal
examination of the patient. The model does not indicate
any peculiar or unnatural pitch to the superior incisors,
but a cursory observation of the patient's face on opening
the mouth showed that the apices of the roots of the supe-
rior incisors were based on a contracted circle, and that any
further marked expansion of the arch and advancement of
the crowns would give a bad pitch to those teeth and a dis-
agreeable expression to the mouth. Furthermore, the upper
arch was already well developed. It was of normal breadth,
and large enough in its circle to admit all the teeth into line.
This was sufficient ground for abstaining from any further
efforts at the enlargement of the upper jaw.
STUDY OF EXTERNAL FEATURES NECESSARY.
4
FIG. 70.

Turning now to the lower jaw, we find it of breadth
equal to the upper, but the teeth jumbled in front and
crowded out of line. And just here develop the necessity
and the wisdom of extraction. As a fact in science, all
these teeth of the lower jaw can unquestionably be brought
into line by an expansion of the arch; and it would be
equally a fact that, if it were done, the deformity of the
mouth would be increased, as an enlargement sufficient for
that purpose would place all the lower front teeth outside
the upper ones. No further expansion of the upper arch
could be effected without spoiling the expression of the
mouth.
142
EXTRACTION OF LOWER INCISOR JUSTIFIABLE.
There remained but one alternative, viz., the reduction
in size of the lower arch. I extracted the right lower in-
cisor, leaving, of course, but three teeth between the canines,
Br
FIG. 71.

Wagtig
and applied immediately the fixture shown in Fig. 70. It
was a very simple plate of vulcanite, with three rings of
elastic tubing attached to it, and when in situ one ring was
stretched over the remaining central incisor and the others
FIG. 72.

over the canines. The plate was cut away behind these
three teeth to permit of their falling back under the strain.
The position assumed by the elastics is shown in Fig. 71.
APPARATUS FOR REGULATING.
143
At the same time a fixture, as shown in Fig. 72, was
adapted to the upper jaw to lift out the left lateral incisor.
When in position its work is that of an elastic ligature tied
to the plate between the central incisors (see Fig. 71), then
passed outside the central underneath the lateral, outside the
canine, and tied to the plate between the canine and bicus-
pid. Such a fixture would inevitably draw in the canine
and central at the same time that it was lifting out the
lateral, did not the plate rest against them and thus prevent
it. Within ten days the teeth of both jaws were in position,
as shown in Fig. 73. The space caused by the removal of the
lower central was entirely closed, and there was no leaning
•
FIG. 78.

of the teeth toward each other noticeable by an ordinary ob-
server; and I doubt whether the absence of that tooth will
ever be detected, except by the professional eye.
The following-described case of irregularity possesses
some features in common with others which have been illus-
trated, but the causes and treatment are so different as to
make the subject worthy a separate description :
Fig. 74 shows the cast of the teeth of a lad ten years of
age. From a study of the casts, I should have been likely
to come to the conclusion that the superior dental arch had
144
been brought forward through some effort similar to thumb-
sucking, and that the treatment demanded a reduction of the
upper arch. The presence of the lad, and a study of the
external features, showed that the upper teeth were but
slightly at fault, and that the profile of the face was altered
by a retreating lower alveolar and dental arch rather than a
protruding upper one. The upper arch was broad and well
formed; the lower was narrowed as well as depressed. The
profile of the face was good except the lower lip, which was
so sunken as to suggest the absence of teeth on the lower
jaw, while the chin was not retreating and showed an har-
monious relation to the other features.
CASE OF RETREATING LOWER INCISORS
FIG. 74.

The treatment was the adaptation of an appliance to each
jaw; for, while there was no marked deformity of the upper
jaw, nevertheless the pitch of the incisors would be improved
by a slight reduction.
The fixture for the upper jaw is shown in Fig. 75, and
consisted of a vulcanite plate, as here illustrated, with a rub-
ber ring through which a stout thread was passed, and the
elastic drawn forward to the lingual surfaces of the incisors.
A bit of the stump of a match-stick a quarter of an inch
long was laid horizontally across the two centrals, and the
thread tied over the stick.
Upon the lower jaw there were not as yet any bicuspids
DRIVEN FORWARD BY WEDGING.
or permanent canines; the only teeth here shown belonging
to the permanent set are the four incisors and the first mo-
lars.
The regulating fixture is shown in Fig. 76. The
FIG. 75.
MA32
FIG. 76.
vulcanite plate has gold spurs projecting between the in-
cisors and canines. These spurs were inserted to keep the
incisors from spreading on the line of the arch. Wedges of
145


S
!!!/1
elastic rubber were then inserted between each tooth, and
between the teeth and the spurs. This operation drove the
teeth forward in two weeks so that, with the reduction of
146
the upper arch, which was simultaneously accomplished, the
upper and lower incisors came in contact. The retaining
plates for each jaw were similar to the regulating plates,
only adapted to the changed positions of the teeth, and were
continued in place for a number of months. The lower
plate, as shown in Fig. 76, was made wider across the mouth
than the cast would receive, and was sprung into its place.
The tendency was to spread the arch, which it did, so that
when the permanent teeth erupted they developed a broader
arch than existed before, and one which corresponded better
with the upper one.
This case is but one of the many which show the neces-
sity of a personal observation of the patient's external fea-
tures as well as the mouth, in order to an intelligent treat-
ment.
CASE OF JUMBLED UPPER TEETH.
The case illustrated below was that of a boy thirteen
years of age, concerning whom there was no other marked
peculiarity, either mental or physical, than the irregularity
in position of the teeth, and a somewhat retarded second
dentition. Upon a careful observation of Fig. 77 it will be
seen that the second temporary molar of the left side has not
been shed, and that the crowns of the first bicuspid of the
same side, and the canine of the right side, are imperfectly
developed. The crown of the latter was pointing, and locked
within the lower teeth on occlusion.
The articulation-which it is not deemed necessary to
illustrate-showed all the teeth behind the six front ones to
be in their proper places; but the canine of the right side
and the central incisor of the left were locked within the
lower teeth, and the others in varying positions of twisting
and lapping, as is fully shown in both illustrations. The
articulation also showed that the superior arch would bear
sufficient enlargement to bring all the teeth into line, and
without giving undue prominence to the upper lip.
The detail of changes required on the right side was to
COMPLICATED RESULTS FROM THE USE OF ELASTICS. 147
bring out the canine, twist the lateral incisor, twist and
bring forward the central incisor; on the left, to twist and
bring forward the central, bring forward the lateral, and
reduce and carry back the canines. This was all effected
with one appliance made of a vulcanite plate, as described in
former cases, with a gold wire anchored in the plate and
passing around the outside, as shown in the engravings.
This, with the straps cut from rubber tubing, constituted
the whole apparatus. To understand its workings, the illus-
trations will have to be closely observed.
FIG. 77.
A semicircular slot is cut through the plate, forming a
little tongue upon which is caught a ring of tubing; this is
drawn between the lateral and canine, comes forward of the
canine over the wire band, and is carried back and caught
on a hook-a part of the band-opposite the bicuspids. The
contraction of this ligature, it will be seen, will carry the.
canine back, and the pressure exerted by its being brought
over the outside of the wire will tend to depress the tooth.
The plate is carried up nearly to the canine, so as to protect
the gum from being cut into by the rubber, which would
happen without such provision. There are two hooks on the
wire in front, opposite the central and lateral incisor, seen
i

148
TWISTING CENTRAL INCISORS.
distinctly in Fig. 78. The lateral incisor of the left side is
operated upon by a ring of smaller rubber tubing caught
over it, and the one hook next the canine.
The left central, which needs twisting as well as bringing
forward, has a rubber ring caught over both hooks. The
action of this ring will bring the tooth bodily forward until
it comes in contact with the wire. If, now, the ring were
caught over but one hook, this would be the end of its ac-
tion; but, being caught over both hooks, and they being
properly placed, and wide apart, the contraction of the elas-
tic will continue after the nearest point of the tooth has
come in contact with the wire. This contraction can only
exert itself between the hook next the canine and that side
of the central, and twisting is the result.
FIG. 78.

"
Wed
The right central incisor, seen in Fig. 77, is a stubborn
offender. In the model and in the mouth it was still more
twisted than appears in either of the engravings. Its cutting
edge was at nearly a right angle with the wire band. Its
forward edge was not too prominent, and the wire band
rested against it. I first attempted to twist it by the same
arrangement of ligature as moved the other central, but it
failed. It was too much twisted, and I could get no hold.
I tied and retied ligatures in various ways, and of various
kinds, but without effect, and ultimately resorted to the in-
sertion of a peg on the lingual and crowning surface of the
tooth near the gum. This peg, which unfortunately is also
indifferently shown in Fig. 77, was made of pivot wood, and
'
149
was about the size of the gold screws now used for the bet-
ter retention of contour fillings. Had such a screw been at
hand at the time, I should probably have used it, although a
wooden peg is of equal service. With one elastic ring caught
on this peg, on the inside of the right central incisor, a vari-
ety of movement was accomplished. As seen in the engrav-
ings, it passed from the wooden peg between the central and
lateral, around in front of the lateral, back between the lat-
eral and canine, around inside the canine next to the bicus-
pid, and then caught on a hook attached to the wire opposite
that tooth. Its contractile movement would first twist the
central; secondly, it would depress the lateral, and bring
that within the arch, were it not for a branch or process of
the plate coming forward and resting on its lingual surface,
which supports it and prevents the reduction; thirdly, the
canine is pulled bodily toward the wire band.
CONTRARY EFFECTS OF ONE ELASTIC.
This system of plate, band, and ligatures regulated these
teeth perfectly, and a retaining plate made in substantially
the same way kept them in position until they became firm.
The retaining plate was, of course, adapted to their advanced
positions, and the wire, which at first formed a part of it,
was afterward removed, as its only function was to hold the
canine of the left side down to its place. The plate, minus
the wire, was worn for a longer period, but only for a few
weeks, as the articulation of the lower teeth was so admi-
rable as to make a retaining plate unnecessary.
It must not be supposed that making and adapting such
an apparatus as this was all that was done to regulate these
teeth. While this is the appliance which was used, and
these are the principles which governed its action, the appli-
cation of those principles and the adaptation and retention
of the fixture was a severe tax on one's ingenuity and per-
severance. In the beginning, a variety of methods in the
arrangement and attachment of ligatures were resorted to,
some proving a success, and some ending in failure. The
action of the elastic, which is caught in the center of the
11
150
plate, and passes over the canine and wire, has an inevitable
tendency to pull the wire down and throw the plate, wire,
and straps all out of place. In this emergency a waxed floss
or flax thread was passed around the neck of the right cen-
tral, and the wire tied immovably to its position. As the
canine became reduced this tendency decreased, the elastic
ligature at the same time getting a better hold over the swell
and around the neck of the canine. Again, at certain stages
it seemed desirable to rest from active aggression upon some
of the teeth while the work continued upon the others. Thus
the left lateral incisor was becoming more tender than the
rest, and exhibited symptoms of elongating; and it was fa-
vored by releasing all strain upon it and gently tying it to the
band, to maintain what it had gained, and await its recovery.
Such a complication of abnormalities is very difficult of
mastery. The inclination of the crowns, and the peculiar
form which their roots may possess, serve often to make
what may seem a simple case one of very difficult accom-
plishment; and the length of time that will be required can
not be foretold, the experience in one case being but little
criterion for another one similar in appearance.
In this case
the patient was in my hands for this purpose ten weeks and
then discharged, the retaining plate only being required to
be worn longer. The passage of the canine and central out
of the lock of the lower jaw was accomplished within a few
days.
REGULATION WITHOUT A "GAG."
There were no blocks built up on the lower jaw to open
the articulation for that purpose. Indeed, in all the cases I
have treated-and they have been many and constant for
years—where some of the upper teeth were locked within
the lower ones, I never made, in any instance, any apparatus
to keep the jaws apart during such movement. I emphasize
this fact, more because in a work from the pen of Mr. Salter,
of London, a "gag," as he terms it, becomes an important
and necessary adjunct in his treatment of such deformities;
such an appliance being in my own experience a cumbersome
BAD RESULTS FROM USING A "GAG."
151
and unnecessary affair. It is necessary only when the opera-
tion of moving the offending teeth is suffered to drag itself
along through many weeks or months. In such cases, the
molar and bicuspid teeth might elongate by being long kept
from natural occlusion, and thus permanently destroy the
articulation. Such cases I have seen, entailing great injury
upon the patient; but the fault was not so much the failure
to build a "gag
gag" on the lower teeth as it was defective
method of treatment of the upper teeth, making it a long
and tedious process. With suitable methods and fixtures
there need be but little time consumed in the passage of
the teeth, so that their cutting edges can be caught outside
the lower teeth; and from that moment the presence of
the "gag" would be objectionable, and prior to that time.
unnecessary. No severe mastication will be performed or
attempted upon tender teeth, and no masticatory force can
subvert the constant action of properly applied elastic liga-
tures.
Fig. 79 illustrates a form of irregularity of frequent oc-
currence. This was in the mouth of a miss fourteen years of
age. The central incisors were pointed; the laterals shut
inside the lower teeth; the canines were very prominent,
and the bicuspids slightly within the line of the lower arch.
The effect was a serious disfigurement to a face otherwise
very pretty. The lower jaw was well formed, the teeth
regularly arranged, and none of them seriously decayed.
The upper sixth-year molars were decayed, and the pulps
exposed, which had given her some trouble; for this reason
mainly they were extracted, the fact that the irregularity
could be more easily corrected without them being a sec-
ondary consideration.
The regulation involved moving back the bicuspids,
widening the arch, reducing the prominence of the canines,
carrying out the laterals, and twisting the centrals. The
whole was accomplished, and perfect symmetry and articula-
152
tion with the lower teeth produced, in just eight weeks. All
the movements above described were carried on simultane-
ously by the use of a vulcanite plate and elastics, as shown
A FAMILIAR FORM OF IRREGULARITY.
******•
B
FIG. 79.

in Fig. 80. A careful attention to the description will ena-
ble the reader to comprehend its multiplied action.
The strap B on each side was caught over the second
bicuspid of the same side, and worn for two or three days.
Tur
FIG. $0.

B
The recent extraction of the molars behind enabled these
teeth to yield readily; the same straps were then made to
inclose both bicuspids of each side. Simultaneously the
EIGIIT ELASTICS IN OPERATION AT ONCE.
153
straps A A were each drawn forward on their respective
sides and caught over the canine on that side. The bearing
was along the regulating plate passing between the first bi-
cuspid and the lateral incisor on each side. The bearing
was such against the bicuspids that it moved them outward
while the canines were being pulled inward and backward.
Subsequently the straps B B were made to include the ca-
nines as well as the bicuspids within their power, and thus
from two independent sources was pressure exerted. The
straps CC were made to draw out the lateral incisors by
passing between the canine and bicuspid around the outside
of the canine, and caught over the lateral. This served also
to assist in starting the canines, which are the most refractory
of all the front teeth. Later on in the movement, when the
canines and bicuspids had started back, the spurs of the plate
to which the elastics C C are attached were cut off to get
them out of the way of the retreating canines, and the straps
B B were carried outside the canines and caught over the
laterals. When the straps B B were pulling on the laterals,
a single part of them was inside the bicuspids, and a single
part outside, but over the canines they were doubled. The
retrocession and the twisting of the centrals was easily accom-
plished by the straps and a cross-bar of wood, as shown in
the central part of the fixture. During the movement there
was difficulty in making the straps stay on the canines, until
a waxed-silk ligature was tied about the neck of each above
the thickest part, and the straps thus tied up to their places.
The bearings of this appliance which antagonized all this
force were around the second molar teeth, behind and against
the alveolar arch of the front part of the mouth, and against
the lateral incisors. In cutting off the tips of the plate at
C C, it was still left to bear against the laterals, but the move-
ment of the laterals was not due to this bearing of the plate,
nor entirely to the action of the elastics.
The immediate result of all this pressure was to so
change the places of the upper teeth that the articulation
CASE OF MISTAKEN PROGNOSIS.
154
was broken up, and in a few days the lower teeth were able
to catch behind the tips of the laterals, and they were in
consequence rapidly driven forward. The action of the
regular lower jaw thus contributed materially to correct
the irregularity of the upper as soon as it was unlocked
from the laterals. The retaining plate, which was worn for
several months, was of vulcanite with a band around the
outside, similar to Fig. 44.
The following case came into my hands soon after I had
completed the one last described. It was the mouth of a lad
about thirteen years of age. A comparison of Fig. 81 with
("#"),}}}
SACH
FIG. 81.

Fig. 79 shows a striking similarity; indeed, so much so
that I had no hesitation in undertaking the treatment, with
the encouragement that it would be completed in a few
months at farthest. The lower jaw, however, was not in as
favorable condition as in the former case.
Fig. 82, which represents a front view with the teeth
closed, shows that one temporary molar remained on each
side below, and all the front teeth were somewhat irregular.
From a study of the case I felt justified in attempting to en-
large the upper arch enough to bring all the teeth into line,
155
and to this end fitted a plate and jack-screw in the roof of
the mouth. In connection with this, elastics were applied to
the canines and laterals, on much the same principle as in
Fig. 80. These were worn a few weeks, and until I became
convinced that the expression of the mouth would be injuri-
ously altered by any further widening.
DISCOURAGING EXPERIMENTS.
Then arose the question of extraction, and as the results.
had been reached so easily in the former case, where the first
permanent molars were extracted, those teeth in this case
were removed. This afforded an opportunity to carry out
the same plan of treatment as in that case, and that course
was pursued for a few weeks with but little success.
FIG. 82.

Then came a series of experiments, in which screws,
inclined planes, and plates with bands were an important
element, of the details of which there is no record, but
which continued for a year and a half before a result was
reached equal to its prototype. In the mean time I had
suffered all the mortification of anticipated failure.
At one stage of the proceeding, when there was a band
around in front to which the laterals were tied by elastics
to bring them forward, the laterals suddenly began to elon-
gate, and within twenty-four hours had dropped half the
length of their crowns. Indeed, except for the immediate
removal of the elastics, I believe that they would have very
soon dropped entirely out. To correct it, the cause was
removed, and a new appliance immediately inserted which
EXTRACTION OF UPPER LATERALS JUSTIFIED.
156
would tend to drive them back with every occlusion of
the jaws. In the course of a few days they had recovered
their former position, and finally were no longer than the
adjoining teeth. These teeth have not been lost sight of,
and there is no evidence that that elongation produced a
disruption of the pulp. Before the conclusion of treatment
I had the satisfaction of seeing the loss of the lower tem-
porary molars, the eruption of the bicuspids, and a general
improvement in the arrangement of the inferior arch result-
ing from occlusion.
One point is forcibly impressed upon us by the history
of this case, viz., that, considering his sex and the aspect as
presented in Fig. 82, it would have been far better to extract
the lateral incisors and force the canines into the gap, espe-
cially in view of the fact that two comparatively sound teeth
-the first molars-were sacrificed.
In Fig. 83 is seen an example of general disorder of
both superior and inferior dentures, found in the mouth of a
FG £3.

lad about twelve years of age. Of every tooth, it might be
said that it held an abnormal position, either within or with-
out the circle, or above or below its proper plane; both
alveolar arches were contracted, the teeth at the sides par-
ticularly pitching toward the center of the mouth. The
upper sixth-year molars were decayed to mere shells, while
:
CASE OF GENERAL DISORDER.
157
the corresponding lower ones had been extracted, and the
second or twelfth-year molars had tipped forward into their
places. Against the first molar on the right side above was
an abscess, and on the same side below was still remaining
the temporary canine, while the permanent canine was stand-
ing outside.
The treatment consisted in the extraction of the tempo-
rary canine and each of the first molars; a plate and jack-
screw for the upper jaw to widen the arch, followed by
appliances on the general principles so abundantly illustrated
in these pages. For the lower jaw a somewhat stiff plate
was made of vulcanite for the inside of the arch, and sprung
into its place; as the arch widened the plate was, warmed
and straightened and replaced. As the bicuspids of the side
teeth were principally in fault, the lower arch was widened
in a few weeks. During this time the irregular front teeth,
including the malposed canine, were bound to it by elastics
and brought into line. The retaining plates for both jaws
were vulcanite, with a gold band in each anchored in the
plate behind the bicuspids, and passing entirely around the
fronts. The disturbance of the alveolar processes by extrac-
tion and by pressure set up an action which brought a cor-
rection of the abnormal plane, as shown in the engraving.
In the “Dental Cosmos" for January, 1870, Dr. McQuil-
len describes a case of irregularity which came under his
treatment. The patient was a young lady of sixteen:
"On bringing the upper and lower teeth together, the
right superior central incisor closed inside of the inferior
central and in front of the inferior lateral, while the supe-
rior lateral was back of the inferior canine, and the left
superior lateral inside of the inferior one, producing an ar-
ticulation as shown in the accompanying illustration, Fig. 84.
The irregularity in this case was so marked as to attract gen-
eral attention, and the occlusion of the teeth, had it not been
DR. MCQUILLEN'S CASES.
corrected, would have eventuated in a permanent and un-
sightly prominence of the lower jaw most destructive to the
harmony of the features. In the course of two months, with
a very simple, easily-constructed appliance, which could be
readily adapted by the patient, the defective position of all
the teeth was corrected, and a result obtained most gratify-
ing to the patient, completely changing the appearance of
the mouth, and greatly improving the expression of the face.
158
FIG. 84.
UU
"The fixture employed consisted of a silver bar of the
thickness of ordinary lower plate for artificial dentures, two
inches in length by a quarter of an inch in width, perforated
by four holes, and then, with a thin, flat file, cuts were made
from the edge of the bar to these holes, making a fixture
similar to the lower figure in the accompanying illustration,
Fig. 85. India-rubber rings, cut from French tubing, were
FIG. 85.
ORSKI
Qara
readily passed over the bar (which rested on the front sur-
face of the superior incisors) and around the deflected teeth.
The constant, gradual contraction of the rubber drew the
lateral incisors into their proper places in the arch. A bar
of similar construction was also used in the lower jaw.
After becoming familiar with the necessary manipulation,
the application of the fixture was made entirely by the
tient, thus relieving the operator of considerable trouble."
pa-
:


159
This method of securing the rubber rings to the metallic
band was described by Dr. McQuillen in 1859, and is sub-
stantially the same as recommended by Mr. Tomes in his
"System of Dental Surgery." Both gentlemen seem to
have adopted this simple expedient and published their plan
the same year.
HIS METHOD OF REGULATING.
Figs. 86 and 87 illustrate cases also from Dr. McQuillen's
practice. "In Fig. 86 the lateral incisors of the lower jaw
stood considerably within the arch. The patient, a little
girl aged eight years, had the bar and rings described above
applied, and at the expiration of a week or two the teeth
were brought into line, and there held by a retaining plate
until they became permanently fixed.
·
·
FIG. 86.

"In Fig. 87, it will be observed, the right superior cen-
tral incisor is considerably outside of the arch. The patient
from whom this cast was obtained, a lady aged thirty-five
years, came under his care about three years ago. From child-
hood she had labored under the peculiar deformity called
limber-jaw or under-hung, with all the lower front teeth
striking outside of the upper, due to a preternatural elonga-
tion of the inferior maxilla. A short time before placing
herself in his hands, by some means or other the right supe-
rior central incisor got outside of the lower teeth, and had
gradually been driven farther and farther forward by the
occlusion of the lower jaw, until it had become not only
very prominent, but quite loose in the socket. As the age
of the patient contraindicated any attempt at a radical reform
1
160 MOVING A CENTRAL AT THIRTY-FIVE YEARS OF AGE.
of the original difficulty (the protrusion of the lower jaw),
the only course that appeared to be justified was to get the
incisor back to its former position, so that when the jaws
were closed it would strike inside the lower teeth. This
was accomplished by throwing an India-rubber ring round
the incisor, and then stretching it over the crown of the first
bicuspid of the same side. The contraction of the rubber in
a few days drew it into place. To prevent the front teeth
from striking during this period, silver caps were placed on
the molars."
FIG. 87.

This would be a dangerous expedient for just such a case
if the lower teeth did not shut outside, and thus lock the
canine and lateral incisor, which are being pressed outward
by the action of the rubber elastic at the same time that the
central incisor and bicuspid are approaching each other.
The power of the elastic to throw them out is equal to the
power drawing the incisor in.
The following quotations and illustrations describe a
practice followed by Professor Flagg, and published in the
FLAGG'S OBJECTION TO INCLINED PLANES.
161
"Transactions of the Odontographic Society of Pennsylva-
nia." Referring to cases where the superior incisors articu-
late within the inferior, he says:
"For the correction of this form of irregularity, the ordi-
nary practice has long been the adaptation of a plate over
the teeth of the lower jaw, upon which inclined planes were
so arranged that, by occlusion with the upper teeth, these
should be forced outwardly, and at the same time some back-
ward movement of the lower teeth be effected by producing
a certain amount of change in the angle of the inferior max-
illa. The application of this force is dependent upon one of
two causes, viz.: the persistent efforts of the patients them-
selves in closing the teeth upon the planes, or by means of
pressure with elastic bands arranged over the head and under
the chin, after the manner of the Fox bandage, for prevent-
ing luxation during extraction. By means of these appli-
ances, the corrections of very bad cases of this irregularity
are sometimes effected in astonishingly short periods of time;
but, on the contrary, it is not unfrequently the case that
month after month passes by without any manifestation of
progress. . . . Children will so protrude the lower jaw as
to bite behind incredibly long planes, and upon the least
accession of tenderness they will only eat such soft food as
can be manipulated with the tongue, and never touch the
planes at all. . . . I think that in the correction of irregu-
larities all apparatus should be self-acting-so constructed as
to require no coöperation on the part of patients, and, more-
over, so arranged as to prevent the possibility of their inter-
ference with its workings.
•
"In consequence of these views I have for several years
abandoned entirely the use of inclined planes, and have sub-
stituted for them, in correcting cases of the kind under con-
sideration, a combination of wire, ligatures, and gutta-percha,
which arrangement I can much more clearly elucidate by
means of models than by description.
"Fig. 88.--Miss A., aged fourteen. Inclined planes had
162
FLAGG'S SYSTEM GAG, GOLD BAND,
been adjusted upon the teeth of this patient, and worn for a
period of one year. From want of coöperation upon the
young lady's part, and from disinclination to bite upon ten-
der teeth, no result was obtained.
FIG. 85.

"Fig. 89.—Front view, showing gold wire adjusted to
upper teeth, silk ligatures thrown around lower teeth, and
gutta-percha guard, to prevent occlusion, molded upon left
TA
FIG. 89.

lower molars and bicuspid. The wire was secured by liga-
tures to the four superior bicuspids, and one central was
gently brought forward by silk. After it touched the wire,
it was firmly attached, and thus having gained strong points
ELASTIC AND SILK LIGATURES.
at either end and in the center of the wire, the remaining
teeth were brought into position with much ease and rapidity.*
"Figs. 90 and 91.-Inside views of both jaws, showing
attachments to wire upon upper teeth, and the apparatus
which was used for drawing the lower teeth in. Silk liga-
tures were thrown around the twelfth-year molars (both
sixth-year lower teeth had been extracted by the gentleman
who had employed the inclined planes, with the view of in-
suring the correction). India-rubber rings (from tubing)
were secured to these teeth, and attached together by a short
double silk ligature; silk was then passed around the lower
FIG. 90.
163

9093
front teeth, and the two rings stretched, as is very clearly
demonstrated in Fig. 91.
“The fact of the more frequent presentation of the lower
permanent teeth posteriorly to the deciduous is probably
known to all of you, and it is my practice, both by teachings
and ligatures, to prevent any attempts on the part of parents
which shall result in removing or even loosening the decidu-
ous teeth, so long as it is possible to retain them with any
comfort to the patient. By this means the inward inclination
* This case does not seem to be dissimilar to the one the author treated with
wedges, as described on page 127.
164 FLAGG'S PRACTICE WITH UPPER AND LOWER CENTRALS.
given to the inferior permanent centrals is so great as to fre-
quently insure their position under the superior centrals;
and, if it is indicated by the presentation of the superior
centrals in the rear of the superior deciduous centrals that
FIG. 91.

ma
this will not be accomplished, I at once remove the superior
deciduous centrals and direct pressure to be made with the
thumb on the palatine faces of the permanent centrals. The
FIG. 92.

ิ
position assumed by the thumb is such as will at the same
time naturally press upon the labial faces of the lower teeth,
and thus a good result is almost always effected.
((
Fig. 92.—Miss L., aged seven. All the superior decid-
HOW TO INSURE A PROPER PRESENTATION OF CENTRALS. 165
uous teeth inside the inferior; marked protrusion of the lower
jaw; a family peculiarity.
"Fig. 93.—The same, open. The inferior deciduous in-
cisors were tied to the laterals to insure the presentation of
the inferior permanent centrals posterior to the superior
deciduous centrals.
"I regard the accomplishment of a natural occlusion be-
tween the centrals as more than half the battle gained, for it
FIG. 93.


Miffl
will readily be seen, by examining the dental preparations of
subjects under six years of age, that the position of the form-
ing teeth is such as will indicate their being governed, to a
very great extent, both as regards eruption and location, by
the proper or improper placing of the anterior teeth; for
the laterals are formed posterior to the centrals in the infe-
rior jaw, and anterior to the centrals in the superior jaw.
-
12
166
A KNOWLEDGE OF KNOTS INDISPENSABLE.
"Fig. 94.—The superior deciduous centrals were ex-
tracted upon the first indication of presentation from the
superior permanents; the thumb used to make pressure to
throw them forward; the inferior deciduous centrals have
been lost naturally, and the occlusion is almost as would be
desirable.
66
Fig. 95. The same, open; ligature securing slight rub-
ber ring thrown around lower sixth-year molar, and attached
to left central, exercising gentle traction. Was tied on at 8
o'clock A. M., and at 1 o'clock P. M. was removed, and the
tooth secured with silk, completely under its permanent an-
tagonist. When the relative development of the other two
NA
AMPIONS.
FIG 94.

teeth will insure retention, the same process will be repeated.
with them, probably in the course of two or three weeks
from this writing. By this means a serious deformity will
have been corrected without annoyance either to patient or
practitioner, without trouble to the latter, and without pain
or much expense to the former.
"One thing is indispensable for the accomplishment of
good results by this method of treating irregularities, and
that is, a knowledge of knots; for teeth are so shaped, so
rounded, and so smooth that ordinary tying will not avail
much. But there are knots which meet every emergency,
from the 'figure-of-8' for protruding incisors to the 'secured
loop' for turning the roundest tooth. These are only to be
ALL SECOND BICUSPIDS REMOVED PRIOR TO REGULATING. 167
taught by demonstration, and acquired by repeated trial and
some little experience.
"Fig. 96 shows an irregularity of the teeth of both jaws
in the mouth of a young lady fourteen years of age. The
treatment consisted in removing all the second bicuspids,
above and below, throwing India-rubber-tubing ligatures.
FIG. 95.

around the six-year molar left inferior, and the left inferior
first bicuspid and cuspid, drawing the two latter backward
and into the arch, at the same time passing a silk ligature
around the lower incisors (Fig. 97) in such a manner as to
force into position an overlapping left central. In the upper
jaw a plate was adapted to the palate, secured by silk liga-
168
NINE LIGATURES OPERATING AT THE SAME TIME.
FIG. 96.

tures to the first permanent molars; pins were placed in the
plate in such a manner as to allow of the attachment of two
Life
FIG. 97.

elastic bands, which were secured by silk threads to the cen-
tral incisors (Fig. 98), drawing upon the mesial face; other
FIG. 98.

169
bands were so arranged as to draw upon each lateral angle of
the centrals, passing between the centrals and laterals from
their palatine faces, and running along the labial and buccal
faces of the teeth unto the first molar of either side; tubing
was thrown around the remaining superior bicuspid of either
side and the molar, for the purpose of approximating these
teeth, thus affording space for the proper placing of the
irregular centrals. By this arrangement nine ligatures were
exercising traction at the same time, gradually and beauti-
PROFESSOR RICHARDSON'S METHOD.
FIG. 99.

mud
fully performing their work of correction. Fig. 99 shows
the result."
The following case of Professor Richardson's is not very
dissimilar to the preceding one:
"The nature and extent of the malplacement of the lat
eral incisors and cuspidati in the case under consideration are
sufficiently indicated in the accompanying cut, Fig. 100.
There is some lateral contraction of the arch, and a rather
marked projection of the upper front teeth beyond the lower.
The subject is a miss, between twelve and thirteen years of
age, of somewhat delicate organization, spare habit, and of
predominant nervous temperament. As there was plainly
inadequate room in the arch for a corrected denture, the
anterior bicuspids were extracted, a procedure which not
170 TEETH MOVED WITH WOODEN PEGS AND VULCANITE PLATE.
only afforded ample room in the arch for the misplaced
teeth, but made it possible to carry all of the teeth ante-
rior to the second bicuspids backward, effecting a nearer
approximation of the upper and lower incisors, and a cor-
responding diminution in the projection of the upper lip.
"After the extraction of the first bicuspids, a narrow
FIG. 100.

Da
Dixo
band of vulcanized rubber (Fig. 101) was constructed, em-
bracing the six anterior teeth. Pressure was made upon the
misplaced teeth by means of wooden pegs inserted in holes
drilled through the band, at such points as were indicated
by the direction which it was desired the teeth should take.
In the present case the pegs rested against the posterior
mesial angles of the lateral incisors in such a way as to force
FIG. 101.

them, when the band was applied, outward and backward,
while those inserted into the opposite or labial portion of the
band carried the cuspidati backward and inward. These
pegs projected but slightly at first, and were lengthened
from time to time, as the teeth moved, their removal and
replacement being but the work of a few minutes. Before
ABNORMAL LENGTHENING OF INCISORS.
171
applying the band, all connecting partitions of rubber were
divided, and the band cut away sufficiently at necessary
points to enable the teeth to move in the desired direction.
In most cases this band may be removed and replaced by the
patient for the purpose of cleansing the teeth.
"The mechanical action of this simple fixture is readily
apparent. The band, when applied, being forced apart by
the intervention of the pegs, acts by virtue of its elasticity
as a clamp or compressor, forcing the teeth in a direction
opposite the insertion of the wooden pins. The band in
this case was first applied on the 4th of November, 1872.
On the 28th of the same month the cuspids had fallen far
enough back to let the lateral incisors take their place
within the circle of the centrals, as shown in Fig. 102.
FIG. 102.

dandin
found the case now complicated with a marked elongation
of the lateral incisors. This was in part accidental, by rea-
son of inflammatory thickening of the investing membranes
and partial luxation, induced by the forces applied to these
teeth, but not wholly so, since the following fact clearly indi-
cates that it was in part also absolute, namely: that, in apply-
ing force to their cutting edges in the manner hereafter de-
scribed, the disparity in length between the centrals and
laterals was about half-way overcome in from twenty-four to
thirty-six hours, the teeth becoming at that point apparently
fixed and immovable, requiring afterward the application of
the same force for some twenty-four days, without inter-
mission, to effect the same degree of shortening, indicating
172
APPLIANCE FOR SHORTENING INCISORS.
unmistakably the absorption of bone and deepening of the
sockets.
"Without any published precedent, so far as I am aware,
I entered upon the novel undertaking of shortening (rela-
tively) the elongated teeth in question, by pressure applied
on a line with their long axes. To this end, a plate afford-
FIG. 103.

P
FIG. 104.
DO
ing fixed points of resistance was constructed, having clasps
attached and pinned to the centrals with wooden pegs rest-
ing against their anterior, and the plate against their poste-
rior surfaces, as represented in Fig. 103. To this plate firm
elastic cords were attached, stretching across the openings

for the lateral incisors. When this plate was pressed firmly
to its place upon the teeth, and held securely by the means
already adverted to, the contractile force of the cords, acting
forcibly and persistently upon the cutting edges of these
teeth, produced the requisite shortening (as seen in Fig. 104)
in twenty-six days from the date of their application. Dur-
·
173
ing this time pressure was also being made upon the cuspids,
which, in addition to forcing them farther backward and in-
ward, assisted in fixing the plate in aid of the shortening
process.
RESULTS OF THE TREATMENT.
"The shortening of the laterals accomplished, the treat-
ment was thereafter directed to the cuspids, forcing them
backward and inward, until the result shown in Fig. 104
was attained. Having brought the latter within the circle
of the anterior teeth, I was content to trust the matter of
their ultimate elongation to the corrective forces of nature.
Finally, a plate was made, resting accurately against the
posterior faces of the central and lateral incisors, and cut
away somewhat posteriorly to the cuspids, to enable the latter
to drop down until they should become symmetrical in length
with the adjoining teeth. The case was dismissed January
30th.
(6
"The efficiency of the band contrivance has been amply
demonstrated in my own practice in cases much more in-
tractable than the one here related, and I confidently com-
mend it as the most simple, practicable, and thoroughly effi-
cient means of correcting a very large class of dental irregu-
larities with which I am acquainted."
There are several points suggested in the treatment of
this case as described by Professor Richardson, to which the
reader's attention is invited.
I have seen the elongation of the laterals in a number of
instances in my own practice, in cases similar to the one de-
scribed, but I have never seen any evidence that there was
such a deposition of bone in the alveolar socket as to make
the elongation permanent. Realizing that pressure upon the
side of a tooth always has a tendency to produce such a tem-
porary thickening of the investing membrane as to lift it
partly from the socket, I have watched the results of the
pressure narrowly, and, as soon as any elongation showed
itself, further progress was delayed until a comparatively
healthy tone had returned. No retrogression was allowed;
DR. MEREDITH WHITE'S CASES.
174
the continued movement was simply arrested and the posi-
tion maintained. I have never known an instance where the
teeth thus temporarily lengthened did not return to their
position unaided within a short time. I think it quite pos-
sible that Professor Richardson was misled, and that his effort
at their reduction was unnecessary.
So far as the operation of shortening or driving teeth
higher into their sockets was a novel operation, he had prob-
ably overlooked the report of the case now found on page.
133, but which was exhibited to the New York Dental
Society May 9, 1866, and a report of the same published
in "The Cosmos" in September of the same year. And
again, in "The Cosmos" for October of the same year, in
the proceedings of the American Dental Association, there
appears a statement in detail of the same case, from which I
quote this passage: The teeth were carried back "and driven
up into their sockets nearly one third of the length of their
crowns."
The method adopted by Professor Richardson in the
general treatment of his case was undoubtedly an effectual
one, but, in the author's experience, open to the objection
of requiring more attention from the operator in adjusting
the pins, etc., than some other equally effective appliance.
Dr. H. Meredith White reports the following cases in
"The Dental Cosmos":
"Miss M., aged fifteen years, came to the office Janu-
ary 2d. Fig. 105 represents the condition of the upper jaw,
with the exception of the two deciduous molars, which were
removed that day. It will be seen that the eye-teeth and
first bicuspids are too far front, and that the incisors are be-
hind their proper arch. It was deemed expedient to draw
back the eye-teeth and first bicuspids to their places before
attempting to bring forward the incisors, it being thought
imprudent to encumber or distress the mouth much. A
·
HICKORY BOW USED IN REGULATING.
175
plate was accordingly made for the jaw, fitting firmly against
the front teeth. In front of and attached to bands that pass
around the first molar teeth were small rings, one for each
band. Attached to each ring was a piece of India-rubber
tubing, which was drawn forward and slipped over the bi-
cuspid of each side. In a few days they were drawn to their
proper places; then a section of tubing was tied to each ring,
and then ligated to the eye-teeth, which were more difficult
to move, it requiring between two and three weeks. By
actual measurement in the mouth, the bicuspids were drawn
back one eighth of an inch, and the eye-teeth three eighths
FIG. 105.

of an inch. These teeth were then held in their places by
means of ligatures, it being found that there was a great ten-
dency to recover their former positions. A bar was then
added to the plate, and passed in front of the incisors, which
were ligated to it; and in three weeks they were in their
proper places.
"A plate with pieces for the back part of the incisors
was then made, and a thin and delicate hickory bow made
to extend to the second bicuspid of each side, which had
now come through. To the bow all the moved teeth were
176
tied, by means of which the teeth were settled and became
firm in a regular arch. The patient continued to wear the
plate to hold the teeth for some time after the completion
of the case. October 10th the patient ceased wearing it.
The plate was kept by the patient, who was instructed to
place it in the mouth every few weeks; and, if any change
TREATMENT DISCONTINUED.
FIG. 106.

in the position of the teeth took place, to resume its use.
Fig. 106 represents the case when finished."
In the following case, reported by Dr. H. M. White, the
patient was in his twentieth year, and in good health :
"The right superior lateral incisor stood entirely within
the arch of the lower jaw. The left superior lateral struck
upon parts of the left inferior median and lateral incisors,
and, by the constant friction to which it was exposed, had
been so much worn on the cutting edge that the dentine
could be seen between the anterior and posterior plates of
the enamel on this account it was shorter than the lateral
of the right side. The arch of the upper jaw was nearly as
small as that of the lower, and the spaces that the laterals
should have occupied were but half sufficient for their ac-
INCLINED PLANES, CRIB-BAND, AND GAG.
177
commodation. The position of the teeth before and after
treatment will be seen by referring to Figs. 107 and 108.
"In regulating these teeth, two things were to be accom-
plished: 1. To enlarge the arch; 2. To place the irregu-
lar teeth in their proper places. These two steps were ac-
complished at the same time. As the labial surfaces of the
laterals were somewhat round, resembling canine teeth, it
was evident that by forcing the teeth forward they would
act as wedges and widen the arch, and at the same time
would gain their proper places. By the aid of inclined
planes, one for each lateral, adapted to a plate fitting the
under jaw, this was gained. In addition to this a plate was
made for the upper jaw, having crib-bands for the first and
FIG. 107.
FIG. 108.


second bicuspids of each side, and a bar to run around in
front of the upper arch, standing away from the labial sur-
faces of the teeth about an eighth of an inch, and soldered
to the crib-bands; patent thread ligatures were secured to
the necks of the laterals, and the ends drawn tightly around
the bar and tied. These ligatures were renewed every three
or four days so as to keep up a continual traction. The in-
clined planes were worn continually, thus making them pow-
erful auxiliaries; in the mean time, by propping the teeth
apart about a quarter of an inch, they allowed the laterals to
slip over the lower teeth. From time to time the bar of the
upper plate was lengthened by placing it over the arm of a
small anvil, and striking it with a small riveting hammer.
This was done to make room for the teeth as they advanced.
178
The central incisors were coming forward at the same time,
and increasing the size of the arch.
"After pursuing this course for three months the teeth
had arrived at their proper places. The inclined plane and
the plate with the bar were now dispensed with; but a new
plate for the upper arch was made, with pieces fitting against
the back parts of the four incisors, in order to prevent retro-
cession or turning of the teeth. This plate was worn nearly
two months, so as to give the teeth sufficient time to become
firm in their sockets. The plate was then left off, there
being no further use for it. The teeth were regular, and
looked very well; but the shortness of the left lateral, re-
ferred to above, was objectionable. Concerning this I con-
sulted Dr. J. D. White, who directed me to tie a string very
tightly around the neck of the tooth, under the free margin
of the gum, which in a few days would cause the tooth to
protrude, and thus make it longer. He said that he had
availed himself of this method in many cases where there
was a shortness of one or two teeth, and had permanently
lengthened teeth in this way, but that great care must be
taken to keep the irritation within proper bounds, and that
growing teeth could always be lengthened in this manner,
and occasionally matured teeth also; but success in the latter
was not always certain.
ELONGATING A LATERAL INCISOR.
"I tied very tightly a patent thread ligature around the
neck of the short tooth, and under the free margin of the
gum. I saw the patient in three days, and observed that
the tooth projected from its socket to a slight extent. The
ligature was still retained, and the patient was seen again in
three days. The tooth had already lengthened sufficiently;
there was considerable irritation and some pain. The string
was removed, and the patient directed not to use that side
of the mouth for several days, and occasionally to apply a
little pounded ice in a rag to the gum above the tooth, and
to return in a week. The patient came as directed. All ir-
ritation had subsided, and the tooth had shortened, but not
EXPANSION OF SUPERIOR ARCH BY DR. J. D. WHITE. 179
to its original state. By practicing this treatment every
alternate week, so as to give the tooth time to recover each
successive shock, the end was accomplished in six weeks.
The tooth is as long as its fellow of the other side, and, after
having its rough edges dressed off, presented a good appear-
ance. It has now been over two years since the affair was
concluded, and so far no ill effect has arisen from this novel
plan of lengthening teeth, which has been very successful in
the hands of him whose advice I followed.
"It may be proper to add that during the first fifteen
days of regulating teeth, by means of any apparatus, there is
always more to fear than during the subsequent treatment,
since violent periostitis is apt to occur, and, if it does, it is
more difficult to treat, and more destructive in its conse-
quences than apparently the same amount of inflammation
occurring during the treatment of a case of irregularity that
has been under way for a longer time."
Prior to 1860 Dr. J. D. White expanded the superior
dental arch by "placing a plate in the roof of the mouth as
far up as it could be extended, but cut through, to make two
halves, with a hinge in front, back of the incisors; this plate
or plates open and shut like a hinge. These plates are fast-
ened to the first molars or bicuspids, as the case may be, and
a spiral spring is attached on either side, with the bow of
the spring extending around behind the front teeth and close
to them, so as to be out of the way as much as possible. It
will be seen (Fig. 109) that the action of the spring is to
separate these plates, which not only force the teeth out, but
also cause the alveolar ridge and gum to follow and mold
themselves accordingly. This is more especially necessary
when the regulating of such cases is commenced before the
complete growth of the roots of the teeth to be acted upon.
We completed the treatment of a case about a year since, to
which we think this apparatus was expressly adapted. It
PRESSURE DERIVED FROM A SPIRAL SPRING.
180
was the case of a child about eight years old. The superior
front incisors and the first permanent molars only were
erupted, and the superior arch and entire row of teeth fell
inside of the lower as completely as one cup or saucer sets
in another. It gave a large and swollen appearance to the
lower border of the face, and a contracted appearance to the
cheek-bones below the eyes. The space between the first
permanent molars only admitted the point of the little fin-
ger, and the roof of the mouth was so contracted as to look
more like a fissure than the roof of a mouth. As a matter
of course, at this age the roots of the molars of the first set
were partially absorbed, and the attempt to force them out
B
W
C
I
FIG. 109.
D

B
W
would be to excite undue absorption and dislodge them pre-
maturely. Besides, if they had been thrown out, the caps
forming in the jaw of the permanent teeth might not follow
the deciduous teeth. In other words, we regarded it as
necessary that the whole, jaw-teeth and all, should be moved
together, to insure success. We have not been disappointed:
the jaw molded beautifully, and in about a year the whole
upper jaw was placed outside of the lower; and it has made
such an alteration in the expression of the face that the
child would not have been recognized except by those who
watched the progress of the case. After the jaw was forced
to the desired position, a solid plate was struck up to hold
181
the parts in their new position until the first molars were
lost and the bicuspids had grown sufficiently long to grasp
each other, lower and upper, to insure the permanency of
the case."
DR. WESTCOTT'S CASES.
In 1859 Dr. A. Westcott undertook the correction of an
irregularity which involved the expansion of the entire su-
FIG. 110.

perior dental arch. In his account of the treatment, as given
in "The Dental Cosmos" of the same year, we are enter-
Mi
FIG. 111.

13
182 POSITIONS OF THE TEETH AT VARIOUS STAGES.
tained with a glowing description of the almost insurmount-
able obstacles he had to encounter. To make such an ap-
paratus as he finally used with success would be quite suffi-
FIG. 112.

dy,j.
PIGARE
cient to deter the ordinary dentist from undertaking the
correction of such deformities. The foregoing figures illus-
trate the cases: Fig. 110 shows the condition of the teeth
FIG. 113.

and jaw, and Fig. 111 the articulation or bite at the com-
mencement. Figs. 112 and 113 show the result at the con-
clusion of treatment, a period of five months. The first
DR. WESTCOTT'S METHOD OF EXPANSION.
object was to expand or spread the jaw laterally—the upper
jaw being, at a point opposite the bicuspids, nearly half an
inch too narrow to articulate properly with the corresponding
teeth of the lower jaw. To accomplish this, the first fixture
employed is the one seen in Fig. 114. This consists of dou-
ble clasps (one for each bicuspid), both soldered to a cross-
bar, bent so as nearly as possible to fit the arch of the jaw.
FIG. 114.
Awghung
3
ទ
This was fitted in all respects as clasps are fitted to a plate,
only substituting the bar (made of silver wire, No. 17) for
the plate. This was made to fit snugly and firmly, and
placed upon the teeth, the curved bar being straightened
from time to time as the teeth moved. Finding that the
fixed connection of the bar with the clasps destroyed the
hold of the clasps upon the teeth, it was substituted by the
one shown in Fig. 115, which was made with joints to ac-
183

FIG. 115.
مترو

commodate such change. With this fixture the arch was
widened at the bicuspids, but then arose the doctor's most
serious obstacle, viz., the enlargement of the arch anterior to
the bicuspids.
His next stratagem was the fixture represented in Fig.
116. This consists, as in the former pieces, of double clasps
(A A), taking the places of those on the bent bar. These
clasps are connected by a straight bar, which is made nearly
184
the whole length of tubular wire. This tube has a screw cut
in its inside the whole length, and is soldered to one pair of
the double clasps. The other pair of clasps are soldered to a
wire which screws into this tube, the object being to length-
en or shorten the bar at will. The clasps being nearly fitted
to the teeth, and the bar so adjusted as to admit of their set-
ting easy, we have the starting-point.
To complete this fixture for the purpose of moving for-
ward the front teeth, we next soldered a flat piece (C C) of
sufficient width for hinge-joints to connect with it the tubes
DDDD, which are to receive the spurs EEEE. These
tubes, which have a screw cut on the inside, are attached to
the flat piece on the bar, by first soldering to the end of each
A COMPLICATED APPARATUS.
E
FIG. 116.
E
LETE
E

E
A
an eye,
F F F F, consisting of a flat round piece to receive
the rivet, holding it to the main bar. Into these tubes are
screwed the spurs, which are to bear and press against the
teeth to be moved. These spurs are kept in place against
the teeth by making a slight depression in the teeth them-
selves, with such a drill as is used for drilling steel or other
metals.
The Doctor's advice to those engaged in the treatment of
such cases contains some valuable suggestions:
"1. Never undertake to regulate teeth until the first set
of teeth are shed, and the second set are in their place. I do
not mean by this that we should never attempt to prevent
irregularity by timely extraction, and perhaps by other means.
"2. When a case is presented, and the proper time has
DR. WESTCOTT'S EXCELLENT ADVICE.
185
arrived for commencing operations, let the inquiries be:
'Does the patient, or the parents, or the guardians, fully ap-
preciate the nature and importance of the operation, so much
so as to place the patient fully at your control, and cheerfully
to remunerate you for your time and skill?' If both these
interrogatories are answered affirmatively, then you may
safely undertake the task; but if either is even doubtful, and
especially the former, you had better dismiss the case.
"3. If you decide to commence the operation, take ac-
curate impressions of both jaws, and of the two in combina-
tion, or an articulating impression, and, before you see your
patient again, or prepare any fixtures, study them carefully
and thoroughly, and come to definite and distinct conclusions
before you make the first move that is seen by the patient.
"4. Set the price, if you can, before you commence, and
require at least one half in advance (which often secures a
punctuality which nothing else will), and be sure to set it
high enough (and there is little danger of your getting it too
high), and then be faithful to the last degree, whether you
make or lose money. Never curtail any effort for fear your
arrangement may not prove profitable.
“5. Consider well the constitution and the health of the
patient. If the constitution is naturally feeble, and espe-
cially if the health is bad, better by far run the risk of con-
firmed irregularity than undertake any operation of this kind
of much magnitude."
I can not refrain from inserting a portion of the report
of the treatment of a case of irregularity which was made
before one of the prominent dental societies and published in
"The Cosmos." It needs no comment other than that it was
not intended as a travesty on mechanical surgery:
"The cast of the superior maxillary, as it originally was,
presented a very contracted arch and irregular set of teeth.
The object was not only to regulate these teeth, but to ex-
pand the roof of the mouth and increase the size of the arch,
186
and without extracting any teeth. The method employed is
as follows:
AN ABSURD METHOD OF REGULATING.
"A cast is obtained from a wax impression. The teeth
and the surfaces of the roof of the mouth to be acted upon
are cut or scraped away to an extent equal to the amount of
space which it is prudent to move the teeth at one time.
The plate is then inserted in the mouth; the patient is
directed to exert force upon it with the lower teeth, which
forces it up into the roof of the mouth, expanding the arch
in whatever direction the force is applied. As soon as one
plate has done its work, a new impression should be taken,
and the process repeated. The length of time necessary for
one plate to be worn varies from a few days to two weeks,
according to the amount of work required of it. If it is but
to move a few teeth, it will settle up in a few hours; but, if
the roof of the mouth is to be spread much, each plate may
have to be worn for weeks. The length of time which each
plate was worn in the present case was about two weeks, the
number of plates already worn being twenty-eight. The case
will require three or six months yet to complete it. When
it is finished, the lower teeth will be commenced with."
This method of regulating teeth he "believed to be the
most effective, simple, and convenient for both parties inter-
ested, and is now beyond the doubt of experiment, although
perhaps published for the first time.”
Fig. 117 illustrates a case of irregularity which Dr. Gil-
mour brought before the Odontographic Society of Penn-
sylvania for advice. The patient was a young lady of four-
teen years, and in the opinions expressed by the members.
there are valuable suggestions:
"As will be seen by the cast, the superior laterals stood
within the arch about half covered by the central incisors,
while the canines were so close to the centrals as to leave
such a limited space as to make it apparently impossible to
DR. GILMOUR'S CASE.
187
draw the laterals into their proper position without sacri-
ficing the bicuspids; at the same time the central incisors
raked outward, so as to make the lip unduly prominent.
The lower front teeth raked inward so much that they did
not approximate the superior teeth when the mouth was
closed. The right upper second temporary molar was still
in place, and the pulp had been removed from the first
lower molar.
"Dr. McQuillen said it was difficult to form an opinion
as to what plan of treatment would be the best to adopt in
treating a case of irregularity of the teeth when the conclu-
sion had to be arrived at merely from an examination of
FIG. 117.

plaster models. An inspection of the mouth and a view of
the features of the patient, in person or by means of a photo-
graph, was a necessary aid in forming a correct diagnosis.
He had frequently been consulted by fellow practitioners
residing at a distance, who had sent plaster models by mail,
but none of them had ever thought of forwarding photo-
graphs of patients. The age of the patient, the laxity or
density of the tissues, the constitutional peculiarities, were
points on which one should be informed, and this could be
best acquired by a personal interview. With these draw-
backs, he would suggest the introduction of a piece of hick-
ory wood between the superior laterals to act as a wedge and
force them past the central incisors, and then would use the
-
188
silver bar and rubber ligatures, as proposed by him in 1859,
the ligatures being attached to the laterals, so as to draw
them into their proper position in the arch. During all this
time an inclined plane made of hard rubber and fitted to the
lower teeth would materially aid in forcing the laterals into
their proper position.
DISCUSSION BY DR. STELLWAGEN.
"Dr. Long would pursue the same treatment as that sug-
gested by the preceding speaker. If the cuts in the bar on
the side toward the cuspids were extended farther back, the
ligatures would press the cuspids back at the same time the
laterals were being drawn forward.
"Dr. Head: When it was necessary to use ligatures, he
had found a plate, with hooks for securing the ligatures, to
produce better results than when attached to a bar, which
frequently gives rise to serious trouble by slipping up on
the gum.
"Dr. Stellwagen: It is essential to success that the pa-
tient should be willing to undergo the suffering necessary to
accomplish the object desired, namely, a regularly arranged
set of teeth; and it will ever be premature if we commence
before such consent has been obtained. Hence the patient
should have arrived at an age capable of reasoning. A sec-
ond step in this by no means inviting branch of practice is
to study the patient's features, both full face and profile,
noting any defects that may be apparent. Many times pro-
tracted suffering, and even serious injury, may be avoided
by remembering that it is unnecessary to expand the alve-
olar arch simply to get the whole of the teeth in position,
where it is large enough to harmonize with the face and does
not impair the voice or mastication. The specialist who un-
necessarily prolongs the treatment to save useless teeth at the
risk of causing more serious disturbance, as dyspepsia, ner-
vous debility, etc., is as fit a subject for ridicule as the igno-
rant physician who overloads the digestive organs with drugs
for neuralgia caused by an exposed tooth-pulp. While it is
questionable or even bad practice to preserve useless teeth,
EXTRACTS FROM TOMES'S "DENTAL SURGERY."
189
always remember that it is rare that any of the six anterior
teeth can be removed without serious deformity resulting
from the loss. The first or second bicuspids, from their lia-
bility to disease, their secondary importance in speech, ex-
pression, or mastication, and finally the spaces left after their
extraction being so easily filled and so frequently sufficient
for the purposes of the orthodontist, are all-sufficient argu-
ments for the sacrifice of these organs in preference to others.
The occlusion of the teeth, the manner in which they tend
to interfere with the movement of each other, also the pro-
posed occlusion to be gained after the treatment has been
completed, should be taken into account."
The following remarks and illustrations are taken from
Tomes's "System of Dental Surgery":
"Some difference of opinion exists as to the best mode
of pressing the teeth outward. Recently, vulcanite plates
fitted to the palate, and extended over the molar teeth, have
been adopted. The vulcanite over the masticating surfaces
of the molar teeth is left sufficiently thick to prevent the
upper and lower front teeth from influencing each other
when the mouth is closed. The plate is fitted to the necks
of the teeth to be operated upon, between which and the
plate portions of dry compressed wood are placed, in cavities
cut in the vulcanite for their reception. Each instanding
tooth will have its corresponding cavity in the plate, the
formation of which requires some little attention. The form
should be similar to that of a shallow drawer, the front of
which has been removed, and so proportioned as regards the
upper and lower surfaces of the plate in which it is cut that
the section of wood will not fall out into the mouth. The
* It will be unnecessary, except in extraordinary instances, to make the pro-
vision here proposed by Mr. Tomes. As described elsewhere, the fixtures and
the disinclination to bite unduly will prevent the lower teeth from retarding the
movement of the upper ones.-THE AUTHOR.
I
190 LIGATURES MAY BE ATTACHED TO TEMPORARY MOLARS.
wood should be fitted to the cavity, and left a little thicker
at that end which lies toward the gum. The plate having
been adjusted to the mouth, holes must be drilled through it
for the admission of ligatures, which may be passed round
and tied to one or other of the molar teeth on each side of
the mouth.
"In arranging the ligatures, care must be taken that they
do not press upon and irritate the gums. It will be remem-
bered that the gums approach nearer to the masticating sur-
faces of the teeth on the lingual than on the labial side.
Hence the holes in the plate should be made at the point
corresponding to the free edge of the gum against which it
rests, and continued obliquely in a direction continuous with
the line followed by the gum in its passage between the
teeth. If this precaution be observed, the ligature, when
tied, will pass in a straight line from the labial surface of the
tooth to the lingual surface of the plate, without interfering
with the gums. In selecting the teeth around which the
ligatures are to be passed, we must be guided by the forms.
and the position of the teeth available for the purpose; but,
should the temporary molars be present, it will be well to
make use of them in preference to the permanent teeth.
The abrupt termination of the enamel renders them particu-
larly suitable for the purpose, and the short period during
which they will be retained renders their injury a matter of
little consequence.
"By the foregoing means the plate may be firmly fixed
preparatory to the introduction of the compressed wood, the
cells for the reception of which will be formed on the one
side by the teeth to be moved, and on the other three sides
by the plate. After compressing for some hours a piece of
dry willow, plane, or some other soft wood, small strips may
be cut off, and from these fragments must be prepared which
will fit with moderate accuracy to the spaces formed by the
plate and teeth, taking care that the grain of the wood runs
parallel with the long axes of the teeth. So soon as the
COMPRESSED WOOD FOR WEDGES.
191
wood commences to absorb moisture it will expand, and in a
direction transverse to that of its grain. In expanding,
either the tooth in front of it must move outward, or the
plate must be driven backward, and with it the molar teeth
to which it is fitted. But, as the front teeth are capable of
the least resistance, they are the first to yield, and therefore
gradually advance before the expanding wood. From time
to time the wedges must be renewed, each new piece being
slightly larger than its predecessor; and, as the teeth move
upon an axis situated near the apices of their respective
roots, the receptacles become changed in form, and it will
FIG. 118.*

| |!11
200
be necessary to modify the form of the grooves in the ivory
plate. If this precaution be neglected there will be a diffi-
culty in retaining the wood after the teeth have been moved
from their original position. The receptacle will have
* "Showing vulcanite plate fitted to the upper jaw, for the purpose of forcing
outward the central incisors. The vulcanite is left sufficiently thick over the
masticating surface of the back teeth to prevent the lower teeth from influen-
cing those to be operated upon. The plate is retained by ligatures passed
through the vulcanite and round the temporary molars; posterior to the central
incisors, the apertures of the cells for the reception of the compressed wood are
shown. Below the figure, a section of the parts in situ is given, showing the
cell in its length, with the piece of wood removed and placed underneath."
192
DETAILS OF TREATMENT.
changed in form as respects the relative size of the upper
and lower portions. Hence it becomes necessary to deepen
that end of the groove which lies near the gum, and the
excavation must be made sufficiently deep to restore the
parallelism which has been lost by the outward movement
of the tooth. When the required amount of change in posi-
tion is considerable, and the half of this has been gained, it
may be necessary to discard the original plate, and substitute
a new one fitted close to the teeth operated upon, so as to
admit a thinner and more manageable wedge than that which
would have been required had the treatment been continued
with the first made apparatus.
"It is doubtful whether, as a general rule, more than two
teeth can be advantageously operated upon at the same time.
If, for instance, the four incisors are involved in the irregu-
larity, it may be desirable to push forward the central teeth
first, and then move the lateral teeth, or vice versa. But in
adopting this plan we must not neglect to take means to
prevent the teeth first operated upon from retreating to their
old place while the others are being forced forward. This
may be accomplished by inserting into the vulcanite frame
pegs of wood, the free ends of which rest upon the backs of
the moved teeth. In this application of the wood the end of
the grain will rest upon the tooth, and, as there is but very
slight expansion lengthwise of the grain, the teeth will be
simply held in position.
"When the whole of the instanding teeth have been
moved outward to an extent sufficient to insure their passing
in front of the lower teeth on the mouth being closed, the
use of the apparatus may be discontinued. Sometimes, how-
ever, it will be found that the back teeth of the upper and
lower jaws, from having been kept apart during the treat-
ment, lose their proper antagonism. They become raised
in their sockets, and prevent the front teeth from meeting
each other; under these circumstances those portions of the
vulcanite plate which extended over the masticating surfaces
METAL PLATES INSTEAD OF VULCANITE.
193
of the back teeth must be removed so as to allow the teeth
to come in contact, while the plate prevents the front teeth
from falling back into the former position. In a few days
the proper antagonism will be restored, and the plate may
be discarded.
"Instead of using vulcanite, metal may be used for the
plate. The molar teeth on either side are capped with gold,
the caps being made so that they fit tightly upon the teeth.
From these a band of metal is extended in front of the
teeth. Holes are drilled in the band opposite to the teeth,
and strong silk thread is passed round the neck of each
tooth and through the corresponding holes, and tied tightly
on the outer surface of the band. The teeth will by degrees
FIG. 119.*

cte
be drawn toward the band; but the process is a slow one,
and requires frequent renewal of the ligatures.
"I have commonly used vulcanized caoutchouc in the
place of silk; with this material the tension is more uniform,
and the renewals need not be made so frequently. The fixing
of the India-rubber to the band was at first a difficulty; tying
was impracticable, and hooks could not well be used.
found, however, that by cutting fine slits with a hair-saw
obliquely through the metal band, and then passing the two
I
* "Shows metal caps fitted to the molar teeth, with a band extending from
them in front of the incisors. To the metal band so fixed, ligatures, after being
passed round the front teeth, were attached, and drew the inverted teeth for-
ward until they came in contact with the band."
I
194
TORSION, OR TWISTING TEETH.
ends of the caoutchouc in a state of tension into them, the
ligatures were firmly retained. Silk ligatures require re-
newal every second day, but the caoutchouc will last double
the time, and will produce a much more rapid effect. I have
in favorable cases succeeded in bringing teeth out in the
course of a fortnight, and the case has been dismissed.
"Torsion, or twisting of the central incisors upon their
axes, is far from rare. The defect in position may be com-
mon to and equal in each tooth, or it may be greater in the
one than in the other, or it may be confined to one tooth
only. Either the mesial sides may be directed toward the
palate, or they may be turned toward the lips, or the one
tooth may be twisted in the one, and the fellow tooth in the
other direction.
“In a case recently under treatment, the right incisor
made its appearance at the age of thirteen, with the lingual
surface parallel with the median line of the mouth. In this
case the tooth is a quarter of a turn out of place; but in-
stances are recorded in which the twisting has extended to
as much as half a turn, so that the lingual surface presents
to the lips. The patient was a female, aged fourteen years.
The right central incisor, up to the age of thirteen, did not
make its appearance, consequently the crown of the right
lateral and left central teeth leaned toward each other, leav-
ing an interval insufficient for the missing tooth to take its
natural position. At thirteen, however, the tooth appeared,
with its median side directed toward the lip, but it was not
till a year had elapsed that the case came under treatment.
The succeeding figure will show the general position of the
teeth, and it may be remarked that the canines were slightly
more prominent than the anterior teeth. A careful exami-
nation led to the conclusion that, supposing the laterals and
the left central incisor were pressed out, so as to range
evenly with the canines, sufficient space would thereby be
gained to allow the twisted tooth to hold the normal posi-
tion. Acting under this impression, a plate was made to fit
TURNING AN INCISOR IN ITS SOCKET.
the palate, and attached to the bicuspids by wire continued
over the crowns of those teeth on either side of the mouth,
and terminated by a small T-like extremity, which, by way
of protecting the teeth, was covered with a thin investment
of floss silk. In this manner the plate was firmly retained
in its place.
195
"The next proceeding consisted in soldering to the back
part of the plate two bands, composed of gold, rendered
elastic by the addition of three grains of platinum to one
pennyweight of the ordinary eighteen-carat gold. The free
ends of the bands were adjusted to press outward and from
FIG. 120.*

utilla

400
छ
the irregular tooth the two contiguous teeth, in the manner
shown in the accompanying figure.
"In the course of nine days, sufficient effect had been
produced to render it desirable that the incisor itself should
"Shows the right central incisor twisted on its axis to the full extent of a
quarter of a revolution, with the adjoining incisors in close contact with its
labial and lingual surfaces. The metal plate used in the first stage of the oper-
ation is shown in situ, with the two elastic bands of gold soldered to the back
part of the plate, and the free ends in a position for separating the right lateral
and left central incisor in order to gain space for turning the displaced tooth.
In the sketch below, the manner of adjusting the wire bands for the retention
of the plate is shown."
196
be acted upon in order that the increased interval should be
occupied by the tooth for which it had been obtained. A
second plate was constructed. In this a bar of gold was
continued in front of the teeth, and attached to the anterior
T-piece on either side. Metal cells for the reception of com-
pressed wood were then soldered to the plate and to the
band. One was placed so that the wood would press upon
the distal angle of the tooth, the other upon the labial sur-
face near the median angle. The forces thus brought into
play, acting in opposite directions, turned the tooth upon its
axis, and were sufficient to influence the impinging lateral
and central teeth, and force them out of the way of the
APPARATUS FOR TWISTING TEETH.
\\\\
۱۱:۰
Atto
FIG. 121.*

thesis
slowly turning tooth. In a few days it became necessary to
alter the position of the receptacles for the wood, and sub-
sequently to move them from time to time toward the re-
treating angles of the tooth.
"After the second plate had been in use three weeks, the
tooth had so far changed its position that the mesial side
stood slightly in front of the left incisor, and the distal side
* "Shows the condition of the case illustrated in the preceding figure after
the adjoining teeth have been separated by the elastic bands, and the displaced
tooth turned slightly from its original position. The plate used in this, the
second stage of the operation, is shown in situ, with the metallic boxes for the
reception of the compressed wood in the positions suitable for effecting the
further progress of the treatment. It will be apparent that the boxes will
require a change of position when the tooth has moved away from them."
REGULATING WITHOUT APPARATUS.
197
a little posterior to the lateral incisor, presenting a degree of
irregularity which would attract but little notice.
"As the left incisor was still a little internal to the arch
which would be described if the canines were taken as the
guide for its formation, a cell was adjusted upon the plate
behind that tooth, and the wood brought into operation. At
the same time, the operation upon the lingual surface near
the distal angle was continued, and the degree of pressure
upon the labial surface was considerably reduced. In the
course of a second term of three weeks, the tooth was
brought into position, ranging evenly with the contiguous
teeth.
"The foregoing illustration will show the principles upon
which the operation was conducted, although the wood-re-
4
CAMELTS
H1
balan
FIG. 122.

rm
و دیگر ویز ا ا الله
taining cells are given in one position only. It must be
understood that they were moved from time to time, so as to
follow up the moving tooth, and so adjusted as to bring the
pressure to bear in such directions as at the time appeared
to be required."
In Fig. 122, copied from Mr. Tomes, it is manifest that
the first step is the removal of the deciduous centrals and
them only.
If the permanent centrals have developed no more than
they appear to have done in this engraving, it is quite pos-
sible to bring them forward to their true position without
14
198
UNFORTUNATE RESULTS FROM EXTRACTION.
the necessity of wearing any fixture. Working at them
with the thumb by the child itself, or with a bit of stick as
a kind of lever, using the lower teeth as a fulcrum, will
often succeed. If an appliance is required, one of the va-
rious forms of adjusting a gold wire or band in front, to
which the teeth may be attached and drawn by elastic liga-
tures, will be found quite effectual.
Fig. 123, another illustration from Mr. Tomes, “shows a
case in which the V-shaped conformation was attended with
unusual contraction in the neighborhood of the bicuspid and
first permanent molar teeth. On the left side both of the
FIG. 123.

bicuspids were removed, and in the right the second bicuspid
was extracted, without any advantage being gained as regards
the contracted condition of the palate. The deformity is so
great, and the base so contracted, that successful treatment
would be attended with great difficulty."
Unless there were circumstances connected with this case
which neither the drawing nor the description suggests, it is
likely that it would have been found quite as amenable to
treatment as the cases of a similar character, described on
pages 107, 115. It is astonishing that any one could sup-
pose that the extraction of any teeth could have any ten-
dency to correct the deformity. Expansion of the dental
EXTRACTION OF SUPERIOR LATERALS ADVISED. 199
arch was clearly required, and extraction of teeth could
under no circumstances promote expansion.
"When the lateral teeth are situated as in Fig. 124, we
need not hesitate to remove them, supposing the antagonism
is normal, and a more forward position of the central teeth
would leave a wide interval between the lingual surface of
the upper and labial surface of the lower teeth on the mouth
being closed. But if the central incisors in such a case passed
behind the corresponding teeth of the lower jaw, it would
then be our duty to bring them forward, and afterward force
the laterals into the space which would be formed by the
previous operation.”
FIG. 124.

I somewhat fear that the advice given above by Mr.
Tomes to remove the offending laterals is not sufficiently
guarded. He says if "the antagonism is normal"; but the
antagonism with the lower teeth may be regarded as natural,
i. e., all the teeth articulating accurately with the correspond-
ing ones, and yet both jaws be too narrow for their proper
relation to the face. In many cases which have come under
my observation similar to the above, the whole upper arch
has been too contracted, and there was found room for the
misplaced laterals as soon as the arch was expanded to its
proper width.
There is also another reason for caution,
which is, that it is very common to find some one or more
frail or decayed bicuspids or molars, and that, if any teeth
ty
1
200
are to be extracted, it is better to take the defective ones and
then force the laterals into line. But the arguments for and
against such practice will be found in full on pp. 45 and 51.
DR. ANGELL'S METHODS.
Dr. Angell, of San Francisco, in "The Medical Press,"
describes his treatment of a case of irregularity for a miss
fourteen and a half years of age.
The left canine of the upper jaw was completely outside
the arch, the lateral incisor and first bicuspid being close to-
gether, and the former so far inside the arch as to close with-
in the teeth of the lower jaw, the contact of which had worn
Smumun
FIG. 125.

D
ים
the enamel considerably from its labial surface. The exi-
gencies of the case required that the bicuspids on the left
side be moved outward and backward. The arrangement of
the teeth and the adjustment of the apparatus employed are
shown in Fig. 125. The six-year-old molar had been removed
because of advanced decay, and the second permanent molar
had not then erupted. The description of the screw here
used will be found on page 73.
"This apparatus was placed in the mouth, when the shaft
D was made to revolve until the fixture was made comfort-
ably firm, when the patient was provided with the key and
instructed to keep the shaft as uniformly firm as possible."
SCREW, ROTATING SHAFT, AND COLLAR.
201
In two weeks the jaw was sufficiently widened, and the plate
as seen in Fig. 126 was adjusted, the molar and bicuspid of
the right side having been moved apart so as to admit a clasp
fitted to the molar. A collar was extended from the plate
Wachter
to the posterior proximal surface of the lateral incisor, and a
nut was soldered to the plate at the point C, near which the
collar was attached, through which a smaller shaft having a
thread corresponding to the nut was made to revolve. To
RESTAURANTS
FIG. 126.

70
FIG. 127.

the opposite end of this shaft was affixed the common chain-
swivel, to which was soldered the original clasp affixed to the
extremity of the first shaft. This apparatus was placed in the
mouth, and the patient again provided with a key and in-
202
CONCLUSION OF TREATMENT.
structed to apply it often enough to keep up a uniform pres-
sure. Within a few weeks both bicuspids were carried back
sufficiently.
The rotating shaft was now removed, and a spring was
soldered to the plate at the point to which the nut was ori-
ginally affixed, and from which it extended so as to press
upon the anterior approximal surface of the first bicuspid, as
seen in Fig. 127. This spring in a few days moved this tooth
so as to leave sufficient space to receive the cuspidatus. The
original collar adapted to the posterior approximal surface of
the lateral incisor was extended and curved so as to press
upon the labial surface of the cuspidatus, and within a week
from this application we had the satisfaction of seeing it
within the arch it was originally intended to occupy.
PART II.
FALATINE DEFECTS.
CHAPTER VIII.
CONGENITAL AND ACQUIRED LESIONS.
CLEFT palate has usually been said to arise from one of
two causes, a congenital or an accidental: the congenital, as
FIG. 128.

its name implies, dating from birth, and its origin being an
arrest of development; and the accidental, as its name im-
plies, being the result of accident or disease.
Strictly speaking, cleft palate is almost always congenital,
CLEFT PALATE ALWAYS ON THE MEDIAN LINE.
204
for the following reasons: In cases where the deformity
arises from an arrest of development, there is a longitudinal
fissure of the palate on the median line, never elsewhere,
and always a fissure; while, in cases of injury to the palate
by accident or disease, the loss of the organ is sometimes
partial and sometimes entire, rarely resulting in any two
cases in a loss exactly the same-frequently in a destruction
of the posterior border and adjacent tissues, and in no wise
"
114
314
TID
124
B
FIG. 129.

49
B
LAUA
resembling a fissure. Such defects are not uniform in local-
ity nor in extent. They consist sometimes of simple perfo-
rations, and at others involve the destruction of the velum,
a considerable portion of the os palati, the vomer, turbinated
bones, and maxilla, and the loss of a greater or lesser number
of the teeth.
Fig. 128 represents a congenital fissure of the velum
only; Fig. 129, a fissure of the soft palate, hard palate, and
ACQUIRED LESIONS OF TIIE PALATE.
FIG. 130.
FIG 131.
C
205

癟
​
206
RESULT OF INHERITED SYPHILIS.
maxilla, also congenital. Letter A indicates the vomer, B
B the turbinated bones, and C C the bifurcated uvula. Fig.
130 shows a partial destruction of the soft palate by dis-
ease; in this case a cicatricial union has formed between the
remnant of the velum and the pharyngeal walls. Fig. 131
shows a perforation of the hard palate arising from the
same cause, and Fig. 132 illustrates the entire destruction of
the roof of the mouth in front of the soft palate, including
the adjacent maxilla and the bones of the nasal cavity, also
caused by disease.
FIG. 132.

It is uncommon to see the loss of a portion of the palate
by accident or disease, which bears any other resemblance to
a cleft palate than a want of entirety; therefore, it may be
said that true cleft palate is always congenital. This defect
is usually accompanied by more or less deformity of the
sides of the alveolar arch and of the teeth. Sometimes the
sides of the arch are forced too far apart, but it is more com-
mon to find them contracted or pinched together, the result,
probably, of the pressure of the external muscles where the
osseous bridge between the sides is wanting. The teeth
·
207
are often irregular, because of the deformity of the maxilla
upon which they are placed, and this is especially the case
with the teeth in the vicinity of the fissure through the
alveolar arch. If the defect follows only one of the inter-
maxillary sutures, the adjoining canine on one side of the
fissure and the lateral and central incisor on the other side
will be likely to be twisted or tipped from a normal position,
and in some cases undeveloped. In cases of double fissure,
where the cleft follows both intermaxillary sutures through
the alveolar border, the incisor teeth which belong to the
premaxillary bone are always defectively developed and ab-
normally placed.
ORIGIN OF CLEFT PALATE.
The origin of cleft palate, as before stated, lies in an
arrest of development, the causes of which arrest are un-
known. Certain it is that the arrestation occurs at a very
early period of fœtal life, probably before the end of the
second month. The development of the fœtus being simul-
taneously from the two sides and uniting on the median
line, it is found in a normal development that union has
taken place by the end of the tenth week; consequently
the causes which operated to induce the arrest were in action
before that time. There has been some evidence that the
deformity was inherited, but, even if such cases were traced
back through the ancestry until we arrived at the initial,
we should be equally at a loss to account for the first ar-
restation. On the other hand, by far the large majority of
cases seem to be free from all inherited taint, and are isolated
cases in the family. It does not seem to be confined to any
class or condition in life, and, like other departures from a
normal type, examples may occasionally be found among the
most cultured and the purest blood; but the large majority
of cases come from the lower walks of life-from the poorly
nourished and physically depraved.
The fissure of the velum or palate varies very much in
its extent in different individuals, showing that in some cases
the active causes were not operating until the union at the
208
median line was nearly complete, with sometimes so slight a
fissure as a mere bifurcation of the uvula, while in others
the arrest was at such an early period that it prevented a
junction of any part of the two halves of the hard and soft
palates, prevented a junction of the intermaxillary with the
maxillary bone, and also prevented the perfect formation of
the upper lip, thus presenting the deformity known as hare-
lip. Thus we frequently see cleft palate without harelip,
and sometimes, though very rarely, harelip without cleft
palate. When the fissure involves the maxilla, it follows
the median line from the uvula until it reaches the inter-
maxillary bone, when it turns aside and continues along one
of the intermaxillary sutures; and, if the lip is involved, the
fissure of the lip always corresponds with the termination of
the defective suture. Consequently, a fissure of the lip is
never on the median line, but always at one side.
In cases where the palatine fissure involves both maxil-
lary sutures, there appears in front a compound or double
fissure of the lip. In such instances, previous to a surgical
operation, the upper lip appears to be entirely wanting; the
intermaxillary bone is suspended from the nasal septum, and
in the roof of the mouth the vomer hangs along the median
line without being joined or articulated to the maxilla on
either side.
HARELIP AND CLEFT PALATE.
Neither cleft palate nor harclip is an arrest of union
merely, but an arrest of the formation of both hard and soft
tissues. If there were full development of tissue and only
failure of union, the evils following would be much easier
remedied. This evil is not so serious with the defective lip
as with the defective velum. In the former case the adjoin-
ing abundant tissue is a reserve upon which the surgeon can
draw with impunity; in the latter there is a scantiness of
tissue and no adequate reserve. Consequently the former
cases, when in the hands of a skillful surgeon to remedy, are
always a success, while in the same hands the latter are fre-
quently failures.
EVILS ARISING FROM CLEFT PALATE.
209
A fissure of the palate would naturally be supposed to
affect primarily deglutition, and the earliest efforts at a rem-
edy were directed to this point; but a closer observation has
shown that in the adult deglutition is not impaired, the re-
gurgitation of either fluids or solids being very rare. With
the infant, the position of the head in taking nourishment is
favorable to deglutition, and long before it has reached ma-
turity it learns by management to overcome the inconveni-
ence or difficulty in swallowing. Accidental lesions, how-
ever, coming generally in adult life, produce in this respect
very great inconvenience. In both cases (accidental and con-
genital) the faculty of distinct articulate speech is seriously
impaired by defects of any extent.
The only evil arising from congenital cleft palate which
demands the interference of science and art is its impairment
of speech. With a loss of any portion of the palate, whether
congenital or accidental, sufficient to make a permanent com-
munication between the buccal and nasal cavities, the perfect
articulation of any spoken language is impossible. In the
English language, spoken with a defective palate, the sound
of D approximates to the sound of N, that of B to M; K
and G become impossible except under very peculiar condi-
tions; and S, T, and Ch become difficult and sometimes
impossible. Besides, the resonating tone-character of both
buccal and nasal cavities becomes entirely changed by their
partial or complete union, or by the change in their form
and dimensions. From these various causes the speech of
people so afflicted becomes altered in tone, indistinct in its
enunciation, wanting in many of its sounds, difficult and
sometimes impossible to understand, and altogether disagree-
able. To such an extent has this cause, and this alone, oper-
ated on a sensitive mind, that it has often in the absence of
relief driven the sufferer from society and made him utterly
wretched. This is quite sufficient to call forth all the re-
sources of science in seeking a remedy.
The cure for these evils must be the closing of the abnor-
甯
​210
mal passage by some means which will restore to the de-
formed organs their functions. In perforations of the hard
palate, unless of extraordinary extent, the method is very
simple. In the loss of the soft palate by disease the remedy
is more difficult; and in extensive congenital deformity still
more complicated means must be resorted to. The treat-
ment of these lesions has been both surgical and mechanical.
The congenital defects have been treated by both surgery
and mechanism, but the acquired cases have been almost
always relegated to mechanism.
THE SURGERY OF CLEFT PALATE.
The surgery of congenital fissured palate is embraced
within the last half century. The first effort of the kind
was made by a dentist, Le Mounier, in 1764; but no impor-
tance was attached to the operation until the time of Roux,
who performed it upon a young American physician in Paris,
about the year 1825; and in this country about the same
period the operation was successfully performed by Dr. John
C. Warren, of Boston, who was at the time in ignorance of
the success of his Parisian confrère. To these gentlemen is
due the credit of the revival of staphyloraphy, and in later
years to Ferguson and Pollock, of London, who contributed
much by their skill to its surgical success.
Staphyloraphy (a word of Greek derivation, signifying
suture of the uvula), although rapidly falling into disuse, is
still maintained by some as being the only treatment which
such cases should receive. It is performed by paring the
edges of the cleft velum, and uniting them with sutures.
Sir William Ferguson, who probably attained a larger per-
centage of success during his time than any other surgeon,
found that success dependent upon the division of the leva-
tor and tensor palatal muscles. Without this division the
strain upon the sutures was such as frequently to break up
the junction and destroy the union; with the tension taken
off by the division of those muscles, the percentage of union
was largely increased.
The fact that such distinguished authority should adopt
•
THE FAILURE OF STAPHYLORAPHY.
211
and continue to practice such an operation during his life-
time was quite sufficient to stimulate others to adopt it with-
out question as to its beneficent results. But one thought in
the interest of patients has seemed to govern all surgeons in
this practice, which was, that a roof to the mouth of natural
tissue must be better per se than no roof or than an artificial
one; and, although the practice has been tested in a thousand
cases by the most eminent surgeons of their time, it has re-
sulted in such a uniformity of failure, considered as a benefi-
cent operation, that it should have been utterly abandoned
long ago. Certain it is that it has been performed many
times when the only apparent object was to gain éclat by the
skillful use of the knife in a difficult case before an admiring
audience, and with no possible hope of even a union or a
surgical success. The only cases in which surgical interfer-
ence is justified are those rare ones of slight separation and
with an abundance of tissue, where the division of the afore-
named muscles would not be essential to success; but, of hun-
dreds of cases that might seek surgical aid, very few would
come under this exception. The reasons for failure are based
upon the anatomy and physiology of the vocal organs, and
upon the mechanism of speech, for the full understanding of
which the reader is referred to the chapter upon that subject,
but which may be briefly stated as follows:
Articulate speech is the result of certain definite sounds,
the combination of different sounds, and of interruptions to
such sounds, which are by common consent associated with
definite ideas, and thus express them. The voice as it issues
from the larynx is modified in its tone and character by
resonance in the buccal or nasal cavities separately, and in
certain cases simultaneously by both. It is directed or inter-
rupted in its passage by certain organs with which it comes
in contact, and thus an almost endless variety of tones and
combinations of tones is created.
One of the most important organs in this direction (inter-
ruption of voice) is the velum palati. It is essential to the
212
EXPLANATION OF THE "YANKEE TWANG."
perfection of human speech that the nasal passage for the
outflow of sound should at certain times be completely shut
off, and all the sound directed through the mouth. If in
such cases there be any escape of sound behind the curtain of
the palate, the purity of speech is destroyed. The soft pal-
ate, in conjunction with the muscular wall of the upper
pharynx, must be under active control to produce this result.
If the palate be deformed, or either it or the pharyngeal
walls paralyzed or inactive, we shall find a change in the
tone of the voice, and more or less indistinctness of utter-
ance, depending upon the extent of the deformity or inac-
tivity. The proverbial nasal twang of the "Yankee" is en-
tirely owing to an inaction of these two organs. There is in
those cases an escape of sound into the nasal cavity which is
altered by the resonance of that cavity, and which should
have been shut off. In passing, we may say that this is not
owing in any sense to a deformity of those organs in the
"Yankee,” but rather to a lazy habit of speech imitated
necessarily by the children whose ultimatum is to copy their
elders, and thus the habit becomes confirmed as the norınal
condition of the speech of a whole community. But the
function of the velum palati in articulate speech is not con-
fined to the interruption of the nasal passage; in the forma-
tion of certain sounds it must be depressed and held in firm
contact with the dorsum of the tongue, and the sound di-
rected and prolonged through the nasal passages. All this
involves a palatal organ of flexibility, mobility, and extent.
The reason why staphyloraphy is so generally a failure,
even where it is a surgical success, is because the newly formed
septum is rigid, tense, and deficient in length; in the large
majority of cases it can not by any possibility be brought
into firm contact with the pharyngeal wall, and imperfect
speech will necessarily and always follow this defect. To
the credit of surgery be it said that it has done probably all
it can under the circumstances, and the only surgical hope of
the future seems to lie in the direction of making the opera-
MECHANISM MORE RELIABLE THAN SURGERY.
213
tion at a very early period of life, with the expectation that,
as the organs develop in tissue, function, and activity, the
defect will be overcome.
As surgery fails, mechanism comes to the rescue. Where
Nature is deficient, she is supplemented by art, and an organ
whose function was destroyed by accident, disease, or want
of development, can have that function restored by properly
adapted mechanism. The restoration of speech to a person
who has once possessed that faculty and lost it through a de-
struction of the palate, is comparatively easy; but to confer
the faculty of perfect speech with an artificial organ, upon
one who has been afflicted from birth with the absence of the
' natural organ, and has grown to maturity without the ability
of distinct utterance, is a much more difficult problem. In
acquired lesions even crude appliances, made without much
skill or accuracy, are often very beneficial; while in congeni-
tal cases the full resources of science and the nicest adapta-
tions of art are needed to accomplish the desired result.
The partial destruction of any organ of speech may occur
after the acquirement of speech, and nature makes an extraor-
dinary effort to overcome the difficulty by a new use and
activity of other organs which in a measure supply the defi-
ciency. Thus, the total loss of speech would follow the de-
struction of the hard palate, but an instant restoration would
result upon the introduction of an obturator. But in a con-
genital case the faculty of perfect speech must be acquired
by practice even after the introduction of the most skillfully
constructed and scientific appliance. In a description of the
treatment of these cases the two classes and the different
Conditions above referred to must be kept distinctly in the
reader's mind.
All apparatus adapted to the roof of the mouth, whether
forward or back, to the hard palate or soft palate, may prop-
erly be designated as artificial palates; but as such instru-
ments may be divided into two distinct classes, operated upon
different principles, and applied in the main to entirely dif-
15
DEFINITION OF OBTURATOR.
214
ferent cases without the possibility of interchange of prin-
ciple, I therefore denominate the one an obturator, and the
other an artificial velum. An obturator, according to this
distinction, is a stopper, plug, or cover, hard, non-elastic, and
stationary, fitted to an opening with a well-defined border or
outline, and shutting off the passage. Such instruments are
of nearly universal application to perforations of the hard or
soft palate resulting from accident or disease, but they are
rarely applicable to a congenital fissure of the velum. An
artificial velum is not a stationary stopper, but an elastic,
movable valve, under the control of the surrounding and ad-
jacent muscles, closing or opening the passages at will, and
is applicable especially to congenital fissures, occasionally
where the soft palate has been destroyed, but never to per-
forations of either the hard or soft palate.
CHAPTER IX.
HISTORY OF OBTURATORS.
THE term obturator is taken from the Latin obturare,
signifying to stop up; and history shows obturators to have
been among the earliest applications of mechanism to the
mouth. The first recorded definite suggestion of a piece of
mechanism to act as a palatine obturator is that of Alexander
Petronius, who preceded the celebrated Ambroise Paré by a
few years. He says: "If the decayed bone of the palate
falls of itself, or if we extract it, the pronunciation is altered
so much so that the patient can scarcely be heard. But it is
possible, in certain circumstances, to repair this loss; for ex-
ample, when there is only a hole in the palate, we can stop
it up with cotton, with wax, with a gold plate, or in any
other way that the genius of the artist suggests, having care
to give to these instruments the same concave form as the
palatine vault.”
The first definite description of an obturator was by
Ambroise Paré, whose first work was published in 1541;
and although Guillemeau, writing fifty years later, says that
obturators were applied by the Greek physicians, it is quite
likely it was more a matter of inference by him than an au-
thentic record of a fact. That the principle of an obturator
was known to the ancient physicians, and that such a prin-
ciple would be easily and naturally conceived by a person
suffering from a perforation of the palate, is more than prob-
able; and therefore it is likely that relief was obtained by
the very simple means within the reach of every one, such
216
AMBROISE PARÉ'S OBTURATORS (1541).
as a piece of sponge or wad of lint thrust into the per-
foration, or a piece of thin leather, or any membranous
substance which could serve the purpose temporarily of a
stopper or covering. But the first recorded attempts at
making a permanent obturator by mechanism are those of
Paré before mentioned. Paré's description is as follows:
Many times it happeneth that a portion or part of the bone
of the palate being broken with the shot of a gun, or cor-
roded by the virulency of the Lues Venerea, falls away,
which makes the patients to whom this happeneth that they
cannot pronounce their words distinctly, but obscurely and
snuffling; therefore I have thought it a thing worthy the
labour to show how it may be helped by art. It must be done
by filling the cavity of the palate with a plate of silver or
1
6:
FIG. 133.


gold a little bigger than the cavity itself. But it must be as
big as a French crown, and made like unto a dish in figure;
and on the upper side, which shall be towards the brain, a
little sponge must be fastened, which, when it is moistened
with the moisture distilling from the brain, will become
more swollen and puffed up, so that it will fill the concavity
of the palate, that the artificial palate cannot fall down, but
stand fast and firm, as if it stood of itself." (See Fig. 133.)
"This is the true figure of those instruments whose certain
use I have seen not by once or twice, but by manifold trials,
in the battles fought beyond the Alps."
Paré gives also another form of obturator, as shown in
Fig. 134, which resembles very much the cuff-button of the
modern toilet. The larger button or disk being adapted to
OTHER FORMS OF PARÉ'S OBTURATORS.
217
the roof of the mouth, and covering the opening, was con-
nected by a revolving stud or screw to an oblong disk,
which represented the extreme length of the perforation.
The head of the stud passing through the larger disk, and
being accessible to a pair of forceps, enabled the wearer to
pass the instrument through the opening, when, by revolv
ing the stud, the long diameter of the upper disk was made
to bridge the short diameter of the perforation, and thus sus-
tain the obturator. The efficiency of such obturators, if
properly adjusted, would seem to leave nothing to be de-
sired. The loss of speech would be instantly restored, and
comparatively little inconvenience would be the immediate
result; but time would develop the fact that any pressure by
a foreign substance upon the adjacent tissues would produce
FIG. 134.


their absorption, and the continued enlargement of the fissure
and the swelling of the sponge by the absorption of moisture
would be eminently conducive to such a result. I have my-
self seen a case recently where a patient had made a wad of
cotton fulfill all the offices of an obturator, and thus enlarge
an opening of moderate size through the roof of the mouth,
until its boundaries were the alveolar ridge and the soft pal-
ate. (See Fig. 170.) The principal objection to the stud
form, Fig. 134, is that it would prevent a final closing of the
aperture from natural causes, experience having shown that,
in many cases where the aperture is only bridged over,
healthy granulations form, and ultimately the gap is com-
pletely filled.
About fifty years subsequent to the publications of Paré
218
GUILLEMEAU'S AND HEISTER'S OBTURATORS.
appeared those of Jacques Guillemeau, but the instruments
which he describes seem in no way to differ from those of
his predecessor. He continues the use of the sponge, mount-
ed in the same way, and also the stud-button.
In 1756 Laurence Heister describes an obturator, but it is
the concave disk of Paré, with but a slight change in the
method of attaching the sponge. These two methods ap-
pear to have been the only ones adopted during a period of
nearly two hundred years.
In 1728 "Le Chirurgien Dentiste," by Pierre Fauchard,
was first published. Fauchard described and illustrated
FIG. 135.

much more complicated mechanism for this purpose than
anything which preceded him; nevertheless, the principle of
support was much the same as that of his predecessors. He
depended upon passing through the aperture and resting
upon the superior surface of the surrounding border; but he
can be readily pardoned such a course with such instruments.
as were complicated with artificial teeth in a mouth where
there were no remaining natural teeth which would give
support. As he seems to have been the first to construct
such formidable apparatus, the ingenuity which he displayed
in their contrivance entitles him to much credit. The plan
PIERRE FAUCHARD'S OBTURATORS (1728).
66
219
which he adopted was that of a concave-convex plate to
cover the fissure; to the center of the convex surface he at-
tached a tube, through which passed a screw, to the supe-
rior extremity of which were attached two wings; the infe-
FIG. 136.

H
rior extremity terminated in the concave surface of the plate
in a small head. The wings were folded together and passed
through the fissure, and, when the artificial palate was in its
place, the screw-head was turned, and the wings were spread
across the fissure, and rested on the nasal surface of the roof
FIG. 137.

of the antrum of Highmore. The wings had each a small
piece of sponge attached to their under surface, which readi-
ly adapted itself to the surface on which it rested, and thus
the pressure of the wings on the tender mucous membrane
220
DELABARRE'S OBTURATOR (1820).
could be tolerated." Various appliances of his are illustrated
in Figs. 135 to 139.
No improvement was made upon Fauchard until Bour-
det, who published a treatise in 1756, recognized the evils of
wearing an instrument in the aperture, particularly the ex-
FIG. 138.
FIG. 139.


FIG. 140.
INT
panding sponge, and recommended arching over the vault
of the palate by thin sheet metal, supported by attachment
with silken ligatures to the teeth on either side, and thus
not only prevent the enlargement of the orifice, but assist
nature in the effort to reduce it.
Nothing of importance in the history of obturators ap

Σ
C
pears again until the advent of M. Delabarre, who published
his treatise on "Mechanical Dentistry" in 1820. He adopted
the ideas of M. Bourdet, and improved the instrument by
substituting metallic bands about the teeth, after the manner
of the modern clasp, in place of the ligatures, for support.
The ligature created an irritation of the gums which the
SNELL'S OBTURATORS (1828).
clasps avoided. Fig. 140 illustrates the improved obturator
of Delabarre. The same author contrived another and some-
what formidable apparatus, which was an obturator and velum
combined; but as the description of the instrument comes
more properly under the head of artificial vela, the reader is
referred to a subsequent chapter upon that subject for the
details.
221
Up to this period we are indebted entirely to the French
for skill in this department, and for its record. All of the
aforenamed authors were French; but since that period the
art and the literature have passed entirely into the English
language, with one notable exception-M. Preterre, of Paris,
who has made a larger number of protheses for the buccal
cavity than any or all of his predecessors.
The first English author of any importance was Mr. Snell,
who published a treatise in 1828. His obturators for perfo-
ration of the hard palate were adapted in recognition of the
principle of simple juxtaposition as advanced by Bourdet;
and, as a proof of the correctness of the principle, he cites a
case under his treatment where two apertures of considerable
dimensions were covered, and ultimately contracted and closed
entirely. This pathological fact being now confirmed by fifty
years of experience added to Snell's, determines the true
principle upon which all obturators or simple perforations
should be based. In the more complicated cases of acci-
dental lesion, requiring an obturator and velum, Mr. Snell
seems to have had considerable experience, and, from his own
account, very marked success. The cases which he relates in
his treatise are exceedingly interesting, and show a true per-
ception of functions to be restored, and a scientific skill in the
adjustment of apparatus which would put to shame some of
the vaunted superiority of the present day. His most in-
genious appliances in which a velum was required were a
marked improvement in simplicity over his predecessors, a
detailed description of which will be found in a subsequent
description of artificial vela.
3
DR. ROWELL'S OBTURATOR (1841).
In 1811 Dr. Warren Rowell, of New York, constructed
an obturator which was sufficiently peculiar to entitle it to a
place in history. The case was one of extensive loss of the
roof of the mouth, including nearly all the teeth, the vomer,
and turbinated bones. The posterior portion of the palatine
aperture was formed, to a considerable extent, of a semi-
cartilaginous substance, possessing sufficient elasticity to allow
a larger body than the opening to be pushed up through it,
and when so forced up it would be supported above the
aperture by the edge returning to its original position. This,
he hoped, would support a light plate, if the obturator could
be so shaped as to rest upon the cartilaginous ledge after it
222.
FIG. 141.
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FIG. 142.


was introduced. Without quoting the description which is
given of his method of procedure, it will be sufficient to
state that the obturator which he constructed consisted of a
plate larger than the opening in the palate, and covering the
anterior part of the alveolar ridge, to which artificial teeth
were attached, and an irregularly shaped drum or air-
chamber, larger above than below, where it was connected
with the palate plate. "The neck of this bulb or drum is
of the exact size of the opening in the palate, and the upper
part or summit has several depressions, which correspond
with the irregular surfaces of the remaining nasal bones.
The anterior part of the palate plate, to which the teeth are
attached, as may be seen in Fig. 141, is composed of two
223
plates, to compensate by its thickness for the deficiency of
the alveolar ridge. The drum is seen rising from the palate
plate, to which it is soldered. In Fig. 142 is represented a
lateral view of the piece. The palate plate and drum are
composed of fine gold, and made very light."
Of this obturator it is stated that it was worn for several
years with entire satisfaction, and restored the functions
of mastication, deglutition, and speech. Nevertheless, the
weight of the piece must have been such, together with the
strain upon the orifice in its constant removal, that it could
not have been permanently supported by resting upon the
superior border of the aperture. It is quite likely that its
permanent usefulness arose from the nicety of its adaptation,
and from the skill acquired by the patient in its management.
We see this last principle illustrated often in cases of badly-
fitting dentures on the upper jaw, that will not keep their
position for a moment except by the constant activity of the
adjacent muscles, and yet the wearers will retain them in
position during the most lengthy and trying ordeals. Dr.
Rowell's obturator was probably so well adapted to such a
case, that there could be no improvement upon it in form,
and it could be bettered only by a change of material for
something of less specific gravity.
Dr. S. P. Hullihen describes in the "American Journal
of Dental Science " an obturator which he constructed for
a case where the velum was lost by disease. He
He says:
"An artificial palate made upon this plan will be com-
posed of four parts: 1, a valve, made from gold plate, as
thin as it can well be worked; 2, a spiral spring about an
inch long, and of the size usually made for whole sets of
teeth; 3, a slide, one inch and a half in length, and of the
width and thickness of a common watch-spring; 4, a plate,
larger or smaller, as the case may require, struck up in the
usual way, to fit the roof of the mouth. The size and form
of the valve are obtained by taking an impression of the pos-
terior opening of the nares. The plate composing it should
DR. HULLIHEN'S OBTURATOR.
DR. HULLIHEN'S OBTURATOR.
224
be struck up in two parts, front and back, which, when sol-
dered together, makes a hollow body (a), as shown in Fig.
143. At the upper end of the valve a small pin is soldered,
FIG. 143.
COMUNE
the point of which looks downward, and of sufficient thick-
ness to fit very tightly in one end of the spiral spring. The
spiral spring must be made of such a length as will permit
the valve to rest slightly upon the upper surface of the rem-
nants of the lost velum. The slide has a pin in the posterior
end, looking upward to receive the other end of the spiral
spring before described. The anterior end of the slide has
a small button looking downward. The slide is attached to
the plate by two small clasps (bb), as represented in Fig. 144.
FIG. 144.
T


80
SHA
Wine G
136
The plate may be made to cover the entire roof of the mouth,
when necessary; or it may be made only sufficiently large to
permit the mounting of the slide. These different plates,
DR. HULLIHEN'S OBTURATOR.
225
when put together, particularly if the plate is to cover the
whole roof of the mouth, make a plate of the form repre-
sented by Fig. 143. Fig. 144 shows the attachment of the
spiral spring to the valve and slide (cc). The staples (bb)
confine the slide to the plate, and there is a button (d) on
the end of the slide, by which the valve may be set back or
forward, as desired by the patient, without removing the
plate from the mouth.
"The plate should be made to fit the several parts for
which it is intended with great exactness. The plate must
fit the roof of the mouth, and the teeth to which it may be
secured, in a faultless manner. The slide must be arranged
so as to permit the valve to be drawn so closely against the
posterior opening of the nares as to close them, or to be
pushed back, so as to leave them entirely unobstructed. The
spiral spring, as, I have before remarked, must be made of
such a length as will allow the valve to rest slightly upon the
upper surface of the remnants of the lost velum. The valve
should be sufficiently wide at its base to overlap the rem-
nants of the velum so far as the parts on each side will per-
mit without producing irritation. No other part of the valve
than the base should be allowed to touch, unless when
brought forward against the nares. Unless all the parts are
so arranged, the palate will not be properly constructed, and
will not, of course, answer the desired end.
"Thus it will be perceived that the peculiarities of this
plate are: 1, a valve to fit the posterior opening of the nares;
2, the attachment of this valve to a slide, by which the pa-
tient is enabled to adjust the valve while in the mouth in
such a way as to admit through the nares just the quantity
of air desired; 3, the mounting of the valve on a spiral
spring, which will permit it to vibrate backward and forward
as the breath is inhaled or exhaled, and also to be moved by
any muscular action that may remain in the remnants of the
lost velum, thereby answering, to a great extent, the pur-
poses of a velum."
T
226
PROFESSOR BUCKINGHAM'S OBTURATOR.
It is hardly conceivable that such an instrument, bearing
in no sense a resemblance to the lost organs, could possibly
restore to any degree the lost functions. That it might have
been of some benefit in a single case is possible; but as a
principle for general application it is defective, and, in view
of modern improvements, the experiment is not likely to be
repeated.
In 1858 Professor Buckingham, of Philadelphia, made an
obturator for "a gentleman who on a previous occasion had
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FIG. 145.

a tumor removed, which covered a portion of the posterior
surface of the hard and the anterior surface of the soft pal-
ate. The surgeon, on its removal, had divided the velum
and uvula, so that the case resembled a congenital deformity.
The attempt had been made twice to bring the soft parts
together again by a surgical operation, which had failed.
Fig. 145 shows the appearance of the parts very clearly—
the letters A and B showing the thickened muscles as they
hung down on the side of the pharynx. He made for this
PROFESSOR BUCKINGHAM'S OBTURATOR.
227
case an obturator (Fig. 146), the plate of which covered the
whole of the roof of the mouth, with a bulb attached to
extend up into the posterior nares, and well back toward
the antero-posterior walls of the pharynx, leaving but a
small space between them. This obturator enabled the pa-
Alle
FIG. 146.

tient to eat and drink without annoyance; without it food
would pass into the nares and occasion much inconvenience.
It also greatly assisted his voice, as many of his words could
not be understood when it was not worn, but he could ar-
ticulate them with great distinctness when it was in place."
FIG. 147.

In January, 1858, Dr. J. D. White published in the
"Dental News Letter" a description of an obturator com-
bined with nearly an entire set of artificial teeth, in a case
of traumatic lesion of the palate. The lost substance is suffi-
ciently represented in Fig. 147 to be understood. The prin-
1
་
1
DR. J. D. WHITE'S OBTURATOR.
FIG. 148.
228
cipal interest in this obturator lies in the materials used.
silver plate was approximately fitted to a cast made in the
usual way from an impression of the parts, and a rim of
silver was raised around the alveolar border to which the
teeth were soldered. But over the whole of this silver plate,
upon both sides, was covered gutta-percha. The silver plate
was small enough to be completely imbedded in the gutta
percha, and knobs of the same material were formed to plug
the openings into the nasal cavity and into the antrum. The
completed instrument is shown in Fig. 148. The appliance
was made before vulcanite came into general use; otherwise
it would probably have been preferred, as being much more

durable. Gutta-percha, however, answers an excellent tem-
porary purpose where immediate use is required.
In the "Dental Cosmos" for 1860 is described an obtu-
rator made by Dr. McGrath to supply the loss of the soft
palate as shown in Fig. 149, the result of syphilis: "The
fissure extended from the posterior opening of the nares
through the velum to the palate bones, and was nearly an
inch in breadth. The uvula was entirely gone, as well as
the lateral half arches, and along with them the palato-pha-
ryngei and constrictores isthmi faucium muscles. In this
case deglutition was impaired to a great extent: the food
would pass into the nares, and the fluids would also pass into
the nasal cavity and out through their anterior openings.
The disease had not confined itself to the palate, but, extend-
ing to the nasal organs, had completely destroyed their inter-
229
nal structure as well as a portion of the nasal bone, to such
an extent as to materially change the external shape of that
organ.
DR. MCGRATH'S OBTURATOR.
"The obturator constructed for this case was of one
piece, and made to cover the hard palate completely, extend-
ing from the central incisors to the posterior wall of the phar-
FIG. 149.

1
ynx, and passing a short distance beyond the edges of the
opening on each side. (See Fig. 150.) The plate was made
to press firmly against that portion of the soft palate which
remained, yet not so firmly as to be the cause of irritation,
the edges of the plate being slightly bent downward for the
same reason; the object being to prevent the possibility of
the soft parts being drawn above the palate, which would
afford a communication with the nares. The posterior edge
16
DR. MCGRATH'S OBTURATOR.
230
of the obturator was bent downward at a right angle with
the body of the palate, and curved so as to form with the
posterior wall of the pharynx an oval opening sufficiently
large to permit the patient to breathe freely through the
nostrils. In the act of deglutition the muscles would con-
tract and press against this portion of the plate, thereby cut-
ting off the communication with the nares. To this plate
were attached three artificial teeth, two lateral incisors and
one molar, the whole being retained in position by means of
clasps around the teeth."
FIG. 150.

We come now to the consideration of the most scientific
obturator which has ever been applied to natural deformities.*
In all the cases described in the foregoing pages, the instru-
ments were constructed for, and applicable to, accidental
lesions only. Whenever a case of congenital fissure pre-
sented itself, and any really scientific effort was made to sup-
ply the functions of the undeveloped organs, it was by an
* The author is not prepared to admit that this obturator is the most scien-
tific instrument for congenital fissure; but, keeping up the distinction between
obturators and vela, it is the most perfect obturator.
DR. WILHELM SUERSEN'S ANNOUNCEMENT.
231
attempt at an artificial velum-Snell and Stearn both claim-
ing complete success in such cases, not by an obturator, but
by a flexible elastic velum. According to the theory followed
by them of expecting articulate speech to result only from
the same muscular activity as with perfectly developed or-
gans, it would be impossible for the same kind of utterance
to follow from a totally different kind of an organ. Hence,
the natural velum being of a very elastic character and an
important organ of speech, it was not deemed possible for
the function of speech, destroyed by its absence, to be re-
stored by any appliance that did not resemble the natural
organ in the important characteristics of elasticity and flexi-
bility. The idea was lost sight of that speech is not a nat-
ural function, like digestion or respiration, but a function
acquired by the education of certain muscles, which are
trained to produce such effects; and consequently, if the
power of certain muscles were destroyed, it might be possi-
ble to train other muscles to new uses and produce similar
results. It could only be in accordance with this last sugges-
tion that an obturator could be of benefit to articulation in a
congenital fissure of the palate.
In 1867 Dr. Wilhelm Suersen described before the Cen-
tral Association of German Dentists, at Hamburg, his method
of constructing obturators, in which he announced a princi-
ple in the mechanism of speech with an artificial organ which
had never before been advanced. From a report of his lec-
ture in the "American Journal of Dental Science," for De-
cember, 1867, I make the following extract:
"In order to be able to pronounce all letters distinctly,
it is accordingly necessary (besides other conditions, which
are far away from our present subject) to separate the cavity
of the mouth from the cavity of the nose by means of mus-
cular motion. That separation is, under normal conditions,
effected, on the one hand, by the velum palati, which strains
itself (consequently by the levator and tensor palati); but on
the other hand, also, by a muscle which, to my knowledge,
232
has, in connection with these operations, not yet received a
sufficient amount of attention-I mean the constrictor pha-
ryngeus superior. This muscle contracts itself during the
utterance of every letter pronounced without a nasal sound,
just as the levator palati does. The constrictor muscle con-
tracts the cavum pharyngo-palatinum, the pharynx wall bulg-
ing out; and it is chiefly on the action of this muscle that I
base the system of my artificial palates.
DESCRIPTION OF SUERSEN'S OBTURATORS.
“These palates, which in all their parts are made of hard
caoutchouc, consist of a teeth-plate suitably attached to exist-
ing teeth, and which, at the same time, covers the fissure in
the hard palate (if such a fissure exists). Where the fissure
commences in the velum, that plate terminates in an apophy-
sis broad enough for filling up the defect. This apophysis is
at the same time of such thickness as to keep up a contact
between the high edges forming the sides of the apophysis
and the two halves of the velum, even when the levator
palati is in activity. To bring about this contact the more
surely, the high edges forming the sides do not rise straight,
but obliquely, toward the outside. The lower surface of the
apophysis, turned toward the mouth, lies on about an equal
level with the velum, if the latter is raised by the levator
palati. But, when the velum hangs loosely downward, the
back part of the artificial palate is lying over it. This back
part, accordingly, fills up the cavum pharyngo-palatinum, and
in such a manner as not to impede the entrance of the air
into the cavity of the nose when the constrictor pharyngeus
superior is inactive. Thus the patient can without any im-
pediment breathe through the nose. But, as soon as the con-
strictor contracts the cavum pharyngo-palati (this happens, as
I will repeat for the sake of clearness, in the utterance of
every letter with the exception of m and n), the muscle al-
ready named reclines against the vertical back surfaces of the
obturator. By this operation the air-current is prevented
from entering the cavity of the nose and compelled to take
its
way through the mouth, and thus the utterance loses its
SUERSEN'S OBTURATORS FOR ACQUIRED LESIONS. 233
nasal sound. To the existence of those vertical surfaces, and
consequently to the thickness of that part of my palates
which fills up the fissure in the soft palate and the cavum
pharyngo-palatinum, I must attach special importance. But
for that thickness, the levator palati, when it rises upward,
would not remain in contact with the side-edges of the ob-
turator, nor would the constrictor pharyngeus be able to
effect a sufficient termination if the portion of the obturator
nearest to it consisted only of a thin plate."
The following engravings illustrate the instruments de-
scribed above:
FIG. 151.

ILLUSTRATION I.—Case of an acquired defect of the soft
palate.
Fig. 151.-Representation of the mouth without the ap-
paratus.
Fig. 152.-The apparatus in situ.
Fig. 153.-Side view of the apparatus.
Fig. 154.-The apparatus seen from the back.
Fig. 155.-The apparatus seen in front.
Fig. 156. The apparatus seen from below.
Fig. 157.-The apparatus seen from above.
The plate a and its narrow and thin apophysis i, which
extends from the boundary b of the hard palate to the com-
234
SUERSEN'S OBTURATORS.
mencement of the defect c, serve only as supporters to the
real thick obturator d. The latter lies in the pharyngo-pala-
FIG. 152.
DE
FIG. 154.
tine hollow, so that the lower surface of the obturator turned
toward the mouth is about on the same level as the rest of
FIG. 155.
FIG. 153.


MART
Y
E

the velum palati, e. Against the vertical side ƒ and back-
edges g of the obturator, the walls of the pharynx lean, if

the latter is contracted by a contraction of the superior con-
strictor of the pharynx. But, if the muscle just mentioned
SUERSEN'S OBTURATORS.
is not in activity, the obturator does not touch the pharynx
wall. The contraction of the constrictor superior, therefore,
closes the valve formed, with the help of the obturator, be-
FIG. 156.
G
235

g
tween the cavity of the mouth and that of the nasal bone,
while any relaxation of the above-mentioned muscle immedi-
ately reopens that valve.
FIG. 157.

ILLUSTRATION II.-Case of a constitutional fissure of the
hard and soft palate.
SUERSEN'S OBTURATORS FOR CONGENITAL CLEFT.
Fig. 158.-Representation of the mouth without the ap-
paratus.
236
FIG. 158.

Acts
Pre
Fig. 159.-The apparatus in situ.
Fig. 160.-Side view of the apparatus.
FIG. 159.
FIG. 160.


Fig. 161.-The apparatus seen from the back.
Fig. 162.-The apparatus seen in front.
Fig. 163.—The apparatus seen from below.
Fig. 164.-The apparatus seen from above.
a
*ILL
SUERSEN'S OBTURATORS.
The designation of the letters is the same as in Illustra-
tion I. The thickness of the obturator begins where the fis-
sure in the soft palate commences. With the high side-edges
FIG 161.
SUMANTEN
-g
h of the fore part of the thick obturator (which edges ascend,
not straight, but obliquely, toward the outside) the side-halves
FIG. 162.
of the fissured velum palati e are in constant contact; even
when the latter are raised by the action of the muscular
FIG. 163.
237


H
SPLAT

TYTT
levator palati. The proportions of the back part, which, in
the same manner as in the case of an acquired defect, fill
up the cavum pharyngo-palati, are as in Illustration I. Kk
238 PECULIARLY APPLICABLE TO CERTAIN CASES ONLY.
are the two halves of the fissured uvula. (See Figs. 158 and
159.)
This form of an obturator in case of acquired palatine
defects does not possess any superiority over any other meth-
od of construction which should make it remarkable. It
has already been shown that a variety of forms may be
adopted which will improve articulation, if the one charac-
teristic be maintained, viz., that when in use the adjacent
muscles are able to meet it and shut off the nasal escape of
sound. It is only when applied to congenital fissure with
success that it rises into a meritorious position.
FIG. 164,

$34
9
Many years have now passed, in which the principle
has been put to a number of tests, and some judgment
may be formed upon it; and there is proof quite sufficient
to sustain the position that the constrictor muscles of the
pharynx may be educated to the performance of functions
which they would never be required to exercise in conjunc-
tion with perfectly developed adjacent organs. To their in-
creased activity and extra developed power is undoubtedly
due the readiness with which patients acquire articulation in
cases where the velum has been totally destroyed by accident
or disease, and its place supplied by a very crude substitute.
My own experience leads me to the conclusions:
SPECIAL USE OF THE SUERSEN OBTURATOR.
239
1. That in most cases of congenital defects the patient
will acquire correct articulation more easily and more cer-
tainly with an elastic velum scientifically adjusted than with
any other form of apparatus.
2. That, in a majority of cases of the like defect, a patient
will never acquire distinct articulation with an obturator.
3. That, where a patient afflicted with a congenital ab-
sence of the palate has overcome the difficulty by wearing
an artificial velum until clear and distinct articulation has
been acquired, he may exchange the velum for an obtura-
tor, and continue to articulate properly.
4. That of all obturators to supply deficiencies of the
soft palate and induce correct articulation, the one introduced
by Suersen contains the truest principle, and is best adapted
to the purpose.
H
Acting on these convictions, I have in late years treated
fissured palates upon these principles, viz.: A patient of in-
telligence is supplied with an artificial velum, after a plan to
be indicated in another chapter. As this form is a very near
approach to the absent organ in form and characteristics, it
is expected that, with proper application, improvement in
articulation will immediately follow, and that the improve-
ment will continue until perfection is attained. When this
period is reached, which may be in a few months or in a few
years, the elastic and more perishable velum may be ex-
changed for a permanent obturator, so adjusted that the par-
tial education of the pharyngeal muscles, as organs of speech,
may be completed.
This treatment has been carried out in a number of in-
stances with my most promising patients, and with gratify-
ing success. The following case from practice is an ex-
ample:
AN OBTURATOR SUBSTITUTED FOR AN ARTIFICIAL VELUM.
-There came to me in 1865 a young man seventeen years
of age, with congenital fissure of the palate, which was con-
INTERESTING CASE OF CONGENITAL FISSURE.
240
fined almost entirely to the soft tissues, the apex of the fis-
sure being in the border of the palate-bone. There was no
harelip and no external deformity to indicate a defective
organ within. His speech had all the characteristics accom-
panying the average case of fissured velum, being so defec-
tive that it was with difficulty he was understood by stran-
gers. He belonged to a family of excellent social standing,
had the advantage of a good education, and was fitted by
FIG. 165.

training to take part in a business in which his father was
largely interested. But his inarticulate speech was an ob-
stinate bar to his advancement. The model of the fissure is
shown in Fig. 165.
I made for him an artificial velum of soft vulcanized
rubber, which is shown in Fig. 166, letter A, and was at-
tached to a gold plate marked B, which was sustained in its
position by being clasped to the first permanent molar on
241
each side of the mouth. This artificial palate when worn
bridged from side to side, and covered all the fissure from
the apex down to the junction of the bifurcated uvula with
the soft palate. The position is shown by the dotted line in
Fig. 165. That portion in Fig. 166 marked C reached across
the pharynx in a somewhat horizontal position, and came
nearly in contact with the constrictor muscles of the pharynx.
Articulation was therefore made possible with this instru-
ment, because the action of the levator muscles was such
that the artificial velum could be lifted until it touched the
AN ARTIFICIAL VELUM.
FIG. 166.

TO
m
posterior wall of the pharynx, and thus shut off the nasal
passages at will.
Immediately on the introduction of this instrument the
patient put himself under the vocal training of a professor
of elocution. His improvement in articulation was rapid,
and he was enabled very shortly to consummate his desires
by taking part publicly in business. His mastery of articu-
lation was so satisfactory to his friends and himself that he
became one of the most grateful persons for whom I ever
rendered a service. Such an expression as this came to me
after a time: "I had the strongest desire as a boy to become
1
CHANGE FROM VELUM TO OBTURATOR.
242
a teacher in a Sunday-school when I came to be old enough,
and it was a most painful thought that I should always be
debarred that satisfaction by my defective speech. Now I
am superintendent of a flourishing mission-school, and I am
constantly called upon to use my voice in that capacity, and
in others, sometimes for an hour, before a mixed audience,
and I am told no one would suspect that I ever had a defect
of speech."
I found in process of time that this patient, by his expe-
rience and more than ordinary intelligence, was a valuable
aid to me in studying the mechanism of speech with an arti-
ficial organ; and, after a ten years' experience with an arti-
ficial velum, I proposed to him to make a change for an
obturator. I had reflected much on the principle advanced
by Suersen in 1867, of educating the constrictor muscles of
the pharynx to become organs of speech, and I had applied
this principle in some cases with more or less success; but I
desired to put the principle to a more scientific test than I
had yet had an opportunity to do. The case of my patient
before described would give me every facility by an intelli-
gent coöperation.
My model of the fissure was obtained, which of course
was the same as shown in Fig. 165. Upon this I formed a
mass of softened gutta-percha, filling up all the roof of the
cast to a level of the teeth, and projecting into and through
the fissure. Its direction followed the incline of the sides of
the gap to about midway its length, when it was continued
horizontally backward, and terminated in a lump or bulb
about the size and shape of an ordinary Spanish chestnut.
This mass when cold was introduced into the fissure, and
after some slight changes of form the bulb was softened in
hot water and again introduced. The patient was directed
to swallow immediately and as frequently as possible.
These experiments of softening and exposing to the pres-
sure of the constrictor muscles in swallowing were continued
until there was no perceptible reduction in size or material
METHOD OF MAKING A VULCANITE BULB.
243
change in the form of the bulb. This muscular activity had
driven a portion of the mass upward and another portion
downward, clearly and distinctly marking the boundary of
the superior constrictor. Such portions of the bulb as had
been squeezed beyond what was needed to shape the obtura-
tor were trimmed away, and the whole more symmetrically
formed previous to making a duplicate in vulcanite.
A final test of the utmost possibilities of contraction of
the pharyngeal muscles was made after all the reduction in
size had been obtained from the yielding of the mass. Any
substance of sufficient stability to retain its position would
resist somewhat the power of muscular contraction; there-
fore, after the mass was carved into shape, it was gradually
reduced in size where the muscles came in contact with it,
until they would barely touch it in the process of deglutition.
As this could not be determined by the eye, the test was
made by painting the pharynx with a little paste of chalk
and water, contact of which with the wax or gutta-percha
surface would show very distinctly.
Having determined with the utmost nicety the ultimate
form of the obturator, it was duplicated in substantially the
same way as is usual in making artificial dentures on a vul-
canite base, except in one particular. Being desirous of
making the whole instrument of as little weight as possible,
I made the bulb hollow in the following manner: After the
gutta-percha form was removed from the flask and the mold
was ready for packing with rubber, I made a paper pattern in
sections of the hollow chamber in the flask which represented
the bulb. By cutting out the sheet rubber to the shape of
these patterns and joining them together at their edges, the
bulb was approximately formed, care being taken to have it
small enough to drop readily into the chamber where it was
to be vulcanized. Previous to closing this unvulcanized bag
a few drops of water were introduced, and the bag hermeti-
cally sealed, the edges being moistened with a little chloro-
form to insure their adhesion. The remainder of the space
"
A PLATE WITHOUT A BULB OF NO VALUE.
244
in the flask was packed in the usual manner, and the whole
vulcanized with no other than the ordinary care. The result
was that the steam formed within the bag expanded it with-
out bursting, and drove it into all the inequalities of the
chamber, and thus produced an obturator so light that it
would float in water. This was finished up and given to the
patient to experiment with.
Figs. 168 and 169 represent substantially the form of this
vulcanite obturator. The broad surface of the rear of the
bulb is essential to the complete closure of the posterior
nares, as are also the high sides which come in contact with
the levatores palati. I have recently seen an instrument which
pretended to carry out the Suersen principle, but it was a
simple flat tongue in the fissure, without sides or rear sur-
face, and the result was a complete failure. It was only an
aggravation without benefit.
In a few days he returned with much to say in its favor,
but also relating that it was impossible to produce certain
sounds which he had learned to do with ease with his former
apparatus. The gutturals were especially defective, showing
that either the pharynx did not meet the obturator, or that
the dorsum of the tongue failed to make close contact with
it, or possibly both. I came to the conclusion, however, that,
as the artificial velum followed down the line of the fissure
to a much lower point than the obturator did, the tongue had
been accustomed to being elevated to only such a point where
it expected to meet with sufficient resistance to retain the
sound until ready for the explosion. If, now, as in case of
the obturator, this base of resistance were removed farther
from the tongue, the sound would naturally be defective in
proportion to the distance.
This led me to an experiment to test the best point at
which an obturator should stop to be met by the tongue for
articulation. I cut the bulb from the apparatus, leaving it
simply as a plate across the roof of the mouth, with a thin,
tongue-like extension continuing down in and along the line
PROPER PLACE FOR THE BULB.
245
of the fissure shown in Fig. 167, letter A. Upon the poste-.
rior surface of this tongue was riveted a bar of gold about
one tenth of an inch in width by half that in thickness, and
five eighths of an inch long, beveled inwardly toward the
plate and running lengthwise (letter C). The bulb, letter B,
was then fitted to the bar with a dovetailed groove, which
would permit it to slide up and down the bar for a distance of
half an inch, thus permitting a very extended range of move-
ment by drawing it higher up into the posterior nares or drop-
ping it down into the pharynx. The bar fitted the groove
so tight that it would keep any position in which it was
placed. Equipped thus with a machine that he could alter
FIG. 167.

C
B
at discretion, my patient began again his experiments, and in
the course of a fortnight returned to me with the discovery
of the exact point at which the bulb must be set to give him
the greatest benefit. This point was at a much lower level
than the instrument had originally provided, being nearly as
low as the uvula, and where I would have supposed before
that it was impossible to tolerate so large an unyielding mass
during deglutition, but I found that he had worn it during
meals without discomfort. His voice and enunciation were
so much benefited that I was encouraged to take the next
step and reproduce the instrument in gold.
The roof of the mouth being very high in the center,
the cast was filled up at that point so as to bring the golden
roof at a lower level and make the dome more symmetri-
17
MAKING A BULB OF GOLD.
246
cal and better formed for enunciation. Subsequently this
space above the gold plate was filled with vulcanite. Twenty-
carat gold was used in both plate and bulb, that which formed
FIG. 168.

the bulb being rolled down as thin as it was possible to work
it, and the whole being a very accurate duplicate in form
of the perfected instrument in vulcanite. Figs. 168 and 169
show two views of this instrument—a side view and a rear
view.
FIG. 169.

I was not surprised to find my patient return to me in a
few days with gratitude and praise unbounded. I had before
made obturators of gold, and upon the same principle, and
247
had always observed the marked improvement in voice that
a metallic sounding-board gave over one of either hard or
soft rubber. In the present instance the gentleman, after
wearing it a day or two until feeling quite familiar with it,
called to his aid a professor of elocution and went into a
large public hall, and for an hour subjected himself to criti-
cism in reading, in singing, and in declamation. The pro-
fessor pronounced his effort as absolutely without fault, and
the clearness, distinctness, and resonance of his voice remark-
able.
THE AUTHOR'S OPINION OF OBTURATORS.
Hom
The sum of my experience with obturators is this:
1. That of all obturators this is the best form for a con-
genital fissure; but, while the wearer is enabled to articulate
perfectly with such an instrument, it is only after he has
learned articulation with another apparatus.
2. That a soft, elastic artificial velum is much better
adapted to the acquirement of articulation than an unyield-
ing, non-elastic substance; but when acquired an obturator
may be substituted.
3. That in very rare cases articulation may be acquired
with an obturator only; but it is the result of the extra
activity of the pharyngeal muscles, while with the elastic
velum the levators of the palate contribute largely.
CHAPTER X.
TREATMENT OF ACQUIRED LESIONS OF THE PALATE.
ANY unnatural opening from the oral to the nasal cavity
which will permit the free passage of the breath will impair
articulation. Any appliance which will close such passage,
and can be worn without inconvenience, will restore articu-
lation.*
Obturators were formerly made of metallic plate, gold or
silver being most commonly employed, and many ingenious
pieces of mechanism were the result of such efforts; but lat-
terly vulcanized rubber and celluloid have almost entirely
superseded the use of metals. These substances have been
found preferable to metals, being much lighter and more
easily formed and adapted, particularly when of peculiar
shape.
From the preceding history of obturators we see that the
makers have in most instances sustained the apparatus by
passing into or through the opening, and by pressure upon
the surrounding tissues. As early as 1756 Bourdet recog-
nized the impropriety of such a procedure, for he says: "Be-
fore considering the cicatrized perforations of the palate as
being of a nature incapable of diminishing in diameter, prac-
titioners should satisfy themselves thoroughly and beyond a
doubt that such is the case. We do not think that this con-
* The student will bear in mind that no cognizance is here taken of open-
ings similar to those described in cases of congenital fissure, where the surgeon
has united the soft palate, and left an opening through the hard palate to be
covered by an obturator.
EXTENSIVE ABSORPTION, THE RESULT OF PRESSURE. 249
dition of permanency can exist, for positive facts attest the
contrary; and as holes made in the cranium with the trepan
close almost entirely, in like manner those of the palate con-
stantly diminish.”
Numerous examples might be adduced to prove the im-
propriety of sustaining an obturator by any fixtures which
act upon the lateral parts, as they necessarily tend to increase
the dimensions of the opening in the palate. In a case re-
FIG. 170.

cently in the author's practice, the patient closed a small per-
foration of the hard palate with a wad of cotton, the swelling
of which tended to enlarge the opening and necessitated a
still larger plug, until the entire roof of the mouth and teeth
were carried away, leaving but a narrow rim along the alve-
olar border. Such a case is shown in Fig. 170. Cases have
also occurred in the author's practice where palatine open-
ings, resulting from disease, have been carefully bridged
over with a plate without entering the perforation or cavity;
healthy granulations were stimulated, and the opening even-
▸
TREATMENT OF SIMPLE PERFORATIONS,
250
tually closed, thus doing away with the necessity of an obtu-
rator.
It is of the greatest importance that all such instruments
should be executed in the most perfect manner, and made to
fit accurately all the parts with which they are to be in con-
tact, so that they may not produce the slightest irritation or
exert undue pressure upon any of the surrounding parts.
This is even more essential than in fitting an artificial den-
ture in a healthy mouth, as in the latter case the tissues
recover their tone often in spite of the irritation of a badly
fitting denture; but, in palatal lesions resulting from disease,
FIG. 171.
FIG. 172.


the system is generally in such condition that a slight irrita-
tion may be followed by alarming inflammatory symptoms.
In simple perforations of the palate, a plain plate of vul-
canite, celluloid, or metal, covering the gap and fitting close
to the adjacent palatal surface, without any attempt to enter
the opening, and sustained by the natural teeth, is all that is
required. Fig. 171 represents such an obturator, sustained
in its place by impinging upon the natural teeth with which
it came in contact. Accuracy of adaptation and delicacy of
form are all that are essential in such cases, and restoration
of the speech will immediately follow.
Fig. 172 represents a more complicated obturator, adapted
to an opening in the soft palate. The necessity for a varia-
tion in the plan will be found in the constant muscular action
IMPRESSIONS OF PALATAL PERFORATIONS.
251
of the soft palate, which would not permit without irritation
the presence of an immovable fixture. This is contrived,
therefore, with a joint, which will permit the part attached to
the teeth to remain stationary, while the obturator proper is
carried up or down as moved by the muscles. The joint, A,
should occupy the position of the junction of the hard and
soft palates. The joint and principal part of the appliance is
inade of gold, the obturator of vulcanite. The projection B
lies like a flange upon the superior surface of the natural
palate and sustains it; otherwise the mobility of the joint
would allow it to drop out of the opening. This flange is
better seen in the side-view marked C. It is readily placed
in position by entering the obturator first, and carrying the
clasps to the teeth subsequently.
Figs. 171 and 172 will illustrate the essential principles
involved in all simple obturators. The ingenuity of the
dentist will often be taxed in their application, as the cases
requiring such appliances all vary in form and magnitude.
The steps to be taken in the formation of an obturator
are not unlike those used in making a base for artificial teeth.
It is essential that an accurate model be obtained of the
opening, the adjacent palatal surface, and the teeth, if any
remain in the jaw. For this purpose, an impression taken in
plaster is the only kind to be relied upon. Care must be
used that a surplus of plaster is not forced through the open-
ing, thus preventing the withdrawal of the impression by
an accumulated and hardened mass, larger than the opening
through which it passed. To avoid this, beginners or timid
operators had better take an impression in the usual manner
with wax. If this is forced through, it can be easily removed
without injury to the patient. From this wax impression
make a plaster model, and upon this plaster model form an
impression-cup of sheet gutta-percha, using a stick, piece of
wire, strip of metal, or any other convenient thing for a han-
dle. This extemporized impression-cup must not impinge
upon the borders of the opening, neither should it enter to
·
252 FREEDOM OF THE NASAL PASSAGES ESSENTIAL.
any extent. With a uniform film of soft plaster, of from
one sixteenth to one eighth of an inch in thickness, laid over
this cup, a correct impression can be taken without any sur-
plus to give anxiety. If the desired obturator is to be only
a cover of the opening, the impression can be readily taken
in plaster by placing a small bit of damp paper over the
opening, which will adapt itself to the border of the cavity
and prevent the plaster from entering it.
Upon a correct plaster model, taken from such an impres-
sion, the obturator should be molded out of gutta-percha or
other plastic substance; the subsequent steps being in prin-
ciple the same as making any other piece of vulcanite. If it
is desirable that it should enter the perforation to restore the
lost portion of the palate, it must not protrude into or in any
way obstruct the nasal passage. The entire freedom of the
nasal passage is essential to the purity of articulation. That
portion of the obturator which occupies the oral cavity should
be made as delicate as possible, consistent with its strength
and durability.
There are many cases of accidental lesions of the palate,
generally the result of syphilis, where the loss is confined
entirely to the posterior part of the soft palate, and where
an obturator would be inadmissible, or at least objectionable.
In such a case an unyielding appliance is undesirable; the
constant activity of the surrounding parts might not tolerate
it without discomfort. The material used for a substitute
should be soft, flexible, and elastic; and elastic rubber is ad-
mirably adapted to the purpose.
Fig. 173 represents a defective palate belonging to this
class, the uvula and a portion of the contiguous soft palate
being destroyed by disease. It will be seen that a portion of
the soft palate along the median line remains, and conse-
quently there will be considerable muscular movement, which
must be provided for, and which may be taken advantage of.
It is desirable to make this movement available in using an
artificial palate, as thereby more delicate sounds are produced
PALATE FOR AN ACQUIRED LESION.
than otherwise. This case presented some extraordinary
difficulties in the fact that all the teeth of the upper jaw had
been extracted; and it was necessary therefore to adapt a
plate which should not only sustain the teeth for mastication,
but bear the additional responsibility of supporting the arti-
ficial palate.
In the choice of material best adapted as a base for the
teeth in such instances, it is preferable to choose that which
will prove the most durable.
the most durable. There are too many interests
FIG. 173.
253

involved to risk the adoption of anything but the best. In
the case under description the patient desired duplicates, and
two sets of teeth were made, one on gold and the other on
platina, with continuous gums. The plates were made like
other sets of teeth, with the exception of a groove located
on the median line at the posterior edge, to receive the at-
tachment for the palate marked C, in Fig. 174, which shows
the set of teeth with palate attached. The wings, marked A
and B, are made of soft rubber; they should be made about
one line in thickness in the central parts, tapering off and
thinning out to attenuated edges wherever the edge comes in
Ke
MECHANISM AND APPLICATION OF THE PALATE.
25+
contact with soft tissues. But, in an emergency, pieces of
the proper shape might be cut from sheet rubber. The ob-
jection to the latter plan is, that the edges are not so delicate
nor so comfortable as when the flaps are especially made.
The frame to support them is made of gold, with a joint to
provide for the perpendicular motion of the natural palate.
When the artificial palate is in use, the joint and frame im-
mediately contiguous lie close to the roof of the mouth; the
rubber wing A bridges across the opening on the inferior
surface or side next the tongue. The wing B bridges across
the opening on the superior or nasal surface, and is also pro-
longed backward until it nearly touches the muscles of the
B
FIG. 174.

H
www
pharynx when in repose. Both these wings reach beyond
the boundary of the opening, and rest on the surface of the
soft palate for a distance of from one eighth to one fourth
of an inch, thus embracing the entire free edge of the soft
palate. This last provision enables the natural palate to
carry the artificial palate up or down, as articulation may
require.
When the organs of speech are in repose, there is an
opening behind the palate sufficient for respiration through
the nares. When these organs are in action, a slight eleva-
tion of the palate or a contraction of the pharynx will en-
tirely close the nasal passage and direct all the voice through
the mouth. The palate thus becomes a valve to open or
255
close the nares, and will be more useful when made with
thin, delicate edges, which will yield upon pressure. An
instrument thus made will restore, as far as possible by
mechanism, the function of the natural organ. No attempt
need be made to restore the form of the uvula; nothing
would be gained by such an effort, as its function in articu-
lation is doubtful.
SEPARATE PARTS OF THE PALATE.
Fig. 175 represents the artificial palate separated into its
constituent parts. The frame is bent at the joint in the en-
graving to show a stop marked D, which prevents the appli-
ance from dropping out of position. C shows a tongue
FIG. 175.

CPS

11
which enters the groove in the plate of teeth and connects
them. The rubber flaps are secured to the frame by the
stud and hooks seen in the engraving. The process for
making the rubber wings will be found described on page
302.
Fig. 176 shows a more extensive palatine defect of the
same class. In this case the entire soft palate is gone, to-
gether with a small portion of the hard palate at the median
line. Although this defect is greater in extent, the means
for its remedy are more simple. The muscles of the palate
are entirely gone, and consequently no perpendicular move-
ment need be provided for. The appliance in this case will
resemble an elastic obturator more than the valve-like palate
256
of the preceding one. The principle here adopted is sub-
stantially that recommended by Mr. Snell fifty years ago,
and subsequently used by Mr. Sercombe, and consists of a
plate with a set of teeth in the usual form, and attached to
its posterior edge an apron of soft rubber, which will bridge
the opening on its inferior surface extending nearly to the
pharynx. Fig. 177 represents the set of teeth with the pal-
ate attached. In Mr. Sercombe's appliance, described on
page 268, this apron was made of the common sheet rubber
PALATE ON THE SNELL-SERCOMBE PLAN.
FIG. 176.

in the market, prepared for other uses, and is objectionable
for two reasons: 1. A want of purity in the materials of
which it is compounded, in many instances substances being
used in its manufacture which would prove deleterious to the
health of the patient; and, 2. Its uniformity of thickness.
It is preferable, therefore, to make a mold in which to form
a palate of pure and harmless material-one which shall be
of sufficient thickness in the central part and at its anterior
edge to give it stability, and yet shall have a thin and deli-
ATTACHMENT OF THE PALATE TO A DENTURE. 257
cate boundary wherever it comes in contact with movable
tissue.
Such a palate may be made in a mold by substantially
the same process as hereafter described. (See page 301.) It
may be secured to the plate by a variety of simple means.
One which will give as little trouble to the patient as any
other is to make a series of small holes along the edge of the
plate, and stitch it on with silk, or fine platina, gold or sil-
ver wire may be used. It is desirable in such a case to have
OVE
FIG. 177.

the plate and palate present a uniform surface on the lingual
side. In fitting the plate, therefore, it may be raised along
the posterior edge from the sixteenth to the tenth of an
inch, according to the thickness of the palate desired. The
rubber will thus be placed on the palatine surface of the
plate, and present uniformity on the lingual surface.
A little thought will show that in this case the patient.
must educate the muscles of the pharynx alone to do the
work of shutting off the nares, which in the former case
was performed by them in conjunction with the muscles of
the palate. Perfect articulation will depend upon the suc-
258 THE IMMEDIATE EFFECTS UPON ARTICULATION.
cess of the patient in this new use of these muscles. In
cases of acquired lesions of the palate, such as are under con-
sideration, this education of the muscles to a new work will
not be difficult. The patient at some former time has had
the power of distinct articulation; his ear has recognized in
his own voice the contrast between his present and his for-
mer condition; the ear will therefore direct and criticise the
practice until the result is attained. It is astonishing to
what an extent muscles may be trained in this way to the
successful performance of an unnatural function. In the
case illustrated by Figs. 176 and 177 the defect had existed
for twenty-eight years, the patient at the time of the intro-
duction of the artificial palate being nearly fifty years of age.
The effect upon the speech was instantaneous. Articulation
was immediately almost as distinct as in youth; and this
remarkable distinctness can only be accounted for upon the
assumption that the pharyngeal muscles had undergone a
thorough training in the vain effort to articulate without a
palate.*
These two cases, chosen to illustrate the application of
artificial palates in accidental lesions, required, as will have
been perceived, entire upper sets of artificial teeth in con-
nection with the palates. This selection was purposely made
because the difficulties to be overcome are much greater.
In cases where there are natural teeth remaining in the
upper jaw, the palate and its connection with the plate would
be substantially the same, and the plate could easily be se-
cured to the teeth by clasps in the same manner as a partial
denture.
* An account of this casc appeared in the "Argus," of Bainbridge, Georgia,
August 1, 1868, written by the patient himself, who was the editor of that
paper.
CHAPTER XI.
HISTORY OF ARTIFICIAL VELA.
THE history of artificial vela begins with M. Delabarre.
In the last chapter a distinction was made between obturators
and artificial vela, which must be kept in mind. The definite
history of obturators goes back more than three hundred
years, and that of artificial vela scarcely more than fifty;
due, possibly, to the fact that there was no suitable material
known, prior to the discovery of caoutchouc, of which a
substitute for the natural palate could be made.
M. Delabarre was, in all probability, the first one who
conceived and put into practical use a soft, flexible, elastic
valve, which would fulfill to any degree the functions of a
natural velum. The case was one of syphilitic origin of ex-
tensive character. The entire roof of the mouth and soft
palate had been carried away, together with nearly all the
teeth, necessitating a formidable apparatus, which was a
combination of denture, obturator, and velum. The denture
was made of mineral teeth mounted on a platinum base, and
sustained in situ by a spring connecting with a skeleton
frame resting upon the lower teeth; restoring, to a certain
degree, the form of the lost structures, and not unlike, in its
general contour, to the full upper denture of the present
day. To the posterior edge of this denture he attached a
velum and uvula of "gomme élastique" (India-rubber).
In reading M. Delabarre's account of this apparatus, he
seems to have been more anxious to conserve deglutition
than to restore the articulation of the voice. To this end he
des
DELABARRE'S "MACHINE."
260
devised a valve in the anterior part of his denture, which,
by a system of compound levers, was connected on the supe-
rior surface with the velum and uvula, and operated by pres-
sure of the forward part of the tongue. Fig. 178, copied
from Delabarre's treatise, illustrates the instrument. A shows
the valve in the roof, which rose up on pressure from below
and was returned by a light spring. B B indicate two levers
hung in the middle upon axes; the anterior end of the first
→ → L W T V W N
! ! ] | | | | | | ÿ ÿ ÿ ÿ ÿ
FIG. 178.

attached to the valve, and the posterior end of the second
attached to the velum and uvula, so arranged that the mo-
tion of lifting the valve would be communicated to the velum
and elevate that also. This "machine," as Delabarre calls it
(the term being singularly appropriate when transferred to
English), could only be operated by the tongue in a certain
position, and therefore the machinery could not have been of
any advantage in articulation, although Delabarre claims that
the whole apparatus was of great benefit to the patient in
THE FIRST ARTIFICIAL PALATE (1820).
261
mastication, in deglutition, and "for the articulation of
words." In the light of modern science we can not regard
the machinery as of any advantage; the velum would, in all
probability, have contributed an equal benefit without it.
Such a complicated apparatus would be likely to become
easily disarranged, and not of a very permanent character;
therefore it is not surprising that we find no record of any
attempt to make an application of it to other cases.
The object of this detailed description is chiefly to give
a clear understanding of the first attempt to make an artifi-
cial velum. Granting that this experiment of Delabarre's
was a complete success, its importance must not be overrated.
The case was one of accidental lesion; and later experience
has shown that a very simple and often a very crude appli-
ance will restore articulation to one who formerly possessed
that function. Nevertheless, to him must be accorded the
credit of the first conception and practical application of the
only material which could be adapted to a velum; and, al-
though the caoutchouc of that day was a very perishable
material, compared with the same substance as improved by
vulcanization, his experiment laid the foundation of success-
ful artificial vela, and, in all probability, encouraged Mr.
Snell, of London, in his experiments made shortly after, and
for which he claims complete success.
Mr. Snell makes the date of his construction of an artifi-
cial velum about 1823, and this is the first record I have been
able to find of any effort to remedy the evils of congenital
fissure of the palate by mechanism. All appliances made
prior to that time were for accidental lesions, and congenital
cases were considered as hopeless except by surgery, and
even at that date the era of staphyloraphy was just dawn-
ing.
His first case was that of a young lady with fissure of
both hard and soft palate along the median line, which does
not appear in the record to have been complicated with hare-
lip. He "obtained a correct model of the defective parts,
18
262
SNELL'S PALATE (1823).
from which a gold plate was formed to fit the roof of the
mouth, reaching as far back as could be worn by the pa-
tient, to the posterior part of which two pieces or flaps of
India-rubber were attached, thus filling up the deficiency of
the soft palate. A small movable piece of the same mate-
rial was also attached, by means of a gold hinge, to the
center of the lower piece, to imitate as near as possible the
natural uvula. A piece of ivory was next fitted to the
upper or back part of the gold plate, and carried upward
until it came in contact with the remaining part of the
septum narium; this was, of course, firmly attached. The
whole was held in its situation by means of two gold springs
soldered to the plate, which were fixed round one of the
molars on each side." Mr. Snell shows, in his treatise, that
the principal object which he desired to attain was an im-
proved articulation of the voice, and for the above instru-
ment he claims most satisfactory results.
In an improved appliance which he made subsequently,
"the piece of prepared elastic gum is attached to the poste-
rior part of the plate, where the natural soft palate com-
mences, extending downward on each side as low as the re-
maining part of the uvula, and grooved at its lateral edges to
receive the fissured portions of the velum. A movable velum
is placed in the posterior center of the elastic gum. That
these may partake of the natural movements of the parts
during deglutition, a spring is affixed behind them, one end
of which is fastened to the posterior and anterior surfaces of
the principal plate, and the other end rests gently against the
posterior face of the India-rubber; this keeps it always in
close apposition with the edges of the fissure during degluti-
tion." It is much to be regretted that there is no engraving
of this instrument; but, from a careful reading of this last
quotation, I am inclined to the opinion that it describes a
velum of triple form, which was not unlike in principle the
one introduced by Dr. Stearn, in America, twenty years later.
(See Fig. 179.)
STEARN'S ARTIFICIAL PALATE (1841).
263
Dr. Stearn's experiments mark a distinct epoch in the
history of artificial vela-not so much from a better under-
standing of the requirements in such cases, nor from a supe-
riority of skill in the adaptation of an apparatus, as from
the accidental good fortune of having brought to his notice
the best substance which has yet been discovered for this
purpose. It was in 1841 or 1842 that Dr. Stearn, a young
graduate in medicine, and a native of Springfield, Massachu-
setts, where he was then residing, became acquainted with
Mr. Goodyear, who was then conducting his experiments in
combining sulphur with rubber to improve it. Dr. Stearn
was afflicted with a congenital cleft palate, the fissure being
confined almost exclusively to the soft palate. He had been
twice or thrice operated upon surgically, but in each instance
staphyloraphy proved a failure, and his only hope of benefit
lay in mechanism. Being naturally of an ingenious mind,
and acquainted with the improvements in rubber, he gave
his attention to the construction of an artificial velum for
himself. When it is considered that he was without any
practical knowledge of mechanical dentistry, and did not,
and could not, make such a model of the parts as is now
considered essential, and that all his efforts were tentative
upon himself, the results were marvelous. He then demon-
strated that a very formidable apparatus could be introduced
within the pharynx, and worn with comfort, and with it
articulate speech could be perfectly acquired. More than
fifteen years after this I came to know Dr. Stearn, and his
voice, articulation, and enunciation were so clear and dis-
tinct that but few would have suspected the deformity with-
out an anatomical examination.
Like most other pioneers in great inventions, Dr. Stearn
arrived at the result by the most complicated means. His
instrument was a marvel of ingenuity, and the process by
which it was made, in the light of modern simplicity, was
an undertaking of some magnitude. Instead of the more
scientific plan, as now used, of obtaining an accurate cast of
STEARN'S WOODEN MOLD.
264
all the parts involved, and to such a cast adapting an instru-
ment, and afterward making a metallic mold in which to
produce the rubber duplicates, he began his work by carving
a mold out of wood, in which to vulcanize the velum. To
obtain some idea of the form to be given to the mold so that
the resultant casting should fit the fissure, he took small im-
pressions of various parts with soft wax attached to the end
of a bent stick, and copied the forms thus ascertained in his
wooden mold. Encouraged by the approval of distinguished
HOB
FIG. 179.

Po
a
V
L
V
surgeons in this country, he visited London and Paris in
1845, and contributed a valuable article upon the subject to
the London "Lancet." His instrument and his ingenuity
were much admired, but it is evident that its complexity car-
ried the idea pretty generally that it was not of universal
application, as we find that the little interest it awakened
soon died out, any efforts made by dentists to adopt it were
abandoned, and in a few years it was unknown to the mass
of the profession, and only remembered as a brilliant excep-
tional effort.
Figs. 179 and 180 are representations of the two sides
F
DESCRIPTION OF STEARN'S PALATE.
265
of the Stearn instrument, the former showing the oral side,
and the latter the nasal or pharyngeal surface of the same
instrument. In Fig. 179, m m show a portion of gold
plate, which continued on the side of the ragged edge until
it was clasped to teeth on each side of the mouth. The
remnant of the natural palate filled the groove marked g g.
The broad lower edge, as seen in the engraving, hung in the
pharynx, and provision was made for the approximation of the
mmu
FIG. 180.

J
FP
W
q
sides of the fissure and for other contractile muscular action
by slitting the body of the instrument up the middle, and,
to prevent sound escaping through the slit, the valve or flap
marked v l v covered it. The action of the artificial velum, -
when subject to muscular movement, would be, that the sides
marked g g would lap over and slide upon each other in the
act of deglutition so easily and readily as not to irritate the
surrounding structures. Owing to the instability of the rub-
ber, and particularly after it had been worn a short time, it
266 DISTINCTIVE CHARACTERISTICS OF STEARN'S PALATE.
became necessary to give extra support to the valve, so that
it should be retained firmly against the body of the instru-
ment; and a gold spring was arranged, as shown upon the
other side of the appliance in Fig. 180 at the letter f. The
curved bands, marked ƒƒƒ and s s, were of rubber homoge-
neous with the piece, and introduced to give stability and fill
out the velum when contractile muscular power was relaxed.
The aforementioned valve was not intended in any sense to
represent the uvula, which its appearance and locality may
suggest, but was a necessary result of the division of the in-
strument along the center.
It was with much satisfaction that Dr. Stearn viewed this
trifold character of his instrument, regarding this method of
providing for the contraction of the surrounding muscles as
a triumph of skill. To quote his own language in 1860: "I
wish to be understood as saying, in exact terms, that I con-
sider the slit and opening through the center, and its closure
by a sort of valve on the anterior surface, as an essential
feature of all artificial vela; and also that I do not acknowl-
edge the remotest obligation to any other person for this one
idea, which did not present itself to my mind until I had
occupied myself with my first case (in 1841 and 1842) for
more than a year. . . . Eighteen years have since elapsed,
and I have not yet conceived any other possible way of con-
structing an instrument at once simple, delicate, and durable,
but in this triple form; and, though I trust and believe that
others will hereafter improve upon my methods, I am con-
fident that this one feature will be preserved in all successful
'obturators.'
999
An important principle, enunciated by Dr. Stearn as es-
sential to the success of all artificial vela for congenital cleft,
was, that the instrument filling the fissure in the natural
palate must be of the nature of a valve, under the control of
the muscles surrounding it, and so arranged that it could be
elevated by them, and thus the nasal passage shut off, as is
absolutely essential in the production of certain sounds be-
MR. EDWIN SERCOMBE'S PALATE.
267
longing to articulate language. This principle was carried
out by him, first, in the character of the material chosen,
being of a yielding, elastic nature; and, second, in the form,
being made to embrace the levator muscles and subject to
their control.
It is remarkable what little effect was produced upon
either the surgical or mechanical treatment of cleft palate by
Dr. Stearn's invention, or by his contribution to the literature
0
FIG. 181.

in the London "Lancet." In such notice of his invention as
was given him in the earlier editions of Harris's "Dental
Surgery," he was called "Mr. Stearn, a surgeon of London”;
and the student looked in vain for such a description of the
apparatus as would enable him to construct one. So entirely
was he lost sight of, that in May, 1857, we find Mr. Edwin
Sercombe, in a paper read before the Odontological Society
of Great Britain, saying: "I knew nothing at the time, nor
indeed until I commenced writing this paper, of Mr. Stearn's
invention. . . . The principle laid down by Mr. Stearn as
268
METHOD OF MAKING SERCOMBE'S PALATE.
necessary for the construction of a useful velum, I recognized
and acted upon, without, as I have already said, knowing of
the existence of his paper; had I known of it, it is more than
likely that I should have contented myself with endeavoring
to imitate his very ingenious contrivance, but, ignorant of his
plan, I was free to work out my own design. My velum is
made of two pieces of vulcanized India-rubber, the larger
piece extremely thin, the smaller much thicker. The shape
of both is represented in Figs. 181 and 182. The dotted line
on both shows where they are attached by sewing to the pos-
terior margin of the gold plate, which has a single line of
FIG. 182.

holes punched in it for this purpose. The exact size of the
larger piece will vary in each case, for it is necessary that its
free convex margin should not touch the back of the pharynx
when the sides of the fissure approximate in the act of deglu-
tition, as, however soft the material of which it is formed
may be, a raw and painful spot will quickly be the result;
but at the same time it must be close to the back of the
pharynx, or otherwise the articulation will be more or less
indistinct, as the sound will not be retained in the cavity of
the mouth long enough to undergo the coining-like process
of articulation, but will escape into the cavity of the nose,
OBJECTIONS TO THE SERCOMBE PALATE.
269
and produce more or less of the characteristic nasal sound of
this lesion. This piece should also be extremely thin, as it is
absolutely necessary that it should adapt itself with great
readiness and completeness to the ever-varying sides of the
fissure; but a piece of such tenuity as is necessary to secure
this vital point, weighted with mucus, would quickly droop,
but for the support which is given to it by the smaller and
stouter piece which lies immediately underneath it. These
two pieces of sheet rubber sewed to the posterior margin of
the gold plate-the thinner to its upper surface, and the
thicker to its lower-have been found in more than one in-
stance to restore to the person using them a distinct articula-
tion."
An examination of these illustrations shows that even
Mr. Sercombe failed to comprehend the principles enunciated
by Mr. Stearn as essential to success. Two principles were
vital to Dr. Stearn's instrument, viz.: first, that the artificial
velum should embrace the levator muscles of the palate so
that it could be lifted by them; and, second, that it should
bridge the upper pharynx behind the uvula and cut off
nasal communication at will. Neither of these qualifications
is seen in Mr. Sercombe's velum, and it is quite safe to say,
as the results of later experience, that perfect articulation
with such an appliance as shown in Fig. 182 for a congenital
fissure of the palate would be impossible.
Ten years after that, viz., in 1867, Mr. George Parkinson,
of London, described his method of making artificial vela (or
rather they might be called movable obturators), which seem
to have been an improvement upon Mr. Sercombe's, but in
no sense an effort to produce anything like the Stearn appa-
ratus:
"In a case of congenital fissure of the palate extending
through the hard tissues and alveolar ridge, after having
taken a correct model of the parts in wax or plaster of Paris,
I commence by fitting a thin plate of gold over the vault of
the palate, as far back as the posterior margin of the palate-
270
bone would have extended had the bony arch been perfect.
To the posterior margin of this plate, by means of a hinge,
is attached a velum, constructed of hard, well-polished, vul-
canized India-rubber, formed in such a manner as to fit the
palatine surface of the remnants of the soft palate and allow
them to glide over it in the act of deglutition. To keep the
velum in its place, one end of a delicate gold spiral spring is
made fast to it, the other end being fixed on the nasal surface
of the gold plate representing the hard palate. This spring
must be so adjusted as just to keep the India-rubber velum
in contact with the soft parts, and allow the portions of uvula
Ca
MR. PARKINSON'S PALATE.
FIG. 183.
Palatine surface.
FIG. 184.


Nasal surface.
on either side to approximate in the act of deglutition. Each
particular case may require some slight modification, but all
that I have treated on this principle have been, I think,
highly satisfactory. The voice is not always immediately
improved, as education of the tongue is necessary in all con-
genital cases. The patients for whom I have constructed
these palates have, without any exception, expressed great
comfort from their use, the only inconvenience ever com-
plained of being a slight nausea on the instrument being first
introduced, which generally passes off after a few minutes.
The materials used are perfectly durable. The only part that
could possibly get out of order is the spring; but this would
271
only be the result of careless manipulation out of the mouth,
and could easily be repaired at a trifling cost."
HISTORY OF THE AUTHOR'S APPLIANCES.
IIISTORY OF THE AUTHOR'S APPLIANCES.-In February,
1860, a young lady about twenty years of age, from Virginia,
was recommended to me by the late Mr. Asahel Jones, of
the then firm of Jones & White, of world-wide reputation
"
310
110
B
•
FIG. 185.

among dentists. She was born with double fissure of the
lip and extensive fissure of both hard and soft palate. The
lip had been operated upon and the gap successfully closed.
The intermaxillary bone had been partially removed, carry-
ing away all the incisor teeth, and leaving a broad gap be-
tween the canines. Fig. 185 is a very accurate representa-
tion of the fissure. In it are seen the disarticulated vomer,
marked A; the turbinated bones, BB; and divided uvula, C C.
-
272
L
SIMPLE OBTURATOR FOR CONGENITAL CLEFT.
In my
desire to benefit her, I re-read all the literature I
could find upon the subject, with but little satisfaction, and
ended in making a plate of vulcanite, of which Fig. 186 is
an illustration. This obturator is exactly like such as are
made even to the present date, and the claim frequently put
forward that they are an improvement upon anything here-
tofore used. It was worn for a few days with entire com-
fort, when my patient informed me that she had accidentally
heard that there was a gentleman in the city engaged in
manufacturing pursuits, who had made a palate for himself
which was a great success. I obtained from her his address
and hunted him up, and the reader may judge of my aston-
FIG. 186.

ishment when I found that he was the veritable "Mr. Stearn,
surgeon, of London," the description of whose apparatus in
Harris I had vainly tried to comprehend.
I recommended the father of my patient to employ him,
and he somewhat hesitatingly consented to make for her an
artificial velum if I would construct the prothesis for the
hard palate. The work was carried on in my office and lab-
oratory, and I early saw that the method of producing the
velum was not as likely to insure mechanical accuracy as a
plan which would naturally be followed by a dentist; and
this stimulated me to endeavor to produce the same result
by my own plan. In due time Dr. Stearn completed his
velum, which, with the hard-rubber obturator and teeth of
THE AUTHOR'S FIRST ARTIFICIAL VELUM (1860). 273
my make, is shown in Fig. 187, drawn from that identical
instrument.
My plan began by obtaining a plaster impression of all
the fissure and all the adjacent surfaces, resulting in the
model shown in Fig. 185. I believe this to have been the
E
E
FIG. 187.
E
H
FIG. 188.
H
H
A
first successful attempt ever made to use plaster of Paris for
so extensive an impression. Upon the model I formed a
pattern of gutta-percha, and copied it in hard rubber or vul-
canite. This vulcanite model or pattern of an artificial velum
was carefully finished, and steps were taken to make a mold
in which to vulcanize duplicates of soft or elastic rubber.
Instead of the wooden mold of Dr. Stearn, I used type-metal,
because of the ease with which it could be cast and the accu-
racy with which the parts could be fitted; and this I believe
to be the first use of type-metal for this purpose. The result
was an artificial velum of much nicer finish than could be
*


274
obtained from wood, but naturally bearing the characteristics
of the Stearn instrument. Mine is shown in Fig. 188. lt
possessed some variations which were of advantage, but they
were of minor importance. The patient alternated in wear-
ing the two, and finally gave the choice to mine; but candor
compels me to say that its only advantage lay in the nicer
adaptation, which was entirely due to the method of proced-
The patient was subsequently seen by a number of
ure.
D..
THE IMPROVED ARTIFICIAL VELUM OF 1863.
A
FIG. 189.
E
F
E
H
-A
.A.
A
D
E
A&
FIG. 1.0.

E

--A
F
distinguished surgeons, and the improvement in her speech
pronounced remarkable; but there remained many imperfect
sounds which practice alone could overcome.
Subsequent experience with other cases showed me that
the form then used, complicated with delicate gold springs,
was objectionable; and my first effort at improvement was
to do away with the gold spring, which kept the central flap
from drooping, and sustain the flap by connections or springs
of the same material. Such a change is shown in Figs. 189
and 190, which are drawings from an artificial velum made
I
275
in 1863. Fig. 189 represents the oral surface, and Fig. 190
the superior or nasal surface. A A A represents the groove
which corresponded to the border of the fissure. EE shows
processes which lapped on to the floor of the nares and as-
sisted in its support. C is the central flap, same as used in
the Stearn palate, and G G are the two bows or springs of
rubber which sustained it. In swallowing, the sides BB
approached each other, sliding under the flap C. This
instrument was made of soft rubber in a type-metal mold,
the mold itself being an intricate affair; but the instru-
ment was simple in its application, and was of as much
benefit in articulation as anything which has been produced
since.
RECOGNITION BY DENTAL SOCIETIES.
At the meeting of the American Dental Convention,
held that year at Saratoga, a gold medal was awarded
me for my success and improvements in such appliances;
and subsequently the Odontographic Society of Pennsyl-
vania awarded me another gold medal for the same rea-
son.
In the autumn of 1864 I visited London, and by invita-
tion read a paper on the subject before the Odontological
Society, December 4th. The criticisms upon the complexity
of my instrument, showing that its production was above
the reach of the ordinary dentist, and the necessary cost of
it precluding its adoption by persons of small means, led me
to serious thought with a view of simplifying it; and, on
December 11, 1864, I conceived and made a model in
paper of the first purely original instrument that I had thus
far produced. This was at once unique and entirely dif-
ferent from anything which had been produced by any one
before. The change consisted chiefly in abandoning the
"triple form" of Stearn, doing away with the central slit,
the flap, and all gold and other springs. These arrangements
in the former appliances, it will be remembered, were to pro-
vide for the movements of the divided uvula and adjacent
remnant of palate. In deglutition, the sides of the fissure
276
are seen to approach each other, and in many cases come
quite in contact. With all the former instruments the dif-
ferent parts lapped and slid on and over each other in deglu-
AN ENTIRELY ORIGINAL ARTIFICIAL VELUM.
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FIG. 191.

WH
FIG. 192.
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tition; but in the new one, Figs. 191 and 192, it will be seen
that the halves of the uvula approach each other between
laminæ of the artificial velum.
For fifteen years I have used this form, and applied it in

hundreds of cases of congenital fissure, and have made no
improvement beyond simplifying the method of production.
I know of no other form, or attempt at making an elastic
277
artificial velum, which fulfills the functions that this one
does; nor do I believe it possible to make a flexible, yielding
instrument, which shall be of so universal application, in any
other form or by any other method.
THE FORM USED TO THE PRESENT TIME.
19
CHAPTER XII.
TREATMENT OF CONGENITAL FISSURE OF THE PALATE.
CONGENITAL fissure of the palate presents far greater dif-
ficulties to be overcome than cases of accidental lesion. The
opening is commonly more extensive, the appliance more
complicated, and the result more problematical. Neverthe-
less, appliances have been made in a large number of cases
which have enabled the wearers to articulate with entire dis-
tinctness, so much so as not in the least to betray the defect.
Most of the earlier efforts in this direction were merely ob-
turators-plugs to close the posterior nares; and the results.
were far from satisfactory.
A reference to the history of obturators and of artificial
vela will show the ingenuity of some of these contrivances.
It was not until it was recognized that the two classes of
cases, accidental and congenital, were entirely distinct that
much progress was made. Nearly every case of acquired
lesion can be treated by an obturator with success; but rarely
will an obturator be of benefit in a congenital fissure, even if
the congenital and accidental lesion present substantially
the same form of opening. The character of the different
classes has been constantly confounded in the discussions
upon the subject, and an instrument admirably adapted to
one class has had claimed for it an equal application to the
other class.
It should be understood, therefore, as a rule to which
there will be few exceptions, that congenital fissure of the
soft palate requires for its successful remedy a soft, elastic,
THE ESSENTIAL REQUISITES OF AN ARTIFICIAL VELUM. 279
and movable appliance; and that, with the most skillfully
made instrument, vocal articulation must be learned like
any other accomplishment.
The various inventions for this purpose are described
under the "History of Artificial Vela." The Stearn instru-
ment, with all its complexity, embodied the true principle,
viz., the rendering available the muscles of the natural pal-
ate to control the movements of the artificial palate. To
Snell is possibly due the credit of having first recognized
FIG. 193.

W
this principle, but his description is so defective as to leave
the matter in doubt.
The essential requisite of an artificial velum is to replace,
as far as possible, the natural form of the defective organs
with such material as shall restore their functions. Muscular
power certainly can not be given to a piece of mechanism,
but the material and form may be such that it will yield to,
and be under the control of, the muscles surrounding it, and
thus measurably bestow upon it the function of the organ
which it represents.
In the discussion of the failure of staphyloraphy on page
SUPERIOR SURFACE OF AN ARTIFICIAL PALATE.
280
211, and in the chapter on "Mechanism of Speech," the
necessity for the separation of the buccal and nasal cavities
in perfect articulate speech is clearly set forth. Therefore,
every artificial palate-whether elastic or non-elastic, of the
character of a velum or an obturator-must be so arranged
that the pharynx can be at times completely closed.
Fig. 193 represents a model of a fissured palate, compli-
cated with hare-lip on the left of the median line. There is
also a division of the maxilla and the alveolar process; the
sides, being covered with mucous membrane, lie in contact
with each other, but they are not united. If desirable for
any reason, a simple surgical operation can be performed,
which will unite both hard and soft tissues at this point of
B
FIG. 194.

A
division. The left lateral incisor and left canine tooth are
missing—whether extracted or undeveloped was unknown.
Fig. 194 represents the artificial velum, as viewed upon its
superior surface, together with the attachment of a plate
containing a clasp and two artificial teeth to fill the vacancy.
The lettered portion of this appliance is made of elastic
vulcanized rubber, to which the velum is connected by a
stout gold pin, firmly imbedded at one end in the hard-rubber
plate. The other end has a head marked C, which being
considerably larger than the pin and than the corresponding
hole in the velum, it is forced through-the elasticity of the
velum permitting—and the two are securely connected. The
process B laps over the superior surface of the maxilla (the
floor of the nares), and effectually prevents all inclination to
}
}
INFERIOR SURFACE OF AN ARTIFICIAL PALATE. 281
droop. The wings A A reach across the pharynx, behind the
remnant of the natural velum and bifurcated uvula. The
wings DD rest upon the opposite or anterior surface of the
soft palate.
Fig. 195 represents a model, the same as Fig. 193, with
the appliance shown in Fig. 194 in situ; the wing D D, in
Fig. 194, and the posterior end of the artificial velum A,
alone being visible in this figure. The reader will bear in
mind that the essential characteristics of this appliance are a
FIG. 195.

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soft, elastic substance filling the gap in the soft palate, with
a flap behind as well as before, which enables it to follow all
movements of the muscles with which it comes in contact,.
and thus perform to a very considerable degree the function
of the fully developed natural organ.
Figs. 191 and 193 represent two cases of remarkably gen--
eral likeness, although they differ twenty years in age and
more than five years in the period of time at which they
were treated. The palate placed in situ in Fig. 191 shows
an instrument which, with variations in size, is of almost
universal application. It is nearly identical with the palate
282 SIMPLICITY AND ORIGINALITY OF THIS APPLIANCE.
shown in Fig. 194, were that one cut across the middle.
Like the other, it is made of soft rubber, and, moreover, it
will need an additional fixture to fill the gap in the hard
palate, and also to keep the artificial velum from being swal-
lowed. In Fig. 194 there is a projection marked B, which
is made of soft rubber, and is intended to assist in support-
ing the velum in position. This is not always necessary or
desirable; there are cases where the velum is quite as well
sustained without this projection, and where, if it were ap-
plied, it would injure the tone of the voice by clogging the
nasal passage.
In the case Fig. 191, if support were desired by lapping
on the floor of the nares, toward the apex of the fissure, it
would form a portion of the hard palate or obturator, instead
of being part of the velum or soft palate, as in the other. It
was to produce this effect by a simple appliance that the
writer labored unremittingly for more than ten years; the
appliance of to-day being no modification in any sense of that
of any other author, but an individual and separate invention,
entirely unlike anything which preceded it, and so simple
that we can conceive of no different way by which perfection
of result can be so nearly attained. Hundreds of instruments
of like character, now being successfully worn, attest the
writer's confidence in it.
Simplicity has gone but one step further, and that has
been to leave off entirely the posterior flap marked A A in
Fig. 194. This has been done in England, France, and Ger-
many, and occasionally in this country, and a parade made
of the fact, as an improvement on the invention of the writer;
but the experience of the past shows that in all these cases
the makers have failed to comprehend the requirements of
the case, and have, in attempting to improve the instrument,
dispensed with one of its essential characteristics.
The latest invention, and one which the author believes to
be of almost universal application, is represented in Fig. 196.
To appreciate the importance of this invention, it must be
283
borne in mind that heretofore an instrument peculiar in form
has been required for every separate case.
Each appliance,
being made in a mold of special adaptation, has therefore
entailed upon the operator a large amount of labor. With
this later invention, it is believed that with a series of molds,
producing a limited variety of palates adapted to the leading
features in such cases, nearly every case of congenital cleft.
can be provided for, upon the same principle as other forms
of surgical appliances made for general use.
THE AUTHOR'S LATEST INVENTION.
FIG. 196.

It was only after years of experience, and the observa-
tion of many cases, that the characteristics which were com-
mon to all could be determined. Those common features
are as follows: a. The fissure through the soft palate is
always in the median line. b. The variations, if any, from
the median line, are anterior to the soft palate in the pala-
tine and maxillary bones. c. Thickness of the border of
the fissure in the remnant of the soft palate is generally
uniform. d. The sides correspond very nearly with each
other in length, breadth, thickness, and contour.
e. The
chief variation in nearly all clefts of the soft palate is in
•
AN UNIVERSAL ARTIFICIAL PALATE.
284
their size or breadth, and this is true without any refer-
ence as to whether the fissure extends forward into the
hard palate or not.
In the author's practice a series of a hundred molds, rep-
resenting as many variations in size, provides for nearly every
emergency; Figs. 197 and 198 illustrate the extremes. Fig.
FIG. 197.
FIG. 198.


197 is the smallest size and Fig. 198 the largest size thus far
ever used.
OBTURATORS AND PALATES COMBINED.-There is another
class of cases, the proper treatment of which has been fol-
lowed by most encouraging results. For fifty years the oper-
ation of staphyloraphy was a favorite one with surgeons, but
the cases in which there was only a partial union were largely
in the majority. In many instances all that had been accom-
plished was simply tying together a small portion of the soft
palate across the back part of the fissure, leaving an opening,
of greater or less size, through the hard palate, anterior to
the newly formed septum. This opening has generally been
plugged with an obturator, but vocal articulation has been
little if at all improved.
OBTURATORS AND PALATES COMBINED.
285
To meet this emergency, a new form of artificial velum
was invented. Fig. 199 will illustrate such a case, with the
obturator and artificial palate in situ. The patient was a
man fifty years of age. The operation of staphyloraphy had
been performed twenty years previously, and an obturator of
silver, and afterward one of vulcanite, had been worn con-
stantly. Nevertheless, the articulation was not benefited,
the reason being the same as in every other case of staphyloric
operation; the new fleshy palate, marked A, not being long
FIG. 199.

30003
EE
A
enough to close by any muscular effort the passage to the
nares. There was, however, some remaining muscular ac-
tion, to utilize which power was the desired object to be at-
tained. Letter B shows the obturator, and letter C the
velum. In this instance the obturator is made of soft rubber,
the same as the velum, and when in use the velum is but an
extension of the natural palate, as seen in Fig. 199, letter A.
Fig. 200 shows the appliance when not in use. The plate D
secures the obturator to the teeth, as in other cases of artifi-
cial palates. In order to introduce the piece, the broad flap
286
C should be first passed through the opening in the roof, and
pushed back, when the whole fixture will readily fall into
correct position. In the case of this patient, the improve-
ment in vocal articulation was immediate and very decided.
UNDOING A STAPHYLORAPHIC OPERATION.
Fig. 201 illustrates another case of a similar character,
but with incidental circumstances much more interesting.
The patient was a lady sixty-two years of age, for whom
staphyloraphy was performed in 1845, and the result was a
remarkable success, so far as the union of the parts was con-
cerned. The union was perfect throughout the entire length
of the fissure, including the uvula; but, although the patient.
FIG. 200.

B
had applied herself diligently to the improvement of her
speech, she was not satisfied with her progress. The fault
being too short a palate, the same as in other cases, the rem-
edy must be the same. But here arose another difficulty.
There was no opening through the roof of the mouth, as in
case of Fig. 199, and there was no method of securing the
desired palate extension to the inferior surface of the natural
palate. To convey to the artificial velum the action of the
levatores palati was essential to success.
After consultation with a skillful and distinguished sur-
geon of this city (Dr. George A. Peters, New York), it was
decided to undo in a measure the operation of twenty-five
years before; and an opening was made through the soft
:
}
FOR A LADY OVER SIXTY YEARS OF AGE.
287
palate on the median line, immediately behind the hard pal-
ate, as shown in Fig. 201. The opening was a single straight
incision, which was subsequently enlarged by wearing a tent
for a short time. There was no pain, and but little bleeding;
and in a few days it was entirely healed. What complicated
the case still further was the loss of all the teeth in the upper
FIG. 201.

jaw, an entire upper denture having been worn for years.
The artificial palate was attached to such a denture, and in-
stead of proving detrimental to the denture, it was an advan-
tage, serving when in place to keep the back edge of the
plate from the possibility of dropping. The marked im-
provement in articulation and the gratification of the patient
were a sufficient justification for the partial undoing of such
an admirable surgical operation.
CHAPTER XIII.
METHOD OF MAKING AN ARTIFICIAL PALATE.
THE success of these appliances depends very much upon
the perfect accuracy of the model, as it is upon this that the
parts are molded. It is essential that the entire border of the
fissure, from the apex to the uvula, be perfectly represented
in the model, as these parts are when in repose. It is also
necessary that the model show definitely the form of the
cavity above and on either side of the opening through the
hard palate, since that part of the cavity is hidden from the
eye. It is desirable, although it is not essential, that the pos-
terior surface of the remnant of the soft palate be shown;
but it is especially important that the anterior or under sur-
face be represented with relaxed muscles and in perfect re-
pose. All the author's experience makes this more and more
imperative.
From an extended intercourse and correspondence with
dentists, I am satisfied that the "taking of an impression of
a cleft palate" is regarded as the most difficult step in the
whole procedure of making artificial palates. While there
is no more important step, there is no necessity for regarding
it as of doubtful accomplishment. It need not be made a
more formidable operation than most of the impressions for
either full or partial sets of teeth; and in many instances I
have found greater difficulty in obtaining a good impression
of the lower jaw where there were straggling teeth than I
have had in ordinary cases of fissured palate.
In cleft-palate cases it is not so much the skill required in
FORM OF A CLEFT PALATE WITH MUSCLES RELAXED. 289
introducing the impression material, as the knowledge of a
correct impression when obtained. It is a common circum-
stance with the inexperienced to obtain an impression of all
the parts in all their intricate detail, and which to their un-
practiced eye is a model of perfection, but which is never-
theless useless. The only impression of a cleft palate which
is serviceable in making such an artificial palate as will be of
benefit to the patient, is one which represents perfectly the
remnant of the velum in its relaxed or hanging position.
FIG. 202.

If the velum and uvula are pushed back by contact with the
impression-cup, or with too stiff plaster or other unyield-
ing material, an unpracticed eye may not be able to detect it
either in the impression or in the resultant model; and an
artificial velum adapted to such a model will fail to confer
the benefit it otherwise should.
There is a common mistake made in accepting an impres-
sion which shows the sides of the fissure distorted by being
drawn up by the levator muscles, and unless such error is de-
tected it will surely lead to failure. If the operator is well
290 HOW TO OBTAIN AN IMPRESSION OF A CLEFT PALATE.
acquainted with the anatomy of the parts and the attach-
ment and action of the levator muscles, there should be no
hesitation in detecting the fault as soon as the impression is
removed. If the operator is at all in doubt, let him study
the parts closely before any effort is made to introduce mate-
rial for the impression. Let him observe accurately the uni-
form line of the anterior surface of the velum, all the way
from the junction with the hard palate to the divided uvula
when the parts are in repose, and then become equally fa-
miliar with the change of form when they are in action.
Fig. 202 shows a fissured palate with the muscles relaxed
and all the parts in repose. In many cases the first view ob-
tained of the fissure will show the sides distorted, and it may
be some minutes before they sink into repose; but more
commonly they will appear in repose, and by touching but
slightly with an instrument the action of the levatores will be
seen catching the edges of the fissure a little more than half
way up to the hard palate, and drawing them aside and up-
ward like elbows akimbo. It is the skill used in not crowd-
ing back the soft parts when the material is introduced, and
the ability to detect any adverse action of the levator mus-
cles, that makes the getting of a correct impression of all
congenital clefts as simple a matter as any important opera-
tion about the mouth.
HOW TO OBTAIN AN IMPRESSION OF A CLEFT PAlate.-
With the requisite anatomical and physiological knowledge
above indicated, the best method of procedure is as follows:
No special impression-cups are needed. The common
britannia tray, of the uniform pattern for a full upper jaw,
is the best thing I have yet used; and this is after repeated
trials and experiments of every conceivable variety, with
forms and cups made especially for the purpose and from a
variety of materials. As the majority of cases will be where
there are natural teeth in the jaw, the description of the pro-
cess will recognize their presence.
M
NO SPECIAL TRAYS REQUIRED.
Select from the various sizes of trays the one best adapted
in size and form to cover all the teeth. Avoid its being un-
necessarily large; to simply cover the teeth and rest steadily
against them, without rocking, and with the handle in the
center of the mouth, is sufficient. Place the tray in position.
against the teeth, and observe the fissured palate and uvula
hanging beyond and below the posterior border of the cup.
Add now an apron or extension to the back edge of the cup,
made of sheet gutta-percha, wax, or any other convenient
material, warming the edge of the cup and sticking it on.
Let this apron come down just to the lower ends of the
uvula, but on no account touch any of the soft tissues. Be-
fore any attempt is made to introduce the plaster, let the
operator be sure that he has seen the tray in the position in
which it will be when the impression is taken, and that the
velum in its relaxed condition does not rest upon nor touch
the apron of the tray. This will measurably guarantee success.
Secondly, let the morale of the performance, as described
on page —, be borne in mind. On no account is the patient
to imbibe the idea that the operation is attended with any
difficulty, or that any particular importance is or need be
attached to the present manipulations. Should the patient
become inquisitive or nervously apprehensive, divert his
mind, as no magnified idea on his part of the importance of
the procedure, nor any interested coöperation, is likely to be
other than detrimental. With plaster of Paris prepared as
described on page, place on the tray a sufficient quantity
to fill the roof of the mouth between the teeth, and extend-
ing down in a thin film, say a sixteenth to an eighth of an
inch in thickness, over the apron. Make no calculation for
an amount coming around outside the teeth, as that provided
for the inner parts will generally be found quite sufficient to
ooze out and cover the teeth. Neither need there be any
provision made, where the fissure extends very far forward,
for carrying plaster away up and getting an impression of
the nares, vomer, and turbinated bones. Neither is it neces-
291
292
REQUIREMENTS OF AN IMPRESSION.
sary to attempt to get an impression of the chamber of the
pharynx or the posterior side of the velum or uvula. Im-
pressions of that character result in beautiful anatomical
models, but when carried to an excessive extent are of no
other practical value; and the attempt to get them often en-
dangers or prevents more important matters. Bear in mind
that, in the present condition of artificial vela, all that is re-
quired of an impression is to show the entire border of the
fissure from base to apex, distinctly defined and in its relaxed
condition, and that in a majority of instances all represen-
tations of details beyond the round border or edge are un-
necessary. With this description adhered to, we have the
process reduced to one of great simplicity, all superfluous
appliances discarded-a common britannia cup, with a gutta-
percha extension and some plaster of Paris, being all the
requisites for this first and most important step.
The introduction of the plaster and its removal being
already described on page, it is unnecessary to repeat.
After removal, the critical eye of the operator will detect if
there are any variations from the desired shape. Sometimes
the bulbs of the uvula will show themselves flattened in the
impression, as they are often so delicate as to be disturbed
in shape by the softest plaster; but this change is not of
much consequence, as they are of little value in any associa-
tion with the artificial velum. If, however, the operator ob-
serves this in the impression, and it is the only variation, and
if for any reason their rotundity is desired, it can be very
readily remedied in the impression by carving out the places
with a round-pointed graver or spoon-shaped scraper. Those
made by Mr. S. S. White, copied from the author's make,
are especially adapted to this purpose.
Descriptions are given to the profession from time to
time of methods for obtaining difficult impressions in cases
similar to those under consideration, where wax or other
plastic material is used for a preliminary impression, to be
changed in form and supplemented by plaster; or again
DETECTION OF ERRORS.
293
where cotton is used to support or sustain the plaster; or
sticks or props of various kinds are employed. All these, in
the experience of the author, are useless; they are but the
leading-strings of infants. With the direct and simple means
above described, experience has shown that a correct im-
pression can be obtained in nearly all cases at the first sitting
and on the first introduction.
If the first attempt ends in failure, a failure will be more
likely to follow a repetition at that sitting than if the pro-
ceeding is postponed. After the first effort the muscles fre-
quently become irritable and quiver, and draw away on the
slightest touch, so that delay until recuperation comes is de-
sirable. It has been recommended by some that a prelimi-
nary treatment be given which should accustom the parts to
being handled. Such a course might be beneficial, but is not
of sufficient importance to delay for any length of time the
treatment of the case to accomplish that object alone. That
they can be made almost insensible to manipulation by treat-
ment and handling is shown in all cases where patients have
worn artificial vela for any length of time and a new impres-
sion is taken; the muscles will then be found so stupidly
quiet as to suggest that they have lost their vitality.
After the impression is taken with all the skill possible,
it is essential that the resultant cast should be submitted to
tests which shall provè its accuracy or its defects. So far as
the artificial palate is concerned, it is essential that the plaster
cast of the cleft shall indicate the precise form of the fissure
from the apex to the termination of the uvula; the sur-
rounding parts being in their relaxed or hanging condition,
without being drawn into angles or wrinkled by the action
of the levatores. The best test is to adapt a trial-piece made
of sheet gutta-percha to the plaster cast, which will cover
the roof of the mouth precisely as would a plate for artificial
teeth. Let this trial-plate be prolonged at the posterior edge
in the form of a tongue, exactly filling the fissure from side
to side, bent to the same curve, and extending to the ter-
20
#
294
CORRECTION OF ERRORS.
mination of the uvula. Being thus adapted to the plaster
cast and then inserted in the mouth, the discrepancies will
readily appear, and the probability is that such a test will
always reveal some variations. The plaster cast must then
be made to conform to the shape of the fissure by additions,
removals, or alterations of incorrect portions. Additions of
plaster can be most easily made with a small camel's-hair
pencil, using the plaster as a thin paint. For this purpose
the most convenient plan is to put a little water in a saucer,
and drop a thimbleful of plaster in the water at one side
use it with the brush, without stirring or mixing. In this
way skilled fingers may build up very considerable altera-
tions in form, and the gutta-percha test will show their cor-
;
rectness.
It is not essential to one of experience that the pharynx
behind the uvula should be taken in the impression. When
the model is obtained from the impression, a representation
of the pharynx can be made, with sufficient accuracy for
practical purposes, by carving. It is only when the floor of
the nares is used for the support of the palate that it bc-
comes necessary to obtain a more complicated impression
one which will represent not only a portion of the buccal
cavity, but all the superjacent nasal cavity. When this is
required, the operation may be divided by first taking such
an impression of the roof of the mouth and fissure as has
been described, which we may call the palatal impression,
and subsequently introducing the same impression again to
get a further impression of the upper or nasal surface of the
hard palate. This can be done by filling the cavity above
the roof of the mouth with soft plaster down to the border
of the fissure, and, while yet very soft, immediately carrying
the palatal impression already taken against it, and retaining
it in that position until the plaster is hard, which can be
easily ascertained by the remains in the vessel from which it
was taken. Taking the precaution to paint the surface of
the palatal impression with a solution of soap, to prevent
IMPRESSION OF THE NASAL CAVITY.
the two masses from adhering when brought in contact,
there will be no difficulty in removing it from the mouth,
leaving the mass which forms the nasal portion in situ.
With a suitable pair of tweezers this mass is easily carried
backward and withdrawn from the mouth, the irregular sur-
face of contact indicating its relation to its fellows when
brought together.
Fig. 203 shows such an impression. The portion marked
A B C will be recognized as that which entered the nasal
cavity. The line of separation from the palatal impression
is indicated in the engraving. The groove marked D shows
the impression made by the delicate uvula in the soft plaster.
A
\\ \\
FIG. 203.
Kit
A
8
AMWY
295

B
ETTIDE
The nasal portion is relatively large, showing an unusually
large nasal cavity. The vomer lies between the projections
marked A A, these projections entering the nasal passages.
The surfaces marked B B came in contact with the middle
turbinated bones; the surface marked C in contact with the
inferior turbinated bones. In many instances these turbi-
nated bones are so large as to nearly fill the nasal passages.
After the model has been tested and corrected as before
described, the gutta-percha trial-piece may be put to still
further use by extending until it nearly or quite touches the
posterior wall of the pharynx. This test is to determine the
length at which the palate can be borne, and therefore the
departure from the line of the fissure across the pharynx
A PATTERN OF THE ARTIFICIAL PALATE.
296
must be at the same point, on the same line, and at the same
angle that the artificial palate is to be worn. When the nasal
portion of the impression does not indicate the superior pos-
terior surface of the soft palate, the part may be represented
in the model by carving.
It is not essential to the success of the artificial palate
that the posterior surface of the soft palate should be repre-
sented with the same accuracy that is required on the infe-
rior surface or on both surfaces of the hard palate. By the
aid of a small mirror and a blunt probe, the thickness of the
velum and the depth behind the fissure can be ascertained.
Approximate accuracy is sufficient, since the portion of the
artificial palate coming in contact with it is so elastic that it
easily adapts itself to a slight inequality, rendering absolute
accuracy less important.
The next step will be the formation of a model or pattern
of the palate. Sheet gutta-percha is preferable for this pur-
pose, although wax or some other plastic substance might
answer. The form which should be given is better indicated
by the drawing, Figs. 191 and 192, than it could be by writ-
ten descriptions.
The Stearn instrument was made to embrace the edges
of the fissure, and was slit up through the middle, so that
when the sides of the fissure approached each other, as they
always do in swallowing, the two halves of the instrument
would slide by each other; a third flap or tongue was made,
and supported by a gold spring, to cover and keep closed
this central slit. (See Figs. 179 and 180.) This complicated
provision for the contraction of the fissure is entirely super-
seded in Figs. 191 and 192, by making the instrument some-
what in the form of two leaves, one to lie on the inferior
and the other on the superior surface of the palate, and
joined together along the median line. When the fissure
contracts, the halves of the divided uvula slide toward each
other between these two leaves.
The posterior portion, marked A in Fig. 191, is made very
SHAPE OF THE PHARYNGEAL PORTION.
297
thin and delicate on all its edges, as it occupies the chamber
of the pharynx, and is subject to constant muscular move-
ment. The sides are rolled slightly upward, while the pos-
terior end is curved downward. The inferior portion, marked
D D, should reach only to the base of the uvula, and bridge
directly across the chasm at that point; and no effort to
imitate the uvula should be made. The extreme posterior
end should not reach the posterior wall of the pharynx by a
quarter of an inch when all the muscles are relaxed (although
subsequent use must determine whether to increase or dimin-
ish this space), thus leaving abundant room for respiration
and for the passage of nasal sounds.
In cases where it is desirable to make the instrument as
far as possible independent of the teeth for its support, the
anterior part which occupies the apex of the fissure in the
hard palate may lap over upon the floor of one or both nares.
Such a projection is seen in Fig. 194, marked B, and like
processes are seen in Figs. 189 and 190, marked E E. Were
it not for this process in the first case, the palate would drop
from the fissure into the mouth, the single clasp at the ex-
treme anterior edge not being sufficient to keep the whole
appliance in place throughout its entire length. Caution
must be exercised that this projection entering the nares be
not too large, or it will obstruct the passage, and give a dis-
agreeable nasal tone to the voice.
The end of the artificial palate should not come against
the pharynx at a right angle, but rather obliquely. Conse-
quently, if the palate is placed at a higher level, a shorter
instrument will reach across; while, if it be placed at a lower
level, a much longer instrument will be required. Both ex-
tremes are objectionable. The longer palate is liable to in-
terfere with deglutition and to split and misdirect the column
of sound in its outward passage, while the shorter one will
affect the quality of the voice as well as make articulation
more difficult. The best form is that which follows the
border of the fissure from its apex down to the junction of
•
298 REASONS FOR THE PECULIAR POSTERIOR FORM.
the uvula, with the palate, and then diverges across the
pharyngeal passage, as seen in Figs. 191 and 195. There is
no difficulty in discovering the line of departure from the
fissure; the uvula, which is bifurcated or rather appears
double, one on each side, is always strongly pronounced in
its bulbous form, and its junction with the palate is always
distinctly marked.
When the fissure is filled or bridged across down to this
point, the instrument here forms the superior boundary of
the fauces, which theretofore was without boundary because
of the fissure. Theoretically it would seem that the artificial
palate should stop at this point, and not continue at a differ-
ent angle across the pharynx; but experience has shown the
necessity for elongating it. The reason for this elongation
is, that distinct articulation of the voice at times requires the
passage of sound to be entirely cut off from the nasal cavity,
while at other times the sound must escape in that direction.
This cutting off of the nasal passage for sound is accomplished
by the simultaneous action of two sets of muscles: 1. The
levator muscles lift and in a sense carry back the artificial
palate. 2. The constrictors of the pharynx bring forward
or contract the pharyngeal wall. This is the physiological
action of the palatal and pharyngeal muscles in the articula-
tion of the voice. With an artificial palate filling a congeni-
tal cleft and terminating at the uvula, it will be found that
when it is raised to the utmost power of the levatores, and
the pharynx is contracted or brought forward to its utmost,
there is still a gap behind the instrument for the escape of
sound, and for this reason the extension must be made. As
an approximate guide for this length it may be stated that if
the artificial palate is of the form described and placed in its
best position, the palatal and pharyngeal muscles being all
relaxed, there should be a space of about a quarter of an inch
between its posterior edge and the wall of the pharynx. But
the final test of this must be when the completed palate is
introduced.
299
All the peculiarities described must be provided for in
the gutta-percha model, which, after having been carefully
formed upon the cast, may be tried in the mouth to ascertain
its length or necessary variations. When its ultimate form
has been determined, provision must be made to duplicate it
in soft rubber. A familiar illustration of the process here to
be adopted is found in the parallel process employed when a
set of teeth is made on a vulcanite base. A model form is
made of wax or gutta-percha, bearing the teeth, and in all its
prominent characteristics has the shape desired in the com-
OBJECTIONS TO PLASTER FOR PALATE MOLDS.
A
FIG. 204


cam nd-"toke
D
San
BANIA A
B
pleted denture, the rubber duplicate being vulcanized in a
plaster mold. In like manner the rubber duplicate of the
palate, as before described, may be made in a plaster
mold.
If plaster is used for the molds, it must be worked so that
the surface shall be free from air-bubbles, or the rubber pal-
ate will be covered with excrescences that can not readily be
removed. But ordinarily plaster molds will be found too
troublesome for general use. They may be put to most ex-
cellent use, however, by using one to make a duplicate of the
gutta-percha in hard rubber. This is not necessary with
SECTIONAL PALATE MOLD.
300
those who have had much experience, but with beginners it
will be difficult to work up the gutta-percha as nicely as may
be desired. A duplicate in vulcanite will enable the opera-
tor to make a more artistic model of the palate, and one
which can be handled with greater freedom.
As in the course of a lifetime a considerable number of
elastic vela will be required, the mold which produces them
should be made of some durable material. The type-metal
of commerce is admirably adapted to this use. A very com-
plete mold is one made of four parts, such as illustrated by
Fig. 204, which will produce a palate in one continuous piece.
C
FIG. 205.

?
The blocks C C are accurately adapted to the body of the
mold marked A, and are prevented from coming into in-
accurate contact with each other by the flanges D D, which
overlap and rest upon the sides of the main piece. B shows
the top of the mold, and the groove E provides for the sur-
plus rubber in packing. Such a mold makes as perfect an
appliance as can be produced. The palate is one homoge-
neous and inseparable piece. The cut sufficiently indicates
the form of the several parts. Each of these pieces is first
made in plaster, having exactly the form desired in the type-
metal. They are then molded in sand, and the type-metal
cast, as in making an ordinary die for swaging. When in
301
use a clamp similar to Fig. 205 is placed around the mold to
keep the several parts firm in their position.
Such a mold requires nice mechanical skill in fitting all the
parts accurately, and, unless the operator has had experience
in such a direction, it is better to simplify the matter. By
making the palate in two pieces, to be joined after vulcan-
izing, as shown in Fig. 206, the mold may be made in two
pieces and with much less trouble. Fig. 207 shows such a
mold, made also of type-metal, but inclosed in a flask for
greater convenience. The flasks are made of brass expressly
for this purpose; but they are not so unlike the flasks in
common use in dentists' laboratories that the latter will not
PALATE MADE IN SECTIONS.
FIG. 206.

answer. The common flask is simply unnecessarily thick or
deep.
This mold is produced in the following manner: The
palate pattern or model having been made in hard vulcanite
and separated into two parts, as seen in Fig. 206, the pieces
are placed side by side in a bed of soft plaster in one half of
the flask. When the plaster is set, remove the patterns and
trim and varnish the surface. This form may be copied in
type-metal by molding in sand and casting. To make the
sand-mold, take a ring of sheet-iron of the same diameter as
the flask and three or four inches high; slip it over the flask
and pack full of sand. Separate them, remove the plaster
from the flask, return the empty flask to the sand-mold, and
fill with melted metal through a hole made in the side or
PALATE MOLD AND FLASK.
302
bottom of the flask, the side being preferable. This half of
the metal mold should be finished all it may need, when the
other may be made by placing the palate patterns on the
metal mold, filling the other half of the flask, and carrying
out substantially the preceding steps.
FIG. 207.

MENDAMO DIENA

'
The palate produced by either of these molds is shown in
Fig. 208. In connection with it is also shown the plate with
clasps which secure it in position by attachment to contigu-
ous teeth. The connection with the plate is by a pin of gold
passing through a hole of the same size in the palate, the
t
303
head on the pin being larger than the hole through which it
is forced. The two pieces of palate made in mold Fig. 207
accomplish the same result when in use, as they are held
together at the forward part by the pin and head, and a few
stitches of silk secure them at the posterior part.
Another plan for a mold, and the one which the author
has adopted for his large series of molds, is made in three
pieces of metal, as shown in Fig. 209. It is the most simple
and at the same time the most complete of any mold yet
invented. It is inclosed in a flask like Fig. 207, but with
the improvement that the resultant palate is complete in
one piece, the same as that produced by the more compli-
cated mold, Fig. 204. A represents the base of the mold
LATEST FORM OF PALATE MOLD.
FIG. 208.

made in one half of the flask; B, the section which occupies
the other half of the flask, and is placed on top of A in
the same relation they hold in the cut, i. e., the under side
of the section marked B fits to the surface marked A, and
between these is the space for a portion of the palate. B,
which we may call the middle section, represents one half of
the palate on one of its sides, and the other half on the other
side, the connection between the two divisions of the palate
being through the opening in the center. The third section
of the mold, C, turns over and fits on top of the middle sec-
tion, and when inclosed in the flask makes the mold com-
plete. When the flask is opened after the rubber is vulcan-
ized, the palate will remain with the middle section, and can
be removed by pulling the smaller part through the central
opening.
304
PACKING THE MOLD WITH RUBBER.
The process of making a palate in any of these molds is
by packing with rubber in substantially the same manner
as when hard rubber is used for a dental base, with which
process it is assumed the reader is familiar. By painting the
surface of the mold with a thick solution of soap, or, better
still, rubbing the mold over with hard soap previous to pack-
ing, the palate will be more easily removed after vulcanizing.
111110
d
A
FIG. 209.

B
The rubber used for this purpose must be a more elastic
compound than that used for a dental base-plate. Partially
vulcanized hard rubber, which is sometimes used, is very
objectionable. Not being completely cured by the vulcan-
izing process, it soon deteriorates in the mouth, becomes dis-
integrated, and all the objectionable ingredients of its com-
position made apparent. The compound used for elastic
DIRECTIONS FOR VULCANIZING.
305
fabrics of commerce will answer if made of selected mate-
rials, but for this purpose it ought to be especially prepared.
The permanent value of an artificial velum is much enhanced
by using only material made with reference to such use.
Such a composition requires not only great care in the purity
of its ingredients, but the proportions and the method of
working the mixture will affect materially for better or worse
the articles made from it. Some rubber compounds possess
a durability greatly in excess of others, and consequent in-
creased benefit to a patient wearing such an instrument. To
obtain the best results, the rubber should be vulcanized for
six hours between 230° and 260° of heat, beginning at 230°
and increasing 5° per hour until the end.
CHAPTER XIV.
INTRODUCTION AND USE OF ARTIFICIAL VELA.
PRESUMING that hereafter many dentists will prefer to
adopt one of the forms of palates already made rather than
go
to the trouble, with little or no experience in that direc-
tion, of making molds and producing them, the following
directions for their successful application will be found valu-
able:
After the plaster cast of the fissure and adjacent parts
has been made and proved as before described, select from
the various forms and sizes of artificial palates one best
adapted to the plaster model. It is not necessary that it
should come to the apex of the fissure if the apex be within
the hard palate; neither is it absolutely essential that it
should reach completely to the apex if the fissure comes no
farther forward than the posterior margin of the hard palate.
But, if the fissure is short and does not come up to the pala-
tine bone, it is better that the artificial palate fill the fissure
to the apex. At all events, it must be broad enough to cover
all of the remnant of the soft palate on each side of the fis-
sure and anterior to the uvula. Place the palate in position.
on the plaster model, and proceed to make a temporary plate
or attachment for the purpose of trying the palate in the
mouth. A very easy method is to insert in the hole in the
palate a bit of common iron wire of suitable size to fit into
it, with the end on the oral side bent toward the front teeth.
Pour a little plaster over the gum, as represented in the
model, about this wire, and reaching back to where it is in-
IMPORTANCE OF HANGING THE PALATE CORRECTLY. 307
serted in the palate. When this is sufficiently hardened it
can be removed, and will prove a convenient way of trying
the palate in the mouth and proving its position previous to
a more permanent and less alterable attachment. It may
sometimes be found that, with all the care and skill used to
prove the plaster model correct, when the artificial palate is
tried in, some variation of its position or hanging may be
desirable. If on trial the only change desired be the pitch
-either to raise or depress it at its posterior end—this can
be readily done by bending the pin as it appears out of the
plaster. But if it requires to be drawn farther forward or
carried farther back, it will be more satisfactory to reset it
on the plaster model and make a new plaster trial-piece as
before. This latter process, which may be termed hang-
ing the palate, is of equal importance to any antecedent step,
as it is quite possible to have an instrument made with the
utmost nicety of workmanship, and yet so unskillfully ap-
plied as to be of little or no service to the patient.
The final security of the palate must be of course by
some connection with the teeth, or, in the absence of natural
teeth, with some plate bearing artificial teeth. An excellent
way of arriving at this result after the hanging of the palate
is determined is as follows: Instead of the pin of common
wire which has been used with the plaster trial-piece, make
one of gold wire of the same size, with a head upon it such
as seen in Fig. 194. Put the gold pin through the palate
with the head on the nasal or upper side, and bend the pin
at nearly a right angle where it comes out of the palate on
the oral side, pointing it as before toward the front teeth.
Proceed as before with the plaster trial-piece, and when satis-
factory pull the palate off the pin, replace the plaster trial-
piece in the mouth, and take an impression in plaster of it
and all the parts desired outside of it. When this impres-
sion is removed, the gold pin will be found standing out of it
in the exact position in which it is desired to hang the palate.
Make a cast into this impression, and the result will be that
FIRST EXPERIENCE WITH A PALATE.
308
the pin is transferred to a model which represents in plaster
the face or oral side of the artificial palate and all the adja-
cent gum and teeth. From such a cast as this there will be
no difficulty, to the ordinary master of the details of the lab-
oratory, in making the attachment. Such a plan as here
described will be found more especially applicable to a vul-
canite or celluloid base. If these materials are used, the
steps are quite simple. The cast represents the whole sur-
face with which the plate is to come in contact, with the pin
in position and bent so as to become anchored in the plate.
If the precaution has been taken to flatten the gold wire at
the end, it will make the anchorage more secure. Upon this
cast and over this wire the form of the attachment or plate
will be worked up as is usual in making a plate for artificial
teeth, and the subsequent steps will also be similar.
Experience has shown that in a considerable number of
cases the pharynx will not at first tolerate so large an appli-
ance without irritation as it will subsequently, or so large
as will best secure the desired results. Consequently, it is
better to introduce an instrument with a smaller pharyngeal
portion. This posterior or pharyngeal part of the instru-
ment can be reduced in size by cutting it down with a pair
of scissors; but this leaves the edges thick and more or less
irregular and ragged, and such a course is therefore objec-
tionable. It will be borne in mind that the pharynx is
made up of muscular tissue covered with a delicate mem-
brane, which becomes excited to action upon contact with
foreign substances, and the first effort will naturally be one
of contraction, as in the process of swallowing. These spas-
modic movements in some are slight and of temporary dura-
tion, while in others the vain effort to swallow the offending
mass becomes uncomfortable. If now the pharyngeal por-
tion of the artificial palate be reduced in size by cutting, the
thick and harsh edges may cause irritation. It is better,
therefore, to make the instrument for the first introduction
with the pharyngeal part reduced in size as it comes from
309
the mold, thus having the thin and delicate edges which are
so desirable for comfort; and equally so in the selection of
a palate already made: the choice of the first is better to be
one which fills the fissure fully as it is desired, but one withi
a smaller pharyngeal extension than will be ultimately re-
quired. With an instrument of suitable materials and prop-
erly adjusted, it will be but a few days before it is worn with
ease, and in a very little time its removal will be a positive
discomfort.
DURABILITY OF RUBBER VELA.
The final length of the posterior extremity will depend
much upon the activity of the muscles of the pharynx.
There is a great difference in the power or control of the
pharyngeal muscles, as shown by different individuals. In
some the action of the constrictors is very great, while in
others there is, even in deglutition, apparently but little
movement. Upon the introduction of the completed palate
the action of all the muscles concerned can be observed, and
thus the length at which the palate shall be finally left can
be determined.
In a case where the pharyngeal muscles are in a very
passive state, some calculation can be made upon a cultivated
activity in the future, for upon their action and control will
depend, in a large measure, the improvement in speech.
The Suersen obturator depends entirely upon this pharyn-
geal action for its success, but it is only in exceptional cases
that they can be educated to the duty otherwise required of
both them and the palatal muscles. It will generally be
found that, as the patient makes progress in the articulation
of the voice, a shorter artificial palate can be worn, and one
which comes nearer to the length of what the natural palate
would have been if not deformed.
The durability of an artificial velum depends much upon
the cleanliness and care of the wearer. In some mouths the
fluids act upon the soft, elastic rubber, and it becomes dete-
riorated much sooner than in others. In some instances
patients have worn one for several years, while others will
21
BEST AGE TO INTRODUCE A PALATE.
310
use one up in a few months. Dispensing with it during
sleep and thorough cleansing frequently with hot water do
very much to prolong its usefulness; and this necessity for
cleansing should be impressed upon the patient's mind.
The age at which it is best to introduce an instrument of
this kind becomes a question of importance, and at as early
an age as the patient would take an interest in developing
its benefit would undoubtedly be preferable. The improper
position in which some of the organs of speech are placed, in
the efforts of the patient to articulate distinctly, becomes so
habitual as to be almost impossible to overcome, and conse-
quently the earlier the age at which it is attempted, before
these habits become firmly fixed, the better. The earliest
age at which the author has introduced an artificial palate
was six years, but the results were not so encouraging as to
justify a repetition of the experiment at that age. The
temporary nature of the teeth, to which attachment must be
made, together with the lack of interest in the expected
benefit, are sufficient to overbalance any advantage that
might be gained in the prevention of bad habits of speech.
In most instances it is not desirable that efforts of this kind
should be undertaken before about the period of the erup-
tion of the second permanent molars. The maxillæ at that
time have attained nearly or quite their full size, and are not
likely thereafter to change so much as to require a different
form or size of appliance.
There is no limit to the advance of age at which an arti-
ficial palate may be introduced. The desire of the patient,
after a recognition of the probable difficulties to be overcome,
would be the principal governing motive. In one instance
in the author's practice marked benefit was derived from its
use within a few weeks after its introduction for a lady over
sixty years of age; but it is not advisable to encourage pa-
tients of that advanced age with the hope of very much im-
provement of speech.
The benefit to be derived from the use of an artificial
RESULTS DEPENDING UPON THE PATIENT.
311
palate depends upon the intellectual status, the application,
and the perseverance of the patient. The responsibility of
the result rests solely with the patient after an appliance best
adapted for the purpose has been introduced. Results can
not be guaranteed. All that can be said is, that appliances
can be made which can be worn with freedom from discom-
fort, and that a large number of persons have made such use
of them as to completely hide in their speech any evidence
of the deformity. The improvement is sometimes rapid and
remarkable, in other cases slow and tedious, showing in the
latter a want of application-an insensibility to the defect
and a dullness of capacity. The result must be accomplished
by the same character of application and training as would
be given by an adult to the mastery of a foreign language or
of a musical instrument.
One of the best methods of practice with an artificial
palate is the effort to acquire with it the use of a foreign
language. The mind becomes thus diverted from the habit
into which it has fallen, and it is sometimes casier to learn
to speak a foreign language well than to break up the habit
of speaking one's vernacular badly. There are certain habits
which cleft-palate people involuntarily acquire, which are no
detriment to them in learning to speak French. Such per-
sons are always endeavoring in their speech to compensate
for the escape of their voice through the nares by a contrac-
tion of the nostrils. The compressor nasi comes to be with
them an organ of speech. The resonance thus given by the
nasal cavity destroys the perfection of their English, because
the nasalization of every sound of the English language save
three affects its purity (see chapter on "Mechanism of
Speech"); but, with the French, nasalized sounds form an
important part of the language. It is for this reason that
M. Preterre, of Paris, has met with so much success with
French patients by the use of an appliance with which it
would be impossible for them to acquire English perfectly.
Experience shows that it is far easier to acquire a foreign
1
312
BENEFITS OF AN ARTIFICIAL PALATE.
language in youth than in maturer years, and for that reason
it is better that all cleft-palate cases come under treatment
at the earliest age admissible. With an instrument scientifi-
cally adapted to the peculiarities of each case, and a training
by some one who understands the mechanism of speech, there
is no reason why every youthful person with such a defect
may not overcome it entirely within a few months.
CHAPTER XV.
BUCCAL AND NASAL PROTHESES.
UNDER the above head will be described certain appli-
ances for the replacement of lost portions of the buccal or
nasal structures. All artificial teeth might with propriety be
included under the general term of "buccal protheses"; but,
as their application and uses are so well known, the illustra-
tions which follow will not embrace the ordinary restoration
of dental organs and their associated alveolar processes. The
necessity for such apparatus arises from the accidents and
diseases to which the buccal and nasal organs are subject,
and consequently nearly every prosthetic effort must be in a
measure an original and unique one.
In all apparatus designed for internal use in either buccal
or nasal cavities, there will be but little difficulty in finding
materials which are applicable to the purpose; any of the
substances used as a base for artificial teeth are suitable, and
the choice will depend upon the peculiarities of the case and
the judgment of the operator. The difficulties will lie in
the construction, for which there can be given no definite in-
struction other than a perusal of the following described
cases.
The attempt at the replacement of a nose may be re-
garded as exceptional, for the reason that it is so conspicuous
an organ that the appearance is of more consequence than
the utility. There is no organ of the entire economy the
loss of which creates such a hideous deformity as the nose,
nor is the successful prosthetic restoration of any organ so
ARTIFICIAL NOSES.
314
difficult. Artificial teeth, eyes, legs, hands, arms, etc., are
all made so skillfully as to escape detection, but artificial
The best of them, however artistic or appro-
priate in form, are but a poor imitation of the adjacent liv-
ing tissue.
noses never.
At the present time there is no permanently durable sub-
stance known which has the color and translucency of flesh;
and furthermore, the frequent changes in the complexion
from variations of temperature, excitement, climatic ex-
posure, etc., make the contrast of an artificial nose all the
more evident. Various devices have been resorted to in the
effort to overcome these objections.
In many respects wax, properly colored, forms the best
imitation of flesh, but its objections are manifest, although it
is sometimes used by those who are willing to put up with
the trouble of constant renewals.
Celluloid has the requisite translucency, and possesses an
advantage over wax in being firmer and more durable, but it
is open to the objection that it is very difficult to perfectly
match with it the adjacent complexion, and furthermore, in
the author's experience, the substance changes in appearance
under prolonged exposure to the weather; this can be partly
overcome, however, by touching up the surface with suitably
colored chalk crayons, whereby a very good effect may be
produced.
The least satisfaction has followed the use of vulcanite,
and painting the surface in imitation of the flesh. This I
have done, and, although the nose was colored by an accom-
plished portrait-painter, there was no life in the organ, and
the result was an æsthetic failure.
I think the most satisfactory thing of the kind I ever
did was made of "rose pearl," a substance similar to cellu-
loid, but much more difficult to work and not now easily ob-
tained. This case is described on page 341.
There is no more appropriate place than this to describe
an experiment with
1
AN EAR MADE OF CELLULOID.
315
AN ARTIFICIAL EAR.
I was applied to by a young man who had no external
ear on the left side of his head, save a little rudimentary
portion of the lobe. It was a congenital defect, and the
absence was so conspicuous as to make him very anxious for
an artificial one. I did not encourage the experiment, but
yielded to his urgency.
A cast was taken of that side of the head, and upon it I
modeled out of wax an ear to match in size and shape his
natural one. This wax model was copied in celluloid. The
artificial ear was secured at its lower end by a bit of gold
wire passing down through the rudimentary lobe, and upon
the upper and concealed surface were two spring-clasps, such
as wig-makers use, by which it was caught to the hair. I
succeeded in getting an excellent imitation of the opposite
ear both in color and form, so that, when in position and the
hair thrown carelessly about it, the falsity of the ear was un-
observable. The change, however, which afterward took
place in the color of the celluloid, together with the instabil-
ity of the attachment, would hardly justify a repetition of
the experiment.
PROSTHETIC TREATMENT OF A CASE OF HEREDITARY SYPHI-
LIS.-In 1872 a miss fourteen years of age was brought to
me by her mother, who said that the child had been for two
or three years under treatment for a catarrhal difficulty, and
that she had lost nearly all her upper teeth. There was no
remarkable change in the expression or appearance of the
face, other than that associated with the loss of the upper
teeth. The upper lip was a little sunken, but no other fea- -
ture seemed to be changed. An examination of the oral
cavity showed three teeth only remaining in the upper jaw,
viz., the first and second molars of the right side, and the
second molar of the left side, while all the roof of the
mouth, between and anterior to these teeth, was gone. The
316
EFFECTS OF INHERITED SYPHILIS.
situation at that time is well illustrated in Fig. 210. A A
represents the inner or oral surface of the lip as it was pulled
out and forward in taking an impression. The semicircle B B
marks the dividing line between the oral and nasal cavities.
This semicircular rim was soft, flexible, and elastic, devoid of
bone or cartilage in any part except at its junction with the
alveolar process which surrounded the roots of the remaining
teeth. The soft palate, marked C, had not lost its integrity;
the uvula and the superior pharynx were also undisturbed.
B
FIG. 210.

Neither were the bones of the nasal cavity destroyed. D D
represents the vomer and turbinated bones, covered with
thickened and puffy tissue, completely filling the nasal cav-
ity, and hanging quite level with the original roof of the
mouth, as indicated by the anterior edge of the soft palate C
and the rim B B.
So completely did these enlargements fill the cavity, and
shut off escape by the nostrils, that the voice was not inter-
fered with in distinctness of enunciation more than com-
monly arises from a cold in the head. Not being alto-
:
APPEARANCE OF THE FACE BEFORE TREATMENT. 317
gether pleased with the general appearance of the tissues,
I consulted with her physician, one of the most distin-
guished in America, who was confident that the disease
was entirely eradicated; that there was no doubt of its na-
ture and hereditary character, and furthermore that "it was
not likely that the mother was aware of either its true
nature or its origin, as he had never conversed with her
on the subject."
I made an upper set of teeth for the patient, using
FIG. 211.

vulcanite as a base, and making it as light as possible.
There was nothing peculiar in this proceeding, from taking
an impression, and going on in the usual way for making
a set of teeth in ordinary cases. They were supported by
clasping around the molars, and lay in close contact to the
tissues filling the nasal cavity. The only gain to the pa-
tient was in the restoration of expression to the upper lip,
and a little improved masticatory power. The articulation
of the voice remained the same.
I saw no more of my patient for two years, when the
mother again brought her, desiring, as she said, that I should
318
CONTINUED RAVAGES OF THE DISEASE.
66
'put a little prop on the teeth, to go into her daughter's
nose and keep it up." The two years which had intervened
had made sad havoc with her features. The bridge of the
nose was sunken, and the end had flattened and receded
until it was nearly on a line with the chin and forehead.
This retrocession of the base of the nose had carried back
the upper part of the lip, drawing it in and over the artifi-
cial teeth and plate, so as to produce a most unfortunate ex-
pression. With the teeth out of the mouth, the deformity of
external features was even worse, and is most accurately shown
in Fig. 211. There being no support for the lip, it fell back
in a straight line from one corner of the mouth across to the
other.
An examination of the oral cavity showed how continu-
ous and destructive had been the disease. Another tooth
had fallen out, and the process had wasted away. The
vomer and turbinated bones were entirely gone. The soft
palate was apparently u disturbed, nor was there any marked
change in the buccal cavity proper; but above the opening
through the roof there was an immense cavern, much larger
than the opening, in every direction. This condition is as
well represented in Fig. 212 as is possible by wood engraving,
but it gives no conception of the height of this cavity, nor of
its breadth in any direction. The former soft and flexible
condition of the rim, marked B B, had now changed to a
cartilage, firm to the touch, and unyielding as a cable, and
the remaining teeth were loose in their sockets, but the tis
sues looked as if the disease had spent its force. The voice,
too, had undergone its changes. From the clearing out of
the nasal cavity had come an improvement in tone, when the
artificial teeth were in place; but when they were out of the
mouth, the voice blowing through the great cavity and the
nostrils rendered speech almost impossible.
Prosthetic treatment now required mainly a restoration
of the external features, and the most serious difficulty to
overcome was the aforementioned contracted band of carti-
THE DIFFICULTIES ENCOUNTERED.
319
lage. Any appliance which did not force out and sustain in
an advanced position the upper part of the lip, and the base
of the nose, would be a failure; and the only safe way, con-
sidering the liability to excite destructive inflammation, was
to compel the cartilage to relax under gentle but constant
and aggressive pressure. Pressure upon one part involved a
base to antagonize against, which would bear without yield-
ing, and without danger, an equal amount of pressure. As
there were no solid opposing tissues to abut against, the
FIG. 212.

problem became a very difficult one, and was only solved by
the determination to spread the appliance over just as large a
surface as possible, fit it accurately to every inequality, and
thus, while the pressure in front was concentrated upon the
median line, it would be antagonized by distribution over a
very large surface.
A second serious difficulty to overcome was the concep-
tion of an appliance which could pass the comparatively
small opening in the roof of the mouth, and then by inherent
power expand, enter the cavity of the nasal cartilage, and
DENTAL, PALATAL, AND NASAL PROTHESIS.
constantly press forward and upward. Measured from front
to rear, the nasal cavity which must be operated upon by the
instrument was nearly twice as long as the entrance to it.
Fig. 213 shows the completed instrument. It was a very
thin shell of black vulcanite. The appearance from below is
that of an ordinary set of teeth. It was intended to restore
the normal contour to the roof of the mouth, pass around the
molar teeth, as seen in Fig. 213, cross over, and lap suffi-
ciently on to the soft palate to shut the opening. The letter
C shows the upper surface of the apron which lies on the
320
E
2
LI
B
FIG. 213.

moooa
anterior edge of the soft palate. B B shows the groove
formed for the reception of the rim of cartilage marked with
the same letters in Fig. 212. The instrument reaches up to
the top of the nasal cavity, but is open front and rear for
respiration, which passes unobstructed through the nose,
through the shell, and behind the soft palate, without en-
trance to or from the mouth.
The processes EE pass into the nose and support the
sunken portions. It must be observed that in the position in
which the instrument is here shown it could by no possibility
pass the opening, as the anterior border of the opening is
represented by a line running from B to B. The nasal ele-
THE MECHANISM OF THE APPARATUS.
321
vator must therefore be so arranged as to fall back of the
line B B to be introduced, and then must expand into its
position. This was accomplished by attaching the elevator
to the denture by a joint, as seen in the engraving, and also
by extending an arm of the elevator within the shell, and
terminating it with a hook. As the imagination must be
drawn upon, the dotted line in the engraving shows the form
of that part concealed from view. The means by which I
should keep up a constant pressure, which should both relax
the cartilage rim and restore the nose, and without too com-
plex mechanism, was another serious problem until I caught
a small ring of rubber tubing over the hook within the shell,
and drew it back to the edge of the shell, and there caught
it over a spur of vulcanite made to receive it. This invisible
rubber strap is also indicated by a dotted line. The nasal
elevator, as shown in the engraving, must be forced back
until it falls completely within the shell, before the instru-
ment can be carried to its place. The patient managed this
without any difficulty, by putting the thumb in the roof of
the denture, and holding the elevator back out of the way
with the forefinger, and, when carried up, the processes E E
readily found their places.
The result, after a year's trial, is shown in Fig. 214.
There was naturally no immediate change. There was very
little irritation from the beginning, and no destructive in-
flammation. The bearings E E caused a little soreness, and
they were wound with lint and covered with simple cerate.
The lower process now comes to the very tip of the nose be-
tween the nostrils, and can be seen or touched in either nos-
tril, but this part, being made pink in color, is not noticeable
to the ordinary observer. It is with no little satisfaction that
I have viewed the action of the elastic rubber as the power
to elevate the nose-a power so completely under the control
of the patient, regulated at will, increased or diminished,
involving little care and no expense, that it leaves nothing
to be desired.
322
METHOD OF GETTING THE IMPRESSION.
The steps by which this nasal shell and denture were
produced were not remarkable, save in two particulars:
First, to obtain an accurate impression in all its details of
so large a nasal cavity, and remove it through so contracted
an opening, is out of ordinary experience. The method pur-
sued in getting the impression was not unlike the course a
mason would follow in plastering a room. The surface of
the nasal cavity was covered with a thin film of plaster laid
on with a camel's-hair pencil and other delicate instruments,
FIG. 214.
until a sufficient thickness was obtained to give it stability,
when it was cracked by a light blow from a mallet and a
small chisel, and the pieces were removed separately through
the opening in the roof of the mouth. Second, the shell
and denture were completed in wax and gutta-percha, as thin
and delicate as finally required, before it was placed in the
flask, and necessarily a core of plaster filled all the interior,
which was readily removed after vulcanization.
FACIAL DEFORMITY AND TREATMENT.-In March, 1867,
there came to me a gentleman about thirty years of age,
:
1

I
323
with a deformity of the right side of the face, involving a
depression of the right superior maxilla and atrophy of the
superincumbent tissues. This deformity did not involve the
malar bone nor the inferior maxilla, and was confined to the
right side of the face; consequently the want of symmetry
between the two sides of the face was quite marked. The
depression of the maxilla was not the result of an accident,
→
CASE OF FACIAL DEFORMITY.
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FIG. 215.

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AND THE
WHERE TO THE OTHER
A
- THE
THE LAST THE RED HEAT THE
WE CONSTANTINE TO HAND-12-17. THE TO
but was developmental and possibly congenital. That the
external deformity was not wholly due to the condition of
atrophy was proved on taking a cast of the mouth, when the
want of symmetry in the two sides was clearly shown. My
attention was more particularly directed to this depression of
the bone, because the patient himself claimed that the de-
formity had been caused by the extraction of the first molar
tooth a few years before; but that this was an error was con-
324
.THE PROTHESIS FOR RESTORATION.
clusively shown by the remaining teeth being in good con-
dition, with but slight absorption of the alveolar process
where the tooth had been extracted, and by the general sink-
ing as above stated. Fig. 215 shows the external appear-
ance, the left side of the face being fair in outline and of
moderate plumpness.
The patient's desire was a restoration of contour by pros-
thetic treatment; and the accomplishment of this involved
the conception of an appliance, and a mode of procedure
very
different from the insertion of an ordinary plumper ad-
justed to artificial teeth, and made to take the place of wasted
FIG. 216.

alveolar processes. It required the displacement of the mus-
cles nearly up to the orbit of the eye, and the forming of a
cavity in the soft tissues into which the appliance could be
introduced. This was done by making gradual encroach-
ments upon those tissues during a period of several weeks,
until the desired result was obtained. The restoration was
due partly to the displacement, as stated, and partly to the
forcing upward of the tissue, thus thickening the cheek and
adding to its fullness.
The prothesis is shown in Fig. 216. It consisted of a
gold plate three eighths of an inch wide, attached to molar
teeth on the left side of the mouth, reaching directly across the
▸
THE APPEARANCE AFTER INTRODUCTION.
325
palatine arch and passing through the space formed by the
extraction of the molar; its continuation from this point was
formed of vulcanite, the body of which occupied the canine
fossa, extended back to the tuberosity of the jaw, and reached
upward to the malar bone. At its anterior part a projection
ran up to probably within a sixteenth of an inch of the in-
fra-orbital foramen, and from the inferior surface a wing de-
•
FIG. 217.

ܟ
When the
--
-
TUTTLE.SCNY
-
scended as low as would be permitted on the closure of the
lower jaw.
Fig. 217 shows the external effect after restoration. This
result was produced, as stated before, not by a single effort,
but by the introduction of the gold plate upon which was
built up the plumper of gutta-percha, adding to its fullness
from time to time with gutta-percha or wax, as it could be
borne. While the gutta-percha was in a semi-plastic state,
22
326
the jaws were exercised so that the form would be somewhat
accommodated to the action of the muscles. In this manner,
such shape as was required for restoration of contour, and
which could be tolerated, was determined upon, and then
the instrument was duplicated in vulcanite.
THE IMPORTANT FEATURES OF THIS CASE.
This was worn with entire ease and comfort for two
years and a half, and required only very slight alterations,
save in one particular. From the great size of the body of
the plumper (its horizontal diameter being three quarters of
an inch), it was desirable to save weight as much as possible,
and it was made open between the wing and the part lying
next the gum. The result was a most disagreeable tone to
the voice-a hollow, cavernous sound, as of the voice lost in
the space created by holding off the cheek from contact with
the gums. The remedy followed immediately on filling up
this space.
At the end of two years and a half the instrument was
broken by accident; and, on duplicating it, some improve-
ments were attempted, which consisted mainly in using soft
rubber for the upper process and for the lower wing. Ex-
perience proved that these were valuable improvements; for
in the first instrument the rigidity of form, due to the unyield-
ing vulcanite, would sometimes produce a rigidity of the mus
cles, noticeable particularly when there was much action, as
in laughter. By the substitution of elastic rubber for these
portions, that disagreeable effect was remedied. The soft
rubber was not attached directly to the gold plate, but the
body of the plumper was made of hard vulcanite, as in
the first instrument, and the elastic compound attached to
that.
The noticeable features of this case are:
1. The atrophied condition was confined entirely to one
side of the face.
2. That muscular tissue can be displaced to a very con-
siderable extent without impairing its freedom of action.
3. That the cheek can not be lifted out so as to leave a
327
space between it and the gum without changing the tone of
the voice and incidentally articulation.
LIFTING A SUNKEN NOSE.
LIFTING A SUNKEN NOSE.-In 1868 I was applied to by
a young woman, a widow in moderate circumstances, whose
portrait is here shown, Fig. 218. She stated that her nose,
which was originally of fair proportions, had sunk within a
recent period, and was naturally a source of much mortifica-
FIG. 218.

tion to her. She had been told by some friends that they
knew of like cases, in which the nose had been lifted up and
a silver bridge or support inserted. With this idea, she had
applied to an eminent professor of surgery for relief, and
was by him referred to me. The object of this reference
was, that, if I would undertake to make and adapt the arti-
ficial bridge, the surgeon would insert it. As the responsi-
bility for the future well-being of the patient would be very
limited in the part which I was called upon to perform, I
made no objection.
328
FIRST SURGICAL OPERATION.
My first step was a cast of the face as shown in Fig. 218.
From this plaster cast I cut off the nose, and dissected away
at the sides at the base of the nose until I came down to an
imaginary bone. The supposed contour of bone I arrived
at approximately by a study of the living face-feeling the
superincumbent tissues-and also by comparison with a skull.
A bridge was then modeled into such form as the case seemed
to require, making due allowance for the nasal tissue which
it was to cover. This model was made permanent in black
vulcanite and highly polished. Vulcanite was chosen be-
cause it would permit of softer, smoother edges than metal,
and would be much lighter; and black vulcanite because it
was believed to be harmless. This bridge is shown in Fig.
A
Fis. 219.

219. The base, marked A A A, was spread out and flattened
like a flange, and adapted to the supposed bone. B
B repre-
sents the support for the middle of the nose.
This bridge
being in readiness, the surgical operation proceeded as follows:
Two incisions were made from the mouth through the
upper lip, one into each nostril. An incision was also made
from each nostril, along, beneath, and behind each wing of
the nose, and along up the base of the nose, three fourths
the distance to the eye. Such incisions are indicated in Fig.
218 by a dotted line. The object of the incision through
the upper lip was to lengthen the columna of the nose, and
thus give the nose more prominence. When this dissection
was completed, the nose was turned up over the forehead,
and the vulcanite bridge applied. The adaptation seemed
329
to be approximately accurate; the bone was still covered
with considerable soft tissue, and I could not observe that
any change in conformation was required. Being left in
position, the nose was turned down over it and the sutures
inserted. A portion of the extra length of the nasal colum-
na was needed, and the remainder cut off; the upper lip was
drawn together, and the operation completed. The nose be-
gan immediately to puff up, and before we had retired from
the scene it resembled a small-sized potato more than any-
thing else in nature. However, the patient was in good con-
dition, and in a very few weeks the lip was so sound that the
scar, which was exactly in the middle, was hardly noticeable.
The lip had lost the rigidity resultant upon the narrowing,
and seemed as mobile as ever. The scars at the sides of the
nose were scarcely observable. Nevertheless, the nose re-
tained its potato-like form.
THE FINALE OF THIS OPERATION A FAILURE.
The retention of the bridge was without discomfort, ex-
cept as a prolonged soreness was observed at the upper end.
This soreness increased until it became evident that the bridge
was shifting its position and twisting around; i. e., the apex
of the bridge was swinging over to the right side of the
nose, and likely to crop out. No external pressure to restore
it seemed to have any effect, and another surgical operation
was determined upon to anticipate the appearance of the
bridge of its own volition. It was then determined that
another bridge should be made with legs to steady it-that
is, processes which should pass each side the vomer, and enter
the nasal canals.
This bridge was also made of vulcanite, and on a suppo-
sititious model. It is shown in Fig. 220, and includes the
dotted line. The second surgical operation consisted in sep--
arating the nose from the upper lip by an horizontal incision,
and continuing up the sides on much the former line.
While this was going on, I had some gutta-percha soft-
ened in hot water, and immediately on the nose being turned
up, and the old bridge taken out, I took an impression of the
❤
A SECOND AND A THIRD OPERATION.
330
surface, and of the nasal passages, to the depth of more than
half an inch. I made a plaster cast of these parts, with all
the rapidity that I could manipulate plaster, accelerated by
the aid of salt, and with equal rapidity of movement the
new bridge was softened by warming over an alcohol blaze,
and adapted to the plaster cast; the processes marked C C,
Fig. 220, entered the nasal passages, and were quite accu-
rately adapted. All this did not take five minutes, and prob-
ably the surgical operation was not delayed more than two
or three minutes. The latter was completed in the usual
manner.
The healing of the wounds went on rapidly; but the
presence of the bridge was uncomfortable, and within a few
A
•
+
FIG. 220.

weeks it became evident that the new bridge, even with its
legs, would not remain stationary. It was getting decidedly
crosswise. A third operation was determined upon, and
also a third bridge. It was hoped that with an accurate
model of the parts, as they revealed themselves at the last
exposure, a new bridge could be made so closely fitted that
it would be an improvement upon the others; and also, as
the nose seemed to need support only in the middle, it was
deemed best to reduce it in size. Therefore, the third bridge
was made like Fig. 220, exclusive of the dotted line. The
nose was again cut off and turned up, and the second bridge
removed. Then came a consultation of surgeons, and a de-
cision that, inasmuch as the nose had now been lifted out for
a considerable time, and some soft tissue had accumulated un-
331
derneath, it would be unwise to insert another bridge; and
consequently the nose was replaced, minus a bridge.
The rest of the tale is soon told. The external wounds
were healed in a short time; the nose began to sink to even
less than its former position, the nasal passages contracted,
and in a little time were completely closed, and respiration,
except through the mouth, was absolutely impossible. And
the last state of this patient was worse than the first.
AN ARTIFICIAL JAW AND OBTURATOR.
ARTIFICIAL JAW AND OBTURATOR. (Gunshot Wound.)--
A Scotch gentleman, under thirty years of age, while on a
gunning expedition in the Southern States, met with a seri
ous wound of the face from the accidental discharge of his
gun. Carrying the gun at his side in the woods, the trigger
was undoubtedly caught by a twig, and the explosion which
followed carried the contents, which consisted of shot, through
the right side of the face. The charge first struck the ante-
rior part of the chin near the symphysis, carrying away a V-
shaped section of the lower jaw and alveolar process with
several teeth. The further course was to the right of the
nose, past the outer corner of the eye, and passing off on the
temporal surface of the frontal bone. In its track it tore
away entirely the right superior maxilla, all the incisor teeth,
the vomer, palatine and malar bones, together with portions
of the temporal, ethmoid, lachrymal, and turbinated bones.
A reference to Fig. 221 will show the general character of
the destruction of the soft tissues, including the right eye.
The patient was of sound constitution and otherwise in
good health, and was sufficiently recovered to come North
within a few weeks after the accident, when he presented
himself to me for treatment. I found the wound healed.
Considerable tissue had formed and filled up the vacancy
made by the absence of the malar bone. The remaining
portions of the inferior maxilla had approximated and united,
and in doing so had destroyed the articulation with the upper
.
TREATMENT OF THE LOWER JAW.
332
teeth on the left side, and also with the upper jaw at the
joint, thus throwing the chin nearly an inch to the right, and
out of line. The hard palate being entirely gone, and no
lips to close the oral opening, articulate speech was impos-
sible; communication could only be made by him in writing.
The patient was sustained solely with fluid nourishment.
The first step was to restore the normal articulation of the
lower jaw. I recommended the patient to place himself
under the surgical care of the late Professor Krackowizer,
FIG 221.
ww
?

whose skill in plastic surgery was unexcelled. I made a
splint to keep the lower jaw in its proper position when re-
placed, and together Professor Krackowizer and myself broke
up the false union and carried the fragments into place,
where they were retained by the splint without bandaging
or other apparatus. This restored also the chin to its proper
relation with the other features.
upon
In the mean time Professor Krackowizer determined
a series of operations for closing the opening in the cheek;
the first of which was to attempt to form a lower eyelid.
DETAILS OF THE DESTRUCTION OF ORGANS.
333
The details of the surgical steps are not important to our
present purpose. The operation for the renewal of an eye-
lid was a success, the flap being obtained by an incision along
the dotted line in Fig. 221, marked A, and bringing the end
marked 1 up to the side of the nose at 1, and making the
attachment. It healed readily, the union was good, and in a
few days a very respectable lower eyelid was the result. It
hjl.
FIG. 222.

**UJIAN.
cardo Alvinitus.
Woman vi
was at this stage that I made the model from which the
drawing shown in Fig. 222 was taken. In this plaster cast we
have a perfect representation of the buccal and nasal cavities
in all their intricacies, including lower jaw, tongue, fauces,
soft palate, turbinated bones, and nasal passages to the nos-
trils.
The impression was made entirely of plaster, and
taken in sections as follows:
Plaster was first carried into all the intricacies of the nasal
334
THE FIRST PROSTHETIC EXPERIMENT.
passages, thus making a roof to the mouth of plaster, the
patient meanwhile breathing below the palate and through
the mouth. When this was set it was removed, and the por-
tions which followed the recesses were broken off the impres-
sion (to be subsequently restored), and the impression re-
placed. The removal of these portions permitted the patient
to breathe above the palate and through the nose. Plaster
was then applied to all the remaining portions of the buccal
cavity and the external adjacent parts, and resulted in a
model as shown in Fig. 222.
The next operation for the patient's benefit was a me-
chanical one of no ordinary difficulty. An observation of
Fig. 222, together with a little reflection, will show that it
was desirable to form a new roof to the mouth, a new jaw on
the right side, and a new cheek-bone, if possible, to restore
contour to the cheek. Such an apparatus must necessarily
be bulky and more or less weighty, and, worse than all, there
was no solid tissue for support. I conceived the idea, how-
ever, that if I could bridge over the roof of the mouth with
something that would abut firmly against and on top of the
jaw on the left side, and extend my appliance upward and
outward into the locality of the missing cheek-bone, the flap
which must ultimately close the cheek would come outside
and under this artificial cheek-bone, and thus support my
whole appliance on that side.
C
My first experiment was with vulcanite. I made a some-
what artistic model, which included a new floor to the nares,
a new roof to the mouth, new jaw, teeth in front and on the
right side, and a malar process. This model was then du-
plicated in vulcanite, and, as the bulk was great, it was made
a mere shell in form, many. parts being not thicker than a
thin cardboard. As it was impossible to make a complete
shell of one piece of vulcanite, the upper part was left open,
and, after the vulcanite was finished within and without, the
top was closed with a piece of aluminum plate struck into
shape, accurately fitted, and cemented into its place. This
DESCRIPTION OF APPLIANCE.
335
instrument in a modified form is shown in Figs. 223 and
224.
The aluminum plate is represented in Fig. 223, and
marked E E. A represents the portion fitting under the
Trincan
D
FIG. 223.

D
the
inner corner of the eye; B, the malar process; D D,
The weight of the
edge which laps on to the soft palate.
whole when complete was very trifling. I have said that the
engravings represent that instrument in a modified form.
The modification consisted in the reduction of the malar
FIG. 224.

00000
process marked B, which in the first instrument was much
larger.
In the preparation of this appliance I had cut away in my
plaster model of the cavity a portion which represented the
soft tissue in the malar locality, a part of my plan being to
RESULTS OBTAINED FROM FIRST INSTRUMENT.
336
make an incision in the natural soft tissues within the cavity
for the reception of my malar process, and thus lift.the tissues
out to the desired contour. When my instrument was ready
for adjustment, Professor Krackowizer made the proposed
incision and the appliance was introduced. The adaptation
was excellent, and the malar process was fulfilling our expec-
tations in lifting out the cheek. With a patch over the
cheek-opening to confine the sound, the patient immediately
articulated distinctly.
In a few days I made a careful examination of the case,
and the piece did not seem to be in such accurate contact
with the firm and healthy jaw of the left side as it had ap-
peared to be on introduction. Furthermore, I observed that
my artificial malar process was immediately under the scar
shown by the dotted line in Fig. 221, and also plainly seen
in Fig. 222. In another few days the discrepancy of adapta-
tion had increased, and the tissue over the malar process was
becoming transparent. Within two weeks from its deep-
seated introduction (there being nearly three quarters of an
inch in thickness of tissue over it) this malar process was on
the outside of the cheek, and everything healed and as solid
as before. The explanation is, that there was nothing but
cicatricial tissue over it in the start, which gave way as soon
as there was any pressure on it, and the appliance traveled
through it without hindrance. Nevertheless, it was not with-
out good results. The first effect was to lift out the external
contour, and new tissue formed and filled up the cavity be-
hind the appliance as fast as it moved, so that in the end
there was much more fullness than there was before the ex-
periment was made. The instrument was then modified in
shape to meet the emergency, and worn to develop any fur-
ther peculiarities.
After a limited trial of wearing it with much satisfaction,
I set about duplicating it in another material. As the final
surgical operation would close the cavity so that the appli-
ance could not be removed, and therefore it must remain
1
337
there during life, I was not willing to subject the patient to
the uncertainties of vulcanite, besides a little prejudice I had
against it on the score of cleanliness and healthfulness. Free-
dom from weight being a great desideratum, I decided on
aluminum. I shall not enter into a description of the annoy-
ing experience in my effort to conquer that material, and in
the end it conquered me. I spent weeks in experimenting.
I sought out everybody I knew who had had any experience
with the hateful stuff. There was no difficulty in getting
the sections of my shell in exactly the form I desired, and in
joining them to each other; but to solder them and make a
shell which would be air-tight, even leaving one last hole for
vent, I found impossible, and at last I gave up in despair and
abandoned the material.
DUPLICATING THE PROTHESIS IN GOLD.
There was but one recourse, and that was gold. I used
twenty-carat gold, rolled down just as thin as I could work
it, and succeeded in making a beautiful shell of very little
weight. To this were attached the few teeth that are repre-
sented in Fig. 224. These were sufficient for appearance,
and it was not desirable to provide any for masticating pur-
poses on that side of the mouth, as masticating would create
a motion which might be prejudicial to the stability of the
appliance. The gold was substantially a duplicate of the
first apparatus, as shown in Figs. 223 and 224. The projec-
tion marked C came down to meet a molar tooth on the
lower jaw, and was made tubular and left open while work-
ing the gold. In this way there was no difficulty in making
the shell otherwise air-tight. Unless there is an opening of
this character, it is difficult to make a perfectly air-tight shell
by soldering. I tested the shell by putting a piece of rubber
tubing on this leg, and immersing the whole in water; blow-
ing in the shell would reveal the slightest leakage by a little
air-bubble on the surface. Ultimately this last opening was
closed without heat.
My appliance being perfected and introduced, Professor
Krackowizer continued his surgical operations. Immediately
338 RESTORATION OF ARTICULATION AND MASTICATION.
on the introduction of the instrument, the Professor per-
formed an operation which shut it in completely. An in-
cision was made across the upper lip, parallel with and about
half an inch from its border, and the whole length of the
mouth. This strip, which was free at the end on the right
side, was stretched, and attached to the cheek on the right,
thus making a new oral opening. At the same time other
incisions were made in the vicinity of the angle of the jaw,
and the cheek worked up until it was brought into contact
with the opposite side of the cavity at the base of the nose.
The cavity was then completely closed. Most of this opera-
tion did well. The lip and mouth were a complete success.
Some parts above gave way, requiring two or three minor
operations, which were much delayed by the unstable char-
acter of the tissue, resulting from so many operations. The
notched appearance in the lower lip was also subjected to an
operation, with much benefit to appearance.
Immediately on his recovery, after the introduction of
the gold apparatus, the patient told me that he masticated
and enjoyed his food as well as he ever did, and there was
certainly not a trace of defect in his articulate speech.
RESTORATION OF JAW AFTER GUNSHOT WOUND.-Dr. J.
A. Woodward, of Philadelphia, described in "The Dental
Cosmos" for December, 1865, an ingenious prothesis made
for a wounded soldier:
"The following case was constructed for a young gen-
tleman who received a severe gunshot wound during one of
the battles in Virginia. Fig. 225 represents the condition of
the upper jaw. The alveolar and palatine processes are en-
tirely removed on the right side. The left central, lateral,
and cuspidatus, with the process and maxillary bone imme-
diately beneath, being broken away from the main part of
the bone, fell inside the lower teeth three eighths of an
inch, and were allowed to become fixed in that position.
339
The
An opening, A, extends from the mouth to the nose.
molars only retain the original articulation, the bicuspids
having been drawn by the contraction of the parts inside the
outer cusps of the inferior bicuspids. The right cheek,
deprived of its support, falls in considerably, and requires
some force to press it to its proper position. An impression-
cup was made to suit the case, with which a sufficiently ac-
curate impression in white wax was obtained. The gold
plate was continued back to the last molar and over and in
front of the remaining three front teeth. On the right side
DR. WOODWARD'S CASE OF GUNSHOT WOUND.
FIG. 225.

it encroached upon the muscles of the cheek; consequently
the cast was built up here, that the edge might be raised
and well rounded. As the opening A is still contracting, the
plate was run across instead of down into it. Around the
second molar was placed a stout clasp. This was slightly
soldered to the plate, and the whole then thoroughly fitted
to the mouth. The articulation was next taken in the usual
manner. The teeth were set as shown in Fig. 226, being at-
tached by vulcanite. To have depended entirely upon clasps
to support the case would have brought too great pressure on
the teeth clasped, as the cheek is continually pushing the set
340
MECHANISM FOR RESTORING THE JAW.
downward, especially when the mouth is open.
A spiral
spring was therefore used on the right side. This was fast-
ened below to a small plate, D, fitting between the second
molar and second bicuspid. Above, the attachment was not
so readily accomplished. The gums of the artificial molars
were ground off nearly to the teeth, and the vulcanite over
them well cut away to let the spring set in. Over this was
stamped a piece of gold plate, the anterior and superior
edges of which were nicely adjusted so as to present a smooth
A
եվ
D
FIG. 223.

MA
Juu
surface with the vulcanite and the plate B. This sort of
shield was extended back to lift the cheek free of the spring,
the posterior margin being smooth and round. Behind it
the food would necessarily accumulate and be difficult of
removal; therefore it was contrived to be taken off and
replaced at the pleasure of the wearer. Fig. 227 shows the
shield with spring and plate for lower jaw. H is a heavy
wire bent at a right angle to hold the front end securely in
its place; G is a small pin to give additional firmness when
the plate is in its position; F is a hasp which passes around
341
the posterior part of the vulcanite and over a catch on the
lingual surface of the set. This catch was driven in the vul-
canite well up to the plate, out of the way of the tongue.
ARTIFICIAL NOSE.
FIG. 227.

A
*147
y
The set has been in use for nearly five months, and seems to
fully meet all requirements."
ARTIFICIAL NOSE.-In July, 1869, a gentleman from a
distant city, a lawyer by profession, applied to me for advice.
His face presented the appearance indicated in Fig. 228. An
examination showed the loss by disease of the soft palate, a
portion of the hard palate, the vomer and turbinated bones,
the nasal walls of the antra, portions of the nasal and maxil-
lary bones, and the cartilage of the nose.
A rhinoplastic operation would not be submitted to, for
various reasons—among which were, the suffering and incon-
venience attending it, the disfigurement caused by it, the
uncertainty of the result, and the doubt of making by such
process a nose which should resemble to any extent the origi-
nal appendage. An artificial nose being the only alternative,
a cast of the face and nasal cavity was taken in the following
manner: The nasal cavity was filled to the orifice with plas-
ter-not in one mass, but in sections, to facilitate its removal.
Before removal, however, the cast of the face was taken, the
plaster coming in contact with that already in the nasal cav-
23
342
ity at the orifice, the precaution having been taken to soap
the surface to prevent the two masses from adhering. After
the removal of the external mask, the sections in the nasal
cavity were pushed backward, and brought out through the
opening caused by the loss of the soft palate.
The sections being all brought together, a cast was made
which showed the surface of all the parts adjacent to the
MANNER OF MAKING A CAST.
Movi
FIG. 22S.

POSITION IN PATIENTS THE ONLINE IN THE
WE ATTENTIONED
OMMANI
nasal orifice, both internal and external. Upon this plaster
cast there was modeled a form of the new nose in wax, made
to resemble the color of the flesh, this wax model being tried.
on the living face from time to time for criticism. The ob-
ject of using flesh-colored wax for this model is, that the
operator is enabled to judge better of the effect of his art
than he could were the material in contrast with the sur-
rounding parts. It is herein that art and mechanism triumph
SUBSTANCE USED FOR A NOSE.
343
over surgery—it being within the power of the artist by such
means to restore this feature so that, in its individual charac-
ter, it shall be in perfect harmony with the surrounding fea-
tures, which it is not possible to accomplish by surgery. The
extra large mass which must be cut from the forehead in a
rhinoplastic operation, to provide for shrinkage, renders it
difficult to preserve the physiognomical relations of the nose
with the face.
The model in wax having been determined upon as de-
scribed, a duplicate must be made of such material as shall
closely resemble the flesh and prove durable. Of all sub-
stances heretofore employed for this purpose, I know of none
FIG. 229.

A
A
which are durable that are not decidedly objectionable in
appearance. All opaque substances, no matter how beauti-
fully they may be painted in imitation, do not look like flesh.
Porcelain or enamel has an advantage in its transparency,
but it reflects the light, and looks like a piece of crockery.
For these reasons collodion was used in this case with re-
markable success-the preparation being that known to den-
tists under the name of " rose pearl," with some modifications
in color to suit the case. With this substance a nose was
made, which had the color, tone, and translucency of flesh,
giving also the delicate little tracery of veins which are so
often observable in the nose toward the tip. This substance
possesses also the qualities of elasticity, strength, and dura-
bility; it is not easily broken, nor affected by exposure to the
311
MANNER OF ATTACHMENT.
elements or thermal changes. The wax model, after being
completed externally, was scooped out inside, so as to leave a
mere shell of not more than a line in thickness. The collo-
dion duplicate was produced by making a die of fusible
metal, pressing the mass into shape, and curing it in substan-
tially the same manner in which "rose pearl" base is worked.
Fig. 229 gives a view of the nose complete, with the at-
FIG. 230.

tachments for securing it in place. A A are pads made of
vulcanite, adapted to depressions in the nasal cavity and con-
nected with the nose by flat gold springs. The gentle pres-
sure of these springs is sufficient to keep the nose firm in its
place; at the same time their elasticity will permit its removal
at pleasure. The border of the nose is brought to a thin,
beveled edge, wherever it comes in contact with the cheek,
and the adaptation is so accurate that at a short distance no
mark of separation is visible. In many cases of the applica-
DR. HOOPES'S CASE OF NOSE, LIP, ETC.
tion of an artificial nose, the attachment has been so insecure
as to require the patient to wear a pair of spectacles to keep
it from moving. Some artificial teeth and a palate, which
were also required in this case, were made independent of
the nose, and it is always desirable that they be disconnected.
The movement of the muscles of the face is such that the
nose should be permitted to yield with them. Besides, a
nose secured by an unyielding connection to a plate of teeth
through an opening in the roof of the mouth must necessa-
rily show all the movements of mastication.
Fig. 230 represents the patient with the nose attached.
The success in this case may be inferred from the follow-
ing extract from a letter received from the patient soon after
his return home:
345
66
Every one here is delighted with my improvement; it
gives me, I am glad to say, no discomfort, and I feel no
weight. Many of my most intimate friends, after being in
company with me several hours, both indoors and in full
light of the sun, believed it genuine flesh, so deceptive is it.
Several medical gentlemen who have seen me have said that,
in all similar cases to mine, they should never again advise
an operation when so neat a thing can be made."
ARTIFICIAL NOSE, LIP, AND OBTURATOR.-The following
is from a report in "The Dental Times" of a meeting of the
Pennsylvania Association of Dental Surgeons in 1864:
"The case referred to by Dr. Hoopes was one treated by
him in the 1860, and published at that time in the ‘Ameri-
can Journal of Dental Science,' an abstract of which is here
appended. H. R., aged forty years, had enjoyed good health
until about fifteen years ago, when he contracted primary
syphilis. Four years subsequently the disease, in a tertiary
form, attacked the internal surface of the nasal bone, and
continued to spread for some five years, when fortunately
its progress was arrested, though not until it had committed
DESCRIPTION OF THE TISSUES DESTROYED.
346
the most terrible destruction of the bones and soft parts of
the face. Fig. 231 inadequately presents the appearance of
the face. It may be better understood by a description.
"The lower margins of the nasal bones are destroyed,
with the entire vomer, the nasal cartilage, and a portion of
the septum. The left inferior turbinated bone is gone, and
a portion of that of the right side. The anterior portion of
FIG. 231.

› was cal
the malar bone is destroyed on the left side, nearly reaching
the antrum; also the superior alveolar process, leaving a
mere rim, with three molar teeth on one side and two on
the other. The central portion of the palatine bones is also
gone, leaving an open space about the size of a half-dollar
piece. Of the soft parts the destruction has not been less
extensive. The upper lip is destroyed, except at the angles
of the mouth; and ulceration had taken away much of the
347
soft tissues of the posterior nares. The muscles of the upper
lip and face that are partially destroyed are the orbicularis
oris levator, labii superioris alæque nasi, and on the left side
a part of the zygomatic and levator anguli oris. It should
be remembered that the sketch given reverses the side of
the face.
"On looking inward and downward, the parts presented
FURTHER DESCRIPTION OF TISSUES DESTROYED.
Fr. 22.

H
a deep, large cavity; the motions of the uvula could be seen
by looking into the nose, and the tongue closed the opening
through the palatine bones. Of course, speech and degluti-
tion would have been impossible, had not the patient con-
tinually kept a large piece of raw cotton in this opening.
The lower lip had also begun to suffer the ravages of the
fearful disease, but it was arrested at this period, and this lip
presented an enlarged appearance, from the healing of a
large granulated surface.
↓
348 MANNER OF MAKING AND ATTACHING THE NOSE.
"The first step in the process of making a mechanical
contrivance to hide this hideous deformity was, to make a
cast in plaster of the anterior portion of the face, and anoth-
er of the mouth. A gold plate was then made, fitting the
roof of the mouth; and upon this were inserted all the teeth
that were deficient, and this plate was clasped to the remain-
ing molar teeth. A model of an artificial nose and upper
lip was then made, as near the natural form as possible. A
cast of this model was filled with hard rubber, which was
then vulcanized. A gold bar was attached to the inside of
the artificial nose, which was made more firm by a cross-bar.
The opening through the palatine bones gave an opportunity
to secure the nose to the plate; this was done by attaching
a short tube to the plate and passing the bar through it.
The plate was then placed in the mouth, the nose was at-
tached to the face, and the bar was passed through the tube,
which held it firmly in position. The stiff, unnatural appear-
ance of the upper lip was hidden by a heavy artificial mus-
tache. The connection between the artificial and natural
nose was concealed by the bow of a pair of spectacles. The
artificial nose was then given a lifelike color, and the illusion
was complete.
"This appliance so fully answered the purpose that the
wearer had, at subsequent times since its introduction, as-
sured him that it was perfectly priceless, and that he felt, if
possible, like a new man.”
ARTIFICIAL NOSE, LIP, AND DENTURE.-Dr. William M.
Herriott made an appliance for a wounded soldier, which he
describes in "The Dental Cosmos" as follows:
66
Corporal Andros Guille, Company K, 97th Regiment
Ohio Volunteer Infantry, aged thirty-two years, was wounded
November 25, 1863, at the battle of Mission Ridge, by a
fragment of shell, which carried away the entire nose to the
turbinated bones, and the upper lip, with anterior portion of
the alveolar process of the superior maxilla, from the right
DR. HERRIOTT'S CASE OF A WOUNDED SOLDIER.
349
to the last two molar teeth on left. He received also other
injury at the same time.
“On or about the following dates, February 11th, Febru-
ary 27th, and April 1st, all in 1864, three surgical operations
were performed by or under the direction of William Otter-
son, M. D., then a brigade surgeon having in charge the hos-
pitals at Nashville, the object being to restore the parts lost;
FIG. 239.

but the first was a failure because erysipelas set in, the others
on account of sloughing and muscular tension. It was then
acknowledged that surgery could not be used to better the
condition of the patient, and he was left as seen in Fig. 233.
"In September, 1864, I constructed the artificial appli-
ance which is shown in Fig. 234, in the following manner:
I first took an impression of the upper part of the mouth,
extending it up as far as possible in front, and from this I
350
APPEARANCE WITH ARTIFICIAL NOSE AND LIP.
secured a model upon which I formed a structure to take the
place of the destroyed hard parts and to act as a base for the
teeth. This accomplished, I laid the patient on his back,
and, having closed the nasal orifices with cotton, I took—
using very soft plaster an accurate impression of all the
parts which the nose and lip were to rest upon; and, procur-
ing a model from this, I built upon it plaster, from which I
*****
FIG. 234.

untilmJh
-N
--
carved the form of a nose and lip. This I used to vulcanize
a nose and lip upon, which are in one piece, covering the lip
with an artificial mustache, which extends so as to hide the
joint of the artificial lip with the adjacent parts, and secur-
ing the piece up and back at the top with a pair of specta-
cles, and back at the lower part of the nose to the artificial
denture, with a gum ligature. The appliance was complete,
and has been worn continually since."
351
ARTIFICIAL NOSE AND OBTURATOR.-The following de-
scription of an appliance made by Professor Wildman is
taken from Garretson's "Treatise on Oral Surgery":
DR. WILDMAN'S CASE OF NOSE AND OBTURATOR.
Fig. 235 will convey an idea of the external appearance
of the patient, but not fully, as the whole upper lip was
cicatrized, and the left cheek depressed near the border of
the cavity.
FIG. 235.
"In May, 1863, a young man," says Dr. Wildman, “aged
twenty-six years, presented himself for the purpose of hav-
ing an appliance made to repair a loss sustained by disease.
Upon removing the black patch which he wore upon his
face, and the cotton with which the cavity was filled (with-
out the latter he could not articulate a word), I found that
the entire external nose was gone; that the nasal bones, the
nasal processes of the superior maxillary, also a large por-
tion of their palatine processes, the approximal parts of the
1

352 DR. WILDMAN'S METHOD OF TAKING AN IMPRESSION.
palatine processes of the palatine, and the turbinated bones
had been destroyed. The soft palate, the uvula, and the
tonsils were uninjured. In looking into the nasal cavity,
the walls of the antrum on the left side were found defi-
cient, and ends of the roots of the incisors exposed and de-
cayed. The tongue was visible through the opening in the
palatine arch.
"Although desirable, it was deemed unsafe to remove
the diseased roots, owing to the yielding nature of the supe-
rior maxillary bones. The disease appeared to be arrested,
and the parts in a sufficiently healthy condition to warrant.
the application of the substitute; and time has verified this,
as, with the exception of the exfoliation of a small scale
from one of the superior maxillary bones, about nine months
since, no change has taken place up to this date.
"The first step in the operation was to procure an im-
pression that would enable me to make a perfect model of
all the parts involved, and their surroundings, in their rela-
tive positions. For this purpose plaster was best adapted,
but its use was precluded by the acrid secretions in the
nasal cavity; wax and paraffine was considered the best sub-
stitute, and used. Owing to the rigidity of the upper lip,
I was unable to use the ordinary impression-cup with suc-
cess, and was obliged to take a rough impression of the
palatine arch, from which a model was made, and a metallic
impression-cup swaged.
"A sufficient quantity of paraffine and wax was placed in
warm water, and, with an assistant to keep it at the proper
temperature, the mode of procedure was as follows: a proper
quantity of the compound was placed in the cup, introduced
into the mouth, and pressed up firmly against the arch; the
part forced into the palatine fissure was at the same time
pressed with the finger, introduced through the nasal cavity,
so that it should give an accurate impression of its lateral
borders. A groove was then cut in this to serve as a key,
and, after oiling it, a piece of the compound was introduced
FURTHER DESCRIPTION OF THE IMPRESSION.
353
through the orifice of the nasal cavity, and passed down to
make the impression of the floor of the nasal cavity. When
sufficiently hard it was carefully removed, the upper surface
trimmed, placed in cold water to give it its greatest firmness,
then introduced into the cavity, and pressed into its proper
position. The metallic cup containing the impression of the
palatine arch was then removed. The next step was to take
an impression of the sides of the cavity, then the top, using
a curved wooden spatula to press the compound in proper
position, being careful to mark or key the parts that came in
contact, and have their surfaces oiled, to prevent adhesion;
and also that the pieces should be thinner in front than in
their posterior parts, so that, when the four pieces forming
the impression of the base, sides, and top were in their
proper position, they would leave a tapering cavity, with its
largest diameter at the front orifice. Into this orifice was
forced a plug or cone of the compound, filling it completely;
in the front of this piece were inserted pieces of match-
sticks, to cause it to adhere to the next piece or mask. The
head was now thrown back to nearly an horizontal position,
wet tissue-paper was placed over the eyebrows and lashes,
the face oiled, and plaster mixed thick was batted on with a
brush. When set, this was removed, drawing with it the
central plug or cone; the different parts were then carefully
removed, and thrown into cold water to give them a con-
sistency to bear handling without danger of injury. On
this central cone all the parts were placed in their proper
position, and the impression of the palatine arch was adjusted
in its proper place. From this a plaster model was made,
giving the upper part of the face, cavities, palatine arch, all
correctly in their relative positions.
"Of the different substances-leather, wood, wax, metal
enameled, and porcelain-used for making artificial noses, I
gave the preference to hard rubber in this case, on account
of its rigidity, strength, lightness, and less liability to injury
by accident.
354 MANNER OF MAKING THE NOSE AND ATTACHMENTS.
"To prevent derangement, it was necessary to make the
appliance as simple as possible; it consisted of two pieces:
the external nose, septum, and floor of the nasal cavity con-
stituted one, having a projection passing downward into the
palatine fissure, as represented in Fig. 236, A; and the ob-
turator B, with a projection rising upward into the palatine
fissure. These projections were made hollow, so that when
the two parts were placed together, as in Fig. 236, there
would be a cavity or box wherein the attachments could
be placed.
"Models were made of the compound of paraffine and
wax, which were strengthened in the weaker parts by im-
gulmar folláry
FIG. 236.

DEAT
B
A
bedding small strips of metal in their substance to give suf
ficient firmness to admit of the necessary handling without
injury. The model was applied to the patient, and the nose
trimmed so as to harmonize with his features. They were
then imbedded in plaster in the usual manner for vulcan-
ite work, with the exception that a stout curved wire passed
through the artificial nasal cavities, extending beyond their
borders, to give strength to the rods of plaster forming
these cavities in the matrix, and thus to prevent their frac-
ture in packing.
"The two pieces were retained in position by a staple
and slide-bolt. In the recess of the part of the floor of the
nasal cavity projecting into the palatine fissure (A, Fig. 236)
was inserted a gold staple. In the recess of the projection
•
355
of the obturator passing into the palatine fissure B were
the gold catch and shield of the slide-bolt. The object of
this shield was to prevent any foreign substance entering
the slot and obstructing the movements of the bolt, also to
give a base of support to the catch. The rectangular up-
right of the catch was soldered to the shield, passed through
it and a longitudinal slot in B, and securely fastened to a
rubber slide inlaid longitudinally, and moving freely in the
lingual surface of the obturator. On the anterior end of
this slide was a small rounded projection, which enabled the
patient, when the two parts of the appliance were placed
in their proper position, with the point of a finger intro-
duced into the mouth, to force the slide backward, thereby
to pass the catch into the staple and firmly secure the ap-
paratus, or, by drawing the slide forward, detach the parts
when desirable to remove them.
ADJUSTMENT OF THE APPARATUS.
"The external nose was painted with oil-color, to give
it as nearly a flesh-tint as possible, although this is not at-
tainable upon an opaque ground. Flesh being translucent,
a true imitation can only be made upon a translucent
ground.
"The apparatus was introduced on June 30, 1863, giving
to the patient great satisfaction and comfort. His appear-
ance was much improved, as may be judged by comparing
Figs. 235 and 237, which were engraved from photographs.
He breathes freely through the nose, and speaks with ease;
the only imperfection in his speech is a nasal twang, and
this is less now than when the instrument was first applied.
The obturator at first extended too far back, and caused
some irritation of the velum; this defect was readily reme-
died.
"The operation proved entirely satisfactory, with two
exceptions: first, the color of the nose was not as natural as
desirable, for the reason already stated; second, in deglu-
tition and speech, when the tongue pressed forcibly against
the posterior part of the obturator, an unpleasant vibratory
356
APPEARANCE OF THE PATIENT WHEN COMPLETED.
movement of the apex of the nose was noticeable. This
could have been remedied by an elastic attachment coup-
ling the two parts of the apparatus, but this mode was ob-
jectionable by reason of its producing constant pressure upon
the delicate parts, and thereby endangering absorption.
A
safer plan was adopted by inserting a small steel pin in the
nose as near as possible to its apex, to which was attached
FIG. 237.

the bridge of a pair of spectacle-frames, these being retained
in position by an elastic cord attached to the bows and pass-
ing around the head. This arrangement answered the double
purpose of counteracting the vibratory movement, and the
bridge of the frames concealing the upper part of the joint
where the nose came in contact with the face, which was
most conspicuous. This apparatus is worn with ease and
comfort by the patient."
ONE OF THE AUTHOR'S CASES.
357
ARTIFICIAL PALATE AND OBTURATOR.-In 1866 there
came to me a lady about twenty-five years of age, with con-
genital fissure of the palate, which had been operated upon
about ten years before by Dr. Hulihen, of Wheeling, Vir-
ginia. The fissure of the velum was complicated with an
extensive separation of the maxillæ, following the line of
FIG. 238.

awww
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TAJCENEJ
་་་་ “-
A
the intermaxillary suture on the right side, dividing the
alveolar arch and also the lip. The lip had been operated
on in early life. At sixteen years of age staphyloraphy was
performed most successfully. The soft palate was united its
entire length, including the uvula.
Fig. 238 is copied from a plaster cast taken at the time
she came into my hands. In it are shown the fissure of the
hard palate and division of the alveolar border, together
24
358
PLATE OF TEETH, OBTURATOR, AND PALATE.
with the united velum; even the marks of the sutures are
distinctly visible in the cast.
For the ten years succeeding the surgical operation the
patient had worn an obturator which closed the remaining
opening. It was skillfully adjusted, and gave her all the
benefit that it was possible to obtain from an obturator
alone. But with ten years of application and an intelligence
equal to the undertaking, she was unable to articulate with
any more distinctness than before the operation. The father
said, "If anything, she does not speak as well." There was
very little mobility to the palate, and, from the closest cal-
culation, there was a space of half an inch in breadth behind
the vėlum, even when the pharyngeal wall was contracted
FIG. 239.

A
toward it. Through this space there was a constant escape
of the voice. Nearly all the vowels were nasalized; g, k, d,
s, and ch she could not make, owing to such escape.
There was apparently but one solution to the problem,
which was to make an artificial extension of the palate to
enable it to meet the pharyngeal wall, and thus cut off at
times the communication with the nasal cavity. The appli-
ance consisted of an obturator not very unlike the former
one, filling the anterior gap, and carrying with it some arti-
ficial teeth to supply the loss of some natural ones; and
attached to its posterior extremity an extension of elastic
rubber, following down the superior surface of the palate to
its posterior border and beyond to meet the pharyngeal
wall.
MANNER OF INTRODUCING THE APPARATUS.
359
This apparatus is shown in Fig. 239, and in Fig. 240 it
is also seen in situ. A shows the obturator, B the elastic
extension, and C the apron or palate, occupying the space
in the pharynx. The same letters apply to both illustra-
tions.
This instrument was introduced by folding the elastic
FIG. 240.

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SIMPLI
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extremity together, grasping it with a pair of tweezers, and
passing it through the opening in the hard palate, when it
would find its natural position on the introduction of the
obturator. Subsequently the patient would carry the palate
through the opening with the tip of the tongue alone. It
created no irritation in the pharynx, and was worn with
entire comfort. The only immediate change was in the
THE CONDITION THIRTEEN YEARS AFTER.
360
tone of voice. The vowels and some other sounds were less
nasalized.
By my advice she went under the training of Professor
Peabody, an elocutionist, and in a few weeks showed very
marked change. She acquired the ability to articulate with
perfect distinctness every sound of the English language,
and in reading, with care on her part, would enunciate every
word and syllable without fault.
Thirteen years have now passed, and the few teeth then
remaining have succumbed to the influences which destroyed
their fellows, and not a natural tooth remains in the mouth.
Within the past year the obturator here described has been
substituted by another bearing an entire upper set of arti-
ficial teeth, and the whole apparatus is worn with as much
freedom as its predecessor, which was attached to the natu-
ral teeth. The speech has not degenerated, but rather im-
proved in ease.
The interest in this case lies-
1. In the remarkable success attending the surgical oper-
ation where the fissure was of such extreme width.
2. In its complete failure to improve the speech or pro-
duce any other beneficent result.
3. That a piece of mechanism can be worn in the upper
pharynx, and with it a person may acquire distinct articu-
lation.
4. The pharyngeal portion of such an apparatus must
be flexible, elastic, and movable.
I
PART III.
MAXILLARY FRACTURES.
CHAPTER XVI.
LOCATION, DIAGNOSIS, ETC.
FRACTURES of the superior maxilla are not of common
occurrence, nor are they so difficult to treat as to involve
complicated apparatus, or indeed in many cases any appa-
ratus whatever. The causes, when the bone is in a healthy
condition, must always be from some form of violence;
while, in an unhealthy condition, so simple a matter as the
extraction of a tooth may cause a fracture. Fractures of the
superior maxilla rarely occur from violence where the infe-
rior maxilla is not involved. An explosion or blow of such
force as to break the upper jaw is likely to break also the
lower jaw, which is still more exposed.
An exceptional case is reported by Mr. Charles Tomes,
where the ascending loop of a bell-rope caught a man by the
upper teeth, and both bones of the upper jaw were torn from
their places downward and outward, so that they protruded
from the mouth.
These fractures seldom require special treatment. When
the displaced portions are replaced, they are not liable to get
out of position. There being no motion to the jaw, nor any
muscular attachment likely to disturb the fragments, and the
bone being quite vascular, union takes place readily. The
treatment therefore requires the readjustment of the frag-
ments, the removal of any detached spicule that might cause
J
362 TREATMENT OF FRACTURES OF THE UPPER JAW.
irritation, and the care which would be given to a contu-
sion.
Mr. James Salter mentions a case where, in attempting
to extract an upper incisor, the whole mass corresponding to
the intermaxillary bone came down, held merely by soft tis-
sue. Upon replacing the fragment it readily united.
When for any reason apparatus seems desirable, such a
splint as shown in Fig. 241, tightening the hooks with liga-
tures of silk or wire, or another with projecting arms and
connected with a skull-cap, upon the principle shown in Fig.
66, page 134, will be all that may be required.
ཚ་
on to the
FIG. 241.

FRACTURES OF THE INFERIOR MAXILLA are of quite frequent
occurrence, and are generally the result of direct violence.
It is not surprising that the aggregate number of cases re-
quiring treatment is large, considering the exposure of the
bone, and that it is without support to sustain a severe shock.
Of all the fractures the surgeon is called upon to treat, there
is more difficulty in the management of those of the inferior
maxilla than those of any other bone. The most prolific
sources of these wounds are kicks of horses and falls from
heights upon the chin. A number of cases are reported
where fracture has resulted from the extraction of teeth, but
LOCATION OF FRACTURES OF THE LOWER JAW. 363
such fracture has generally been confined to the alveolar pro-
cess, and very rarely has there been a complete division of
continuity from such cause.
There is considerable disagreement among surgeons as to
the part of the bone most frequently broken. Ehrichsen
thinks it occurs more commonly near the symphysis than at
any other point, while Boyer makes the statement that it
never occurs there, but at the weakest part of the bone,
i.e., on either side of the symphysis; but as long ago as
Hippocrates fracture at the symphysis was known and rec-
ognized. Garretson regards the weakest part of most infe-
rior maxillæ, with an unbroken dental arch, as on the line of
the roots of the canine teeth; but, when teeth have been
extracted, the weakest part may be at the point of their
removal. Gibson, of Philadelphia, was strongly inclined to
the opinion that age had much to do with the location of the
fracture, and that with young people it commonly occurred
at the symphysis.
In a case which came under the author's treatment in
1866, of a boy about seven years of age, the fracture was at
the symphysis; but, in another case of a boy eight years of
age, which was treated in 1877, the fracture was near the
mental foramen. Both these cases were the result of the
kick of a horse. Houzelot mentions a case where there was
fracture of both condyles, both coronoid processes, and also
at the symphysis; and similar cases are also reported by
others. Hamilton's experience would show a very large pro-
portion as occurring in the body of the bone, forty-two out
of forty-five, of which fifteen were at or near the mental
foramen, and four were vertical at or near the symphysis.
Fracture of the ramus seems from the few cases reported
to be quite rare. This exemption may be accounted for by
the protection given by the muscles and integument, by the
natural strength of the part, and by the ease with which
the articulation might slip and thus break the force of the
blow.
364
INJURY TO THE INFERIOR DENTAL NERVE.
Many cases are recorded of fractures through the neck of
the condyle. In one case reported by Holmes, the neck of
the condyle was fractured, with displacement of the lower
fragment into the meatus auditorius externus. Fractures at
this point are, as a rule, most serious, leading frequently to
fatal results through brain complications. There are, how-
ever, marked exceptions. Watson reports the case of a man
who fell from the yard-arm of a vessel, receiving in addition
to other injuries fractures of both condyles. The case re-
covered, but with deformity of the jaw and but limited
movement. No attempt apparently had been made to pre-
vent such a result.
Fractures of the alveoli are exceedingly common, and
occur in the practice of every dentist, but are not considered
a matter of much moment unless unusually extensive. Jour-
dain, in his primitive treatise on dentistry, makes a good deal
of them, but brings nothing forward to sustain his views.
The alveolus is frequently involved in fracture along through
the margin. Occasionally pieces of greater or less extent
are detached, containing one or more teeth; and cases have
been noted where the only fracture detected was confined to
this part of the jaw.
It might be supposed, from the anatomical relationship
of the parts, that, when the inferior maxilla is broken ante-
rior to the ramus, more or less serious injury might be in-
flicted on the inferior dental nerve and vessels; but this does
not appear to be the case. Possibly, as suggested by Hamil-
ton, the symptoms of this lesion may be hidden by the band-
ages or apparatus employed to retain the parts in apposition.
Dr. St. George Elliott says, "I have never seen a case where
there was any indication of injury to this nerve, although in
treating many cases, particularly of gunshot wounds, the
laceration was at times most extensive." Ehrichsen never
knew a case where permanent trouble resulted from such
injury. Holmes held the same views, and Middeldorpf
makes the statement that it never occurs.
COMPOUND AND COMMINUTED FRACTURES.
Nevertheless, cases of temporary or permanent paralysis,
complete anesthesia of the parts supplied, convulsive mus-
cular movements, facial spasms, neuralgia, etc., are reported
by such authors as Desirabode, Flajani, Boyer, Bérard, Heath,
and others, as the result of fractures of the jaw and laceration
of the nerve. Chelius, in his work (1845), states that com-
monly there is much bruising and injury of the soft parts,
tearing of the nerves and accompanying vessels in the canal,
with severe nervous symptoms, convulsive movements of the
facial muscles, severe pain, deafness, or violent bleeding.
We are led to believe that either his experience in the mat-
ter was very limited, or the cases that came under his obser-
:
wil
sta'tits
FIG. 212.
P
40140
365
Mitte
vation were remarkably severe. One strongly suspects that
he has drawn largely upon his imagination for his descrip-
tion.
Surgically, nearly all fractures of this bone are compound
—that is, they communicate with the surface of the soft
parts; but, with the exception of gunshot wounds, they are
only compound as regards the interior of the mouth, the skin
generally escaping much severe laceration. Malgaigne con-
siders comminution in ordinary cases as rare, but Hamilton
reports that nearly fifty per cent. of his cases were commi-
nuted, and Elliott confirms this view by his own experience.
As this injury to the bone is rarely fatal per se, there are
comparatively few specimens to be found in the medical
museums. Heath was able to find but fourteen in all the
}

366
London hospitals. Fig. 242* represents a specimen which
was taken from a patient who, falling from a great height,
received fatal injuries. The illustration clearly indicates the
location and direction these fractures often take. There is
in this case, added to a double fracture of the condyle pro-
cesses, an oblique fracture of the right coronoid, and also
one to the left of the symphysis.
DISPLACEMENT.-As might be supposed, there is generally
more or less displacement, depending somewhat upon the
blow received, and somewhat upon the action of the muscles
attached. How much of such displacement is dependent
upon the first or the second of these causes is a disputed
point among surgeons. Garretson says:
Garretson says: "If the freed por-
tion be the anterior or chin part, it will be dragged downward
and backward by the action of the genio-hyoid, hyo-glossus,
and digastric muscles. If it be at the line of the cuspid
tooth and at the upper portion of the ramus, the fragment
will be displaced inward by the action of the mylo-hyoideus,
upward by the action of the masseteric, and forward by the
action of the pterygoidei. If the fracture be single, and
beneath the attachment of the masseter, crepitation will be
present, but little displacement. If the neck of the bone is
broken, the body is dragged forward by the action of the
pterygoid, crepitation and mobility will be very apparent,
and much pain will attend the movements of the jaw, pro-
duced by the displacing action of the temporalis." Bertrandı
states that, when the fracture is near the angle, the smaller
fragment is drawn backward by the pterygoid and masseter,
the sterno-hyoid and digastric not having power enough over
the lower fragment. Ehrichsen states that the displacement
is greater in double fracture the nearer that fracture is to
the symphysis. Very elaborate arguments have been made,
based upon the functions of these muscles rather than upon
actual and critical examination of the results of fractures.
DISPLACEMENT OF FRAGMENTS.
* From Sir William Fergusson's "Practical Surgery."
INFLUENCE OF THE MUSCLES IN DISPLACEMENT.
367
In the author's experience the actual displacement has not
always agreed with the theoretical.
Dr. Elliott says: "I believe with Malgaigne that undue
weight has been given to the action of the muscles in pro-
ducing displacement. It is admitted that in some cases mus-
cular action no doubt plays an important part, but in the
main I think it will be found that the force and direction of
the blow have had the principal share in the production of
this trouble. It must be remembered that the muscles below
the jaw, antagonized as they are by the masseter and tem-
poral, are, in common with those of other parts, in a passive
FIG. 243.
*

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state until contracted through voluntary effort, and are not
likely to oppose with any force efforts made to reduce them.
Although theoretically the anterior fragment should be
drawn downward by the hyoid and digastric muscles, yet
cases have been reported where this fragment was several
lines above the posterior."
I have noticed that where the fracture is oblique, or there
exists any comminution, there will generally be found more
or less disarrangement of the fragments. But the contrary
may not hold good, for there may be considerable displace-
ment even in vertical fractures through muscular action;
and, where that action is in the same direction as the frac-
ture, it will doubtless occur.
368
DIAGNOSIS OF FRACTURE.
Heath is no doubt correct in his supposition that in
double fracture, one on each side, the obliquity is generally
at the expense of the outer tablet of the anterior fragment;
or, in other words, the line of fracture would follow the gen-
eral direction on either side of a line drawn from the center
of the base of the tongue outward and forward, the lines
thus forming a Ʌ with the base outward. Now, where frac-
tures follow this law, their reduction, retention, and subse-
quent union without deformity are not matters of much
difficulty. But, where the obliquity is not the same on either
side, the difficulties are vastly increased. This is well shown
by Fig. 243, from Heath, representing a specimen in King's
College, London. Here, the obliquity not being the same on
either side, great difficulty was experienced in reducing the
displacement and holding the fragments in their proper rela-
tionship. In a similar case reported by Malgaigne it was
found quite impossible to reduce the displacement, the case
ending fatally.
DIAGNOSES.-The symptoms attending a fracture are rarely
obscure. There is always unnatural mobility, generally crepi-
tation, more or less pain, particularly at the seat of the frac-
ture, a good deal of salivation, with but little haemorrhage.
There is also displacement of fragments, which the irregu-
larity in the line of the teeth shows readily, together with
contusion and laceration of integuments.
Where the diagnosis is difficult, particularly if fracture of
the coronoid or condyloid process be suspected, the surgeon
by passing the index-finger into the mouth well back can, in
conjunction with the other hand, so manipulate the parts as
to detect the fracture should any exist. This examination
should be further extended to determine if there be any dis-
location, particularly if from the nature of the blow such a
result would be likely to occur.
In such cases there is almost always dislocation, or at least
displacement. Should this occur, Ribes has described an ex-
cellent mode of reduction; in fact, it is the only way it can
369
be successfully accomplished. The index-finger of the right
hand is carried into the mouth, and the displaced fragment
searched for. With the aid of the left hand, applied exter-
nally, the piece is to be replaced and held in its normal posi-
tion by forcing the jaw upward against the superior maxilla.
Prognosis is generally favorable, there being but little
danger to life save in those exceptional cases where the force
of the blow has been sufficiently great to produce compres-
REDUCTION AND PROGNOSIS.
FIG. 244.

Win
Supps &
sion or concussion of the brain, and in those cases of gun-
shot wounds where great comminution and subsequent ne-
crosis have exhausted the economy. Nor is there usually
much deformity following this fracture, unless through the
carelessness of the surgeon in charge. The simplest cases
do not require special care, and do well with little treatment;
indeed, there are many eminent medical men who place all
their reliance upon a bandage alone.
Necrosis is not a very uncommon sequence, and most
unfortunate is it for the patient when it occurs. Probably
EFFECTS OF NECROSIS.
370
in the majority of cases of non-union and false joint, it could
be traced to necrosis. Hamilton states that all his cases of
non-union were the result of this disease. Heath also con-
siders it the cause of much disfigurement.
e
FIG. 245.

Fig. 244* is an illustration of the effects of necrosis in
producing permanent deformity. It is that of a specimen in
St. George's Hospital Museum, where union had occurred
after the loss of much substance.
Figs. 245 and 246 * are taken from a model of a patient
who received a kick from a horse, causing a compound com-
FIG. 246.

minuted fracture of the lower jaw. On account of necrosis
the central portion was removed, producing the deformity
shown in the illustrations.
Irregular union, or non-union and false joint, may also
* Heath.
•
TIME REQUIRED FOR UNION.
371
occur, either from unusual difficulties in the treatment of the
case, or from neglect, or from the unwillingness of the pa-
tient to submit to the necessary restraint.
Ordinarily, fractures of the lower jaw readily unite, some-
times without the aid of art. The time necessary to reëstab-
lish bony union varies with the circumstances of the case.
Boyer considers forty days sufficient, Malgaigne thirty, while
Hamilton had one case where seventeen days were sufficient.
In my own practice I have never seen a case where there was
FIG. 247.
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positive union earlier than on the twenty-first day. Smith
had a case where this reparation was delayed one hundred
and thirty-seven days; Physick another where nine months
were necessary; while Dupuytren met with one of three
years' standing before union took place. Sometimes, how-
ever, notwithstanding all that art can do, no union will
occur, and a false joint exists at the seat of fracture. This
seems to have been the result upon one side of the jaw in the
celebrated case of Secretary Seward.*
Fig. 247, also from Heath, represents a specimen from
* See "American Journal of Dental Science," 1868, p. 218.
!
372
FIBROUS UNION AND NON-UNION.
University College, and is an example of fibrous union. In
this case it will be seen that from the ramus on the right side
to the canine on the same side the bone was replaced entirely
in this way.
Figs. 248 and 249 are illustrations of a case of ununited
fracture in the mental region, the result of gunshot injury
received in the Crimea, and reported in the "Dental Re-
view," 1858–59. The symphysis, with the incisors, right
canine, and one bicuspid tooth, having been carried away, the
jaw was divided into two unequal portions, which when at
rest remained in apposition, but when the mouth was opened
FIG. 248.
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FIG. 249. ·

there was unequal muscular action, one piece overriding the
other.
TREATMENT. The earliest form of treatment was prob-
ably by the ligature, mentioned by Hippocrates in the fifth
century B. C. It met with much favor in the early days of
surgery, and has been practiced to some extent even down to
our own time. No doubt there are cases where it might
prove the best and simplest form of treatment; it is, how-
ever, only admissible where the neighboring teeth are firmly
fixed in the jaw. The ligature, whether of metal or silk,
should always be applied to at least three teeth on each side
of the fracture, and will be found more useful on patients in
373
middle life, for at that period the teeth are held most firmly.
With the young they are more easily moved, and periosteal
trouble is more prone to follow; while in those advanced in
life they are often not sufficiently sustained by the alveoli to
withstand the necessary tension.
The objections to this method of securing the fragments
are, that the adjoining teeth are frequently loosened by the
blow, and would be still further injured by the strain of a
ligature. Even if not affected by the accident, the tendency
of the ligature is to slip down about the necks of the teeth,
irritate the gums, and produce loosening. Besides, in all
FIG. 250.
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B
TERVISE, ETTER
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The
TREATMENT WITH LIGATURES.

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cases where there is strong tendency to displacement, it will
be found impossible to reduce the fracture and retain it
accurately in juxtaposition by ligating the teeth.
Another and better method of using a ligature is to pass
it through holes drilled in the ends of the fragments. Dr.
Buck, of New York, seems to have been one of the first (1847)
to use this method, which was afterward adopted by Hamilton
and others. Dr. Kinloch, of Charleston, S. C., treated a case
successfully in this manner in 1858, using silver wire for the
ligature. In 1863, Mr. Thomas, of Liverpool, adopted a new
and peculiar method of securing and tightening the wires,
which is illustrated in the following figures.
Fig. 250 shows a case of fracture at the symphysis.
25
"
374 MR. THOMAS'S METHOD OF WIRING A FRACTURE.
B,
After the holes had been drilled through the bone at A and
"the silver wire was passed through the opening at A.
Next the tubular needle was passed through B, into the open
end of which the return end of the wire was introduced.
Then the tubular needle was withdrawn, and with it the
wire. The use of this needle is to act as a director to the
internal opening of the aperture at B, and to obviate a second
of delay in searching for the entrance from behind forward
of either openings A and B. Afterward the end of the wire
at A was inserted into the slit of the key, and twisted in three
Α.
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FIG. 251.

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B
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or four coils, the same being repeated with the end of wire
at B, until the fracture was fixed. On the fifth day it be-
came slackened, and required the use of the key in the coil
at A or B. Either would do, though it is best to choose the
smallest coil for tightening, and to notice first if the cross-
piece of the wire A is well into the slit B. This case re-
quired tightening every three or four days. In twenty days
the fracture was firm and united.”
In Fig. 251 is shown a case where but one hole was
drilled, the other end of the wire being secured between the
teeth.
Mr. Wheelhouse, of Leeds, varied this operation by the
MR. WHEELHOUSE'S METHOD OF WIRING.
375
use of flat-headed silver pins, which were passed through
holes drilled through the broken ends of the bone. After
drawing the pins through from the interior outward as far as
the heads would allow, the two points were bent in opposite
directions, and were drawn together and fastened by a silk
ligature wound around them from side to side, as shown in
Fig. 252. This illustration also shows that the ligature
passed over the tops of the teeth and through a hole in the
>>> # # «Quran
FIG. 252.

head of each silver pin. Theoretically there would seem to
be but little use for the latter part of this device.
The transition from a wire suture to a wire splint is not
difficult. Gunnel E. Hammond (Paris, 1870) devised an
appliance which was used during the Franco-German war.
But, as gunshot-wounds generally produce compound com-
minuted fractures, the cases where it might be used could
not in the nature of things have been many. To derive the
full value of this device, all or nearly all the teeth must be
376
in situ, and must be sufficiently firm to assist in supporting
the fragments.
Fig. 253 is an example of an ordinary case of fracture.
GUNNEL E. HAMMOND'S WIRE SPLINT.
FIG. 258.

ال
Fig. 254 shows the form of the wire splint, which passes
behind and in front of all the teeth, and may be made in one
FIG. 254.
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piece, as shown in the cut, or the ends may meet in front of
the central incisors and be twisted together. Fig. 255 shows
the application. The loop of fine binding-wire, shown in
377
Fig. 254, is carried around each tooth, and the ends are
twisted together on the outside, including in its folds both
sides of the splint-wire. No doubt cases occur from time to
time where this arrangement might answer an excellent pur-
pose, although, for reasons already mentioned, its use would
be limited. Furthermore, even where the necessary teeth
are in situ and are sufficiently firm, it would frequently be
found quite impossible to get any wire between them. How-
ever, when it can be used, it presents advantages in the
rigidity with which the fragments are kept in place, the
ORIGIN AND USE OF BANDAGES.
FIG. 255.

SOLUURDEN
facility with which the mouth can be kept clean, and the
absence of all external appliances.
BANDAGES. The simplest form of treatment, as well as
the most universal, is that of bandages. The origin of this
practice is hidden in the darkness of bygone ages. It is but
the natural act of the sufferer, that he may avoid the pain
caused by the moving fragments. The first recorded use of
this means is found in the works of Soranus, who lived in the
second century; and from his time to the present it has been
the most popular treatment for these injuries.
Syme says in his "Surgery": "The fragments are easily
retained in contact by tying up with a handkerchief. Paste-
378
board is sometimes used, but it is generally unnecessary, and
wood and cork wedges still less." In view of the multi-
plicity of methods to which surgeons have been obliged to
resort, as described in the following pages, this remark savors
of inexperience. Various ingenious forms of the bandage
have been introduced, each possessing some special merit in
the estimation of surgeons as applied to certain cases.
Bertrandi (1787) used the four-tailed bandage, with a hole
in the center for the point of the chin to rest in; and in
THE FOUR-TAILED BANDAGE.
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FIG. 256.

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conjunction with it wire ligatures were used for oblique frac-
tures. This form of bandage is illustrated in Fig. 256.
Gibson's bandage, shown in Fig. 257, consisted of a roller
from one and a half to two inches wide and eight yards long;
and its application is described by Garretson as follows:
"First: Place the initial extremity in front of the ear; carry
down beneath the chin; pass up on the opposite side, and
meet the initial by passing over the fronto-parietal region far
enough back to prevent slipping; repeat this turn three
times. Second: Reverse in front of and a little above the
379
ear, and make three turns around the circumference of the
vault. Third: End the third of these last turns at the occi-
THE GIBSON BANDAGE AND THE BARTON BANDAGE.
FIG. 257.

put, and carry three times around the occipito-mental circum-
ferences."
The Barton bandage, which antedated Gibson's, was ap-
plied as follows: "Place the initial extremity behind the left
ear; carry it around the side of the head over the right pari-
FIG. 258.

etal bone; cross to the right over the neighborhood of the
fronto-parietal suture; carry down beneath the chin; carry
up on the opposite side; cross on the forehead; carry around
HAMILTON'S BANDAGE.
380
the left parietal bone, and meet the beginning of the roller
at the occipital prominence or a little below it; continue the
turns until the bandage is exhausted." (See Fig. 258.)
Hamilton's method, as shown in Fig. 259, is a marked
improvement over the earlier forms. It is composed of a
firm leather strap, which passes under the chin and up over
the head, and is tightened with a buckle.
This is sup-
ported by two counter-straps made of webbing, one passing
FIG. 259.

across the forehead and the other fastened under the occiput.
It has only the slight disadvantage that it requires a special
shape, and can not be made at the moment of application;
but this objection is common to nearly all valuable appliances.
Where side-pressure can do no harm, this bandage is worthy
of general adoption.
Dr. Garretson, of Philadelphia, has introduced a still sim-
pler form, which he finds to answer every purpose in his own
practice. It consists of a strip from one and a half to two
inches wide, and a yard and a half long. By standing be-
GARRETSON'S BANDAGE AND PASTEBOARD SPLINTS. 381
hind the patient and placing the middle of the strip under
the chin, it is easily completed, as seen in Fig. 260.
A valuable adjunct to the bandage in many cases is an ex-
ternal splint of pasteboard or gutta-percha. It can be made
FIG. 260.

by taking a piece of binders' board cut in the shape of Fig.
261. It is then soaked in hot water until it has become suffi-
ciently softened, bent into the shape shown in Fig. 262, and
molded to the chin. When dry it makes a firm, close-fitting
cap, over which the bandage is carried. This splint, with
FIG. 261.
FIG. 262.


one of the foregoing bandages, and occasionally pieces of
cork or wedges between the teeth of the upper and lower
jaw, constitutes the almost universal treatment of fractures
of the inferior maxilla. Its popularity arises from its sim-
plicity. The materials, or their equivalent, are nearly always
I
GENERAL OBJECTIONS TO BANDAGES.
382
at hand. Really no ingenuity whatever is required to use
them. The majority of medical practitioners throughout the
land, such as are nearest to the patient at the time of the ac-
cident, are neither skilled in mechanics nor ingenious. It is
not surprising, then, that such simple apparatus should become
the sole reliance of most practitioners. As to the results, if
union is obtained without external deformity, the case is re-
garded as successfully treated; and yet in all but the simplest
cases it will be found upon a close scrutiny by an expert that
the grinding surfaces of the teeth of one or both fragments
have lost their natural occlusion with their antagonists. Fre-
quently only a moiety capable of actual contact remains, and
thus more than half the power of the masticatory apparatus
has been sacrificed.
The objections to the bandage and its adjuncts are, that
to do their work effectually the lower jaw must be bound im-
movably against the upper. This prevents the patient from
being properly fed, as only fluid nourishment could be re-
ceived, and not even that if the dental arch be unbroken.
To meet this objection, the corks or wedges were introduced;
but again, when there is a strong tendency to displacement,
they do not prevent it. In cases of oblique fractures the
action of the bandage causes the fragments to overlap, and
especially in cases of necrosis it contracts the jaw. In a ma-
jority of cases of complicated fractures in the author's prac-
tice, it has required great strength to right the pieces, and it
has been almost impossible to bring them into accurate articu-
lation with the upper jaw; and immediately upon the power
being relaxed, some portion would drop out of line before
even any bandage could be applied. Hamilton's objections
are, that "nearly all the bandages and slings recommended
for this fracture are inefficient, and are exceedingly liable to
displacement. That portion of the apparatus especially which
in most forms of dressing passes in front of the chin, and is
made fast under the occiput, intended only to prevent the
sling from sliding forward, does not fail to depress the
NECESSITY OF MORE EFFICIENT APPARATUS.
383
chin, and increase the tendency to overlapping of the frag-
ments."
This condition of things was recognized long ago, and
showed the necessity of appliances operating upon an entirely
different principle from any described. These principles,
and the apparatus which has been devised from time to time
in their application, should be more fully apprehended than
they are generally by surgeons of the present day; and to
this end the author has made an exhaustive investigation of
this subject in all its history.
•
CHAPTER XVII.
INTERDENTAL SPLINTS.
INTERDENTAL splints have been the occasional recourse of
surgeons for a hundred years. They were first recommended
by Chopart and Desault in 1780. The earlier forms were
nearly always used in conjunction with a submental com-
press and a clamp, which will be described hereafter. The
FIG. 263.

Jus
.1
later forms have had a bandage sometimes for an adjunct,
and at others have acted entirely by fixation within the
mouth. Since the discovery of the value of gutta-percha
and of vulcanized rubber, this form of apparatus has been
carried to great perfection.
Dr. T. B. Gunning, of New York, seems to have been
the first who used vulcanite for splints for fractured jaws.
It can hardly be regarded as a remarkable invention, as the
same material was then in common use among dentists for
splints in regulating teeth. In 1861 he made a splint similar
385
to Fig. 263, which held the jaws apart and covered both
upper and under teeth. An opening was made in front for
the reception of food, and the lower jaw was bound into the
splint by a bandage over the head. The plan of this splint
was the same as that made by Nasmyth and used by Liston
many years before. Subsequently Dr. Gunning made other
splints, which covered the lower teeth only and left the jaw
free to move. These latter were made fast sometimes by
BEAN'S INTERDENTAL SPLINT AND BANDAGE.
FIG. 264.

thread or wire ligatures around the teeth, and at others by
screws passing into holes drilled into the teeth.
In 1864 Dr. J. B. Bean, of Atlanta, Georgia, who after-
ward lost his life on Mont Blanc, treated many cases of frac-
tured jaws which occurred in the Confederate army. His
interdental splint was much the same as Gunning's, but his
compress and bandage were different. (See Fig. 264.) This
bandage will be recognized as similar to Hamilton's, but the
mental compress is made of a thin piece of wood with a
suitable padding. Dr. Bean's success in forty cases which
he treated was undoubtedly the result of the nice mechani-
386
cal skill with which he made the interdental splint. His
plan involved taking casts of both jaws, and reconstructing
the model of the fractured jaw by articulating it to the
model of the upper. His splint made upon such a model
would produce results in accordance with his skill in restor-
ing his model.
Dr. Wilhelm Suersen, of Berlin, reports the treatment,
with an interdental splint, of a number of cases of gunshot-
wounds of the jaw, which occurred during the Franco-
German war of 1870. His splint was made of vulcanite
upon a reconstructed plaster model, which method he de-
SUERSEN'S CASES OF GUNSHOT FRACTURES.
FIG. 265.
FIG. 266.
scribes as original with him, but which was the same as used
by Tomes, Bean, and Gunning, and also described and pub-
lished several years before that date by the author. Fig.
265 shows a case which came under his care five weeks after
the accident. Fig. 266 illustrates the splint left open along
the top for cleansing. After its introduction it was not re-
moved for fourteen days. At the end of seven weeks the
jaw was in a normal condition and perfectly healed.
Fig. 267 shows a case of double fracture occurring on
each side near the canine teeth. The splint made for this,
shown in Fig. 268, did not include the anterior fragment.
When the splint was applied that portion was easily pressed
into place, and remained so until the cure was complete,
which occurred in about six weeks.
!

387
Fig. 269 shows a case where the anterior portion of the
jaw, including six teeth, was carried away, and the remain-
ing portion fell together, as seen in the cut. As three
months had elapsed since the injury, and a callus had
GO 14 »
SUERSEN'S METHOD OF TREATMENT.
Till
FIG. 267.
formed, replacement was undertaken gradually. The splint,
Fig. 270, was made in separate halves, of vulcanite, and
thickened at the approximate ends, between which a brace
of hickory was used and lengthened from time to time until
the jaw was restored to its normal condition.
FIG. 209.
FIG. 268.

ос
FIG. 270.


ment.
Fig. 271 shows a case of dislocation and serious displace-
"The left fragment was dislocated inward, and at
the same time very much elevated, so that the bicuspids
touched the hard palate." The splint (Fig. 272) and the
treatment were similar to the last described case.
388
SUERSEN'S SPLINTS.
In his report of the above cases Dr. Suersen makes no
mention of bandages or any other apparatus than that de-
scribed. The author is at a loss to understand how each of
these splints could unaided have retained the broken jaw
immovably. It is my own experience, as well as that of
others, that in only rare cases will a simple interdental splint,
be it never so accurately fitted, hold the fragments immov-
ably. Either bandages, screws, wires, or ligatures of some
kind must be resorted to.
Dr. Harrison Allen treated a case in the Pennsylvania
Hospital, in 1871, under extraordinary circumstances. The
FIG. 271.
Comunis
FIG. 272.
A


patient was a laborer in whom insomnia was absolute. The
first attempt at correcting the fracture was to hold the frag-
ments in position with silver wire until the soft parts had so
far recovered as to permit a chin-cap and bandage to be ap-
plied. But, in consequence of the semi-maniacal condition
of the patient (apart from the mechanical difficulties always
attending such cases), the wiring of the teeth was of no per-
manent use. Recourse was then had to a double interdental
splint of vulcanite, upon the plan of Liston and Nasmyth;
i. e., a plate for each jaw connected together, but leaving an
opening for the reception of food. (See Fig. 273.) It was
for a time held in position by means of screws placed in
orifices previously drilled in the enamel of the molar teeth,
389
after the method proposed by Gunning. But it was after-
ward deemed advisable to pass bolt-like screws through the
entire thickness of the splint, at points corresponding to the
small normally present spaces between the cervical portions
of the crowns of the molar teeth. This modification held
the parts as in a vise, and entirely removed them from the
control of the patient. His attempts to tear the splint from
F
DR. HARRISON ALLEN'S CASE.
FIG. 273.

199
his mouth, or to dislodge it by facial contortions (which
attempts were limited only by his strength), proved inef-
fectual. By the end of the twelfth week the screws were
loosened from the lower jaw, and the parts examined. To
his disappointment, the fragments were ununited. The dis-
placement, however, did not recur. The apparatus was im-
mediately readjusted-regardless of the remonstrances of
the patient—and retained about four weeks, when the parts,
being again examined, were found firmly united.
In "Guy's Hospital Reports" for 1874 is described Mr.
26
390
Henry Moon's method of treating similar fractures. In Fig.
274, letter A shows a vulcanite splint, which is secured in its
place by wire ligatures passing around the teeth and tightened
by twisting with a pair of pliers. This splint may be used
with or without the cap B, which is fitted to the upper
teeth.
MR. HENRY MOON'S SPLINT.
The foregoing descriptions are quite sufficient to illustrate
the various forms and attachments of simple interdental
splints. Without doubt they fill in certain cases every re-
quirement.
The objection to them lies in the fact that a special
FIG. 274.

MOOX
unclea
B
A
00
splint must be made for each case, and only an ingenious
and skillful mechanician is equal to it. For the battle-field,
or for those who meet with such accidents beyond the range
of a dentist, this method of treatment is unsuited. In such
cases gutta-percha has many times been successfully used.
The first use of this substance for this purpose was by Ham-
ilton in 1849. Dr. St. George Elliott, of London, assistant
surgeon of United States volunteers during the late war,
says: "I believe, from much experience in the treatment of
these fractures, that there is no one material or apparatus
that can meet all requirements as fully as gutta-percha. It
is particularly valuable in military practice, where systems of
DR. ELLIOTT'S METHOD OF USING GUTTA-PERCHA.
391
bandaging are frequently useless from gunshot. comminution
of the jaw, and where it is impracticable to use vulcanite
splints specially adapted to the teeth.
"Where it is found desirable to use this material for the
purpose, it is first heated in boiling water, taken out and
worked in the hands, they being protected by occasional dip-
ping in cold water. A sufficient amount is taken of the mass
to construct the splint, say a roll about four inches long and
one inch thick. While still soft and warm, this roll is intro-
duced, one end first, as far back between the teeth on either
side as possible; the other end is then bent and introduced
into the mouth on the opposite side, the whole taking the
form of a horseshoe. The piece is then pressed gently
against the upper jaw and held there by one hand, while the
other gently lifts the lower jaw into contact with the gutta-
percha, forcing the points of the teeth slightly into the soft
material. The gutta-percha is now left in position in the
mouth until sufficiently hard to be removed without bending.
This may be facilitated by cooling the outside by cloths wet in
ice-water. When the material is removed from the mouth the
indentations of the teeth of the lower jaw indicate their posi-
tion, whether normal or not. If the displacement of the frag-
ments is not great, they can be forced into position by build-
ing up with softened bits of gutta-percha inclined planes, so
arranged as to act against the end of the fragment in the act
of closing the mouth, thus forcing the parts into their proper
position. I have also forced individual teeth that had been
knocked out of place into line by a slight modification of the
same means. When it has been ascertained that the parts of
a fractured jaw are where they should be, the splint is again
removed from the mouth and trimmed with a knife, and -
holes cut in the center and sides for the reception of nourish-
ment and for cleansing. The splint is now returned to the
mouth, and the lower jaw, being held against the upper by a
bandage. The patient can now talk, and without inconve-
nience take his food. Of course mastication is out of the ques-
11
›
392
tion, as the jaws are kept tightly closed until union has taken
place."
THE BEST TREATMENT FOR FRACTURES.
Mr. Walter Campbell, of Dundee, has recently described
his method of fitting a metallic splint and lining it with
gutta-percha; but his process is so complicated that a better
result could be obtained in less time and with less trouble by
using vulcanite.
The best treatment involves primarily the readjustment of
the fragments and fixation; and, secondarily, that fixation of
the bone shall not interfere with its functions nor with the
required dressing of any associated wound. As the function
of the inferior maxilla involves movement at its articulation,
it follows that the most perfect bandaging is subversive of
this function, and shows the superiority even of any of the
modes of wiring, where they have been successfully used.
Unquestionably, all things considered, the best apparatus
yet devised is an interdental splint which operates by direct
pressure on the teeth and jaws and counter-pressure on the
chin. Such an apparatus is not necessary in all cases, nor is
it applicable to every case of maxillary fracture. It would
be of no special value in a fracture of the coronoid or condy-
loid processes, nor of the rami; but for nearly all cases of
breaks in the body of the bone it is superior to all others,
and this superiority becomes more marked the more exten-
sive is the injury. Even in cases of necrosis of considerable
extent, a properly adapted interdental splint, with its adjunct,
a submental compress, will prevent contraction, and will en-
able the bone to retain without deviation its original rela-
tion.
The earliest record of an interdental splint is that of
Chopart in 1780, either invented by him, or the record of a
German method first published by him. It was made of a
brace of iron or steel on either side of the jaw, covered and
placed on the teeth with counter-pressure by screws against
a sheet-iron or other plate under the chin. Another form
used by Chopart and Desault consisted of iron or steel hooks
SPLINTS BY CHOPART, RUTENICK, HOUZELOT, ETC. 393
caught on the teeth on either side of the fracture, and tight-
ened with screws from a submental splint of sheet-iron or
other material. This somewhat crude apparatus involved all
the essential principles of the more finished inventions of
the present day.
Rutenick, a German surgeon, in 1799 made a combination
of internal and external splints, and a bandage which con-
sisted of a semicylindrical or grooved piece of silver placed
across the fracture on the teeth. This splint was held firm
FIG. 275.
CUMBERL
***********
midi
MARGELY BROKE
FIG. 276.


OF
against the teeth by steel hooks, one end of which rested on
the plate, and being curved passed out of the mouth and
straight down through holes in a horseshoe-shaped submental
splint of wood. The steel hooks were drawn tight by nuts
under the splint. Also to this wooden splint were attached
the bands which connected with a skull-cap on the top of the
head. This latter arrangement foreshadows the submental
splint and bandage used by Dr. Bean.
Bush, of England, made a similar apparatus in 1822,
which Malgaigne subsequently modified by using a cap of
sheet-lead over the teeth; and in 1826 Houzelot added still
another variation by which the submental plate was movable
391
SPLINTS BY LONSDALE, BERKLEY HILL, ETC.
on a central vertical rod, and was held in any position by a
screw.
نار
FIG. 277.

FIG. 278.
Lek
Fig. 275, reduced from the "British Journal of Dental
Science," 1877, illustrates substantially these various appli-
ances. The same principle is involved in them all, and the
variations or modifications are more for convenience than as
O
A to va

essential requisites. Lonsdale's splint was invented in 1832.
He used an ivory cap over the teeth at the seat of the frac-
ture, and his counter-pressure was derived from the lower
splint in a similar manner to Houzelot's.
MOON'S SPLINT AND EXTERNAL APPARATUS.
395
Fig. 276 shows a modification of this device by Mr.
Berkley Hill, and Fig. 277 still another variation by the
same surgeon, in using in place of the ivory cap of Lonsdale
a metallic cap made from an impression of the jaws and lined
with gutta-percha.
In Mr. Moon's paper, before referred to, he describes an
FIG. 279.
F

D
B
ETÉKELEN
C
22
apparatus used by himself, which is a kind of combination
of the Lonsdale splint and those which preceded it.
Fig. 278 shows an interdental splint made of metal and
wired to a molar tooth on the right side, and to the canine
tooth on the left side, in a case where there were three frac-
tures. Fig. 279 shows a portion of the external apparatus.
B is a vertical rod passing through the frame A and secured
396
by the nut at the lower end. The horizontal rod D enters
the mouth, and the cap E rests upon the inside splint. This
rod is fixed by the screw F. Fig. 280 shows the apparatus
in situ. The frame is made in halves, which lap on each
other and permit its being narrowed as circumstances re-
quire. A horizontal plate passes under the chin, and the
whole is sustained by webbing at the top of the head and at
the back.
MOON'S APPARATUS APPLIED.
FIG. 280.

B
A point of interest in Mr. Moon's paper is as follows:
"Mr. C. Heath, in his excellent essay on 'Injuries and Dis-
eases of the Jaws,' quotes and coincides with the opinion of
Sir W. Fergusson and other surgeons, that the majority of
cases do well with merely the simple bandage not very tightly
applied.' From this dictum, if 'doing well' means doing as
well as they might do, I must-with all respect for the au-
thority quoted-altogether dissent. . . . A properly made
interdental splint tends to shorten the time required for
union, averts pain, and prevents the formation of pus, which,
when formed at the point of fracture, is apt to pocket in the
soft parts around; and, lastly, it insures the restoration of the
exact form of the unfractured jaw."
HAYWARD'S SPLINT AND BULLOCK'S SPLINT.
397
A far simpler, and I believe an equally effective, appa-
ratus is that constructed by Mr. Hayward, of London, in
1858. He took casts of the jaw, and made a metallic plate
fitted to and covering the teeth on both sides of the fracture,
and to some extent the gums. From either side of this
splint strong bent wires were soldered, which were curved in
H
P
B
FIG. 281.

Sm
romy
F
P
H
such way that they passed out on each side of the mouth.
(See Fig. 281.) To these arms, H H, a submental gutta-
percha splint, was fastened, and the whole secured by a four-
tailed bandage—although just why a bandage was necessary
is not patent. Mr. Berkley Hill considers this the first at-
tempt made to use a plate properly fitted to the teeth.
Ten years later Dr. Bullock, of Savannah, Georgia, made
a similar splint of vulcanite. The arms were of stout iron
FIG. 282.

wire, and were set in the splint opposite the bicuspid teeth,
and, coming out at the corners of the mouth, the ends were
bent to form a loop, as shown in Fig. 282. Through these
loops a strong cord was passed, which bound the submental
splint under the chin. This submental splint was formed
from a cigar-box cover, and should show two holes on each
side, instead of one, to give it more security.
398
THE AUTHOR'S METHOD OF MAKING SPLINTS.
The most natural recourse for the treatment of a fracture,
by one who is familiar with the mechanical details in making
appliances for the mouth, is an interdental splint. Every
dentist, in correcting irregularities of the teeth, makes use
frequently of a great variety of interdental splints. The
impressions, the models, the making and the adapting of
splints, come therefore to be an almost daily practice. For
this reason it is not strange that, although the treatment of
fractures usually falls to the general surgeon, the most im-
proved appliances and consequently the best method of
treatment have emanated from dentists. And because of
this special knowledge, we find that the inventions and the
suggestions made by different ones, and original with each,
bear a striking similarity to each other. This is particularly
marked in the idea of taking a model of fractured jaws, and
correcting the displacement in the plaster model. This was
done by Tomes, Bean, Gunning, Suersen, and the author,
and probably others, each one without the knowledge of the
other, and each believing the idea to be original with himself.
THE AUTHOR'S METHOD.-For more than fifteen years I
have made and used interdental splints in various forms, as
the particular case seemed to require, and have experimented
more or less successfully with splints made of silver, tin, vul-
canite, and gutta-percha-the first three with and without
gutta-percha lining.
In cases of double or triple fracture, I have always found
much displacement and much difficulty in replacing the frag-
ments, the tendency to displacement being so strong that the
pieces would fall away again immediately on the force which
held them being relaxed; and this has been the case also
sometimes with a single fracture. The effort to reduce the
fracture has at times required much ingenuity in the manage-
ment of pries or levers between the fragments or against the
upper teeth, while at others pieces of stout cord have been
tied around certain sound teeth, and one displaced fragment
pulled in one direction and another in a different one.
THE AUTHOR'S METHOD OF MAKING SPLINTS.
The failure to always get the broken jaw into its original
shape, so as to either fit a gutta-percha splint or to even get
a correct impression, led me to abandon any attempt there-
after to reduce the fracture prior to making the splint, and
instead thereof to take an impression of the parts as they
were found, and restore the jaw in the model. The same
want of success in bringing the parts into exact apposition
made me devise the splint shown in Fig. 283. This was
entirely original with me, and its success was so great in a
number of cases that it was with a shade of mortification that
I afterward found that it was virtually a copy of Mr. Hay
ward's splint, figured on page 397.
FIG. 283.
399
B
The body of my splint has sometimes been made of vul-
canite and sometimes of cast-tin. In both cases the arms
have been imbedded in the body at the time of making.
These arms were of steel wire one eighth of an inch in diam-
eter, and, coming out at the corners of the mouth, passed
back along the cheek on a line with the teeth. They should
curve upward a little as they emerge from the mouth, to
avoid pressure upon the lower lip, and should terminate near
the angle of the jaw. Their stiffness was such that a band-
age drawn tightly from the extreme end of one arm under
the jaw to the other would bind immovably the body or in-
terdental splint to the teeth and jaw.
Fig. 284 shows the model of a case of triple fracture, and
}

*
HAMILTON'S VIEWS OF THIS FORM OF SPLINT.
400
Fig. 285 shows the application of the splint to a reconstructed
model, the same as it would be used in the mouth. It has
been a favorite idea of mine that for all fractures of the body
of the bone an interdental splint ought to be so nicely ad-
justed that the dental arch when placed in it would assume
its exact original relation, and that mastication might be per-
formed upon the top of the splint. In Fig. 285 are shown
the indentations on the upper surface of the splint made to
receive the cusps of the upper teeth; and, as such an appli-
ance is used without binding the lower jaw against the upper,
the patient is likely to use the splint to masticate upon as
w
FIG. 284.

OD
soon as he has the desire to. Another advantage which this
method has shown in practice is that, being accurately
adapted to both lower and upper teeth, there is little ten-
dency for it to get out of place; and, as soon as the frag-
ments have become united enough to prevent displacement,
the arms of the splint may be cut off and all external ad-
juncts dispensed with.
Of this apparatus Professor Hamilton very kindly says:
"The vulcanized apparatus invented by Norman W. Kings-
ley, of this city, in point of simplicity and effectiveness,
exceeds any which I have yet seen. If I were to recom-
mend any form of apparatus constructed with a view of
permitting mobility of the jaws during the process of
union, it would be this, which has been employed in a
DIFFERENT KINDS OF SUBMENTAL COMPRESS.
401
number of cases at Bellevue Hospital, and in no case has
failed to give satisfaction."*
I have resorted to various methods for making the sub-
mental splint or counter-compress. I have used pasteboard,
gutta-percha, leather, a brass cap fitted over the chin, plaster
of Paris, elastic rubber, a piece of a shingle or a cigar-box
cover, etc., etc. One of the simplest as well as one of the
best is a bit of thin board of a somewhat triangular form, hol-
FIG. 285.

Athl
lowed out at the back for the neck, with the rounded apex in
front of the chin, and the sides standing beyond the jaw.
By making a few cuts with a saw in each side, this submental
splint is easily bound with a cord laced back and forth to
the arms of the interdental splint. This compress may be
padded with whatever is most convenient. Spongiopilin I
have found to answer an excellent purpose, but it is not
always at hand, and is not essential. This method of making
the submental compress has, in addition to its simplicity, the
advantage in cases of necrosis of making only vertical pres-
* Hamilton's "Surgery," and "Fractures and Dislocations," fifth edition.
402
TREATMENT OF A CASE OF TRIPLE FRACTURE.
sure, avoiding any tendency to contraction of the base of the
jaw, and as a general thing giving an opportunity to treat
any abscess which may have formed without removing the
dressings.
Another form of submental compress is illustrated by the
following case which was treated in Bellevue Hospital: The
bone was broken in three places, viz., at the symphysis, be-
tween the bicuspid teeth, and at the angle, as shown in Fig.
286. There was considerable displacement of the fragments,
the anterior piece containing three incisors, the canine and
first bicuspid being much depressed and pushed backward;
FIG. 286.

ODMA
O
the second or middle fragment was considerably elevated
from its normal position. There was an external wound
two inches in length, reaching back from the symphysis
along the line of the jaw. This wound was dressed with
carbolic acid and glycerine, and a four-tailed bandage ap-
plied. The next day the teeth at the anterior fracture were
wired together, but the strain was so great that the wires
broke after a couple of hours. The application of wires to
hold the fragments was repeated from day to day for several
days, but continued to fail. One week from the accident the
fragment containing the molar teeth was detached. Fig. 287
represents this sequestrum full size.
SEQUESTRUM AND SPLINT.
Two weeks after the accident had occurred, impressions
were taken preparatory to making an interdental splint.
The condition in which the jaw was found at that time is
well represented in Fig. 286. The splint, which is repre-
sented by Fig. 288, was applied substantially as shown in
FIG. 287.
MA
403

Fig. 289. No effort was made to reset the jaw after the
impressions were taken until the splint was adjusted. The
fragments resumed their natural position immediately upon
FIG. 288.
رضا

the introduction of the splint and the application of the
external bandage, as seen in Fig. 289. This bandage was a
simple, broad, elastic rubber band, such as are for sale by
stationers; it covered a pad over the chin, made of gutta-
percha, softened and modeled into proper form. The elas-
ticity of the band was such as to force the fragments into
GUTTA-PERCHA PAD AND RUBBER BANDAGE.
404
the splint and bind them firmly to it, thus allowing entire
freedom to the jaw for the reception of food. The superior
surface of the splint was carefully articulated to the upper
teeth, and a little experience enabled the patient to masticate
without difficulty. During a period of ten days after the
adjustment of the splint, it was occasionally removed and
kept off for some hours, in consequence of extreme tender-
ness of the external surface. After that time it was worn
continuously (except such removals as were required for
FIG. 289.

****
HARD MARATHON LARSONS WERE CONSTANCE OF THINGS THAT
THEMES WATER SOME OF
BINET AND HERE WAS AND FAMED TRESORENTON STONES EN REINS-
***
cleansing) for two months, when union was found to have
taken place, and the articulation of the teeth was correct.
Another device which I have sometimes used is illustrated
by the following case of a carpenter, fifty-two years of age,
who was struck by a heavy bar across the left side of the
face in assisting at the launching of a vessel, March 1, 1873.
The blow produced a lacerated wound of the upper lip, an
inch long, situated three fourths of an inch above the right
angle of the mouth; also a double fracture of the superior
maxilla, and a triple fracture of the inferior maxilla. The
CASE OF FRACTURE OF SUPERIOR AND INFERIOR MAXILLA. 405
fracture of the superior maxilla extended from behind the
second bicuspid of the right side across the roof of the
mouth, through the alveolar process on the left side, in the
place where the first molar had been extracted; thence
around in front, above the teeth, to the right side. There
was also a second fracture passing between the central and
lateral incisors of the right side, running along the median
line, and intersecting the one before described. These two
fragments, containing all the teeth anterior to the molars,
were somewhat displaced, but there was little difficulty in
restoring them, and none in retaining them in position.
FIG. 270.

The lower jaw was broken in three places—one fracture
occurring at the right of the symphysis, the second at the
left of the symphysis, and the third at the neck of the con-
dyle of the right side. The displacement of the fragments
was very marked; the anterior one, containing the two cen-
tral incisors, was pulled down and backward, while the larger
fragment of the right side, containing six teeth, was de-
pressed at its anterior end, and much elevated posteriorly.
The position of the fractures and the displacement is shown
in Fig. 290.
The wound in the lip was closed with three silk ligatures,
and a four-tailed bandage applied to the jaw; but a few
days' trial proved its inefficiency, and impressions were taken
•
27
406
TONGUE-HOLDER JOINED TO A SPLINT.
preparatory to making an interdental splint. When the im-
pression of the upper jaw was removed, it detached and dis-
placed the loosened portions, but they were readily replaced,
and required no support. The splint used in this case was
an adaptation of the tongue-holder or duct-compressor, in
common use among dentists. The internal portion was
made of vulcanite over a reconstructed model of the jaw,
and the chin-piece padded with spongiopilin, as shown in
Fig. 291. Its application to the jaw is shown in Fig. 292.
The splint was applied on the 9th of March. The pa-
tient experienced no pain or discomfort from wearing it,
FIG. 291.

and ate the ordinary hospital food without difficulty. On
the 20th of March he was discharged from the hospital, and
on the 10th of April union was firm, with no deformity.
This device answers an excellent purpose for any fracture
near the symphysis. In fact, it is not essential with it, in
cases of simple fracture, that the interdental splint be made
of vulcanite, for gutta-percha may be substituted. For any
fracture behind the canine teeth, where there is much ten-
dency to displacement, it does not do so well, because the
internal splint and mental compress can not cover the pos-
terior fragment and antagonize each other with sufficient
rigidity. Recourse may then be had to the form shown in
OTHER FORMS OF INTERDENTAL SPLINTS.
407
Fig. 283; but fractures of the ramus, or of the coronoid or
condyloid process, can receive no benefit from an interdental
or any other splint except incidentally.
I have in other cases used an apparatus almost identical
with Houzelot's, and have also resorted to various other de-
vices, each including some form of clamp, but none of them
involving any principle which is not indicated in some of the
previously described inventions.
FIG. 292.

A modification has been made in the attachment of the
arms, by which they can be unshipped from the splint if
necessary without removing it from the mouth. This is
shown in Fig. 293. The connection of the arms here with
the splint is by having the end A flattened, and when used
inserted into a corresponding sheath or groove in the side of
the splint B. This method complicates the manufacture, and
possesses no marked advantage over the others except the ease
with which the arms can be detached.
1
408
SPLINT WITH ARMS DETACHABLE.
My inclination in most cases is to use the form shown in
Fig. 283. If the circumstances require that such an inter-
dental splint be made, as will involve taking a cast of the
jaw, then this form is quite as easily produced as any other,
and fills all the requirements of the more complicated and
clumsy apparatus of Moon, Lonsdale, and others. Its advan-
tages lie entirely in the skill with which the plaster jaw is
reconstructed, and the accuracy with which the splint is
AUESTOW.SC
FIG. 293.

A
B
made; for, if either of these qualities is wanting, a splint of
this form is of no more value than gutta-percha or a more
imperfect method, and may even do positive harm. I fancy
that it is because interdental splints have been so bun-
glingly made and applied that they have met with no more
favor with certain eminent surgeons who have tried them.
To a dentist, in view of the foregoing, the directions for
their manufacture are very simple, as follows: Restore to
position displaced fragments as far as can be done without
much effort, the only object being that it makes it a little
409
easier to take an impression. I have always used plaster for
such an impression, and see no reason for using any other
substance, and indeed know of no other substance as good.
The impression of the deranged fragments may be taken as
a whole in an impression-cup; or, if inconvenient to do so,
it can be taken in sections without any cup. Either course,
in my practice, has answered equally well. The only object
is to obtain casts of all the fragments, either together or
separate. Take also in plaster an impression and make a
cast of the upper jaw. No dentist should be at all in doubt
as to the relation which the fragments of the lower jaw
should hold to the upper. There are invariably, even if
there are but few teeth in the mouth, certain marks of abra-
sion on the antagonizing surfaces which identify with exact-
ness the position which the fragment formerly sustained to
the upper jaw; and like means of identification I have never
failed to find even in mouths of children where there were
shedding and erupting teeth; therefore there is no excuse
for failing to reconstruct the model of the lower jaw, and
make it identical with the original in its normal condition.
Upon such a model the construction of the splint of vul-
canite involves no manipulations which are not common.
Sheet-wax, a single line in thickness, carefully pressed over
the teeth, and to a little extent encroaching upon the gums,
gives the form required. If the fracture is in front, the
splint need not cover all the back teeth; but, if it be at the
sides, it is better to cover all the teeth of that side. It is
also better to set the casts of the upper and lower jaw in an
articulator, and thus make prints of the upper teeth in the
wax, to be retained in the splint.
One of the easiest things of which to make the arms is
a couple of discarded excavators, flattening the ends which
are to be imbedded, and curving them with much care, after
the form indicated in Fig. 285. The flattened ends should
be made quite broad and thoroughly imbedded in the splint,
as much strain comes upon them. The subsequent steps are
DIRECTIONS FOR MAKING A SPLINT.
•
410
TIIE ADJUSTMENT OF A SPLINT.
familiar to every dentist. In finishing, it is better to enlarge
the sockets for the teeth a little, so that there will be no im-
pinging upon the crowns when the splint is introduced, and
also to make openings through the top or side against each
tooth adjoining the fracture, so that it can be determined
when the fragments are fully in their place. These latter
holes will be convenient to use in cleansing the apparatus by
inserting in them the nozzle of a syringe.
If the splint is properly made, the teeth of each frag-
ment will follow into the indentations prepared for them
without severe pressure; if they do not, it is quite as well
to bind the splint to its mental compress and await events.
It will probably be found a few hours later that they have
regained their place without further aid. The free move-
ment of the jaw has a tendency to work the displaced frag-
ments into position. In a healthy subject the fracture will
require but little treatment beyond the adjustment of the
splint. Great relief is felt almost immediately that the parts
are restored and bound in their normal position, and cleans-
ing the mouth with suitable antiseptic washes is the principal
care required.
If there are external wounds or abscesses, they will be
treated according to the requirements of each case, where
rules will be of little benefit, and the dressing must be left
to the judgment of the one in charge.
It is quite evident from what has been written that inven-
tion in the treatment of fractures of the lower jaw, especially
within the past one hundred years, has been most active, and
the apparatus of to-day is but a modification of that of yes-
terday or of a century ago. The idea of a splint of univer-
sal accommodation seems to have possessed in some degree
the mind of every inventor; but it is also evident that, the
more general the application of any particular apparatus, the
more clumsy it becomes.
The experience and observation of the author lead to
the following conclusions: That, in the present state of the
VALUE OF GUTTA-PERCHA FOR A UNIVERSAL SPLINT. 411
arts, the only interdental splint in the hands of the general
surgeon, which can make any claim to be of universal appli-
cation, is one that can be made at the moment by a person
of moderate ingenuity from gutta-percha; and to Hamilton
is due the credit of its first application.
When gutta-percha fails, as it has in my practice fre-
quently, even where it was inclosed within a covering of
metal, recourse must be had, I think, to one of the forms.
of clamps of which so many have been devised; and it is
hardly wise to regard one form as certainly the best in all
cases.
In a fracture at the angle, or of the ramus, or of the
coronoid or condyloid process, uncomplicated by a fracture
in the body of the bone, an interdental splint would be of
no value, while a bandage would be clearly indicated.
As before intimated, the success of any specially made
interdental splint will depend much more upon the mechani-
cal skill and nicety of its construction than upon the peculiar
principle involved in it. The best results are not likely to
be obtained by using only one form of splint, without refer-
ence to the location or direction of the fractures, and success
will depend quite as much upon the judicious selection of
apparatus already proved as upon any effort to increase the
present large variety.
PART IV.
MECHANISM OF SPEECH.
CHAPTER XVIII.
PHYSICS OF SOUND AND PHYSIOLOGY OF THE VOICE.
ARTICULATE speech is the result of vocal sounds, single
or combined, continuous or interrupted, varied by pitch, vol-
ume, and intensity. It is based upon the physics of sound,
a knowledge of the latter being essential to a comprehension
of the mechanism of the former. All sounds, whether har-
monious or discordant, are caused by the vibrations of mat-
ter. Musical sounds and noises are equally the result of
vibrations; the first being the result of periodic or regular-
recurring vibrations, and the second of those which are ir-
regular, confused, non-periodic. Wherever there is. sound
there is motion; and, conversely, wherever there is motion.
there might be sound, if there were a medium by which the
vibrations could be conducted to our ears, and our ears were
capable of apprehending the vibrations.
As our ears are constituted, they will not appreciate a
sound which is the result of less than 16 vibrations to the
second, nor will they take cognizance of sound when the
vibrations exceed 40,000 per second. The lowest note of the
double bass in an orchestra has 403 vibrations to the second,
while occasionally an organ-pipe is introduced the note of
which has but 16 to the second. The lowest C in a piano of
7 octaves has 32 vibrations, and the highest C 4,096. At
10,000 vibrations, sound becomes piercing and loses its mu-
#
413
sical character. At 32,000 to 40,000, the ear fails to take
cognizance of the successive shocks. The vibrations which
reach our ears may arise from a multitude of causes. They
may originate in the air itself, or in some substance far re-
moved, and be conveyed by the air to us.
The same number of vibrations always produce a sound
of the same pitch, without reference to the substance or
cause of motion; the duration, intensity, and quality may
differ, but the pitch, with the same number of vibrations, is
invariably the same. The intensity, strength, or loudness of
sound is due to the amplitude of vibrations, or the distance
the vibrating body traverses and the length of time the vi-
brations continue.
ALL SOUNDS COMPOSED OF DIFFERENT TONES.
No sound, emanating from whatever cause, and heard by
the ear as a single sound, is a simple sound; it is always a
compound or composite one, made up of a number of tones
of different intensity and pitch, together with a possible ad-
mixture of noises, which combined constitute the sound as
heard. For example, if a string drawn to the proper tension
to emit a sound be plucked, it will not vibrate throughout
the entire length as one vibration, but will be divided and
subdivided into vibrating segments of varying lengths, each
of which will emit a different tone. The longest segment,
producing the most ample vibration, gives the loudest tone,
and also the pitch to the clang, and its sound is called the
fundamental tone. The other tones made by the shorter
segments mix with the fundamental tone, the higher in pitch
being the overtones, and the lower in pitch the undertones;
and the whole constitutes the clang which is heard as one
sound. The fundamental tone is always associated with
tones higher or lower in pitch, or with both, which modify
it. The difference in the quality or timbre of the same
musical note as emanating from different instruments, such
as the violin, clarionet, and organ, is due to the different.
admixture of overtones and undertones with the fundamental
note.
414
THE REËNFORCEMENT OF SOUND BY RESONANCE.
,
The medium through which sonorous vibrations are gen-
erally received by the ear being the air, we find such vibra-
tions affected by the substances with which they come in
contact. Soft substances will absorb sound, while hard ones,
on the contrary, will reflect sound. A room hung with
massive drapery will muffle and absorb sound, while one with
polished walls will reflect and echo it.
One of the most interesting phenomena of the physics of
sound is its augmentation or reënforcement by secondary
causes. A sound emitted by one body may cause another
sounding body, capable of the same number of vibrations,
to become sonorous by vibration, and the sound will then be
repeated, augmented, and prolonged; but the two sounding
bodies must be attuned in unison. For example, a musical
sound made near the strings of a piano will cause the strings
in unison with it to vibrate and emit the same sound, which
may be continued even after the first has ceased. A hollow
body or a short tube closed at one end, containing a column
of air of a certain length, can be made to resound by bring-
ing its open end near a sounding body. The sound emitted
throws the column of air into motion, and these vibrations,
being identical with those of the sounding body, augment or
reënforce the original note. If the column of air in such a
resonating tube is not in unison with any tone of the com-
bination or clang, no response will be heard; but, if in uni-
son with any tone of the clang, such tone will be augmented
or reënforced. Thus, a resonating body may augment the
fundamental tone, or, by unison with one of the overtones or
the undertones, will reënforce that to the exclusion of all
others. The shape of such resonating cavities may be va-
rious; the material of which they are constituted is not im-
portant; wood, glass, metal, rubber, or putty can be formed
into a resonating cavity. Resonance depends more upon the
form and dimensions of the cavity than upon the substance
of its walls.
The recognition of this phenomenon is the key to the
ORIGIN OF THE HUMAN VOICE.
415
mechanism of speech. Man speaks with his voice, and voice
is simply sound caused by vibrations, and subject to all the
laws which govern sound arising from any other source.
The apparatus which produces voice is both simple and com-
plex-simple in its action, but complicated in its structure,
and still more complicated and wonderful in its results. The
combined power, the compass, and the richness of tone of the
human voice are unapproached by strains from any other
instrument.
Voice is intimately connected with one of the vital func-
tions of life. Every breath we breathe can, with slight effort,
be made to utter a sound. The vocal apparatus depends upon
the breathing apparatus for its action and its power. The
same current of air driven from the lungs in natural respira-
tion, will produce sound by the slightest alteration in the form
of the air-passages.
"The principal organ concerned in the production of the
voice is the larynx (see Fig. 294, A A). The accessory organs
are the lungs, trachea, the expiratory muscles, and the mouth
and resonant cavities about the face. The lungs furnish the
air by which the vocal chords are thrown into vibration, and
the mechanism of this action is merely a modification of the
process of expiration. By the action of the expiratory mus-
cles the intensity of vocal sounds is regulated. The trachea
not only conducts the air to the larynx, but, by certain varia-
tions in its length and caliber, it may assist in modifying the
pitch of the voice. Most of the variations in the tone and
quality, however, are affected by the action of the larynx
itself, and of the parts situated above it.
"It is impossible to give a complete account of the struc-
ture of the larynx, without going more fully than is desirable
into purely anatomical details. We propose here only to refer
to the situation of the vocal chords, and to indicate the modi-
fications which they can be made to undergo, in their relations
and tension, by the action of certain muscles.
"The vocal chords are stretched across the superior open-
ANATOMY OF THE VOCAL ORGANS.
416
ing of the larynx from before backward (Fig. 294, B and C).
They consist of two pairs. The superior (B), called the false
vocal chords, are not concerned in the production of the voice.
They are less prominent than the inferior chords (C), although
they have nearly the same direction. They are covered by
an excessively thin mucous membrane, which is closely ad-
Ed
FIG. 294.

100
herent to the subjacent tissue. The chords themselves are
composed of fibers of the white inelastic variety, mixed with
a few elastic fibers. The true vocal chords (C) are situated
just below the superior chords. The anterior attachments
are near together at the middle of the thyroid cartilage, and
are immovable. Posteriorly they are attached to the mov-
able arytenoid cartilages; and, by the action of certain mus
417
cles, their tension may be modified, and the chink of the
glottis may be cpened or closed. These ligaments are much
larger than the false vocal chords, and they contain a very
great number of elastic fibers. Like the superior ligaments,
they are covered with an excessively thin and closely-adherent
mucous membrane.
PHYSIOLOGY OF THE VOCAL ORGANS.
"Anatomists usually divide the muscles of the larynx into
extrinsic and intrinsic. The extrinsic muscles are attached
to the outer surface of the larynx and to adjacent organs,
such as the hyoid bone and the sternum. They are concerned
chiefly in the movements of elevation and depression of the
larynx. The intrinsic muscles are attached to the different
parts of the larynx itself, and, by their action upon the articu-
lating cartilages, are capable of modifying the condition of
the vocal chords.
"During ordinary expiration none of the intrinsic mus-
cles seem to act, and the larynx is entirely passive, while the
air is gently forced out by the elasticity of the lungs and of
the thoracic walls. But as soon as an effort is made to pro-
duce a vocal sound, the appearance of the glottis undergoes
a remarkable change, and it becomes modified in the most
varied and interesting manner, with the different changes in
pitch and intensity which the voice can be made to assume.
Although it is sufficiently evident that a sound may be pro-
duced, and even that words may be articulated, with the act
of inspiration, true and normal phonation is effected during
expiration only."
" *
The trachea conducts the air from the lungs to the larynx,
and reënforces the sound to some extent by vibrations of the
column of air in its interior. The trachea can be elongated
and shortened at will. It is shortened and its caliber in-
creased in the production of low notes, and elongated and
contracted in the higher ones. The larynx also varies in
capacity in the same individual, both its length and breadth
* Flint.
CAUSE OF THE RESONANCE OF THE VOICE.
418
being diminished in high notes and increased in low
ones.
"The most important modifications of the laryngeal
sounds are produced by the resonance of air in the pharynx,
mouth, and nasal fossæ. This resonance is indispensable to
the production of the natural notes. The velum palati is
fixed by the action of its muscular fibers, so that there is a
reverberation in the bucco-pharyngeal and naso-pharyngeal
cavities; that is, the velum is in such a position that neither
the opening into the nose nor into the mouth is closed, and
all of the cavities resound (D, Fig. 294).
"As the notes are raised, the isthmus contracts, the parts
immediately above the glottis are also constricted, the reso-
nant cavity of the pharynx and mouth is reduced in size,
until finally, in the highest notes of the chest register, the
communication between the pharynx and the nasal fossæ is
closed, and the sound is reënforced entirely by the pharynx
and mouth. At the same time the tongue, a very important
organ to singers, particularly in the production of high notes,
is drawn back in the mouth. The point being curved down-
ward, its base projects upward posteriorly and assists in
diminishing the capacity of the cavity.
"In the changes which the pharynx thus undergoes in
the production of different notes, the uvula (E) acts with the
velum, and assists in the closure of the different openings.
In singing up the scale, this is the mechanism, as far as the
chest-notes extend. When, however, we pass into what is
known as the head-voice, the velum palati is drawn forward
instead of backward, and the resonance takes place chiefly in
the naso-pharyngeal cavity.'
"*
Difference of pitch in voices is due chiefly to the greater
length of the vocal chords in low-pitched voices, and to their
shortness in higher ones. The same note sung by a male
voice and a female voice shows the difference of an octave,
* Flint.
MODIFICATIONS PRODUCED BY ACCESSORY ORGANS. 419
owing to the difference in the number of vibrations. In
the low chest-tones the vocal chords are elongated, and at
the minimum of tension that will allow of regular vibration.
Differences in quality are due to peculiarities in the con-
formation of the larynx, and to variations in the size and
form of the auxiliary resonant cavities. Many of the dif-
ferent qualities of the human voice are due to the differ-
ence in the length, breadth, and thickness of the vibrating
ribbons.
Voice is produced first, and to a limited extent, by the
vibration of the column of air in the larynx during the act
of expiration; secondly, and principally, by vibrations of the
vocal chords; and, thirdly, by resonance in the buccal and
nasal cavities.
The accessory organs in producing modifications of the
voice are the pharynx, the velum palati, the tongue, teeth,
and lips.
The pharynx (F F, Fig. 294) may be likened to a muscu-
lar tube or bag, open and continuous below the œsophagus,
open
and continuous above with the nasal
passages, and
open
also in front to the buccal cavity. Its walls are muscular,
and capable of powerful contraction, even to complete closure
of the passage. The pharynx executes an important office
as an organ of speech-passively as a resonating cavity, and
actively by the movements of its constrictor muscles. By
them the upper portion of the pharynx is contracted, and its
posterior wall advanced until it meets the palate, and thus
throws the voice forward into the buccal cavity. This action
of the pharynx can be studied with ease in cases of cleft
palate. Movements which are hidden in a normal condition
are then fully exposed to view. I have observed many cases
where, in the effort to produce certain sounds, the superior
constrictor would develop a ridge or roll of considerable
magnitude horizontally across the pharynx. This pharyngeal
movement, important in normal articulation, becomes an es-
sential requisite to success when articulation with an artificial
420 INFLUENCES OF THE PALATE, TONGUE, TEETH, ETC.
palate is attempted. In a normal condition, the posterior
nasal passages are closed by the combined action of the
palate and the constricted pharyngeal wall. In an abnormal
condition of absence of the palate, the pharyngeal action may
be made to perform the office of both.
The velum palati or soft palate is a muscular curtain,
attached to the posterior edge of the bony roof of the mouth
or hard palate, and hangs down as a partition between the
buccal and nasal cavities, forming the double-arched boundary
to the fauces, with the pendulous uvula dropping like a tas-
sel from its center margin (Fig. 294, D E). It is composed
entirely of muscular tissue, and is overlaid with mucous
membrane. It moves like a valve between the buccal and
nasal cavities-now against the pharynx, directing the out-
ward current through the mouth, now against the dorsum of
the tongue, directing the current through the nose, and again
hanging between the extremes, dividing the current and col-
umn of sound, and permitting it to pass through both chan-
nels. In another chapter are ample illustrations of the dis-
astrous results to articulation which follow its loss. It is
only necessary to bear in mind that more than three fourths
of the sounds of articulate language depend upon the integ-
rity of the palate for their perfect enunciations.
The tongue is generally regarded as the most important
organ of speech; but it is said that there are numerous
instances where the tongue has been lost by accident or de-
sign, and the sufferer continued to articulate as before. In
variety of movement, the tongue plays the most important
part in altering the resonating capacity of the buccal tube or
cavity.
The teeth, as organs of articulation, have not received the
attention from dentists that their importance demands. They
have been regarded by them almost universally as organs of
mastication merely; and, when artificial ones were required,
if the masticating ability was secured without seriously inter-
fering with the looks, both dentist and patient were satisfied.
INFLUENCE OF THE LIPS, NARES, NOSTRILS, ETC. 421
The neglect to recognize them as important organs of speech
has arisen partly from the general ignorance in reference to
the mechanism of speech, and partly because neither the en-
tire loss of the natural teeth, nor the substitution of very
inferior artificial ones, has actually destroyed articulation.
Nevertheless the dentist may interfere very seriously with
the comfort of both a speaker and listener by a badly ar-
ranged artificial denture.
The only remaining organs to which attention is directed
in this system for the production of speech, are the cheeks
and lips, nares, and nostrils; but their physiological action is
not such as to require here an extended notice, further than
to say that any considerable departure from a normal con-
dition, through deformity or disease, will impair their func-
tions. Morbid growths in the nares, destruction of the tur-
binated bones or the vomer, a fissured lip, or an enlarged
nostril, commonly associated with a hare-lip, are all abnormal
conditions affecting articulation.
<<
Having thus made ourselves familiar with the physics of
sound and the physiology of the voice, it remains to describe
how voice becomes speech. Articulate language is an aggre-
gation of definite sounds associated with definite ideas, which
in the progress of time has become so complex a system that
nearly every idea of the most subtile brain can be conveyed
to another mind by sound alone, and from habit we come to
regard the idea and the words which express it as almost
identical. It is difficult to think, and impossible to reason,
without our thoughts formulating themselves into words.
But thoughts were not first formed into words and then
uttered in speech: words are the outgrowth of the effort to
express ideas by sound and the combinations of sounds. It
is the natural instinct of a child to express its general wants
by sound, and, as it develops in intellect and its wants become
more definite, it adopts from its superiors the sounds which
express its specific wants.
A remarkable illustration of how naturally a human being
·
28
4
THE NATURAL ORIGIN OF ARTICULATE LANGUAGE.
422
resorts to sounds to express its wants, without adopting the
conventional form, occurred in my own family. A little
daughter of mine had a nurse in infancy who was very mu-
sical, and was constantly singing or humming little strains of
music. The child caught them up and associated certain
notes or strains with its own wants and ideas. Until she
was nearly three years of age she rarely articulated a syl-
lable beyond "papa" and "mamma." I began to fear she
never would speak. During this period all her wants were
made known by harmonious strains, which we came to under-
stand as readily as if it were our own vernacular. It was
astonishing to observe to what extent and perfection this
musical language of a child could be carried.
man.
So habituated are we from infancy to interpreting sounds
as expressing definite ideas, that few of us ever realize that
this is one of the most wonderful functions possessed by
All articulate speech must of necessity be acquired ;
there can be no natural language. The accepted arrange-
ment of sounds is purely arbitrary, and derives its power
from the common consent and use of such arrangement; in
this way isolated communities tend to form dialects, and in
time apparently different languages. With such an elaborate
system as the speech of civilized nations has now become,
expressing by sound the nicest shades and distinctions of
thought, we might expect to find the mechanism of speech
so complicated as to be beyond our comprehension; but the
investigations of scientists within the last few years, particu-
larly since the introduction of the laryngoscope, have cleared
up and exposed the nature of vowel-sounds, which was in-
comprehensible for ages.
The human voice is caused by the action of the expiratory
muscles driving the breath outward through the larynx. The
sound produced by vibrations of the vocal chords is not a
simple sound, but a clang. The buccal cavity and the nasal
cavity become resonators; the palate, tongue, jaws, cheeks,
lips, and nostrils being capable of altering and modifying the
THE ORIGIN AND EXPLANATION OF VOWEL SOUNDS. 423
form and dimensions of these cavities to a very great extent;
but whatever shape they assume they will have, like all other
hollow bodies filled with air, their own tone-character in each
different form and dimension. Consequently, as the sound
passes out through the mouth, some one tone of the clang
which is in unison with the tone-character of the buccal cavity
at that moment will be augmented and intensified. This re-
enforcement by resonance changes the quality or timbre of
the laryngeal clang. "In this changed timbre consists the
nature of vowel-sounds. A vowel is the timbre which re-
sults from the increase by resonance of one or more tones in
the laryngeal clang."*
Pure vowel-sounds can be made only by resonance of
the buccal cavity alone and in its normal integrity. Let
any other cavity communicate with it, and its tone-character
is destroyed, and par consequence the purity of its vowel-
sounds; make a communication with the nasal cavity, either
great or small, and pure vowel-sounds are impossible. The
power to change the shape and size of the oral cavity being
great, equally great is its power to change the laryngeal clang.
This change of timbre in the clang may be continuous and
uninterrupted within the compass of the voice, from the
lowest tones to the highest; and what are called the different
vowel-sounds are but points along this vocal stream which
our ears distinctly mark and separate one from another.
Articulate language may adopt as many divisions of this
vocal stream as the ear can distinguish, but practically it is
not desirable to burden a language with extremely nice shades
of sound. Max Müller says, "Vowels in all their varieties
are really infinite in number." As a precise statement this
can not be correct, and as an approximate statement it is only
theoretically true. The human voice is heard only within
certain limits, and practically there can be no more vowels
than appreciable changes of timbre and pitch within those
limits.
* Professor Elsberg.
I
THE MECHANISM OF THE FORMATION OF VOWELS AND CON-
SONANTS.
CHAPTER XIX.
THE five most distinctly marked vowel-sounds used in the
English language are OO, O, AH, A, E.* These five vowels
Lo
1:1
MOGUD OF
00
****
FIG. 295.

BROSS
are not to be confounded with the five vowel letters of the
English alphabet, a, e, i, o, u. The English names of these
* Dr. Bristowe, in a recent lecture before the Royal College of Surgeons,
England, makes thirteen vowel-sounds in the English language, which he illus-
MECHANISM OF 0.
letters do not express the distinction between the principal
vowels as well as the Italian pronunciation of the same let-
ters. OO is the original Anglo-Saxon name for U. In Eng-
lish the sounds AH and A, which are distinctly separated in
the laryngeal clang, are expressed by one letter; in Italian
the same sounds are expressed by A and E. The written
vowels in both languages are the same, but the spoken vowels
represented by them differ; we are obliged, therefore, to
fabbaaa
300
O
425
FIG. 296.

adopt the designations of 00, O, AH, A, E, to express in
English the five principal vowels.
trates by the fundamental vowel in each of the following syllables or words:
past, pat, pet, pate, pit, peat, pauper, pot, potent, put, boot, pur, putty. But even
this illustration will not suffice to convey a clear apprehension of his designa-
tions. The words which he has chosen are not pronounced uniformly wherever
English is spoken. Cultivated scholars use a different vowel in some of them
from what the lecturer evidently intended. (London "Lancet,” April, 1879,
p. 507.)
426
MECHANISM OF AH.
These sounds constitute the fundamental vowels of nearly
all the languages of the world. In the production of these
vowels, according to Tyndall, the laryngeal clang undergoes
the following changes: "For the production of U (00 in
hoop) I must push my lips forward so as to make the cavity
of the mouth as deep as possible, at the same time making
the orifice of the mouth small. This arrangement corre-
sponds to the deepest resonance of which the mouth is ca-
AH
FIG. 297.

6.5.8 HOss,
pable. The fundamental tone of the vocal chords is here
reënforced, while the higher tones are thrown in the shade."
In Fig. 295 is shown the position which the tongue, pal-
ate, and lips assume in making 00. The tip of the tongue
is much depressed in the floor of the mouth and its back
lifted high toward the soft palate, but it does not touch the
roof of the mouth at any point; the jaws are opened and the
lips contracted, so that the oral cavity becomes bottle-shaped,
427
and the passage through the nares is completely shut off by
the conjunction of the palate and pharyngeal wall.
"The vowel O is pronounced when the mouth is so far
opened that the fundamental tone is accompanied by its
strong, higher octave." In Fig. 296 the organs are repre-
sented; the lips are not so close, and the tongue is not so
much retracted at the tip nor lifted so high at the back as in
the former illustration.
A
1
MECHANISM OF A.
FIG. 298.

BROSS.NY.
"In the production of the sound AH, the higher over-
tones come principally into play. The second tone may be
entirely neglected; the third rendered feebly; the higher
tones, particularly the fifth and seventh, being added strong-
ly." In Fig. 297, illustrating the organs during this sound,
we see the oral cavity distended to its greatest capacity; the
mouth is wide open; the tongue lies comparatively flat, and
the veil of the palate is lifted to its highest elevation. To
make a resonating cavity which shall produce AH, some per-
MECHANISM OF A.
428
sons curl the sides of the tongue upward in the form of a
trough, while in others the same cavity is formed with the
tongue full along the median line.
"The vowel A derives its character from the third tone,
to strengthen which by resonance the orifice of the mouth
must be wider, and the volume of air within it smaller than
in the production of O. The second tone ought to be added
in moderate strength, while weak fourth and fifth tones may
also be included with advantage." In Fig. 298 the marked
change from AH is seen in the elevation of the tongue, and
FIG. 299.

A
a reduction in the dimensions of the vocal tube. We find
now, for the first time thus far, the tongue touching the roof
of the mouth. This contact is shown in Fig. 299 by the
black patches on the alveolar border against the molar teeth.
The method by which this was determined is described fur-
ther on.
"To produce E, the fundamental tone must be weak, the
second tone comparatively strong, the third very feeble; but
the fourth, which is characteristic of this vowel, must be
intense. In order to exalt the higher tones which character-
ize the vowel-sound E, the resonant cavity of the mouth
429
must be small." In Fig. 300 we see the tongue lifted higher
than in making any preceding vowel, and the resonant cavity,
in both form and dimensions, in striking contrast with that
of OO. In E, it partakes of the nature of an elongated
tube. The reduction of the vocal passage is also seen in
Fig. 301, where the contact of the tongue is shown to extend
the whole length of the sides of the alveolar border.
E
MECHANISM OF E.
FIG. 300.

A.5.BROSS
The foregoing five illustrations cover the entire compass
of vowels from the highest to the lowest; all the others
heard by Bristowe, and more even as claimed by some, find
their relative position somewhere between the extremes of
E and U (OO). It will be observed that in each of the sec-
tional illustrations the soft palate is elevated, the pharyngeal
wall bulges forward, and the uvula lies in firm contact against
it. This shutting off of the nasal cavity is essential to the
purity of vowel-sounds. If there be any escape of breath
FRENCH NASAL VOWELS.
430
or sound, however small, behind the curtain of the palate,
the vowels will be nasalized.
This is the explanation of the peculiar vowels of the
French language. In addition to those used in English,
there are several which are characterized by resonance of the
nasal cavity, showing that, at the time of their formation,
the palate and pharyngeal wall are relaxed. These nasal
vowels are essential to the perfection of the French language,
but when introduced into English destroy its purity. This
is a loose habit of speech among some English-speaking peo-
F.....akosS.
+
FIG. 301.

لا
ple into which large communities have fallen. By a slack
conjunction of the posterior border of the palate and the
pharyngeal wall the whole speech is affected disagreeably.
The illustrations here used are the result of personal
studies of the organs in action in many cases, and are the
record of one mouth in particular with well-developed or-
gans. The means adopted were as follows:
I made a cast of the roof of a mouth extending back
and down to the boundary of the fauces, and upon this cast
fitted a very thin and delicate plate of black vulcanite, cover-
ing the entire roof within the teeth and the palate. Two or
431
three such plates were made, duplicates of each other in the
roof of the mouth, but varying in the palatine portion. One
of these plates is shown in Fig. 302. In this one, the sides
of the posterior or palatine portion have been cut away,
leaving a tongue extending down to the uvula; one of the
others covered the whole palate, and in another the whole
palatine portion was cut away. When used to test articula-
tion, one of them was painted with a film of chalk, wet up
with alcohol so that it would dry quickly, and then intro-
EXPERIMENTS IN ARTICULATION.
FIG. 302.

duced into the mouth, and the sound to be experimented
upon made as clearly and distinctly as possible, and the plate
removed. If the tongue touched the roof of the mouth, the
teeth, or the palate in any part, the white surface of the chalk
was removed, exposing with the utmost distinctness the black
surface in contact. The form of the contact in a given sound
was delineated upon a clean plaster cast of the roof of the
mouth, and the experiment continued with the same or some
other sound. Those plaster casts were copied in the fore-
going and following illustrations.
These experiments were repeated over and over again
EXPERIMENTS IN ARTICULATION.
432
with the same sounds at different times and on different days,
until uniformity was proved and the various plaster casts
became a record of the exact position of the tongue in mak-
ing these sounds. The separations of the jaws and lips were
determined accurately by measurement, the varying positions
of other organs by repeated observation and other tests, and
all drawn to a uniform scale and here reduced. They are
therefore consistent with each other. But it must be borne
in mind that, even if it were possible to obtain absolutely
accurate models of the organs of speech while in action, of
any number of cases, it is not probable that any two of them
would be exactly alike. It is not supposable that all persons
in making the same sound place the active accessory organs
-the tongue, palate, etc.-in the same identical position.
Variations to a greater or less extent can be observed in every
one. Exactly the same resonating cavity in shape is not likely
to exist in any two jaws. With the fixed portion of any buc-
cal cavity differing somewhat in form from every other, the
changeable portions, such as the tongue and palate, adapt
themselves to the circumstances and produce a resonating
cavity of the same tone-character. The variations in the
position of the articulating organs as seen in different per-
sons in producing the same sound are then understood. So
long as the integrity of the accessory organs is preserved a
resonating cavity of like tone-character can be formed.
The limits of this chapter will not permit an analysis or
explanation of the mechanism of all the sounds that combine
to form articulate language. As it is intended solely for the
English reader, no attempt will be made to describe such
sounds as may form an important element of other languages,
but which are not heard in any word in English. To a reader
who is unfamiliar with a foreign language it is very difficult
to convey, other than by vocal demonstration, an apprehension
of those sounds which are peculiar to that language. Nor
shall we undertake an investigation into certain nice distinc-
tions of pitch, timbre, and tone, which would lead us away
DIVISION INTO VOWELS AND CONSONANTS.
433
from our main object. We shall rather confine ourselves to
the distinct sounds of the English language appreciable to
nearly all ears, and represented by characters or letters. The
difference between these is so well marked and the mechanism.
of their formation so positive that we can discover it, describe
it, and illustrate it.
Articulate speech is made up of vowel and other sounds
-pure, interrupted, or checked. The English language, like
all other languages, is divided into vowels and so-called con-
sonants. Authorities disagree as to the exact number of
vowels for the reasons before given, and they also disagree
as to the number of consonants. One reason of the disagree-
ment is that some class all the sounds other than vowel as
consonantal; others subdivide these, reducing the number of
real consonants; and the disagreement is still further in-
creased by the divisions not being always the same.
Again, there would be a difference as to the whole num-
ber of sounds to be called by any name. Accepting for the
present the term consonant as including all sounds other than
vowel, we find them classified as labial, dental, palatal, and
nasal, each term bearing some relation to the locality in which
the formative action takes place. There are various other
divisions and subdivisions of consonants, making distinctions
of great interest to the physiologist and phonologist, but
which are also beyond the scope of our present purpose.
These interruptions to the phonetic stream are of equal im-
portance to articulate speech with the vowel-sounds, as the
stoppage of a sound may become as distinctly associated with
an idea and express it as the sound itself. This oral current,
which by modifications, interruptions, and stops forms the
consonants, is not a vocal stream like that of the vowels, but
it is a breath-current driven from the lungs in the same man-
ner, sometimes accompanied by vocal vibrations and some-
times not; nearly one half of the consonants are formed
without voice, and are simply breath-currents of greater or
less force, modified by resonance or interrupted by the acces
•
•
POINTS OF INTERRUPTION IN THE ORAL STREAM.
434
sory organs. Every breath-consonant in the English language
has its associated vocal fellow; i. e., in every instance in
which a breath-sound becomes an element in our language,
NICE
FIG. 303.

there is another element added by vocalizing a like breath-
current.
There are three definite points along the vocal pathway
FIG. 304

EME
where the voice is brought to a complete stop. They are the
posterior margin of the palate, the alveolar border, and the
lips. Figs. 303, 304, and 305 illustrate these positions. In
Fig. 303 the root of the tongue is brought into firm contact
435
with the palate; in Fig. 304 the tip of the tongue is in
contact with the alveolar border immediately behind the
front teeth; and in Fig. 305 the contact is by closing the
lips.
MOVEMENTS IN SOUNDING PAPA.
There is no better way of making a description of the
consonants appreciated than by beginning with the simplest
articulate sound of childhood.
The first title applied to a parent is the easiest and most
natural for infancy to pronounce. Papa is simply the sound
of P joined to the vowel AH. The vowel-sound has been
described; and, to produce the sound of P, we have only to
FIG. 305.

stop the sound of AH by closing the lips. In making the
sound of AH (see Fig. 297) all the principal as well as the
accessory organs are in their most easy, natural, and unre-
strained position. The sound of AH is but the natural voice
of the child flowing out of the mouth, when it is stopped by
closing the lips and suddenly opening them to allow the force
of breath-current to expend itself, and the sound of P is the
result. It makes no difference whether the movement of the
lips follows or precedes the emission of sound; the P lies in
the act of closing and opening the lips joined to a vowel-
sound. Repeat this shutting of the lips upon the sound of
AH with sufficient rapidity, and we have Papa, the simplest
MECHANISM OF P AND B.
436
and easiest word in the English language that a child can
utter. (See Fig. 306.)
P is not simply a check or stoppage of a vowel; it must
have an associated breath-current for its completion. If it
follows or checks the flow of a vowel, the lips must be
opened to permit the escape of a little puff of breath, or
the P is not complete. When P begins a syllable this puff
passes instantly and undistinguished into the vowel which
follows.
P & B
FIG. 306.

0000
P is a breath-consonant, and its associate vocal fellow is
B. Its formation is identical with that of P until the lips
are closed, but after the closure the sound is not stopped,
but continued in the buccal cavity, which is the distinctive
characteristic of B. It is not important that the sound be
prolonged after the closure of the lips, but it is essential
that it be momentarily heard in the confined buccal cavity.
As an experiment the sound can be prolonged, but only
MECHANISM OF M.
437
until the buccal cavity becomes filled with air, when it
ceases. Like P, it matters not whether it precede or follow
the vowel with which it is connected; its value is the same.
B is a vocal consonant.
In the formation of both P and B (see Fig. 306) the pal-
ate and pharyngeal wall are in contact. Escape by way of
the nostrils must be impossible, or the characteristic sound of
B made by filling up the buccal cavity is lost.
M
FIG. 307.

Let the palate drop at the time of making B, and permit
the sound to pass out at the nostrils, and M is the result. M
is a vocal-nasal consonant, and its formation is identical with
P and B in the closure of the lips, either preceding or follow-
ing a vowel. Physiologically the difference between B and
M lies solely in the position of the palate (see Fig. 307). We
thus see that P is the result of the complete stoppage of a
vocal stream by the lips; B is a stoppage by the lips, but the
29
ILLUSTRATION OF THE MECHANISM OF T AND D.
438
sound continued in the buccal cavity; M, the same stoppage
of a vocal stream by the lips, but the sound directed through
the nasal passages where it may be prolonged indefinitely.
Any one interested in this subject can verify these experi-
ments upon himself; indeed, it is almost a daily occurrence
that we meet some acquaintance whose Ms are all turned
into Bs, by a stoppage of the nasal passages from cold or
otherwise.
These sounds are called labial because the lips are prin-
T & D
FIG. 308.

cipally concerned in their formation; the tongue does not
necessarily come in contact with the roof of the mouth in
their enunciation. The mechanism of their production is
confined to the lips and palate, and any contact of the tongue
with the roof at the time is only incidental and dependent
upon the vowel-sound with which either of these consonants
is joined. Thus in PAH or MAH there is no contact; but,
439
in PE and ME, the tongue will touch the roof at the sides,
as seen in Fig. 301.
In considering the second class of consonant-sounds,
termed dental, we may use another illustration from the
child's vocabulary-TA-TA. This syllable is as simple as
papa, and its only difference is that in papa the lips stop the
emission of sound, while in TA-TA the vocal sound or vowel
AH is stopped by placing the end of the tongue upon the
gum immediately behind the front teeth, as shown in Figs.
308 and 309. The only physiological difference between P
DESCRIPTION OF THE SOUND OF TA-TA.
་་་་་་་
FIG. 809.

TO
D
and T is that the current is stopped by the lips in the first,
and by the tongue in the second. In all other respects they
are equal. Make the vowel AH and interrupt it rapidly as
described, and we have the continued sound of TA-TA. In
Fig. 309 we see that the conjunction of the tongue with the
gum is not only in front at its tip, but extends the whole
length of the alveolar border or dental arch. To make the
sound of T, it must be in contact for this entire distance.
If the vowel-sound were made with the tongue in con-
tact only at the tip, and the sound escaping at the sides, L
would be produced instead. It is this entire contact and
410
ILLUSTRATION OF THE MECHANISM OF N.
escape only at the tip which gives the peculiar sound of T.
This sound will be more readily apprehended, perhaps, by
placing it after the vowel, as in at. T we call a breath-
consonant, the same as P, because the voice is not concerned
in the formation of either. As we found B was the vocal
associate of P, so do we find the vocal fellow of T to be D,
and bearing the same relation. B was the filling up of the
N
FIG. 31).

oral cavity with voice while the lips were closed either at the
beginning or ending of a syllable; so is D formed by filling
up the contracted oral cavity with voice, while the tongue is
in contact with the roof of the mouth, as seen in Figs. 308
and 309.
We see here, also, the palate and pharyngeal wall are in
contact, preventing all escape by way of the nose, and the
sound of D may be continued until it fills the oral cavity,
when it must cease by limitation of space. But if now the
DESCRIPTION OF THE MECHANISM OF N.
441
palate be relaxed, so that the sound can escape through the
nares, it may be continued so long as the lungs can furnish
the power to vibrate the vocal chords, but it is no longer D,
but N (see Fig. 310). The relaxation of the palate and
pharyngeal wall change D into N, and, conversely, any
enforced stoppage of the nasal outlet turns N into D. In
my experiments I found that the surface of tongue-contact
with the roof was greater in N than in T or D (see Fig.
311); but I attribute this to the fact that N can be more
easily prolonged than either of the others, and the contact is
FIG. 811.

N
ww
1972!!!
likely to become more general. This is probably more acci-
dental than essential.
The third distinctly-marked point at which the vocal cur-
rent is interrupted is the posterior part of the oral cavity,
and, like the other two, its function is the making of three
sounds-a breath, a vocal, and a nasal sound. Thus, when
the extreme back of the tongue is brought into contact with
the soft palate in front of and above the uvula, closing the
passage to the mouth, and at the same moment the upper
part of the pharynx is advanced to meet the palate behind,
and stop egress by the nares, the organs are in position to
MECHANISM OF K AND G.
442
make K or G. In the cul de sac thus formed above the
larynx, the breath or voice accumulates. If breath only, the
sudden relaxation of the tongue produces an explosion which
is the sound of K. If the cavity be filled with voice until
the relaxation comes, the sound will be G. These sounds
are so intimately related that it is often difficult to distin-
guish between Ko and Go, when spoken by persons of loose
habits of enunciation. The essential requisite of G is that
DOG
K & G
FIG. 312.

זין
the sound be heard in the throat prior to its union with a
vowel, or if it follows a vowel, as in hog, it must be made in
the same way as above described. In Fig. 312 is illustrated
the position above described. In my own case, I found that
the tongue-contact with the soft palate was greater in making
G than in K, and this is indicated in the illustration by a line
showing the tongue at a higher elevation. The difference is
also seen in two other views, Figs. 313 and 314. Neverthe-
--·*..*
ILLUSTRATIONS OF K, G, AND NG.
FIG. 313.
K
Locat
Ng
FIG. 314.
less, there is no physiological difference between them. A
perfect G can be made with the limited contact of K.
The nasal sound of this group is NG, and is the result of
FIG. 315.
G
443



MECHANISM OF NG.
444
the relaxation of the pharyngeal wall, while the tongue and
palate are in continued contact. The sound which would
otherwise be G is thus nasalized, and becomes a distinct ele-
mentary sound, for which our alphabet furnishes no character,
and the only method of expressing it is by the combination
of N and G, this being the sound given when those two let-
ters are combined. The surface contact is also greater, as
shown in Figs. 315 and 316, but this greater contact is not
essential; it is only incidental.
--
.-.-.-
FIG. 316.

Ng
There is another class of sounds which form an important
part of articulate language of a different character from those
we have been considering, and which are made principally in
the front part of the mouth. Instead of being interruptions
or checks to vowel-sounds, they are continuous, and may be
prolonged indefinitely. They are the result of a current of
air driven through a small aperture, and are vocal or not,
according to the sound desired. For example: Place the
edge of the lower lip against the edge of the upper front
teeth, and drive a current of air through between the teeth,
or through a narrow aperture between the edge of the teeth
and the lip, and F is the result. The termination of a vowel-
MECHANISM OF F AND V
F & V
FIG. 317.
sound by a breath-sound in this manner forms a syllable with
F, or the reverse; beginning a vocal sound by a breath-sound
in this manner produces the same result. We can change F
FIG. 818.
445


F
V
446
into V by vocalizing the breath. The two are formed exactly
alike; the current of air past the teeth being with voice in one,
and without in the other. In Figs. 317 and 318 are seen the
positions of the various organs during their production, the
contact of the tongue with the roof of the mouth being limited
to a small space on the alveolar border, near the back teeth.
Another pair of the same character is S and Z. S is one
of the most important sounds of the English language, and
MECHANISM OF S AND Z.
S & Z
FIG. 319.
a defect in its enunciation is more noticeable often than any
other sound. It is simply a current of air driven through a
narrow chink, producing a hissing sound, the counterpart of
which is frequently heard arising from a variety of causes
outside of human speech. Place the tongue against the
upper gum in the same way and position as when T is
formed, but relaxing the end or tip and making a narrow
passage for escape, as in Figs. 319 and 320. The sound of
1

447
S is formed by a current of air driven through this chink.
Its corresponding fellow, Z, is a vocal sound, and is made
with the tongue and other organs in exactly the same posi-
tion; but the breath-current is vocalized in one, and unvo-
calized in the other.
MECHANISM OF SH AND ZH.
A third pair of like character is SH and ZH-SH as
found in hush, ZH as found in azure. These are not com-
binations of other sounds, as of S and H, but distinct ele-
mentary sounds for which our alphabet has no separate
FIG. 820.

SN
characters, SH being breath and ZH vocal. The aperture
for these sounds is similar to that of S, but wider and higher
up in the roof of the mouth, which seems to take away the
sharp, hissing sound characteristic of S. (See Figs. 321 and
322.) There is considerable latitude in making this sound,
and its pitch may be varied considerably without seeming to
affect its importance. For example, the lips may be held as
in P, or they may be considerably protruded. The advanced
position seems to be the easier and more natural, but the
result for purposes of speech is essentially the same.
A fourth pair of the same kind is found in the two
448
}
ILLUSTRATIONS OF SH AND ZH.
Sh & Zh
FIG. 321.

sounds of Th as heard in thin and thou, the former being
breath and the latter vocal. In its formation, the tongue lies
close to the gum against the back teeth, and the aperture in
FIG. 322.

SH
ZH
ILLUSTRATIONS OF THE MECHANISM OF TH.
Th
FIG. 323.
** **❤
front is broad, similar to that in Sh, but the tongue is more
advanced and lies closer to the front teeth and adjacent gum.
(See Figs. 323 and 324.) In Fig. 324, the firm contact is
FIG. 324.
TEHDE
TH
449


MECHANISM OF CH AND J.
450
shown by the solid black, and the lighter contact by the
shaded portion of the cut. There may be some latitude in
the position of the tip of the tongue without materially
affecting the result. The sound can be produced with the
tongue projecting beyond the edges of the upper teeth, or
retracted entirely within the dental border.
Still another pair of like character is formed with Ch and
J; Ch being a breath-sound, and J its vocal associate. It is
Ch & J
FIG. 325.

get
claimed by some that these are not distinct sounds, but com-
binations of others already described, the former being made
up of T Sh, and the latter of D Zh, but I found the tongue-
contact to be higher up and farther back, as shown in Figs.
325 and 326, and therefore give them a separate description,
Practically it is of no consequence whether they be distinct
sounds or a combination; the mechanism is so nearly the
same as to be difficult to decide.
H, which usually remains unclassified, strictly belongs as
FORMATION AND CLASSIFICATION OF H.
451
much to the same group we are considering as F, S, or Sh.
It is an aspirate (rough or hard breathing) made in the throat,
and can not be specially illustrated. Its natural vocal asso-
ciate is the vowel AH, and together they form a pair belong-
ing to the class under consideration. In the minds of some,
H seems to have been misapprehended in its formation and
association with other sounds. It appears to be the result of
forcing the breath sufficient to create an audible current of
air prior to the vibration of the vocal chords, and nothing
more. Any other value it may have is derived entirely by
FIG. 326.

Ch
J
resonance from the cavity or tube which it traverses. To
produce the sound of H, there is not required any change in
the position of the vocal organs from that which will admit
of quiet breathing. For example, a whistle may be placed
between the lips, and all the respiration may pass through it
without audible sound; it is only when force is used to create
more rapid vibrations of air that the sound is heard. H is
the sound of an air-current without vocal vibrations, which
sound is modified by resonance the same as the vowels.
This explanation of H is the explanation of the forma-
tion of whispered speech which by some has been considered
#
·
452
EXPLANATION OF WHISPERED SPEECH.
mysterious. The only audible sound in whispering is that of
a forced current of air; and the formation out of it of syl-
lables and words is by resonance without voice, the resonating
changes in the buccal and nasal cavities being identical with
those when the vocal chords vibrate. It requires more lung-
power to produce this audible current of air than it does to
produce sound by vibration of the vocal chords when they
are under tension, and for this reason whispering is more
L
FIG. 327.

tiresome than speaking. A little reflection will show that in
whispered speech there can be no double consonants, such as
we call vocal and breath consonants. Vocal consonants can
not exist in true whispered speech; consequently, whispered
language is deprived of eight elements which enter into
articulate speech. Papa and Baba in whisper are the same,
so are also Ko and Go, etc.
We have thus described all the so-called consonantal
sounds of the English language save two, and arranged them
THE FORMATION OF L.
453
in two classes, the first class consisting of three groups of
trios, and the second class of six pairs. The two exceptions
to this classification are L and R, both of which partake as
much of the vowel character as the consonantal, and are
usually called semi-vowels.
L is produced by holding the tip of the tongue in con-
tact with the gum as in T, but relaxing it at the sides, and
uttering through this passage the vocal current. In Fig. 327
this relaxation of the sides is shown by a lighter band across
the tongue. In Fig. 328 this contact with the roof of the
FIG. 328.

***
mouth is seen to be only in front. L also receives some
characteristic augmentation from the vibrations of the sides
of the tongue as the current passes. Physiologically the
sounds of L and D are so nearly alike that D is confined in
the mouth and L escapes at the sides of the tongue, all the
other organs being in the same position. Their near relation-
ship is readily observed by the ease with which they are both
sounded in words where they come together, as in "handle";
the L then takes the place of a vowel, the two sounds blend-
ing without the interposition of a vowel. During its pro-
duction the palate and pharyngeal wall must be in contact,
30
·
MECHANISM AND FORMATION OF R.
454
or the sound will be imperfect. Although not entirely
destroyed, it will be nasalized by the escape.
In Fig. 329 is shown the position of the tongue in making
the sound of R. The oral cavity at the time of the formation
of this sound corresponds with that in the production of the.
vowel AH. In fact, many people sound R so slightly that it
is little if anything more than the vowel AH. But the for-
mation of R requires that the tip of the tongue should be
OCC
004
R
FIG. 329.

pointed upward and vibrated while the current is passing.
With some the tip of the tongue is distinctly felt against
the roof of the mouth during these vibrations; while with
others it is below, as represented in the illustrations. Neither
does it seem requisite that the tongue should be pointed to
the same locality in the roof-it may be farther forward or
farther back. The sound of R is produced by the rapid
interruption of the voice, in the above-described manner, in
the middle of the mouth. In some languages this sound is
C, W, X, ETC., REPETITIONS OF OTHER LETTERS, 455
much more marked and distinct than it is generally made
in English. With some English-speaking people it is an
affectation of refinement to banish it almost entirely.
The foregoing explanation comprises nearly all the dis-
tinct sounds which form the English language. The sounds
of the other letters of the alphabet not here named are either
repetitions or combinations of those described, or are not so
distinctive in their mechanism as to be illustrated by dia-
grams. For example, C is a repetition of K, or S, as it is
used either hard or soft. G soft is the same as J, and W is
3
* * * * *❤❤
P
FIG. 330.

R
so nearly the vowel "OO"* that a diagram can not illustrate
any appreciable variation. X is a combination of K and S,
etc., etc.
The foregoing descriptions and diagrams are not advanced
as the only method by which the different sounds they illus-
trate can be produced. They are nevertheless believed to be
* Bristowe says: "The sound of the English vocal W differs from the
vocal 00 mainly in the fact that the fundamental vowel-sound is produced in
the larynx, and receives its coloring from the oral cavity; while the distinctive
sound of the consonant, though also colored by the resonance of the oral cavity,
is manufactured at the labial orifice."
USUAL CLASSIFICATION OF CONSONANTS UNSATISFACTORY.
456
the arrangements of the various organs which are universally
found to be the easiest, and most in conformity with physio-
logical function. As a scientific experiment, many of the
sounds can be perfectly produced or closely imitated in some
other way. For example, S can be made with the tip of the
tongue curled backward in the roof of the mouth, T may be
made with the tongue placed at various points, etc., and even
musical instruments and machines can be made to produce
vowels, and to a limited degree consonants. Children do not
place their organs for articulation as the result of scientific
teaching, but as the result (not the cause) of the effort to
imitate the sound; and, as the action of the organs acquired
in that way is almost universally identical, it proves the one
to be normal and the variations abnormal.
I have adopted the usual divisions and designations of
vowels, consonants, and semi-vowels, but it is a classification
that will hardly satisfy any one who becomes familiar with
the subject. Of the so-called consonants, nearly one half are
not consonanti. e., with sound (vocal sound) or sounding
with. P, B, T, D, K, and G are called mutes; but B, D,
and G are certainly not mute, nor are P, T, or K any more
mute than F, Th, or others.
The table on page 457 shows a classification more in accord-
ance with their mechanism. This table, proceeding from
right to left, may represent the oral tube or cavity from the
vocal chords to the lips inclusive, and the sections indicate
the points along the line where the sounds are made or
checked.
A
The following explanation of the mechanism of vocal ar-
ticulation supposes the normal integrity of all the organs con-
cerned, each fulfilling its natural function. In the production
of all the vowel-sounds of the English language the veil of
the soft palate is elevated and hugs the posterior wall of the
pharynx. This is essential to the formation of resonating
cavities of uniform tone-character. Consequently, if the
palate be destroyed or congenitally absent, a new resonating
457
cavity is exposed, and the tone-character of the buccal cavity
is changed. These sounds can no longer be made in the same
way, and in many cases can not be made in their purity at
all. In some other languages, the French, for example, na-
salized vowels and other nasal sounds form an important part
of the speech, but when such sounds are introduced into the
English they destroy its purity.
Breath.
Nasal.
Vocal......
•
TABLE OF SOUNDS WITH NEW CLASSIFICATION.

•
f
Cont
tact of both
of both Lips.
Teeth and Lip.
P
ue and Te
M
Tongue and Gum.
B ▼ Th
Tongue and Gum.
D
Tongue and Gum.
N
F Th T S Sh Ch K
Z
First position.
ad Roof.
Second position.
Zh
Tongue and Palate.
000
Third position.
J
Throat.
G
Ng
II
Ah
A dissertation on the mechanism of speech would be left
incomplete if it were confined to articulation with normal
organs alone. It is a remarkable provision of nature that in
many cases destruction of an organ does not involve a destruc-
tion of the function performed by it, and this is notably the
case with vocal articulation. The teeth may be suddenly
destroyed, and at first the effect seems disastrous; but very
shortly the lips and tongue accommodate themselves to the
change, and the function of the teeth in articulation is nearly
or quite regained. The palate, which performs such an im-
portant office, may be destroyed, and its loss compensated for
Ga
Į
458 SOME EXPERIMENTS WITH CLEFT PALATE PEOPLE.
nomena.
in a great measure by an increased activity of the pharyngeal
muscles and a new use of the muscles of the nostrils. The
phenomena in abnormal articulation are often truly remark-
able. In my practice of treating congenital and accidental
lesions of the hard and soft palate, I have seen nearly every
conceivable variety of deformity and have observed the phe-
In congenital cases the absence of the palate is
often compensated by an extraordinary use of other organs in
a manner that would seem impossible. The inability on the
part of some to make this compensation gives greater variety
to the phenomena, so much so that it is quite impossible to
declare by an observation of a defective palate without the
aid of the ear what its effect is upon the individual's speech.
Neither the size nor the extent of the deformity will deter-
mine the effect upon articulation because of this compensation
by other organs. A few examples from practice will illus-
trate these points :
A lady, about thirty years of age, belonging to the higher
grades of society, of intelligence and education suited to her
station, came to me for treatment. The fissure of the palate
was confined to the velum, the apex of the cleft reaching
only to the edge of the hard palate. I wrote upon a slip of
paper the following syllables: GO, KO, SO, HO, JO, DO,
CHO, NO, TO, and repeated them on the slip several times
promiscuously, and handed it to her to pronounce aloud as
distinctly as possible. Of the whole list, HO, JO, and NO
were the only ones that could with certainty be distinguished.
All the rest were alike pronounced NO. No difference what-
ever appeared between her GO, KO, and SO. Theoretically,
the S and CH were in her power to make perfectly, and D
and J approximately, and K and G the only ones theoreti-
cally impossible. No amount of training from infancy had
served to develop these sounds, which came to her only after
the introduction of an apparatus.
-
In another case, of an Irish girl in the lower walks of
life, nineteen years of age, with a fissure exactly similar to
EXAMPLES OF ARTICULATION WITH CLEFT PALATE. 459
the foregoing, the same experiment was tried, with additional
syllables of a more complicated character-such as ist, idst,
ox, etc. This experiment was tried before the introduction
of any instrument, in the presence of a number of surgeons,
who were only governed by their hearing in determining her
pronunciation. Every syllable was so distinct that it was not
mistaken by any one. In this exercise the listeners were not
aided by any knowledge of the syllable before it was spoken
by the patient. The only criticism was the nasalization
which, when she came to read or in conversation, made her
speech disagreeable. Theoretically, her K and G should
have been entirely wanting, but they were so clear that she
was not mistaken in a single instance.
A third case was as follows:
A father brought his son to me—a young man of mature
years, who had fissure of the soft palate only. I was not
favorably impressed with the intellectual development of the
young man.
He seemed stupid, and had but little realization
of his own condition. His speech was very bad-much worse
than most cases where the fissure is no larger than his. His
reading was a monotonous, half-idiotic sound, with but little
distinction of vowels, consonants, syllables, or words. After
two or three interviews I came to the conclusion that it would
be hopeless to expect any improvement from him in the use
of an artificial palate, and I frankly told the father that I
could not encourage the undertaking. Upon being urged
for reasons, I stated them as delicately as possible, as being
based on what seemed to me to be defective mental power.
But such an intimation was not to be listened to by the fond
parent, who saw no reason why "his boy" should not have
an artificial palate as well as any one else, as he was ready to
pay for it. After a complete understanding by them of what
would be necessary for him to do for himself after my work
was done, I made and adjusted the appliance. Within the
same hour after its introduction, I set him before me and
directed him to imitate exactly every motion of my lips and
1
460
every sound of my voice. After a half hour's training he
enunciated every sound of the English language with all the
distinctness and precision of one with well-formed organs.
This he would do under my dictation, executing my will
almost as if he had no will of his own. Not only sounds,
but words and sentences were repeated with clearness and
distinctness; and I began to repent the discouragement I
had given them. But passing from my dictation, he dropped
into his former habit of monotonous indistinctness, and I
became less hopeful of ultimate results.
Another case was that of a young lady, sixteen years of
age, unusually bright and intelligent, with fine musical and
artistic taste. The fissure extended through both hard and
soft palates to the base of the alveolar ridge. Externally
there was a hare-lip, which had been operated upon in in-
fancy. With this patient K, G, and S were impossible.
By no effort could she make any sound approximating to K
or G, and her effort to make S was a gurgle in the throat.
CH was unattainable, as well as such combinations as ist,
dst, ks, etc. So sensitive was she to the defect that she kept
herself from society, and was growing morbid under her
affliction. Realizing her utter inability to pronounce some
words, she finally formed the habit of avoiding the use of
such words in her conversation, and either used synonyms or
expressed the idea by a differently constructed sentence. I
constructed an apparatus for her, and three years afterward
she read before the same company of surgeons before referred
to. She had conquered every sound singly and in its more
complex combinations except S, and this was still made in
the throat. It was nevertheless made distinctly, and could
not be mistaken for any other sound; but it was made im-
properly, and was wanting in the sharpness which character-
izes S. K and G were perfect, and the former nasalization
of the vowels had passed away.
ARTICULATION WITH CLEFT PALATE AND HARE-LIP.
An entirely different manifestation from any of the pre-
ceding was that of a man thirty-five years of age, who had
CASE OF A MAN WITH DOUBLE HARE-LIP.
461
double fissure of the palate complicated with double hare-lip.
The lip had been very skillfully operated upon in early life.
He had grown a heavy beard and mustache, and as the suture
of the lip was on the median line the parting of the mustache
was natural and graceful, and there was no external suggestion
of any deformity. The intermaxillary bone had been re-
moved, and all the incisor teeth, leaving a wide gap between
the two sides of the maxillæ, covered in front by the lip.
WHE
I A
Fra. 321.

linke,
GREE
Fig. 331 represents a model of the mouth referred to. A A
shows the bifurcated uvula at the extremity of the remnants
of the soft palate, which is here shown as drawn up under the
action of the levatores palati. B is the superior pharyngeal
constrictor, drawn forward and in contact with the uvulæ.
CC shows the palato-pharyngeal muscles, the borders of the
pharynx, and DD the palato-glossus. The vomer and tur-
binated bones are seen exposed in the anterior part of the
nasal cavity.
In this case, the sounds of TII, T, D, S, Z, SH, ZH, CH,
462 PERFECT GUTTURALS MADE WITHOUT A PALATE.
and J were entirely wanting. His speech was so bad that in
giving him a passage to read before an audience not a word
of all he read was understood by his hearers; and yet this
man could pronounce the sounds of K and G with the ut-
most clearness and distinctness, not to be misapprehended or
misunderstood. The phenomenon was a mystery to me until,
in my further experiments with him, I discovered that he
brought the root of the tongue and the advanced pharyngeal
wall into contact. The absence of so important an organ
in normal articulation was here compensated for by a little
greater activity of the pharyngeal constrictor and the tongue.
o
FIG. 332.

This action of the superior constrictor of the pharynx could
be very plainly observed by tickling it with a camel's-hair
pencil when the patient's mouth was open, when it would
develop into a strongly marked ridge or cord horizontally
across the pharynx.
The formation of a cul de sac above the vocal chords,
essential to the production of K or G without the interpo-
sition of the palate, is shown in Fig. 332. The sounds of
T, D, etc., were impossible because the necessary obstruction
to the tongue in their formation was wanting, and art must
be resorted to, to supply a barrier.
Altogether the most extensive deformity of this kind,
and the one having the most disastrous influence on the
DESCRIPTION OF A MOST EXTRAORDINARY DEFORMITY. 463
speech that I have ever seen, was a young man upon whom
Professor J. L. Little, of the College of Physicians and Sur-
geons, New York, operated for compound hare-lip, and who
afterward came into my hands for an artificial palate. The
patient was nineteen years of age, and up to that period no
operation had ever been performed upon the lip. The de-
formity was horrible. The intermaxillary bone with its
integument was suspended from the septum of the nose
nearly at its tip, and behind it there was no upper lip what-
ever. There was no roof to the mouth from front to rear;
the gap was the widest I had ever seen. So also was the
distance across the jaw from the outside of the molar teeth,
and the distance between the canines, the greatest I have
ever measured. Dr. Little was very successful in his opera-
tion on the lip, removing the deformity entirely. Previous
to the introduction of an artificial palate, the following-
described experiment was tried in the presence of a number
of well-known surgeons: I wrote upon a slip of paper the
following syllables, which the patient pronounced to the best
of his ability, repeating each one several times: BO, SO,
TO, HO, MO, FO, KO, PO, GO, DO, ZO, JO, NO, VO,
CHO, THO, SHO, RO. The sound given by him to each
of these syllables was written by the gentlemen present as
nearly as they could be understood. A comparison of the
various records showed that the only unmistakable syllables
of the whole list were KO, GO, and HO—all throat-sounds.
Of the doubtful ones, NO and MO were interchangeable,
and so were LO and RO; and, of all the others, no sound
that he gave was any clew to the syllable he was trying to
pronounce. The explanation of his inability is not difficult.
It was quite impossible for him to make the labial sounds
when he had no upper lip, and, in the short time which had
elapsed since Dr. Little's operation, he had not learned to
use it; and the absence of any alveolar ridge in front pre-
vented the formation of all dental and other sounds made in
that locality.
I
464 CONTRAST BETWEEN CONGENITAL AND ACQUIRED LESIONS.
One of the most peculiar features of this case was the
production of K and G. In all other cases of similar charac-
ter the action of the superior constrictor of the pharynx
could be seen when irritated and examined, but I could
excite no visible action in him, and to ascertain where the
conjunction was which formed those sounds I tried the fol-
lowing experiment: Pulling the tongue forward, I painted
the back wall of the pharynx with some chalk and water
and required him to articulate K or G; and then pulling
the tongue again forward, the contact was marked by a trans-
fer of the chalk to the tongue, but at a lower point than I
had ever seen before in any person. It was not the superior
constrictor, but the middle constrictor, which was in action,
and at a point a little above the glottis.
The foregoing examples are sufficient to illustrate the
variety of phenomena observed with congenital cleft-palate
people.
In cases of such persons as have lost the whole or a por-
tion of the palate by accident or disease, the result is an im-
mediate convincing proof of how articulation is normally
accomplished. Any considerable perforation or loss of the
roof of the mouth makes recognizable speech impossible.
Such people, after a time, overcome some of the difficulties,
partly by a use of the nasal constrictors and partly by an in-
creased activity of the pharyngeal constrictors. But as these
lesions generally occur in adult life, the sufferers rarely ac-
quire the same facility seen sometimes in congenital cases.
Nevertheless, a simple apparatus filling or covering the per-
foration restores normal articulation immediately.
PART V.
THE ESTHETICS OF DENTISTRY.
CHAPTER XX.
ART CULTURE IN DENTAL PRACTICE.
THE title of this chapter may suggest to some the discus-
sion of only ideal or imaginative subjects. Its object, how-
ever, is no mere poetic exaltation of dentistry, but rather a
treatise on a preeminently practical branch of mechanical
surgery.
"In no department of dental practice does the want of
that taste which indicates artistic culture become so manifest
as in the failure to restore the natural expression by the
replacement of lost dental organs. It is unquestionable that
the majority of the profession, engaged in this branch of
practice, have given more thought and labor to the best
methods of restoring impaired functions-securing comfort,
usefulness, and durability in artificial dentures-than to the
equally important question of correlation of the substitutes
with the general physical characteristics of the patient. To
this account are to be charged the unseemly incongruities
constantly staring the observer in the face from mouths
whose lost organs have been replaced in disregard of this
universal law. No matter how anatomically correct, or how
skillfully adapted for speech and mastication, an artificial
denture may be, yet if it bear not the relation demanded by
age, temperament, facial contour, etc., it can not be otherwise
than that its artificiality will be apparent to every beholder.
A VIOLATION OF ESTHETICS ABHORRENT.
"This law of correlation-harmony-running through
nature, attracts and enchants us by an infinite diversity of
manifestations; the failure to recognize its demands by art
is correspondingly abhorrent to our sensibilities. In the
social gathering, a lady who appreciates the law of harmony
delights the eye by the taste displayed in her attire; another,
though more elaborately and expensively adorned, yet failing
to harmonize the details of her costume, attracts attention
only by the impression of incongruity. We hear frequently
from a lady who is selecting a bonnet, or from a gentleman
purchasing a hat or other article of wearing apparel, the
question to a friend, Does this become me? the query indi-
cating the recognition that, however exquisite the material
or excellent the manufacture of the article, a certain law of
fitness prevails, the failure to comply with which makes the
wearer appear ridiculous. We meet in the street one the
color of whose hair we expect, by the law of association, to
be fair or sandy; and, if otherwise, a wig or a dye is in-
stantly suggested.
"There is a relation between the physical form and the
voice, from which we are led to infer in advance the charac-
ter of the tones which from any given individual may be
expected. This law of association, in any case, having led
us to anticipate a bass voice, the anomaly, should a falsetto
greet us, is almost ludicrous.
466
"So, not to multiply examples, the dullest observer learns
instinctively the demands of this great law of correlation.
The artist's success depends upon the extent of his percep-
tion of it. The botanist esteems it a guide-post in his in-
vestigations. The comparative anatomist regards it as a
fundamental principle. The scientist, in every direction of
research, knows its importance. To the dentist, the extent
of its recognition determines his status as a mere mechanic
or an artist.
“A broad, square face, or an oval; a large, coarse-featured
man, or a delicately organized woman; a miss of eighteen,
PROSTHETIC AND ÆSTHETIC DENTISTRY AS SCIENCES. 467
or a matron of fifty; a brunette or a blonde-these and
other varieties present as many differing types, with teeth,
in size, shape, color, density, etc., corresponding. If, then,
teeth correlated in their characteristics to those which nature
assigns to one class be inserted in the mouth of one whose
physical organization demands a different order, the effect
can not be otherwise than displeasing to the eye, whether the
observer be skilled in perception, or intuitively recognizes
inharmony without understanding the cause. A careful ob-
servation and record of these distinguishing characteristics—
correlations would go far toward establishing prosthetic and
æsthetic dentistry as 'exact' sciences. There is as rich a field
thus opened, and as worthy of culture, as those which are
attracting so many to microscopic and other investigations of
the tissues; an opportunity as promising as that which incites
others to perfection in structural prosthetics; and a reward
in professional status and pecuniary remuneration, not less
deserved than that which is accorded to superiority in any
other branch of practice.'
* 66
Theoretically, dentistry is a science and an art. Practi-
cally, to a very great extent, it has been empiricism in place
of science, and bungling mechanism in place of art. Never-
theless, it has established its claims to be a science by its
investigations, and by its organized system of practice; but,
as an art capable of taking rank as one of the fine arts it
seldom finds an advocate, and still more seldom a practitioner.
The dental surgeon assumes for his department a position of
superiority, and consigns the other to the workshop, where
the only idea of art comprehends ordinary mechanics. As
a consequence, artistic dentistry has never risen, except in
rare individual cases, to anything above mechanical dentistry,
and the very term by which the department is known is used
as one of reproach. In every assemblage, public or private,
on the street, in the drawing-room, or wherever we may turn,
* Dr. James W. White, "Dental Cosmos," 1872.
A
468 IDEAL ARTS AND MECHANIC ARTS CONTRASTED.
we see displayed the disgraceful productions of these dental
mechanics. It becomes a serious question whether the art
of dentistry, aside from some methods in operating on the
natural teeth, has, with all the inventions and improvements
of the last decade, made any advance. The operative depart-
ment has assumed to be the department par excellence and
per se, and we see the results in the education of a new pro-
fessional generation, who ignore any knowledge of prosthetic
dentistry as unworthy their talents; not realizing that a mas-
tery of all its elements will do more to perfect their skill
even in the one department, than any other course that could
be pursued.
It can be demonstrated beyond a peradventure that these
ignored and despised branches of dental practice are capable
of high idealization, taking rank with sculpture and other
branches of fine art; capable of appealing (though in a more
limited manner) to the same sentiments and emotions, and
requiring for their expression the identical talent and imagi-
nation which characterize the sister arts. With the ancient
Greeks, all works which exhibited skill were called works of
art, and to the present day the term art, in its broad signifi-
cation, is applied to every skillful physical or intellectual
performance. In this sense, music, poetry, painting, sculp-
ture, architecture, dancing, oratory, medicine, and surgery
are equally arts.
In this broad sense every operation in dentistry is an art.
But as the arts have multiplied, terms of distinction have
become necessary; as fine arts and mechanic arts, with all
their subdivisions. All that ministers to the aesthetic sense,
stimulating the imagination, belongs to the fine arts; all
that contributes to the physical comfort, and the utilitarian
progress of mankind, we class as mechanic art.
The mechanic arts may demand consummate skill for
their execution; they may require for their development
rare inventive faculties, and their combinations of mechani-
cal principles and powers may be truly wonderful; but their
)
ART CULTURE NEEDED IN PROSTHETIC DENTISTRY. 469
individual works require but little effort of the brain in their
reproduction. Education in skillful manual labor, without
the capacity to originate a single new idea, is all that is re-
quired. The laws which govern their reproduction are those
of mathematics, and to be able to copy a given form with
exactness is the sum of the talent required. They may be
directly of more practical value to mankind, but they make
no appeal to the finer emotions of our being. In all that
excites the imagination, that calls into action the affections,
or leads the mind away from the contemplation of the ma-
terial and sensual, they are dumb.
The ideal arts, on the contrary, furnish this gratification,
and wheresoever art falls short of this requirement it can
make no higher claims than that of mechanism. For illus-
tration: It is easy to conceive, in this day of cunning work-
manship, that it would be possible to make out of cast iron
an artificial denture-teeth, gums, and base of the same
metal-which would fulfill perfectly all the utilitarian re-
quirements of such an appliance. It might be accurately
fitted to the jaw, and admirably articulated with the antago-
nizing teeth. For comfort in wearing, and for power of
mastication, it, would be all that was desired, and yet it
would not have one element of dental art in its construction.
It would be purely a mechanical performance, and come
under the head of dental mechanics.
-
In that common and every-day operation in dental prac-
tice, called “taking the bite "—particularly when there is an
entire upper and under denture to be supplied-there is re-
quired, for its highest success, a talent far greater than that
exercised by the sculptor upon the same limited locality.
Aside from the inherent good taste, or appreciation of the
beautiful, on the part of the operator, there must be some
knowledge of physiognomy, of facial expression, of the har-
monious relations of one feature with another, and of sym-
metrical proportions; besides the judgment to decide upon
the best method for purposes of utility. All the details in
31
470 ART CULTURE UNNECESSARY IN SURGICAL DENTISTRY.
making an artificial denture, such as taking an impression,
making plaster casts, making dies, swaging plates and fitting
them to the gums, are all purely mechanical processes. All
these may be perfectly carried out by one who has no appre-
ciation whatever of the beautiful, of harmonious proportions,
colors, or sounds; but, in the one process of taking the bite
-no matter whether the plate or base is gold, silver, platina,
or gutta-percha―none but an artist can go through its various
stages successfully.
Dental practice, by an inherent law and by common con-
sent, is divided, in the main, into two departments: one,
commonly termed the "operative" or "surgical," which is
made to include all efforts for the preservation of the natural
teeth, and all surgical operations in the buccal cavity; the
other, called "mechanical" (but in place of which I much
prefer “prosthetic," as more appropriate), includes the mak-
ing of all appliances for the correction of deformities of the
buccal cavity, but principally the making and inserting of
artificial teeth. In the practice of surgical dentistry, as has
been before intimated, there has grown up an unwarrantable
assumption that all that was refined and cultivated, all that
was worthy the exercise of our noblest faculties in the pur-
suit of our profession, was to be found in this department,
and that mere mechanics, wholly unqualified by education in
science and art, were deemed capable of practicing the other.
The only performance of surgical dentistry which requires
a talent and skill equal to the mechanic arts is the introduc-
tion of fillings into the cavities of decay, and this skill is
mere manual dexterity, guided by good judgment; its high-
est achievements at the present day are in the so-called con-
tour fillings made of gold, in which an attempt is made to
restore the form of a tooth injured by accident or decay.
Every tooth has an individual character and expression,
not only in harmony with every other in the same mouth,
but by the same divine law, when in a normal condition, in
harmony with the features and character of the creature, be
And
PROSTHETIC DENTISTRY AS AN ART.
471
he animal or man. These physical characteristics are so
marked and prominent that the merest novice has no diffi-
culty, as a rule, in locating any human tooth that has been
removed from its fellows; and yet, of the attempts at resto-
ration of any large portion of the crowns of teeth by den-
tists, there are few that bear any very close resemblance to
the original form of the lost part. If a cast were taken of
these restorations, and examined sɛparately, how few would
identify them as being any portion of any tooth! The cusps,
the depressions, the sutures, the easy and graceful outlines,
and all that marks the individual teeth, are wanting. With
the same portion of a natural tooth, even duplicated in an-
other material, as a perfect copy in plaster, there would be
no hesitation in identifying its locality with a tolerable cer-
tainty; but a cast taken of many a restoration would not be
suspected of its original application.
The skill, therefore, exercised in every operation on the
natural teeth is purely mechanical, and in æsthetic culture
bears no comparison with its associated department. No
performance of the dentist can make any pretension to be a
fine art, separate and distinct from all others; but, as a sub-
division or specialty of one of the arts, dentistry is entitled
to a consideration which it has never received.
-
Prosthetic dentistry, as an art, is a department of sculp-
ture. Form in individual members, form in grouping and
arrangement, and form as a medium of expression, are
equally the distinguishing characteristics of both sculpture
and dentistry. Every effort of the brain in the production
of a statue is spent upon the clay model. It is this which
the artist studies, and, as he knows that every variation of the
form changes the expression, and that expression is a key to
the character, so does he bend with all earnestness to every
detail, building up here and depressing there, swelling out
this muscle and relaxing that, until in satisfaction his work
is consummated. This model in clay is the end of the artist's
labor; the mechanic now takes it out of his hands, and every
472
"TAKING THE BITE" A PROCESS IN ART.
succeeding operation, until it appears the finished marble, is
only one of mechanism. In like manner, the conception and
execution of a properly devised artificial denture admits of
the work of the artist and of the mechanic, with the line as
distinctly drawn.
In the construction of an artificial denture everything
that relates to its appearance belongs to art; everything that
affects its utility is controlled by mechanism. It is not only
possible, therefore, but very common to see artificial teeth
that are worn with great comfort, and may be as serviceable
as any that can be made, and not a single element of true art
has entered into their construction. The adaptation to the
jaws, and the articulation for masticating purposes, in these
days of plastic materials, involve no skill beyond that pos-
sessed by many a mechanic; but the form and color of the
teeth selected, their arrangement with each other, and the
adaptation of the whole to the demands of the unimpaired
features, present an appearance which is a grim satire upon
dentistry as an art.
Reference has already been made to the knowledge, skill,
and good taste required in "taking the bite." This process
is, in fact, the very first step in making an artificial den-
ture which calls for æsthetic culture. Its mechanical details
are very simple, but its possible artistic results are wonder-
ful.
With the trial-plates, of whatever material, adapted to
the gums, a very simple method is to take some small blocks
of any soft wood, say a half inch in length and width by less
than that in thickness, and secure them to the trial-plate in
the locality of the bicuspids. It will be found more con-
venient to place the side of the wood, and not the end, in
contact with the plate, as it will be easier to split off shavings
or chips when placed in this way, and thus reduce on trial
any unnecessary height. For sticking these blocks, a prepa-
ration of common rosin two parts, and beeswax one part, will
be serviceable. One block will be required for each side of
473
the upper plate, and also one for each side of the lower, and
the blocks of each plate must be so placed as to antagonize
with the blocks of the opposite plate when all are in the
mouth. The plates may be then adjusted and some estimate
made of the probable required length, or rather height.
These will be likely to be too long, but can be readily re-
duced as before indicated; when the result is approximately
reached, a rim of soft wax may be formed on each plate.
Common beeswax, or wax with some paraffine added, will be
easily manipulated. The plates must be readjusted to the
mouth, and the patient directed to close the jaws until the
blocks come in contact; after which, in the mouth and out
of the mouth, as is most convenient, the external form of
the wax will be so manipulated as to produce upon the ex-
ternal features the desired contour and expression. The
author attributes so much importance to these mechanical
details, and in his own practice intends to be so very precise
in the results, that he rarely requires another sitting from the
patient for the purpose of "trying in the teeth," before they
are completed. Even for the greatest utility of the piece,
without any reference to its artistic appearance, all the time
and care should be here given that is required to insure
absolute precision of length and fullness, and these steps can
be so carefully conducted that, on the final adjustment of the
completed dentures, not the slightest alteration in the articu-
lating surfaces will be necessary. But in an artistic view
this sitting of the patient is the all-important one; for, as
before stated, the wax must be worked up to the exact con-
tour of the completed denture. It will not do to leave it to
the guesswork of an assistant, or to the half-forgotten memo-
ries of a hurried observation. The artistic effects must be
produced in the wax and retained in the duplicating denture,
and this can not be done at lightning-speed. It requires
calmness, deliberation, and repeated trials of the wax forms.
The author has in many instances spent a half day over one
patient at this important sitting, and been rewarded with an
PROCESS OF TAKING THE BITE.
474
COÖPERATION OF THE PATIENT UNDESIRABLE.
ultimate result that not only gratified himself, but the patient
and the friends.
During this process but little aid can be obtained from
the patient, by an anxious coöperation or by any suggestions.
It is far better that the patient remain in ignorance of the
importance of this sitting. The attempted and well-meant
efforts of the patient generally end in failure to the operator,
and, if this coöperation is discovered, it is better to adroitly
lead the mind away to the contemplation of some other sub-
ject. Patients under these circumstances have a most per-
verse way of doing just what neither they nor the operator
desire. Therefore it is that a result which shall determine
final precision can only come in the mind of the operator
from repeated adjustments, and with some movements of the
mouth and cheeks to show muscular action and expression.
Before the dismissal of the patient, the center of the lips,
and also the line of their parting, should be marked on the
wax; and, in the final arrangement of the teeth, it is prefer-
able, as a general rule, that the cutting edge of the superior
central incisors correspond with the line of the separation of
the lips when in repose. This will always insure the ex-
posure of the teeth when the mouth is in action, without
presenting them unduly.
After the bite is completed, the immediate subsequent
steps can be conducted by a skilled mechanician, and will
vary somewhat with different individuals; but the instruc-
tion in that branch of mechanics is already so ample in
various text-books, that it is unnecessary to follow it. We
will rather turn back and again consider the same process,
but solely from the aesthetic aspect.
In the patient before us we find a countenance deformed
by the entire loss of the teeth, superior and inferior; alve-
olar processes more or less absorbed, wasted and unsupported
muscles, sunken cheeks and lips, and a nose whose cartilagi-
nous portion has lost its hereditary character. With the wax
and props between the jaws, as before described, the first step
AN OPPORTUNITY TO DISPLAY IDEALITY.
475
will be to decide upon the profile. This is not only primary
in the order of the work, but it is of primary importance.
It is the central point around which all the modeling re-
volves, and becomes the standard which governs all the other
features. The profile well chosen, all the other features will
be made to harmonize with it, and according to the profile
will correspond in form the beauty of all the other features.
No face was ever repulsive where the profile was beautiful,
and no face can be made beautiful where the profile is ugly.
This outline can be determined better by having some stand-
ard of beauty in the mind as an ideal toward which we are
working. This idea of a standard, or typal face, is not a
mere whim of the fancy, which allows each individual to
select, construct, or adopt such a one as his refined or per-
verted taste might choose, but it is one which belongs to a
perfectly balanced intellectual and physical head-one which,
in its elements and characteristics, is not uncommon in na-
ture at the present day, and one which existed and has been
accepted as such from the earliest historic times.
The construction of this ideal head or face is reduced to
a system and governed by a canon, which has remained with
but little variations from time to time for a period of over
four thousand years. On the monuments of Egypt there is
such a canon recorded in stone, which gives the proportions
of the entire human system externally, as then accepted.
From that day to the present there have been proposed
probably a hundred systems. Nearly every artist of re-
nown, from Polycletus, Michael Angelo, and Leonardo da
Vinci, down to our contemporaries, Page and Story, has
suggested slight variations. But through all this criticism
of the whole figure, the proportions of the individual fea-
tures of the face and head have remained substantially un-
changed.
-
The following system for drawing the profile head is
taken from Wiegall's "Art of Figure-Drawing":
“First draw a vertical line, equal in length to the height
476
of the intended head, and then draw two straight lines at
right angles to it, at its extremities; these two horizontal
lines will touch the top of the head and the lowest point of
the chin respectively. Divide the vertical line into four
equal portions (see Figs. 333 and 334).
"The first portion marks the vertical distance between
the top of the head and the front roots of the hair;
RULES FOR DRAWING AN IDEAL HEAD.
nose;
FIG. 333.
FIG. 384.


"The second, that from the hair to the root of the nose
(between the eyes);
"The third, the length from thence to the bottom of the
"The fourth, that from the bottom of the nose to the
bottom of the chin.
"Bisect this fourth portion, and the point of bisection
determines the lower point of the under lip.
477
"Again, divide this last part (i. e., from the nose to the
front of the under lip) into three portions:
"The lowest portion determines the thickness of the
under lip;
"The next above determines the thickness of the upper
lip;
"The uppermost, which is rather longer than the middle
one, determines the distance between the nose and the upper ·
lip.
RULES FOR DRAWING AN IDEAL HEAD.
"These points being determined on the vertical line, next
draw between the horizontal lines, but touching only the
lower one, an oval, the larger diameter of which, being ver-
tical, is to be equal to the length of the vertical line from its
top to the point marking the opening of the mouth or the
top of the upper lip, and its lesser diameter equal to three
fourths of the larger, and let it be placed so that the ex-
tremity of its lesser diameter may touch the vertical line a
little above the point marked for the roots of the nose. If
this oval be carefully drawn, in its course it will pass some-
what behind the front opening of the mouth and the middle
of the upper lip, and through the commencement of the
chin under the lip; it will determine the angle of the under
jaw (not its course); and it will pass through the center of
the ear.
"From the point on the vertical line opposite the upper
lip, draw a straight line perpendicular to the vertical, and
meeting the oval; the bisection of this straight line will give
the commencement of the upper lip.
"The projection of the nose before the vertical is nearly
equal to the distance from the bottom of the nose (where it
intersects the vertical) to the opening of the mouth.
"The vertical dividing the nose equally, the width of the
wing of the nose is equal to its projection in front of the
nostril.
"If a straight line, parallel to the vertical, be drawn some-
what behind the wing of the nose, and intersecting the oval
•
RULES FOR DRAWING AN IDEAL HEAD.
478
below the under lip, the point of intersection is the com-
mencement of the chin.
"The length of the mouth is equal and parallel to the
projection of the nose before the face.
"The length of the ear is equal to that of the nose, and
its place is found by its center being in the oval (distant at
the length of two noses from the facial line); therefore, by
its being parallel with the nose, and equidistant from the top
of the head as the nose is with the nose.
“The highest part of the head lies immediately over the
top of the ear.
"A line drawn from the middle of the forehead to the
middle of the chin will give the inclination of the eye, the
position of which is further determined by the top of the
eyelid being opposite the root of the nose.
"And if upon the straight line, drawn from the middle of
the back of the ear to the middle of the forehead, an equi-
lateral triangle be drawn, its vertex determines the point of
the chin."
A comparison of a few leading types with this ideal pro-
file will enable us to make a better application of the knowl-
edge to the practice of dentistry. Fig. 335 is a drawing of
the head of the Apollo Belvedere, a masterpiece of Greek
art, which has been accepted as a standard of male beauty
for hundreds of years. The object of the artist in the rep-
resentation was evidently the portrayal of the highest type
of physical rather than intellectual beauty, and the character
of this deity gave him abundant opportunity. The general
line of the forehead and nose is the same. In many of the
Greek statues it is a single straight or nearly straight line
from the tip of the nose to the top of the forehead, and it is
this line that forms the distinctive characteristic of the Gre-
cian profile. But the parts to which special attention is
called are the nose, mouth, and chin. None of these fea-
tures will admit of any material modification without de-
tracting from their beauty. Fuseli, a celebrated lecturer on
F
COMPARISON WITH GREEK ART.
479
art, said: "Shorten the nose of the Apollo by but the tenth
of an inch, and the god is destroyed." Observe, therefore,
the relation that the nose bears to the upper lip, and also the
relation of the upper to the lower. The nostrils take the
general direction of the mouth; were they to be raised at
their posterior boundary, it would give the face a sneering
and contemptuous look; or, were they drawn down, it would
give a surly and morose expression. The relative propor-
tions of the features are substantially the same as those
adopted by all artists. The chief elements of beauty are, a
FIG. 385.
BICK
FIG. 235.


short, finely curved, and prominent upper lip; a full, round,
but less prominent lower lip; and a strongly marked depres-
sion at the base of the lower lip, giving roundness and char-
acter to the chin.
The next illustration, Fig. 336, is that of another Gre-
cian divinity, a head of Medusa. In many respects it is the
most remarkable female head I have ever seen. The analy-
sis of this profile shows that it possesses the same general
characteristics; and these characteristics of the lower part of
the face are elements of beauty wherever found. Thus,
while at the present day the pure Greek type is very rarely
seen, we nevertheless do see, in all handsome profiles, very
480
much the same outline in the lower part of the face that has
been indicated; the variations being in the upper half of the
face, and not in the lower.
COMPARISON WITH AN AMERICAN TYPE.
An additional illustration is shown in Fig. 337, a drawing
from life of another type of profile of not uncommon oc-
currence. Indeed, if I were to describe the American type,
I should be as much inclined to give that name to this form
of features as to any other, it being quite as universal as any
other type which is distinctive, and which possesses the ele-
ments of beauty. The proportions are much the same as in
the preceding illustrations, and, to a considerable extent, the
Pota
FIG. 337.
Dan
зас
FIG. 338.


SALID
characteristics of beauty in the lower part of the face are
the same.
I present here another drawing, Fig. 338, of the
same face some months after the loss of the upper and lower
teeth, and here we mark the beginning of that deformity
which it is our duty to remedy. The mouth is sunken, the
lips compressed, the end of the nose flattened, the nostrils
drawn down, and the whole line of beauty in the lower part
of the face gone. It will be interesting to follow this de-
velopment a little further, and Fig. 339 is another drawing
of identically the same face in all the minutiae of detail,
except the region around the mouth. Here is exhibited that
wonderful transformation from youth and beauty to age and
481
ugliness; and all those peculiarities which were noticed in
the earlier stages are still more strikingly developed. The
last drawing shows the face shortened a quarter of an inch
in the life-size, and yet that very limited change throws the
whole out of balance. It is now in the power of the dentist
to remodel this face, and it is important to carefully consider
whether any greater improvement can be made than simply
restoring the features to their original form and position. I
think the more it is studied, the more certain will be the
conclusion that the original form in this case harmonizes bet-
ter with the upper features than any change it is possible to
CHANGES WROUGHT BY THE LOSS OF TEETH.
FIG. 339.

ho
(Clow
make. I experimented upon the patient from whom these
illustrations are taken, and found that any material variation
from the original form showed a want of correspondence
between the lower half of the face and the upper.
In contrast with this last, let us examine one of the ugly
developments of nature, and one in which, when the change
that we have been considering takes place, and which we call
deformity, we find is really a step toward comeliness. This
face, Fig. 340, will be readily recognized as a type of many,
and one which, at first glance, seems to have hardly a re-
deeming feature; and yet, when analyzed, it is only the
lower half of the face that is decidedly ugly. It is only the
482
IMPROVEMENTS POSSIBLE IN A RESTORATION.
cartilaginous and movable part of the nose, together with
the two lips, which give this beastly look. The forehead is
not bad, neither is the chin. It is worth considering what
can be attempted here for improvement. To make a mouth
like the mouth of the Apollo would be impossible. Such a
mouth, in conjunction with other features, which we can not
alter, would only be making a deformity of a beautiful indi-
vidual member. There is, however, no danger of commit-
ting such an error; the features can only be manipulated to
a limited extent. But we can depress the lower end of the
FIG. 249.
FIG. 341.


nose, raise the nostrils, retract and shorten the lips, and
shorten and improve the face by raising and advancing the
chin. Instead of attempting, in a case like this, where all
the teeth have been lost, and the alveolar processes absorbed,
to restore the features to their original position, as we would
in a former illustration, we should study to avoid that, and
at the same time study to avoid the appearance of a sunken
mouth. Fig. 341 will show such a result. It is the same
face as in Fig. 340, but with the chin raised a quarter of an
inch. The advantage gained is decided; in the former case
the same process produced deformity.
But we do not always get improvements by the absorp-
THE REMODELING OF A LIVING FACE.
483
tion of processes and the retreating of lips. It is not uncom-
mon to find the upper lip less prominent than the lower, and
that, too, when the teeth are fully developed underneath.
In such a case it is manifestly desirable, if the free move-
ment of the muscles of the upper lip will permit, to advance
it to the line of beauty.
The movements of the mouth must also be carefully
studied, for it is possible to produce a most desirable change
to be observed when the mouth is in repose, but when seen
in action the expression from overstrained and unduly taxed
muscles is disagreeable. In modeling, therefore, great re-
spect must be paid to expression, for a pleasing expression is
of far more consequence than a scientifically beautiful out-
line or contour. This leads very naturally to the steps to be
followed subsequent to the establishment of the profile.
The extraction of the canine teeth, with their long roots,
destroys the expression of the face more than that of any
other teeth. The roots of these teeth support the wings of
the nose, and, when extracted, allow that feature to be dis-
agreeably drawn down, together with the formation of a
deep wrinkle immediately behind it. The wax model will
require in many cases to be well carried up at this point, or
this feature will not be restored. But avoid making the
crowns of the canine teeth too prominent. These crowns
lie under the corners of the mouth, and there is hardly any-
thing more disagreeable than to see the corners of the mouth
strained when in repose, or revealing when opened two tiger-
like fangs. Be careful also not to strain the upper lip so
that its beautifully curved line is obliterated, and the mouth
present only a straight incision.
Preserve also the groove which should indicate the median
line below the nasal septum, which is also a mark of beauty.
With the lower lip, also, use the utmost care that only its
edge be advanced, and that it be entirely undisturbed at its
junction with the chin; and, if possible, at the corner of the
mouth let the lower lip fall within the upper. And, lastly,
481
REMODELING AND RESTORATION GRADUAL.
consider the support and consequent form which will be
given to the cheeks. If all the processes which have already
been indicated have been skillfully performed, this last will
be comparatively easy of accomplishment. With all the
other features in harmony, and only sunken cheeks to fill out
to correspond, the labor will be light. But here, too, there
is danger of exaggeration. It is not difficult to build out to
an excess, and suggest a swollen face or a morsel of some-
thing foreign in the mouth.
In the restoration of the features after the teeth have
been for a long time removed, the cheeks and the lips not
having been supported meantime by art, both the comfort
of the patient and the necessity of preserving the identity
would suggest that the entire restoration be not accomplished
at once. In like manner, when the features are to be re-
modeled, and the muscles taxed beyond their original devel-
opment, the change can be made gradually with ease, and
without sacrifice of expression. The muscles must be al-
lowed freedom of action, and it will sometimes be quite
difficult to permit this, and at the same time give the most
desirable form. It will be borne in mind, however, that the
muscles can be developed into a use which is not common
with them, and certain expectations for the future may be
predicated on this fact. A striking illustration of the extent
to which a displacement of the muscles and consequent build-
ing out of the cheek can be carried, will be found on page
324, in the report of a case where the side of the face from
the orbit to the lower jaw was lifted from its natural resting-
place to the extent of three quarters of an inch.
The foregoing remarks upon the remodeling of the fea-
tures and restoration of expression must be regarded as only
suggestive. Definite rules can not be given; the art can
only be acquired by observation and experience.
"This branch of æsthetics must, of necessity, be worked
out by every one for himself. He will succeed or fail just
in proportion as he has the ability to observe the hundreds
A QUOTATION FROM PROFESSOR AUSTEN.
485
of models which are perpetually before him, and as he has
the further and rarer ability to apply his observation to the
special cases that are in his laboratory. Imitation of nature
is the rule. Limitations of art, and individual capacity,
make the exact observance of this rule comparatively rare.
We replace the sixteen teeth with only fourteen, and often
make them shorter and every way smaller than the natural
organs. We do not make the grinding surfaces interlock
with such deep cusps as in nature. At one time we can not
avoid an unnatural fullness of artificial gum; at other times,
the contraction of the absorbed arch compels the setting of
molar teeth nearer the median line than the original teeth.
Notwithstanding these and many other disadvantages, the
perfection of the dento-ceramic art is such, that a skilled
artist, who is quick to observe what nature requires, can in
the majority of cases falling under his care supply the lost
dental organs with great accuracy, and preserve that higher
order of beauty which grows out of the harmony of his
work with the expression of the face and entire person.
But no dentist can give to his work this kind of beauty, who
does not systematically study the natural organs as they daily
present themselves in the operating chair.
"Few patients would object to the pressure of a roll of
wax (two inches long and about a half inch thick) against the
closed teeth. A model from this impression would give the
size, form, arrangement, and articulation of all except the
molar teeth. A well-matched porcelain tooth (more than
one might be required) would add to these data the color of
teeth and gum. To this add also the age, sex, physical
characteristics of the face, and the physical temperament.
If the dentist would have a case and books for the registra-
tion of one such carefully made observation every week, he
would, at the end of two years, have a collection which, as a
practical guide in the selection and arrangement of artificial
teeth, would prove of incalculable value. These fixed rec-
ords of minute details are made still more useful by a habit
32
486 HARMONY AND SYMMETRY WITHOUT UNIFORMITY.
of close observation in society. In this way a set style or
mannerism may be avoided, which so often stamps' dental
work with meaningless uniformity of expression.
""*
A
In all these efforts the law of harmony must not be for-
gotten. A skinny forehead, angular eyebrows, hollow eyes,
and depressed temples, associated with full lips, plump
cheeks, and a well-developed chin, will strike even an ordi-
nary observer as an incongruity. In the study of human
faces, the student of nature will find new and pleasing won-
ders continually; and, to carry out the law of harmony, his
highest powers of discrimination will be in constant requi-
sition. He will find, to his astonishment, that what might
be termed mechanical symmetry is lacking in every face.
So accustomed do we become to the general configuration of
the human head, that we rarely if ever view it critically. A
close comparison of one side with the other of almost any
face will detect grave departures from uniformity.
straight line from the center of the forehead to the center of
the chin will not necessarily bisect the nose, showing that
the median line is not a straight line, but a curve. Neither
the eyes nor the eyebrows will occupy the same angle to the
median line; one side will be higher than the other, and the
same is true of the mouth. The distance from the corner of
the mouth to the outward corner of the eye will not measure
the same on both sides. The horizontal circumference of the
skull being ovoid, the face does not occupy the precise front,
it being longer from the anterior median line to the posterior
median line on one side than the other. By standing behind
a person and looking over the head, thus bringing the face
reversed to the eye, these deviations from mechanical per-
fection may be more readily noticed. By such observation
we may learn that a slight variation in the fullness of the
cheeks will harmonize better with the surrounding features
of that side than if both were equally plump.
* Professor Austen.
THE SELECTION AND ARRANGEMENT OF TEETH. 487
In making an artificial denture, the next step which de-
mands æsthetic culture, after taking the bite, is the selection
and arrangement of the teeth.
The making of artificial teeth is purely the performance
of a sculptor. To produce the original model, when the
market is to be supplied with duplicates, calls into exercise
the same talents. To copy carefully the various forms of
teeth as they are presented is art, only in a limited sense.
To carve an imitation of a natural denture-not a copy of
any specific presentation-which will possess, in each indi-
vidual tooth, a character in harmony with the whole num-
ber, and with the face; to so arrange the whole as to assist
in the very best expression of the surrounding features;
and, in addition, to give them the color and tone of nature,
is an artistic accomplishment in the highest sense. Copying
is simply a mechanical achievement; in all larger objects the
perfection of the duplicate can be ascertained by measure-
ment: nachines are now made to duplicate almost any
irregular forın that is required. In smaller objects, a cor-
rect eye to detect variations takes the place of instru-
ments.
A copy admits of no ideal embellishment. In making a
copy there is no liberty; but, in creating an imitation, the
mind works with a freedom from all restraint. The true
artist therefore rises above a mere copyist, and brings forth
his imitation-which is in fact a new creation, and not the
copy absolutely of anything. In the production of artificial
teeth to supply the market, but little art is required. The
exercise of good judgment in the selection of natural organs
to be duplicated in form and color, does not call into use the
highest artistic talent. Artificial teeth, when made by manu-
facturers, should be in appearance, so far as they will be ex-
posed in service, strictly copies from nature. We say copies,
because the manufacturer can not by any possibility take
cognizance of the peculiarities of the individual for whom
they will be used. He can not, therefore, indulge in an
A
488 TIE EVIDENCE OF A LACK OF ART CULTURE.
imitation, and benefit the dentist so much as by strictly
duplicating nature, in a full variety, and leaving to the den-
tist to hide as far as possible the individual incongruities by
an artistic arrangement. It is somewhat surprising that the
manufacturers have produced such admirable imitations of
nature as are now often found in the market, when the de-
mand for their productions has come from a class of men
who were, to a considerable extent, devoid of æsthetic cul-
ture. Taking the profession as a whole, the manufacturers
have probably in this respect been the educators, rather than
the followers. This is evidently reversing the natural order
of things. Manufacturers are but commercial men actuated
by the love of gain, governed by the laws of trade-demand
and supply; and it is a shameful comment upon a profession
of the pretensions of dentistry, that a trade which cares
only to supply what is demanded, should have the credit of
teaching a profession its own wants. Manufacturers make
what will sell, and it is not to be wondered at that the mar-
ket is filled with inferior productions, so long as there is a
sale for them. But it is to be wondered at that a profession
which is brought into daily contact with the natural teeth,
and should be distinguished for its good taste, are such par-
tial observers as not to detect the inferiority.
This lack of cultivation is evidenced in other ways be-
sides the one referred to. In a majority of the publications
where engravings of the teeth are used as illustrations, the
forms are positively ugly; and it is not the fault of the en-
graver: he follows copy closely, even to the imperfections.
In the illustrations of the correction of irregular dentures,
the models furnished the engraver, while conveying some
notion of the change which has occurred, show in a majority
of instances a disregard of the form of the teeth which
would otherwise make the illustration much more effective.
It is easy to see in many cases that the impression from
which the model was made was taken in wax, and all the
defects made by the draft of the wax in the removal are
AN IDEAL TYPE DESIRABLE.
489
shown in the model-left untouched, and carefully copied
by the engraver. This lack of appreciation of the beautiful,
graceful, and true lies clearly with him who furnishes the
model.
The beneficial influences upon the mind of having it
fully impressed with an ideal standard are not inconsiderable.
It becomes a great help in the determination of any type to
be used or adapted to any given case. With the mind thor-
oughly conversant with any given standard of excellence, it
becomes very easy, by the laws of the association of ideas,
to make or select teeth with such deviations from it as may
be desirable. It will be remembered that the most pleasing
forms in nature are those with the softest and most graceful
outlines; hard and angular forms do not give pleasure, ex-
cept by contrast.
In the development of the natural teeth the laws of har-
mony as universal in uninterrupted nature are beautifully
illustrated. In the youth from twelve years old and upward,
the features of the face present their most charming appear-
ance; all the lines are soft and rounded; sharpness and an-
gularity come on with maturity and old age. The teeth
obey the same law. In youth, immediately after their full
eruption, they present their most perfect appearance; their
cutting edges and grinding surfaces are beautifully modeled;
but as age advances the abrasion from the antagonizing teeth,
together with the almost imperceptible friction of one against
another in the same row, continually act so as to modify this
form. Thus, in taking the extremes, we find the perfection
of full development in the youth changed to a mere stump,
without beauty, in old age.
To describe all the types that are found in nature, and -
which may be in perfect harmony with the surrounding fea-
tures, would be impossible. It would be assumption to give
any one as possessing all excellence; but, as in art there may
be a standard or ideal, accepted by a majority of cultivated
people, so we may present a type which shall combine the
490
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beauties of many, and from which deviations may be made
as circumstances require.
1
DRAWINGS OF TEETH FROM NATURE.
In Fig. 342, Nos. 1, 2, 3, 4, and 5 show the front view of
two canines, a central and lateral incisor, and a bicuspid.
They are drawn larger than nature, to render their peculiari-
ties more forcible. It will be seen that neither in their out-
lines nor any portion of their surface are there straight lines.
or angles; every portion of the surface presents that easy and
graceful contour which an artist loves to dwell upon. The
outlines of the incisors, which are less undulating than those
of any other, are still far from square or angular. Each side
is unlike any other side, and the cutting edge, which becomes
square from abrasion as age advances, is, when fully devel-
2
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3
4
FIG. 342.
5
6
7
S



oped, curved and wavy; and this line, fuller in the center
and depressed each side, is continued up the face of the
tooth, forming a gentle ridge perpendicularly along its sur-
face.
The narrower and rounder parts of the tooth will also
be observed; the changes from the flatter portions coming
not by regular inclination, but at a point about two thirds
the length of the crown from the cutting edge, the outline
dips by a graceful sweep into a depression, which is common
to all well-formed teeth. This line of beauty is very often
neglected in artificial teeth; when arranged in a denture with
the shape as given by the mold, the spaces between them
have the appearance of being made with a separating file, so
perfectly uniform are they.
All the teeth anterior to the molars have a ridge more or
CHARACTERISTICS OF EACH TOOTH.
491
less perceptible running perpendicularly along the face of
the tooth; this is sometimes very faint in the incisors, but is
shown very bold and in striking contrast in the canines. In
the incisors it always assumes a curve with an inclination
toward the median line; but, with the canines, this order is
reversed, and the ridge curves the other way, as in Fig. 343.
The central and lateral incisors, as any ordinary observer will
have noticed, are very much the same in their general con-
tour; the principal difference being, that the laterals are not
FIG. 348.
000

quite as wide in proportion to their length, and are about one
third narrower than the centrals.
In Nos. 2 and 5 are represented two types of canines.
No. 2 harmonizes better with the incisor shown here than
does No. 5. No. 5 would be more appropriately classed with
longer and slimmer associates. The characteristics of canine
teeth are equally developed in both. The same graceful lines
of beauty that marked the incisors are here also seen-the
same depression on the sides of the upper third-the chief
difference being that the canines at that point are rounder
and bolder than the incisors; but, below the upper third, the
difference is radical. The central ridge is very prominent
and terminates in a cusp, and the wavy line of the cutting
edge of the incisors is duplicated, one on each side of the
cusp, thus: The posterior approximal surface is distinguished
by a symmetrically formed tubercle, more or less
defined, but most certainly a mark of beauty.
This tubercle is better delineated in No. 7, which
is a profile view of No. 2. In No. 5, this tubercle,
with its corresponding prominence on the anterior approximal
surface, is developed higher up on the tooth, which consti-
1
492
tutes the main difference in the two types. In Nos. 1 and 8
we have a pure type of a bicuspid, the resemblance to the
canine being easily seen-the same bold surface, cusp, undu-
lated outline, and posterior tubercle; the chief deviation in
the external appearance being in a pretty well-defined tu-
bercle on the anterior approximal surface, and a relative
reduction in size.
PECULIARITIES OF EACH TOOTH.
The characteristics of these three classes of teeth, viz.,
incisors, canines, and bicuspids, are not confined to their
front view. Their profiles are equally peculiar, as shown in
Nos. 6, 7, and 8. The central face of the incisor shows a
regular curve. The canine has no less than three different
planes or curves; the boundary between the upper third and
that below being marked by a decided prominence, while at
the corresponding point on the bicuspid the profile is flat and
the main fullness is below. The peculiarities thus pointed
out are all that concern the appearance of artificial teeth.
The second bicuspid does not differ materially from the
first, except that in nature it is generally smaller; and the
molars are placed so far back as not to call for any especial
criticism upon their appearance.
In passing we desire to call attention to a point that is
almost always overlooked by the mere mechanical dentist.
The profile of the lingual surface is almost invariably curved,
very rarely straight.
These teeth are oftener used to pass a clasp around than
any other, and, in a majority of
instances, the clasp at that point
is made flat; and of course fits
the teeth very inadequately. The
trouble arises from a supposition that the model is perfect,
whereas if the impression is taken in wax, the model is sure
to be faulty, and it is very often the case even with plaster
impressions; and again, a lack of observation as to the real
form, so that the model may be trimmed if defective.
It is not to be expected that the artist, be he manufac-
Q
or thus.
D
493
turer or dentist, will conform strictly to the forms before
illustrated to any great extent. The instances in which one
peculiar shape is the very best that could be selected as
adapted to all the requirements of the case are few, com-
pared with the whole number. In the type presented we
find a beauty of form that is rarely seen except in youth.
The undulation of the cutting edges of the incisors soon
gives way, in the friction of antagonism, to a line more
nearly square with the sides of the teeth. Any one of but
limited observation has noticed, in many cases, the serrated
edges of the incisors, both superior and inferior, immediately
after eruption, and also that in a little time this peculiarity
has passed away. This wearing away of the antagonizing
ends of the teeth is the most natural modification of the
perfect form of the tooth, and is common to them all. A
great variety of forms can be made, all harmonizing with
what we see in nature, by taking a well-developed type, and
producing the appearances above indicated. Thus, by cut-
ting off the ends of the teeth as exhibited in the illustration,
we give the semblance of age, and that without in the least
changing the form of the upper portion.
HOW A GREAT VARIETY MAY BE MADE.
By having the mind clearly impressed with an ideal
standard, appropriate selections from a ready-made stock will
be more easily made; or, when the desired form is not sup-
plied, changes may be secured to a limited extent by grinding.
One thing is to be especially avoided, mannerism. The
adoption in all cases of any type, or its variations, however
excellent, can only end in deformity. Too many artists are
mere mannerists, either by carrying some single idea of their
own into all their works, or, what is more common, copying
the modes and peculiarities of genius, and thus caricaturing
rather than imitating nature. Mannerism is always an evi-
dence of weakness.
For a complete knowledge of probable and possible varia-
tions, the student must be a close observer of nature. His
standard of beauty will finally be the result of the rejection
494 HOW TO OBTAIN THE BEST ARTISTIC RESULTS.
of Nature's defects, and the combination of her excellences.
Imitate Nature rather than attempt to copy her. A copy of
any one presentation would not probably convey as pleasing
an impression as an adaptation of an imitation by an artist
who had thoroughly studied the requirements of the case.
That method of making artificial teeth which requires for
success the possession of the highest order of artistic talent,
is undoubtedly carving. In this case the artist can not to any
extent copy Nature; he is compelled to imitate her, and upon
that art which conceals art his success depends. Not only
must he carve each individual member with a character
which shall harmonize with the external features, but the
arrangement (or "grouping," as an artist would term it)
must be the result of most careful study.
There is another style of work which requires a lower
order of talent, but in which the results are in many cases
quite equal to the best efforts at carving. Continuous-gum
work, known as the invention of Dr. John Allen, is the
result of the arrangement of single teeth in any desired
form, and the completion of the operation by forming
around them an artificial gum. No doubt, if the teeth in
the market were, in form, color, and variety, all that is
needed to meet the requirements, this method of forming an
artificial denture would be all that art demands. It would
then possess all the merit of carved work, and in some re-
spects afford even greater opportunity for artistic display,
being also much easier of accomplishment. As it is, the
same taste and study are required in grouping as in carved
blocks.
Absolute rules can not be given for this art. Suggestions
only can be made which may prove a valuable aid. It must
be borne in mind that we are not dealing with the natural
organs, and some allowances and deviations must be made.
for that almost imperceptible difference in appearance that
exists in the artificial ones, even when they are the most per-
fect of their class. Well-formed natural teeth please the eye
495
when symmetrically placed even close together in the arch.
Artificial teeth under like arrangement nearly always betray
their origin.
SUGGESTIONS TO A PAINTER APPLICABLE.
The following suggestions to the painter are equally per-
tinent and applicable to the dental artist:
"Nature never repeats herself, even in two sides of a leaf.
Such precision belongs to machine-work; and, in studying
nature, we learn that variety is no less necessary to a pleasing
composition than unity. To the grace and beauty of the
whole work, harmony is indispensable. Without harmony
each part may fail of the effect intended, however true in
design. There must be harmony of line, harmony of group-
ing, harmony of light and shade, harmony of coloring, har-
mony of expression; each part must be so adapted as to
correspond to the rest. The attitude must be in keeping
with the expression; the color, with the subject treated; and
the accessories must be true both to the character and the
age represented: an harmonious whole is always more or less
pleasing in itself, independent of subject or style."
The application of these principles for a number of years
in the arrangement of artificial teeth, has satisfied the writer
that in no other way can so pleasing effects be produced.
The gratification of the eye by a judicious deviation from
uniformity is nowhere more strikingly illustrated than in
landscape gardening. The traveler who is familiar with the
ancient parks or gardens of the Continent of Europe, laid
out with all the regularity of squares on a chess-board, the
trees and shrubbery often trimmed or twisted into fantastic
shapes unlike the free growth of nature, experiences a sense
of great relief in visiting the parks of England, where the
art in the arrangement is less mechanical and more concealed.
This formality and stiffness is not displeasing at first to the
uncultivated, but the eye soon wearies of it, and seeks relief
in variety. It is this action of the mind we must consult in
the arrangement of artificial teeth; and, in doing so, it does
not follow that the mind will be able to recognize the cause
HARMONIZING TEETH WITH CHARACTER.
196
of that which gratifies it. The aesthetic sense may be fully
satisfied without being aware of the true reasons of the satis-
faction.
We have shown the undulations of line manifest in every
view of each tooth. To harmonize with this character we
must avoid straight lines in the arrangement of the whole.
The teeth ought to be so placed that their cutting or grind-
ing ends will not all be upon the same level. There is no
FIG. 344.

better way of arriving at a correct taste or judgment in this
arrangement than by an observation of the most symmetri-
cally developed skulls at our command, and by a comparison
of such with those of a lower order.
By universal consent, the highest type of physical and
intellectual beauty is accorded to the Caucasian race, and the
skull shown in Fig. 344 is one that may be studied with
profit. Our attention will be particularly drawn to the gen-
eral uprightness or vertical line of the profile, and the cor-
respondence of the teeth with that line. In teeth and jaws
A COMPARISON OF SKULLS.
harmoniously developed, with such a well-developed cranium
as here shown, there is found the highest standard of beauty
in the arrangement of the teeth. The six or eight front
teeth—all that are particularly exposed to view in life—nei-
ther protrude nor recede; there is no marked peculiarity
about their position which would suggest the possibility of
improvement. The canine teeth, which in many skulls are
so large or so prominent as to suggest the origin of their
HIGHSS
FIG. 345.
497

MUI
name, are here moderate in size, close within the circle, and
inconspicuous. Any material deviation from such an arrange-
ment in an otherwise symmetrically developed skull will
nearly always incline to deformity. By cutting off the
cranium from the maxillary portion, by an imaginary line
passing from the condyloid process through the socket of
the eye, it will be seen that the relation of the brain in size
to the lower part of the face is as two to one; i. e., that two
thirds of the skull is given to the brain, and but one third to
the jaws.
498
THE SKULL OF A GORILLA.
Passing now to the skull of a negro, as shown in Fig.
345, we see a marked change in all the points to which our
attention was given in the Caucasian. The cranium is di-
minished proportionately; the maxillary apparatus is in-
creased. The profile is much inclined; the jaws protrude;
the teeth correspond with this protrusion, and the canine
teeth are larger and more conspicuous. Drawing a line from
the condyle to the eye, as in the former case, we find the skull
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FIG. 346.

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nearly equally divided. Evidently the intellectual qualities
are more feeble, and the animal more pronounced.
Our next illustration is from an order below the human,
and yet with strikingly similar characteristics. Fig. 346
represents the skull of a gorilla, which may be accepted as
the extreme of the Caucasian. Here the relation between
the cranium and jaws is exactly reversed. The brain occu-
pies one third of the skull, and the jaws two thirds. Equally
marked is the great increase in size, prominence, and power
of the canine tooth.
Attention has been thus particularly given to the canine
499
teeth, because their size and position in the arch affect the
expression of the face more than those of any other teeth.
There are many instances in the setting of artificial teeth
that require a variation in the position of the canines, to
correspond with general but marked peculiarities of physi-
ognomy; but caution and good taste must be exercised in
this determination, or characteristics belonging to the infe-
rior races, or to mere animals, will be portrayed.
PROFILE OF THE UPPER TEETH.
The line of the cutting edges, as before stated, must not
be a straight line. Fig. 347, copied from a well-developed
upper jaw, is evidently the type toward which we should
approximate. This view shows that line to be a double
curve, dropping in front and elevated at the back. The
FIG. 347.

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same line marks the edge of the most beautiful upper lip,
being doubled to represent the whole lip, and is familiarly
known as the form of "Cupid's bow."
The line of the lower jaw is the same as that of the upper
jaw from the last tooth forward to, and including, the bicus-
pids; and from thence, in the lower jaw, it curves upward,
thus making provision for the natural lap of the superior
incisors over the inferiors. Fig. 348 shows a type of a lower
jaw which articulates with the foregoing upper one, in which
the difference of line is clearly manifest.
There is a wide range admissible in the curve of the
dental arch, between the extremes of a semicircle and a
parallelogram. The width of the normal curve must be de-
termined by the surrounding features. There can be no
•
PROFILE OF THE LOWER TEETII.
500
fixed standard; otherwise the characteristic features of races
and families would be destroyed. Fig. 349 shows a departure
from a regular curve which is sometimes admissible. Such
an arrangement is probably the best for masticating purposes,
but would be objectionable in some cases on account of the
fullness of the canines, which might give an unpleasant
expression. If the denture were for a rugged face, full
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of strong lines and marked character, it might be admis-
sible to make the canines still more prominent; but, in
the face of a delicate lady, with the features rounded and
symmetrical, even so much prominence as is shown in this
drawing would be inadmissible. The more regular the
features, the more difficult it is to avoid regularity in
setting artificial teeth without producing deformity; for
deformity is only relative, and what would deform one
501
would enhance beauty in another. But there are some other
peculiarities about this drawing that it is well to copy to a
considerable extent, and those are the lines that flow back
from the canines to the last molar. It will be observed that
the two bicuspids and the adjoining two molars are nearly on
a straight line, and that the third molars stand wider apart;
thus, at the back the teeth curve outward rather than inward
-the very reverse of a semicircle. When the arch is wide
at the bicuspids in a person of delicate form, the effect is
very disagreeable. The best width of an artificial denture
FORMS TO COPY AND FORMS TO AVOID.
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FIG. 349.
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in any given case must be governed by utilitarian rather
than æsthetic influences; nevertheless, the width at the back
being decided upon for masticating purposes, the form of
the arch in front is often quite under our control.
For the position of teeth in the arch, an almost indefinite
variety is admissible; comprehending their rotation on their
axes, the
spaces which separate them, and deviations from a
uniform curve. Artificial teeth will always look better if
placed so that the form of each is clearly relieved against the
shadow of the spaces between them. A compact row in an
aged person, where there are many external evidences that
nature is giving way, strikes almost any one as an incongruity.
33
THE EXPRESSION GIVEN BY POSITION.
502
With age we see a shifting of position of the natural teeth,
which is in perfect harmony with the wasting of muscle and
tissue which characterizes advanced life. For the best artistic
effect, the spaces between the teeth should not be uniform
in width, but there may be comparative uniformity in the
two sides of the mouth. In general, the central incisors will
look better if nearly or quite in contact, but may be relieved
by a space between them and the laterals. The canine may
or may not be separated from the lateral by a decided space,
but a considerable vacancy may be left between the canine
and bicuspid without any detriment to beauty.
In addition to the variety that may be caused by a judi-
cious distribution of spaces, a very good effect upon the
expression will be caused by the partial rotation of a tooth,
or by giving prominence to one or more in the arch.
For natural expression, the central incisors and canines
must occupy a fixed and unalterable location. The centrals
control the profile of the mouth, while the canines support
and give character to its corner; the two most important
points in the whole arrangement. There can be but little or
no deviation admissible in the location of these teeth, but a
partial twisting or a different inclination may often be re-
sorted to with good effect. The central incisors will, how-
ever, generally appear better by having them stand with
their flat faces on a line with each other; but the canines
may be rotated slightly, in either the same or opposite direc-
tions, without disfigurement.
The lateral incisors and bicuspids should occupy positions
subordinate to the canines and centrals. Considerable lati-
tude may be shown in placing the lateral. It may have a
greater inclination toward the median line than the others,
or it may be twisted more on its axis; the anterior corner of
the cutting edge may be thrown forward of the central, or
the whole tooth may stand within the arch; either method
carried to a limited extent will add to the naturalness of the
effect. The bicuspids should stand within a curved line
+
503
formed by the centrals, canines, and molars, partially hidden
by the prominence of the canine.
The foregoing remarks apply entirely to the construction
of an upper denture, but are of greater force when entire
upper and lower dentures are to be supplied. The character
decided upon for the upper will govern the character to be
given to the lower set. Where any great number of the
natural teeth remain upon the lower jaw, and an entire upper
set is to be supplied, the character of the lower teeth will
influence the form and arrangement of the artificial ones,
and thus the suggestions before made will be modified to
meet the case. Perfect harmony would therefore require
that noticeable defects or irregularities in the lower natural
teeth should be imitated, in a modified form, in the construc-
tion of the upper. Thus, marked irregularities of position
below will indicate an irregular arrangement above, but not
necessarily to the same extent. Permanent discolorations on
the surface of the natural teeth would also indicate a modi-
fied imitation of the same on the artificial.*
IMITATION OF DEFECTS ADMISSIBLE.
It is the comparative perfection of artificial teeth, to-
gether with their stiffness and formality, which, even if the
color be appropriate, betrays them in persons of full age.
Tricks or devices may be justifiably resorted to in such cases.
The grinding of the cutting edges, to produce the appear-
ance of a natural tooth broken or bruised by abrasion, is such
a device, and may be adopted occasionally with much benefit.
Not that there is any intrinsic beauty in a broken tooth, nor
that there is any charm in its contrast with a perfect one;
but the eye is so accustomed to see these slight defects in the
* In 1852 I was called upon to insert an upper set of teeth where the natu-
ral lower teeth were sound, but stained by long neglect, in marked and irregular
spots over the surface. After finding myself unable to remove the discolora-
tions, I resolved to imitate them, and carved a set of teeth and stained them in
the baking with a preparation of terra di sienne. After they had been worn a
year they were exhibited in the mouth of the patient to the Jurors at the
"World's Fair," in New York, in 1853, and elicited their highest commendation.
(Vide Jurors' report.)
504
natural teeth, that it comes to regard them as only allied to
nature.
GOLD FILLINGS IN ARTIFICIAL TEETH.
The insertion of gold fillings in exposed portions of the
teeth is another trick which can sometimes be made available
with propriety. In the construction of a partial set, where
there are fillings in the natural teeth which are exposed to
the ordinary observer, harmony suggests that there be no
large number of artificial teeth inserted, perfect in their
form and appearance. It is then eminently proper to adopt
this device, but the filling should not be conspicuous or ob-
trusive. In making an entire set, this trick has little to
recommend it. The means at our command in such cases
are sufficient to enable us to conceal our art without resorting
to the questionable device of suggesting to the mind decay,
and thus induce the inference that the organs are natural.
In the case of the partial set, harmony with the exposed
natural teeth may require it; but in an entire set it is of
doubtful propriety.
The manufacture of porcelain teeth is one of the most
difficult of arts, and when in its infancy its best results were
found among the few dentists who had to some extent ob-
tained the mastery over the most refractory of ingredients,
and who had the ambition and genius to excel in carving;
but the difficulties to be overcome were such as naturally to ·
deter others from the desire to obtain knowledge under such
adverse circumstances; and, in due time, the manufacturers
perfected their wares, so that none but an exceptional few
could have excelled them. The average dentist is therefore
not only compelled to accept such as the market affords, but
it is more than probable that his patient will be better served
by a.judicious selection coming from his own cultivated taste
than by any attempt of his own to manufacture them.
With gum teeth for plate-work, there is but little latitude
for artistic effect consistent with the mechanical execution;
with blocks made for rubber there is still less freedom of
arrangement for the operator. Single teeth without gums
CRITICISM ON TEETH AS NOW MADE.
505
are the only ones that will permit us to exercise our taste
unlimitedly.
In entire sets, where the absorption of the alveolar pro-
cess necessitates a substitute to restore the contour, we find
ourselves limited at present to three methods, viz.: the Eng-
lish method of forming the gum of vulcanite, the same as
the base; a platina plate with a continuous porcelain gum;
and celluloid; the continuous gum, as has been before re-
marked, presenting advantages in an artistic point of view
which are thus far unequaled. Some effort has been made
by the manufacturers to furnish an imitation of the continu-
ous porcelain gum in a forın adapted to a plastic base; and,
considering all the mechanical difficulties to be overcome,
their efforts have resulted in considerable success.
Far more artistic talent, as well as mechanical skill, is
required in making from a mold a block of several teeth
joined by a gum, than in the production of single teeth.
The suggestions heretofore made as to their arrangement
apply here with the same force to the manufacturer as to
the dentist in his adaptations to a special case. Many of the
sections made for vulcanite show conclusively that the artist.
who modeled them could never have studied nature very
long nor very closely. There is often displayed far more of
the artist's invention than his imitation. Many of the little
details which go far to influence the appearance of the whole
are neglected. For instance, the teeth will often be fused
together with particles of the tooth body left between them
before baking; and it is equally common to find the beauty
of the teeth in their form ruined by a V-shaped separation
between them, terminating in contact with the gum, half
way up the tooth; or, again, to find the central and lateral
with such a space on one side and the corresponding space
filled up. The point of gum between the teeth is often pale
and indistinct. In these blocks the individuality of the tooth
should be especially clear, brought out by a clean and well-
defined space, and the color of the gum between in sharp
506
GENERAL REMARKS ON COLOR.
contrast, or the tout ensemble will betray the porcelain char-
acter of the material used.
Professor Austen says: "Artificial teeth should imitate
the natural organs; yet there is a perfection of form and
arrangement which it is not advisable to imitate. To disarm
suspicion as to their artificial character, it is often desirable
to impart a measure of irregularity. An overlapping lateral,
a missing bicuspid, a worn canine, an incisor, bicuspid, or
molar apparently decayed and filled with gold, an exposed
neck from absorption of the alveolus, are among the legiti-
mate devices of the skillful mechanician who has the ‘art to
conceal art.' If there are any defective natural teeth re-
maining to be matched, still higher art is required. A per-
fect porcelain incisor is no fit companion for one that is
partly broken, decayed, and discolored; and since no art can
make the defective tooth perfect, and yet the patient retains
it, there is no alternative but to give so much imperfection
to the artificial one as shall take away that striking con-
trast which so painfully offends our æsthetic sense of fit-
ness."
It is questionable whether any suggestions or criticism
upon the color and tone of artificial teeth will be of any
benefit to the student. That it is, in many respects, of equal
or more importance than individual form, is undoubted; for,
with an artificial denture faulty in form and bad in arrange-
ment, if the tone and color exhibit good taste in the selec-
tion, it is a redeeming trait, and worthy of praise. But the
faintest shades are of so much importance in this matter,
and they are so undefinable, the names of colors and their
variations often conveying a different idea from what was
intended, that it is impossible to give more than the general
suggestions of good taste. Fair teeth are admissible in
younger persons; deeper hues are required for the aged.
While we sometimes find in old persons natural teeth very
fair to look upon, there is a seeming incongruity about it
which we are not justified in imitating. It is safer to err
HARMONIZING DIVERS COLORS.
507
upon the side of inserting those of a deeper tone than is
really required, excepting when some of the natural teeth
remain, and then faithfully matching or at least selecting a
color that harmonizes, and will not be obtrusive or conspicu-
ous. The canine teeth in nature are less translucent and
more deeply shaded than the incisors or bicuspids. This
should certainly be imitated so far as the canines are con-
cerned; but, in the opinion of the writer, we shall produce
a better effect with artificial teeth by not inserting bicuspids
of lighter shade than the canines. The artificial tooth does
not absorb the light as does the natural one, and when placed
in shadow as the bicuspids in situ, they are rendered more
conspicuous. Where natural teeth of divers colors are scat-
tered, and the vacancies are to be supplied, it is our duty to
harmonize in color each artificial tooth with its natural neigh-
bor.*
It will be manifest that it is simply impossible to carry
all the foregoing suggestions into practice with some of the
methods of constructing sets of teeth now in use. One of
the greatest difficulties to overcome is the scientific one, viz.,
to discover and combine in just proportions the materials
which will produce this wonderful imitation. In no other
art with which the writer is acquainted have imitations of
nature been carried even now to such perfection. The
making of artificial flowers has perhaps come the nearest to
it. Certain it is that, of the materials which chemistry has
already furnished us, it is possible to obtain most wonderful
results. The color of a tooth is dependent principally upon
* I was required on one occasion to insert the four superior incisors. One
of the canines was of exceedingly fair color; the other was very much dis-
colored by a black amalgam filling on its anterior approximal surface, which
the patient on no account would have disturbed. A block was made in which
the side of the lateral incisor next the discolored canine was deeply stained with
platina, and a most excellent imitation in color was produced, and the other
teeth were vari-colored, grading in shade from one canine to the other. The
effect was very good, destroying the conspicuousness which the discolored canine
would have shown in contact with an unstained associate.
E
508 WANT OF INDIVIDUALITY IN ARTIFICIAL DENTURES.
the proportion of its ingredients; its tone upon the action
of the fire in burning or baking. The fault of many of the
porcelain teeth of this country is the crudeness or rawness
in their appearance-a lack of translucency, which a little
more heat would very much improve. It would blend the
colors more perfectly, give them more vitality, and soften
down the hard and angular lines of the mold. It is perfectly
in the power of our manufacturers, with the materials now
in use, to make a general improvement.
One thing which is much wanted is to increase the variety
of darker shades; not by hurrying into the market a lot of
poorly baked blue or yellow teeth, but by a careful imitation
of those organs in persons who have been habitually neglect-
ful, until their teeth have acquired a tone or color which
can not be removed. While the dentist at large is depend-
ent upon the manufacturer, he must cultivate his taste until
he is able to select the most suitable shade which is prepared
for him. When one or more of the front teeth are remain-
ing, either above or below, in a fair state of preservation, a
tolerably correct idea may be gathered of what is needed;
and careful observation made of just such cases, as well
as of all partial sets, taking into consideration the age, com-
plexion, etc., will do much to improve his judgment and
enable him to make suitable adaptations when he has no
such help.
When we consider the infinite variety of the human
countenance, and the equally infinite diversity in form of the
jaws which a dentist sees (no two being exactly alike), and
then consider that there are thousands with a conformation
of jaw peculiar to each, who are wearing artificial teeth of
exactly the same size, shape, and color, in fact all cast in the
same mold, and really belonging to but one individual, we
begin to realize the paucity of our resources.
In the loss of the teeth, the absorption of the processes,
and the wasting away of the muscles and tissues, as we have
seen, the greatest possible detriment is caused to the expres-
THE CULMINATION OF EXCELLENCE.
509
sion of the human countenance. The complete restoration
of these features, with all their power of expression, by art
-art so consummate in the selection, arrangement, and adap-
tation of its means as to defy detection—is one of the crown-
ing glories of dentistry as an art.
CHAPTER XXI.
ANATOMY AND PHYSIOLOGY OF EXPRESSION.
To no one does the study of the human face, in its va
rious forms and aspects, recommend itself with more force
than to the dental practitioner; for, called upon as he is, not
only to relieve suffering humanity from the greatest pain to
which flesh is heir, but also to repair the ravages of decay,
either in efforts directed toward the preservation of the
natural organs, or, when these are lost, to supply artificial
substitutes, if he is not as quick to perceive and as able to
retain in his memory the nice shades of expression of the
same face, and the characteristic points of resemblance or
difference between various individuals, as the sculptor or
painter, he will fail in many essential particulars to meet all
the just and proper demands upon him.
Apart from this general interest shared by all in the
human face, it is important that those engaged in certain
departments of life should become thoroughly acquainted
with the mechanism, so to speak, by which the record is
made. To the speaker, whether in the pulpit, at the bar, or
on the stage, gesture is all-important; to the artist, whether
as a painter or sculptor, expression is everything; and last,
though not least, to the dentist a faithful discharge of duty
demands that he should, in the performance of his operations
on the teeth, invariably endeavor to preserve the natural ex-
pression of the face, or when the ravages of decay have
eventuated in the loss of the dental organs, that the lost ex-
pression should be restored by the introduction of properly
+
511
constructed and adapted artificial substitutes. To each and
all of these, and particularly to the latter, if they desire to
attain the highest possible point of excellence, an intimate
acquaintance with the ANATOMY AND PHYSIOLOGY OF EXPRES-
SION is indispensable.
A KNOWLEDGE OF PHYSIOGNOMY INDISPENSABLE.
It is generally conceded that the proportionate relation of
the bones of the face to those of the cranium has much to
do with the moral and mental qualities of the individual;
in other words, that a high order of intellect is usually mani-
fested by those in whom the cranium is large, the forehead
broad and high, and the bones of the face small; while the
animal propensities are generally evinced in a marked de-
gree, and preponderate over the intellectual, in those with
depressed foreheads, compressed temples, and large and
massive jaws. The opposite extreme is sometimes pre-
sented, in which the bones of the face are so dispropor-
tionately small, in comparison with the cranium, as to
constitute a marked deformity. Again, a want of har-
mony between the different bones of the face is occasion-
ally presented; as, for instance, when the inferior maxilla
is very large and massive, or unusually small, in comparison
with the superior maxilla, or vice versa. This hypertrophied
or atrophied condition may occur in any of the bones, and
of course when existing will mar the harmony of the sur-
rounding parts.
❤
In extreme old age, the atrophied condition of the jaws,
due to the gradual loss of all the teeth and the absorption of
the alveolar processes, produces that decided alteration in the
features of the aged with which we are all so familiar. The
change which invariably takes place in the angle of the lower
jaw in consequence of the disappearance of the teeth and
processes causes the chin to project, and when the jaws are
closed the nose and chin approximate each other. Even
when apart, the falling in of the lips so encroaches upon the
oral cavity as to make it too small for the tongue, and thus
renders the speech feeble and indistinct. It is here that the
512 EXPRESSION DEPENDENT UPON MOVEMENT OF MUSCLES.
skill of the mechanical dentist finds a field for artistic labor,
not only by replacing the lost expression of the face, but
also by restoring the medium through which the wants and
thoughts of the individual are made known to others.
Arising from various parts of the bony framework, and
then mainly converging to one or the other of the two great
centers of expression, the eyes and mouth, there are a num-
ber of muscles on whose action the varying play of the fea-
tures depends.
FIG. 350.

Ara
Old Age.
wxxas
W
WMU
Ap
Sütvite
angg
Fig. 351 illustrates the principal muscles of the face con-
cerned in expression. The Occipito-frontalis (A A) consists
of two broad but fleshy bellies, with an intervening aponeu-
rosis resting upon the arch of the skull, and over which it
slides; the posterior portion of the muscle arises from the
superior curved line of the occipital bone. The principal
parts of the anterior fibers are inserted, or blend with the cor-
rugator supercilii, and the superior margin of the orbicularis
palpebrarum. The minor portions of the right and left fron-
tal muscles unite together some distance above the root of
the nose, and are inserted at this point and send down fibers
ILLUSTRATION OF THE MUSCLES OF EXPRESSION.
which are continuous with the pyramidalis nasæ. Function:
It moves the scalp, elevates the eyebrows, and induces the
transverse wrinkles of the forehead.
The Corrugator Supercilii (1, 1) lies under the occipito-
1. Corrugator Supercilii.
2. Pyramidalis Nasi.
3. Orbicularis Palpebrarum.
4. Levator Labii Superioris.
5. Zygomaticus.
6. Levator Labii Proprius.
7. Compressor Nasi.
S. Depressor Alæ Nasi.
FIG. 351.
A
A. OCCIPITO-FRONTALIS.
9. Nasalis Labii Superioris.
10. Orbicularis Oris.
11. Levator Anguli Oris.
12. Triangularis Oris.
13. Quadratus Menti.
14. Levatores Menti.
15. Platysma Myoides.
16. Buccinator.
513

:
frontalis, and is a small, pyramidal muscle, arising from the
inner extremity of the superciliary ridge; its fibers proceed
outward from their origin and blend with those of the occipito-
frontalis and orbicularis palpebrarum. Function: It draws
514
DESCRIPTION AND FUNCTION OF FACIAL MUSCLES.
the eyebrows and eyelids inward, and produces the vertical
wrinkles of the forehead.
The Pyramidalis Nasi (2) is usually regarded as a pro-
longed slip of the occipito-frontalis, which continues down-
ward on the bridge of the nose, where it blends with the
compressor nasi. Function: It draws down the inner angle
of the eyebrows, and produces the transverse wrinkles on
the bridge of the nose.
The Orbicularis Palpebrarum (3, 3) consists of a thin,
flat plane of elliptical fibers, which extend around the whole
circumference of the orbit and eyelids. It spreads outward
on the temple and downward on the cheek, but the only
fixed points of attachment to the bone are at the inner mar-
gin of the orbit. Function: It closes the eyelids.
The Levator Labii Superioris Alæque Nasi (4, 4) is a thin,
triangular muscle, arising from the upper part of the nasal
process of the superior maxilla by a pointed extremity, and,
as it descends along the side of the nose, gradually increases
in breadth, and then divides into two slips, one of which is
inserted into the ala of the nose, and the other blends with
the orbicularis oris. Function: It elevates the upper lip
and ala of the nose, and dilates to a considerable extent the
latter organ.
The Zygomaticus, Major and Minor (5, 5), arise, the
latter in front of the former, from the malar bone, and then
pass downward and outward to the upper lip and angle of
the mouth, where their fibers blend with the orbicularis oris.
Function: They raise the upper lip and draw the corners of
the mouth outward, as in laughing. By these muscles the
corners of the mouth are raised in smiling, so as to form the
dimple; in laughter, still higher, so as to swell the cheek,
wrinkle the eyelids, and compress the eyes, even until the
tears begin to flow.
The Levator Labii Superioris Proprius (6, 6) arises from
the lower margin of the orbit, where it is attached partly to
the superior maxilla, and partly to the malar bone; its fibers
DESCRIPTION AND FUNCTION OF FACIAL MUSCLES. 515
pass downward and inward, and blend with the upper part
of the orbicularis oris. Function: It is the proper elevator
of the upper lip, and at the same time carries it a little
inward.
The Compressor Nasi (7, 7) arises narrow and fleshy from
the canine fosse of the superior maxilla, and its fibers con-
tinuing upward and inward expand into a thin aponeurosis,
which unites on the dorsum of the nose with that of the
muscle of the opposite side. Function: The compressors
may act either as dilators or as constrictors of the nares.
Depressor Labii Superioris Alæque Nasi (8), covered by
the orbicularis oris, arises from the myrtiform fossæ of the
superior maxilla, as a short radiating muscle, whose fibers
diverge upward and outward; the ascending fibers terminate
in the septum and back part of the ala of the nose; the
others curve forward and blend with the upper portion of
the orbicularis oris. Function: It draws the upper lip and
ala of the nose downward, and thereby constricts the anterior
nares.
}
The Orbicularis Oris (10, 10) is a great sphincter muscle
surrounding the mouth, and, although it has no bony origin
or insertion, as we have found, a large number of muscles aris-
ing from the different bones of the face center here and
blend their fibers with those of this muscle. Function :
It closes the lips.
The Levator Anguli Oris (11), covered by the preceding
and the zygomatici muscles, arises from the canine fossæ just
below the infra-orbital foramen, and its fibers pass downward
and outward to be inserted into the orbicularis oris at the
angle of the mouth. Function: It raises the angle of the
mouth and draws it inward.
The Depressor Anguli Oris (12) arises from the external
oblique line of the lower jaw by a broad base, and its fibers
converge as they pass upward to be inserted into the angle
of the mouth, where they unite with the orbicularis oris, the
zygomaticus major, and the levator anguli oris. Function:
516 DESCRIPTION AND FUNCTION OF FACIAL MUSCLES.
It draws the corners of the mouth downward, and is the
antagonist of the muscles just named; when they all act
together, the mouth is drawn backward.
The Depressor Labii Inferioris (13) arises from the ob-
lique line of the inferior maxilla, just in front of the ante-
rior mental foramen; it is a quadrilateral-shaped muscle,
and its fibers pass upward and outward to be inserted into
the lower lip. Function: It draws the lower lip downward
and a little outward.
The Levator Labii Inferioris (14) arises from the incisive
fossæ of the lower jaw external to the symphysis; the fibers
pass downward and a little forward to be inserted into the
chin. Function: It raises and protrudes the lower lip.
The Buccinator (16, 16) is a broad, thin muscle, arising
from the outer border of the pterygo-maxillary ligament, and
the external surface of the alveolar processes of the upper and
lower jaw, commencing at the first molar tooth and passing
backward. The fibers of the muscles converge, and are
inserted into the angle of the mouth and the upper and
lower lips. Function: It compresses the cheek, so as to
assist mainly in driving air from the oral cavity, as in blow-
ing on wind-instruments.
While the muscles already described as the superficial
muscles of the face are mainly concerned in the varying
expressions of the countenance, it must be remembered that
those deep-seated muscles, the temporal, masseter, and exter-
nal and internal pterygoid, which are the active agents in
the comminution of food, sometimes play an important part
in expression. This is markedly manifest in the aged after
the loss of the dental organs, with whom the shortening of
the face, the protrusion of the jaw, and the approximation
of the nose and chin, under such circumstances, are due to
the contraction of these muscles, and the influence which
they exert in modifying the shape of the lower jaw, by alter-
ing the angle which the ramus forms with the body of the
bone in early manhood. Considerations such as these indi-
517
cate the propriety of a brief description of these muscles, in
connection with the subject under consideration. The first
of these-
ILLUSTRATION OF THE PTERYGOIDEI.
The Temporalis, arises from the entire temporal fossæ,
and forms a broad, radiating muscle, whose fibers, as they
descend, converge into a flat tendon, which is inserted into
the inner surface of the coronoid process of the lower jaw.
Function: It raises the lower jaw.
The Masseter is a quadrilateral-shaped muscle, which
ul.
LOWER
/////////
FIG. 352.

GREAT WINC
OF
SPHENOID
UPPER A
FLOWER HEAD
JAW
GOID
ANGLE
ACC
.Sn
CARTIL
CONDYLE
guita
arises from the malar process of the superior maxillæ and
the zygomatic arch, and is inserted into the posterior third
of the outer surface of the body of the lower jaw, and the
ramus from the coronoid process to the angle. It has two
planes of fibers, superficial and deep. The first pass down-
ward and backward, the second downward and forward.
Function: It draws the lower jaw upward and forward, or
upward and backward.
The Pterygoidei are illustrated in Fig. 352. The Ptery-
goideus Externus arises by two heads (1, 1) from the ptery-
goid ridge of the great ala of the sphenoid bone, the outer
34
518 THE MUSCLES OF THE EYE AND ITS EXPRESSION.
surface of the external plate of the pterygoid process, and
part of the tuberosity of the palate-bone; and its fibers
pass horizontally backward and outward, to be inserted (2)
into the neck of the condyle of the lower jaw. Function:
When the two muscles act together, they draw the inferior
maxilla directly forward, so as to make the lower front teeth
project beyond those of the upper. The protrusion of the
chin in those who have lost their teeth is greatly due to this
fact. The lateral sliding motion of the lower jaw in masti-
cation is effected by the alternate contraction of the muscles
of the right and left sides.
The Pterygoideus Internus (3), like the masseter, is quad-
rilateral in form, and arises from the pterygoid fossa of the
sphenoid and the tuberosity of the palate-bones; its fibers
pass outward, downward, and backward, to be inserted into
the inner surface of the ramus and angle of the lower jaw.
Function: It draws the lower jaw upward, and, from the
obliquity of its fibers, also assists the pterygoideus externus
in carrying the jaw forward and from side to side.
There are other muscles, in addition to those just de-
scribed, which are somewhat concerned in expression.
Among these are the depressors of the lower jaw and the
other muscles of the neck, by means of which the head is
thrown into various positions, under the influence of the
different passions; but it would be foreign to the subject to
present even a brief description of them. It is proper, how-
ever, to refer to the ocular group of muscles, for the eye is
not only one of the most prominent features of the face, but
also one of the most expressive. When the rest of the face
is so completely under the control of the will that it is im-
possible to determine what is passing in the mind of another,
the eye frequently reveals everything. So true is this that,
when the tongue says one thing and the eye another, men of
observation and experience invariably believe the latter. It
is the position of the organ, whether in the sidelong, upward,
or downward glance, the fixed, prolonged gaze, or the rest-
THE GREAT LINES OF CHARACTER IN THE FACE. 519
less, roving motion, that serves as a key, unlocking to the
mind of the attentive observer that which another is striving
to conceal. The muscles by which these varied movements
of the organ are effected are six in number, and consist of
two groups, the first of which are four straight muscles, the
rectus superior, inferior, externus, and internus; the sec-
ond group is formed by two oblique muscles, the obliquus
superior and inferior. In addition to moving the eye up-
ward and downward and from side to side, if all the muscles
of either group act together, a retraction of the eyeball is
induced by the contraction of the Recti, or a protrusion of
the ball by similar action on the part of the oblique. Squint-
ing or strabismus, either convergent, looking inward, or
divergent, looking outward, which gives such a peculiar
expression to the face, is due to a want of harmonious action
in the ocular group, and may be caused by overaction or
paralysis of a muscle from cerebral disturbance, or it may be
the result of imitation. The levator palpebræ, which is in-
cluded in this group, is the elevator of the eyelid.
The great lines of character are the lines of the zygomatic
muscle, coming from above, and of the triangular muscle,
coming from the chin; and the moving point toward which
they all act is the corner of the mouth. In cheerful emo-
tions they all rise toward the eye, which becomes full and
distended. In the depressing passions the features sink, the
eye is languid, and the whole countenance has a serious,
thoughtful cast.
Dr. Holmes
says: "All parts of the face doubtless have
their fixed relations to each other and to the character of the
person to whom the face belongs. But there is one feature,
and especially one part of that feature, which more than any
other facial sign reveals the nature of the individual. The
feature is the mouth, and the portion referred to is the cor-
ner. A circle of half an inch radius, having its center at the
junction of the two lips, will indicate the chief focus of the
expression."
520
THE MOUTH THE CHIEF FOCUS OF EXPRESSION.
The orbicularis is the opponent of all the muscles which
are concentrated from various points to the lips; and it is
by the successive action and relaxation of these antagonistic
muscles that so much and so varied expression is given to
the mouth. It tremblingly yields to the superior force of
its counteracting muscle, both in joy and in grief. It relaxes
pleasantly in smiling. It is drawn down more powerfully by
its opponent muscles in weeping. This is the largest and
strongest muscle of the face; it antagonizes all the rest, and,
from an opening as wide as the mouth can acquire, it shuts
it at pleasure, so closely as to retain the breath against all the
force of the lungs. The union of so many muscles at the
angles of the lips produces that fullness about the mouth'
remarkable in those who are thin and muscular. In the
child or youth whose face is plump, they make the dimple
in the cheek.
The bones determine the general form of the face; one
great muscle, the masseter, gives the rounding of the cheek;
the rest are delicate and movable muscles, and the character
of the face centers around the mouth and nostrils where those
muscles converge. A thin and delicate face gains in expres-
sion where the cheek is hollow, and at the angle of the mouth
where the lines are strong. In a full face these lines are
obliterated, and the delicate turns of thought and feeling are
lost. All but the more violent expressions of passion are
buried in the mass.
The muscles described, like the bony framework on which
they rest, would be without motion but for their connection
with the brain, through the medium of special nerves, whose
function is to give to the various parts of the face that vitality
and ever-changing expression which constitute the charming
attraction of the human countenance.
Of the twelve pairs of cranial nerves, five pairs are con-
cerned in expression, and three of them are distributed to
and give motion to the muscles of the eye. Thus the third
pair of nerves, or the motor oculi, sends branches to all of
FUNCTION OF THE FIFTH AND SEVENTH NERVE. 521
these muscles, with the exception of the motor externus and
the obliquus superior, to the first of which pass the fourth
pair, or motor externus nerve, and the second is connected
with the sixth pair, or nervus pathetici.
The fifth and seventh pairs of nerves are distributed to
the muscles of the face; the latter, also named portio dura,
or facial, emerges from the stylo-mastoid foramen, and then,
passing through the parotid gland, is eventually distributed
exclusively to the superficial muscles in the form of a plexus,
named pes anserinus. It is purely a motor nerve, upon the
integrity of which the expression of the countenance and
the varied play of the features depend. This has been de-
monstrated in the most satisfactory manner by experiments
on animals and in pathological conditions in man. Strange
as it may appear now, it was formerly supposed that the
painful affection named tic-douloureux was seated in this
nerve, and resection of it at the stylo-mastoid foramen was
frequently performed for the relief of patients, but with no
other result than inducing paralysis of the superficial muscles
and loss of expression on the side of the face operated upon,
the patients being unable to close the eyelid, elevate the ala
nasi, or move the cheek or that side of the lips, and yet at
the same time still suffering as much from the disease. Pa-
ralysis of this nerve is sometimes induced by cerebral dis-
turbance or the presence of a tumor beneath the ear, and is
usually denominated Bell's palsy, on account of the true
nature of the affection having been made known by Sir
Charles Bell, to whose genius and laborious experimental
research the world is greatly indebted, not only for their
knowledge of this disease, but also for much that is known
at present of the nervous system. Paralysis of the portio -
dura does not affect in the slightest degree the function of
the temporal masseter or pterygoid muscles (and therefore
interfere with mastication), as they derive their nerve-force
from the motor branch of the fifth pair. The dependency
of these muscles on the motor branch of the fifth can be
522
CLASSIFICATION OF EXPRESSIONS.
readily demonstrated by divisions of the nerve on each side
in animals, when the lower jaw at once falls, and the subject
operated upon is rendered incapable of raising the jaw or
masticating its food. If the nerve of one side only is cut,
the parallelism of the jaw is destroyed; or, in other words,
the muscles of the side operated upon, being paralyzed, fail
to bring the jaw in contact with the upper, while on the
sound side it is effected as usual.
Presuming that sufficient has been said with regard to
the points already touched upon, we will now pass to the
consideration of some of the expressions presented by the
countenance when under the influence of the different pas-
sions that affect the mind of man. It is impossible to de-
scribe all of these; and the attempt, at best, in the considera-
tion of those to which attention will be directed, must of
necessity be merely suggestive of an interesting and instruc-
tive subject of study.
All the facial expressions may be classified under two
heads the exhilarating and the depressing. The angle of
the mouth and the inner extremities of the eyebrows, as
points where a number of muscles concenter, are the most
movable parts of the face, and on their changes expression
chiefly depends. No better illustration of this fact can be
afforded than in the caricature, with which every one is
familiar, representing two faces joined together, in one of
which the elevation of the angles of the mouth gives a most
joyous expression to the face; on reversing or turning the
picture upside down, however, depression of the same mouth
at the angles produces a correspondingly despondent expres-
sion in the other face.
In laughter, the various muscles which have been de-
scribed as inserted into the orbicularis oris have entirely
overcome the action of that muscle, whose function is to
close the lips. When a ludicrous idea enters the mind,
as a general thing it is in vain to try to keep the mouth
closed. The antagonistic muscles concentering there exert
MUSCLES CONCERNED IN LAUGHTER.
523
a force beyond all control, and frequently the more de-
termined the effort not to give way to the inclination, the
more marked and explosive eventually becomes the dem-
onstration. The elevator muscles, inserted in the upper lip
and the angles of the mouth as the active agents in drawing
the mouth upward, produce a fullness of the cheeks which,
pressing upon the lower eyelids, throws the skin into wrinkles
under them. At the same time the teeth are exposed; while
by the contraction of the orbicularis palpebrarum the eyes
are almost concealed, and, by compression of the lachrymal
FIG. 353.
Laughter.
gland, frequently suffused with tears. Together with this,
the agitation of the muscles of the throat, neck, chest, and
diaphragm produces audible cachinnations. The corners of
the mouth that are thus raised in laughter are distorted in
pride, drawn backward in rage, drop lower in grief, and in
palsy fall quite down.
In the reverse of this, or weeping, the lips are drawn
apart by the converging muscles; but, in place of the ele-
vation of the corners of the mouth, they are now drawn
downward by the depressor anguli oris; the nostrils, at
the same time, are dilated, and the tears flow profusely
from under the convulsively closed eyelids over the flushed
་
f

7
1
MUSCULAR ACTION IN WEEPING.
521
cheeks; while the veins of the forehead are distended and
the inner part of the eyebrows is drawn upward and in-
ward by the combined action of the corrugator supercilii
and the occipito-frontalis. The muscles of the throat, chest,
and diaphragm are spasmodically affected, and the respira-
tion is frequently interrupted by sobs.
Bodily pain, the manifestation of which in the face of
patients is frequently an important means of diagnosis, not
only in children, but those of a larger growth, is a condition
that particularly claims attention from a professional and
inn
www
PERKAMLAR
FIG. 354.

(a)
Crying.
2
humanitarian point of view. Here let me say, in passing,
that pain is by no means what it is usually regarded, an
unmixed evil. Paradoxical as the statement may appear, it
is frequently a blessing rather than a curse, as it is the chief
means by which we become aware that some important organ
is diseased. Without such intimation, the part affected might
have become disorganized to such an extent as not only to
destroy the function of the organ, but also to place life itself
in jeopardy. This applies with peculiar force to those organs
which it is our duty to save; for it is the unpleasant sensa-
tion of pain which generally drives our patients to us, and it
ILLUSTRATION OF EXTREME PAIN.
is the various manifestations induced by the pain endured
which enables the experienced practitioner to determine the
nature and extent of the difficulty.
525
In extreme pain (except in cases where the patient is
suffering from periodontitis, when the occlusion of the jaws
intensifies the suffering), the teeth are brought together with
great force and ground against each other by the temporal,
masseter, and pterygoid muscles; the saliva frequently flows
in large quantities from the mouth, which is drawn open
FIG. 355.

Extreme Pain.
laterally; the face flushed, the veins distended, the nostrils
dilated, the eyebrows raised, the forehead thrown into hori-
zontal wrinkles, the eyelids widely opened, and the tears
coursing over the cheeks, betray in the most unmistakable
manner the suffering endured.
In joy, the face is lighted up with a smile by the gentle
elevation of the eyebrows, the lively and sparkling appear-
ance of the eye, and the pleasant expression of the mouth,
which, without being separated, is drawn aside at the cor-
ners.
526
ILLUSTRATION OF TERROR.
In fear, the head sinks backward between the elevated
shoulders; the eyes are fixed and staring; the eyebrows are
raised to their utmost by the occipito-frontalis, which, in
addition to a contracted state of the scalp, causes the hair
to stand on end; the face is ghastly pale, and the cheeks
are hollow, shrunken, and in convulsive motion, like lips
which are wide open, owing to the dropping of the lower
jaw; the breathing is short, labored, and spasmodic.
FIG. 356.

LADE PENE
Fear and Terror.
•
In rage (see Fig. 357), the inflamed and glaring eyeballs,
owing to the contraction of the oblique muscles, seem ready
to dart from their sockets; the brow is thrown into deep
vertical wrinkles by the corrugators; the nostrils are dilated;
while, through the clinched teeth but open mouth, words of
hate are delivered with emphatic force.
It is claimed by physiognomists that the true character
may be read in the countenance. Whether or not physiog-
nomy is yet reduced to so exact a science as this statement
would indicate, certain it is that the natural characteristics
527
of mankind are very strongly marked in the face; and so
generally is this accepted as a truth, that first impressions
received are acted upon with a very strong faith in their
correctness. The nature of an individual is often refined by
external influences, until the face is no longer a complete
index to it; but even then the physical conformation is
slowly modified and ultimately harmonizes with it. The
growth of nations in Christianity and civilization abundantly
proves this fact. Nations whose early history shows them to
have been but very little above the brutes, in their gross
EFFECTS OF CIVILIZATION ON PHYSIOGNOMY.
FIG. 357.

Rage.
sensualism and savage ferocity, and whose countenances bore
the marks of their natures, have, as they advanced in refine-
ment, developed also into beauty and comeliness. Indi-
vidual cases like this take place in a single generation, and
instances are not rare which are within the knowledge of any
observer.
A knowledge of physiognomy can only come in its full-
ness from long-continued observation of the infinite variety
of faces which we are continually meeting. The harmonious
relations of one feature with another must be so fully com-
prehended, that it will be possible to restore a lost part, in
all its perfection, by a knowledge of what is demanded by
528 THE VALUE OF TEETH AS A MEANS OF EXPRESSION.
those features remaining. No single feature of the face is
more capable of changing the entire expression than the
teeth. This is markedly evident when a classic face, which
in repose excites admiration on account of the symmetry and
regularity of the features and the purity of the skin, has
not only the illusion dispelled at once, but a feeling of loath-
ing induced, by a smile revealing, in place of pearls, black-
ened and crumbling snags; while, on the other hand, a very
ordinary and homely face, when lighted up by a smile which
uncovers clean, white, regular, and symmetrical teeth, be-
comes pleasing and attractive.
The general appearance of the face is not merely affected
by the condition, presence, or absence of the front teeth, but
the hollow, sunken cheek reveals in the most unmistakable
manner the loss of bicuspids and molars. The symmetry of
the face in this way is frequently destroyed by the inex-
cusable extraction of these teeth because a proper valuation
is not placed upon them as masticatory organs, and on the
score of appearance, by practitioners and patients, it being
supposed that, as back teeth, their absence will never be
noticed.
In the introduction of artificial teeth, the greatest care of
course should be exercised to preserve or restore the natural
appearance of the face. To do this with any prospect of
success, however, it is important that the anatomy and physi
ology of expression should be made a careful object of study.
It is important, for instance, that the teeth should be so
arranged as not to give a sunken appearance to the mouth,
or to make it so prominent as to obliterate the groove or
depression in the middle of the upper lip, the concavity
which naturally belongs to the space between the lower lip
and chin, and the lines which the action of the muscles
creates on each side of the mouth, extending from the wings
of the nose to the corners of the lips.
All artists and physiognomists agree that the mouth pre-
sents a greater variety of expressions than any other feature.
IMPORTANCE OF A KNOWLEDGE OF PHYSIOGNOMY.
529
In portrait-sculpture the mouth is the feature of all others
for denoting expression. Neither the eyes, nose, forehead,
ears, nor chin, or all combined, have the power of conveying
that of which the mouth is capable. It speaks, even without
utterance, of every emotion of the heart; love, anger, pride,
scorn and contempt, equally with joy and sorrow, have their
insignia stamped upon the mouth. These changes are so
rapid, and their continuance so evanescent, that the phrase
"catch the expression" is often used with but little idea of
its full signification. These various movements around the
angle of the mouth require careful observation for their full
comprehension; and it must have already become apparent
that this knowledge is of vital importance to him who would
succeed in the art of dentistry, and that without it the con-
summation of excellence can never be attained.
INDEX.
ABNORMALITY, definition of, 4.
Abnormal lengthening of incisors, 155,
171.
Absorption of condyles, 189; of palate
and maxillary bones, 249.
Absorption and reproduction of bone,
57; not simultaneous, 60; more rapid
in youth, 61.
Absurd pathological law, 65; method of
regulating teeth, 186.
Accessory vocal organs, 419.
Accidental causes of irregularities, 8;
lesions of the palate, 248-258 (see also
"Buccal and nasal protheses" and
"History of obturators").
Action of the pharyngeal constrictors,
232, 238, 419, 429, 458, 462.
Adjustment of a splint, 410.
Adults, regulating teeth for, 62, 160.
Esthetic considerations of abnormalities,
41; dentistry as a science, 467; consid-
erations in artificial dentures, 501.
Esthetics of dentistry, 465.
Age for regulating teeth, 61; for intro-
ducing artificial palates, 310.
Alarming symptoms in modern civiliza-
tion, 24.
Allan's (Dr. Geo. S.) case of regulating,
137.
Allen's (Harrison) case of fracture, 388.
Allen's (Nathan) observations on degen-
eration of race, 19.
Alteration of the inherited type of den-
tal arch, 53; of condyles, 139; of pro-
files, 480-483.
Aluminium, use of, 334; failure with,
337.
Alveoli, movement depending upon elas-
ticity, 60; fractures of, 364.
American type of profile, 480.
Anatomy of the vocal organs, 416; and
physiology of the larynx, 417; and
physiology of expression, 510.
Ancient and modern jaws, 3.
Angell's screws for regulating teeth, 74;
cases of regulating teeth, 200.
Anstie (Prof.) on the function of the
trigemini, 21.
Antiseptic care of regulating apparatus,
67.
Apollo Belvedere, head of, 478.
Apparatus, for regulating teeth: Screws,
69; vulcanite plates, 70-87; jack-
screws, 70, 100, 107; Angell's jack-
screws, 74; Farrar's jack-screws, 74;
wedges, 75, 118, 129, 145; elastics, 76,
147, 152; rubber tubing, 77, 81; T-
catch and elastics, 77, 97; cross-bar and
hooks, 78; retaining plates, 79, 81, 105,
108, 130; gold bands, 79, 87, 108, 158;
linen and silk ligatures, 81, 190; in-
clined planes, 82, 161, 177; levers,
85; models, 95; bandage, 119, 137;
match-stick, 125, 144; gold frame,
132; skull-cap, 134, 137; chin-cap,
137; wooden pegs, 149, 170; McQuil-
len's cross-bar, 158; gag, 162, 177;
Flagg's knots, 166; hickory bow, 175;
crib-band, 177; spiral springs, 180;
Westcott's crutch, 183; Westcott's
screws, 184; compressed wood, 189,
191; rotating shaft, 201.
Appliances for palatine defects, see "Ob-
turators" and "Artificial palates
for facial deformities, see 46 Buccal and
nasal protheses"; for fractured jaws,
see "Bandages" and "Splints.""
Arch, normal type of dental, 2, 28, 41;
saddle-shaped, 31, 44, 115, 198; crush-
ing the dental, 97, 100, 127; V-shaped,
triangular, contracted, 97, 100, 107,
113, 122; protruding, 131.
Arrangement of artificial teeth, 499, 502.
Art culture in dental practice, 465; need-
ed in prosthetic dentistry, 469; un-
necessary in surgical dentistry, 470;
evidence of a lack of, 488.
Articulate language, composition of, 421.
Articulate speech with cleft palate, 209,
458-464; with an artificial velum, 241,
258, 312; immediate effects of an ob-
turator, 248, 258; with cleft palate and
double harelip, 461, 463.
Articulating models for regulating, 95.
Articulation of teeth altered, 52, 110,
124, 127; of condyles altered, 139.
""
532
Artificial dentures, idealism in, 472;
made by carving, 494; continuous gum
work, 494; arrangement of, 499, 502,
503; discoloration, 503; made irregu-
lar, 503; tricks and devices, 503; criti-
cisms on, 505; want of individuality,
508; culmination of excellence, 509.
Artificial car, 315; bridge for a nose,
329; jaw and obturator (author's
case), 331, (Woodward's case), 339;
lip, 345, 350.
Artificial noses, 314, 341, 345, 34S, 351;
impressions for, 342, 350, 352; mak-
ing a cast, 342, 353; of rose pearl,
343; manner of attachment, 344, 348,
350, 354; and lip, 345, 348; use of
spectacles with, 348, 350, 356.
Artificial palates, history of, 259; for
acquired lesions, 253-258; for congen-
ital cases, 259-312; first for a congen-
ital cleft, 261; first use of India-rub-
ber, 259'; Delabarre's, 260; Snell's,
262; Stearn's, 263; Sercombe's, 267;
Parkinson's, 270. Author's, 271-287;
first (1860), 271; improvement of
(1863), 274; original invention, 276;
latest invention, 283; of hard rubber,
272; essential features, 266, 279; gold
springs discarded, 274; characteristics
of shape, 280, 281; support for, 282;
for universal use, 284. Method of
making, 288; pattern of, 296; shape
of pharyngeal portion, 297; made in
sections, 301; directions for vulcaniz-
ing, 305; introduction and use of,
306; hanging, 307; attachments, 257,
307; experience with, 308; durability
of rubber, 309; best age for introdu-
cing, 310; care of, 310; benefit from
wearing, 310, 312; results depending
on the patient, 311; training the voice,
311; effects upon speech, 241, 258,
312; and obturator, case in practice,
357; on the Snell-Sercombe plan,
256; objections to common sheet rub-
ber, 256; molds, see "Palate-molds."
Artificial velum, see "Artificial pal-
ates" definition of, 214.
INDEX.
Atrophy of the face, 322; of the jaw in
old age, 511.
Austen (Prof.) on aesthetics, 484; on
concealment of art, 506.
Author's cases from practice: regulating
teeth, 96-157; obturators, 239-251,
272, 285, 287, 357 (see also Buccal
and nasal protheses "); artificial pal-
ates, 253-258, 271-287, 357; fractures,
398-411.
Bad results from extraction, 44, 47, 117;
using a gag, 151.
Ballard's theory of thumb-sucking, 11.
Bandage in regulating teeth, 119, 137.
Bandages, origin and use of, for frac-
tures, 377; Gibson's, 378; four-tailed,
378; Barton's, 379; Hamilton's 380
Garrettson's, 381; objections to, 332
Bean's, 385.
Barker's (Dr.) extraction objected to,
114.
Barton's bandage, 379.
Bean's interdental splint and bandage,
385.
Benefit from wearing artificial palates,
310.
Bicuspids, extraction of, 189.
Breath-consonants, 434.
Bridge for a nose, 328.
Bristowe's division of vowel sounds, 424.
Buccal and nasal protheses, 313–360.
Buckingham's obturator, 226.
Buck's method of wiring a jaw, 373.
Bulb for an obturator, 245; made of
gold, 246.
Bullock's splint, 397.
Bush's splint, 393.
Canine teeth, extraction or retention of
temporaries, 7; as affecting expres-
sion, 483, 498.
Capacious jaws of idiots, 32.
Care of regulating apparatus, 66; of arti-
ficial palates, 310.
Cartwright, his examination of skulls,
2; on the cause of irregularities, 13.
Carving instruments, 292; teeth, 494.
Causes of irregularities of the teeth, 4, 7,
8, 10, 11, 24.
Celluloid for noses, 311; for an ear, 351.
Central incisors, proper presentation in-
sured, 165.
Changes wrought by the loss of teeth,
474, 481, 528.
Character as shown by the teeth, 496.
Characteristics of an artificial palate,
266, 279-281; of sculpture, 471; of
each tooth, 491.
Chief focus of facial expression, 512, 519.
Chin-cap and skull-cap, 137.
Chinese and Indians' teeth, 4.
Chopart's splint, 392.
Civilization affecting development, 13,
19, 22, 24.
Clang, composition of, 413, 422.
Classification of consonants, 433; of con-
sonants unsatisfactory, 456.
Classification of facial expressions, 522.
Cleft palate always on the median line,
204; and harclip, 204, 208, 461, 463;
origin of, 207; evils of, 209; defective
speech with, 209, 458-464; surgery of,
210; common features, 283; muscles
relaxed, 289; impressions, 290; pre-
liminary treatment, 293; detection
and correction of errors, 293, 294;
treatment, see "Artificial palatés."
Closing the jaws with apparatus, 119,
137.
INDEX.
Coleman's investigations into irregulari-
ties, 2.
Color used in plaster, 94; of artificial
teeth, 506.
Comparison of skulls, 497.
Compensation for loss of the palate, 458.
Composition of a clang, 413; of articu-
late language, 421.
Compound and comminuted fractures,
365.
Compress, submental, 381-407.
Compressed sponge in impressions, 93;
wood for wedges, 189, 191.
Compressor nasi, misuse of, 311.
Conditions of perfect dental develop-
ment, 23; of a proper diagnosis, 40.
Condyles, absorption of, and new articu-
lation, 139; fracture of, 364, 407, 411.
Conservatism in diagnosis, 41.
Consonants, classification of, 433; forma-
tion of, 433; breath and vocal, 434;
mechanism of, 435-455; classification
unsatisfactory, 456; and vowels, new
table, 457.
Constrictor superior of the pharynx,
232, 238, 419, 429, 458, 462.
Continuous-gum work, 494.
Contracted dental archi, theories of ori-
gin, 11, 12, 27, 98, 99, 111; maxilla,
Tomes's case of, 116.
Contrast in speech in congenital and ac-
quired palate cases, 213, 464; between
ideal arts and mechanic arts, 468.
Coronoid process, fracture of, 364,407,411.
Correct articulation of paramount im-
portance, 43.
Correlation of irregularities to idiocy,
26-39.
Crib-band in regulating, 177.
Critical period in regulating teeth, 66.
Criticism on fracture treatment (Moon's),
396; on teeth as now made, 505.
Cross-bar and hooks, 78.
Crowded position of teeth before erup-
tion, 16; during eruption, 17.
Crushing an arch, 97, 100, 127.
Crying, 523.
Culmination of excellence in artificial
teeth, 509.
Cups for impressions, 90; extemporized,
251; for palates, 291.
Defects of the palate, sec "Palatine de-
fects"; of the speech, 209, 212, 459,
463.
Definition of abnormality, 4; of obtura-
tor, 214; of artificial velum, 214; of
fine art, 468; of mechanic art, 468.
Deformities, definition of, 2; of jaws
seen in private practice, 29; of jaws
seen in public schools, 29; resulting
from the loss of teeth, 474, 481, 528.
Deformity of the jaw created by treat
ment, 108; increased by enlargement
533
of arch, 108, 141; of the face, 317, 322,
332.
Degeneration of the race, 19, 22, 24.
Delabarre's artificial palate, 260.
Demeanor in taking impressions, 92.
Dental arch, normal type, 2; triangular,
theories of the origin, 11, 12, 27, 98,
99, 111; variations of, 28, 41; triangu-
lar or V-shaped, 97, 100, 107, 113, 122;
crushed, 97, 100, 127; widened, see
"Expansion of dental arch."
Dental development of the future, 25;
societies, recognition by, 275; palatal,
and nasal protheses, 813-361; nerve
injured by fracture, 364.
Dento-ceramic art, 485, 504.
Desault's splint, 392.
Description of vowels (Tyndall's), 426
of an extraordinary cleft palate, 463
of facial muscles, 513-518.
Destruction of facial bones, 333.
Development of teeth independent of
jaws, 5, 19; influenced by heredity,
9, 12, 100, 106.
Diagnosis of idiocy (Down's), 27, 38; of
fracture, 368.
Diagnosis of irregularities, 40-56; Mc-
Quillen's, 187; Stellwagen's 188.
Difficult impressions, examples of, 93,
322, 333.
Directions for vulcanizing artificial pal-
ates, 305; for making a splint, 408, 409.
Disastrous results from neglect of regu-
lating apparatus, 136.
Discoloration upon artificial teeth, 503.
Discouraging experiments in regulating
teeth, 155.
Discrepancy in size between jaws, 110.
Dislocation, Ribes's method of reducing,
368; with fracture, 368.
Disordered eruption, 6.
Disorganization of dental system in ab-
solute idiocy, 33.
Displacement of fragments in fractures,
366; muscular action in, 366; Elliott
on, 367; illustrations of, 402, 405.
Division of language into vowels and
consonants, 433.
Double harclip, 204, 460, 463.
Down's (Dr. Langdon) examination of
idiots, and diagnosis, 26, 38; asylum,
dental peculiarities, 34.
Drawings of teeth from nature, 490.
Duct compressor used for splint, 406.
Dwarf's teeth, 18.
Dwinelle's (Dr.) invention for jack-
screw, 70.
Ear, artificial, 315.
Effects of nursing on dental develop-
ment, 10; of thumb-sucking on den-
tal dévelopment, 11, 111; of civiliza-
tion on dental development, 13, 19,
22, 24; of neural disturbances on de-
•
*
35
534
INDEX.
velopment, 21; of lunacy or insanity
on development, 25; upon the nervous
system by regulating teeth, 55; of ne-
crosis, 370; of civilization on physiog
nomy, 527.
Elasticity of the alveoli, 60.
Elastics, 76; rubber tubing for, 77, 81;
application of, 77, 147, 152; fastenings
for, 80; twisting incisors with, 103,
147; complicated results of, 147; con-
trary effects of, 149, 160; eight oper-
ating at once, 153; and silk ligatures,
163; for nose-clevator, 321.
Elevator for a nose, 320.
Elliott on displacement, 367; his use of
gutta-percha, 390.
Elongation of upper incisors avoided,
132; of laterals arrested, 155; of up-
per incisors, 171; of laterals, 178.
Elsberg's explanation of vowel sounds,
423.
English and Italian vowels, 425.
Enlarged tonsils associated with irregu-
lar teeth, 11, 99.
Errors corrected in cleft-palate impres-
sions, 294.
Eruption of teeth, 16; orderly, 5; dis-
orderly, 6.
Etiology of irregularities of the teeth, 1.
Examination of idiots, Dr. Down's, 26;
author's, 30-34.
Expansion of dental arch, apparatus for
upper jaw, 70, 100, 107, 129, 163, 180,
183, 184, 200; apparatus for lower jaw,
71, 72, 79, 145; author's methods,
96-156; Tomes's method, 116; Flagg's
method, 162; J. D. White's method,
179; Westcott's method, 183.
Experiments in regulating, 155; with
pharyngeal muscles, 243; in articu-
lation, 431; with cleft-palate people,
458-464.
Explanation of the Yankee twang, 212;
of vowel sounds by Elsberg, 423; of
whispered speech, 452.
Expression of the canine teeth, 499; af-
fected by the teeth, 502; anatomy and
physiology of, 510; dependent upon
muscular action, 512; centering about
the mouth, 512, 519, 520; of the face
classified, 522.
Extensive absorption from pressure, 249.
External features, study of, essential,
53, 141.
Extraction, premature, 5; of canines
(temporary), 7, (permanent), 483, 498;
selection of teeth for, 43; unjustifiable,
44, 46, 54; bad results from, 44, 117,
198; or retention in doubtful cases,
45, 51; or retention of upper laterals,
45, 51; of upper laterals, 45, 51, 54,
156, 199; necessary, 48, 109; of low-
er incisor, 48, 142; of sixth-year mo-
lars, 48, 109, 151, 155; justifiable, 49;
of first bicuspids, 49, 169; by Dr. Bar-
ker objected to, 114; Truman's views
on, 114; of second bicuspids, 167; of
bicuspids, 189; of temporary incisors,
197.
Extraordinary deformity of palate, 463.
Extreme pain, illustration of, 525.
Eyes and mouth the centers of expres-
sion, 512; muscles of, 518.
Facial deformities, treatment, 313-361;
atrophy, 322; deformities, prothesis
for, 324; deformities the result of a
gunshot wound, 331; bones, destruc-
tion of, 333; deformities considered
æsthetically, 474, 481; features, irreg-
ularity of, 486; muscles, illustration
and description, 513-518.
Factors of a diagnosis, 40.
Failure of staphyloraphy, 211, 358; in
wiring a jaw, 402.
False articulation of teeth, 52, 110, 124;
joint in fractures, 370.
Farrar's screws, 74.
Fastenings for elastics, 104.
Fauchard's obturator, 219.
Fear, illustration of, 526.
Feeble mind, inert effects on dental de-
velopment, 24.
Fees, 56; Westcott's advice regarding,
185.
Fibrous union of fracture, 372.
Figure-drawing, Wiegall's, 475.
Fine art, definition of, 468.
Fixtures for regulating, period for wear-
ing, 64.
Flagg's system, gag, gold band, etc.,
162; practice with upper and lower
centrals, 164; use of knots, 166; use
of nine ligatures, 168.
Flasks for palate-molds, 302.
Flattening incisors, 104.
Focus of facial expression, 512, 519.
Forces used in regulating teeth, 68.
Formation of a clang, 413, 422; of vow-
els and consonants, 424; of conso-
nants, 433; and classification of H,
451.
Forms of teeth, ideal, 490.; to copy and
to avoid, 501.
Four-tailed bandage, 378.
Fractured jaws, impressions of, 409.
Fractures of the upper jaw, 361; of the
upper jaw, treatment of, 362; of the
lower jaw, 362; of the lower jaw, lo-
cation of, 363; of the ramus, 363, 407,
411; of the alveoli, 364; of the con-
dyle and coronoid processes, 364, 407,
411; paralysis from, 365; compound
and comminuted, 365; displacement,
366; Elliott on displacement, 367; dis-
location with, 368; diagnosis, 368
prognosis, 369; irregular union, 370;
false joint, 370; non-union, 370, 372;
INDEX.
time required for union, 371; fibrous
union, 372; ligatures, 372; sutures,
373; wire ligatures, 373, 375; Syme's
treatment, 377; submental compress,
381, 385, 393, 396, 397, 401, 404, 407
Harrison Allen's case, 388; best treat-
ment of, 392; Moon's criticism on
treatment, 396; reduction, 398; au-
thor's method of treating, 398-411;
failure in wiring, 402; illustrations of,
402, 405; triple, of inferior maxilla,
402, 405; of superior and inferior max-
illa, 405; double, of superior maxilla,
405; of inferior maxilla, reduction of,
408.
Fragments, displacement in fractures,
366.
French nasal vowels, 430.
Function of the trigeminal nerve (An-
stie), 21; of absorption and reproduc-
tion of bone, 57; of absorption and
reproduction of bone not simultane-
ous, 60; of absorption and reproduc-
tion of bone more rapid in youth, 61
of the palate in speech, 209, 212, 420;
of the palatal and pharyngeal mus-
cles, 298; of the trachea, 417; of the
larynx, 417; of the nasal fossæ, 418;
of the pharynx, 418, 419; of the
tongue, 420; of the teeth, 420; of the
lips, 421; of the nares, 421; of the
nostrils, 421; of the facial muscles,
513-518'; of the fifth and seventh pairs
of nerves, 521.
Fundamental tones of voice, 413.
Gag, regulation without, 140, 150; bad
results from using, 151; of gutta-
percha, 162; Flagg's system, 162;
use of, in regulating, 177; Tomes's,
189.
Garrettson's bandage for fractures, 381.
General disorder of the teeth, illustra-
tion, 157.
Giants, teeth of, 18.
Gibson's bandage for fractures, 378.
Gilmore's case of regulating, 186.
Gold bands and vulcanite plate, 79, 87,
108; frame on upper incisors, 132;
springs for palates discarded, 274;
medals awarded the author, 275; fill-
ings in artificial teeth, 504.
Greek art, 478; profiles, 479.
Growth of teeth and jaws independent,
5, 19.
Guillemeau's obturator, 218.
Gunning's splint, 384.
Gunshot wounds of face, 331, 339, 349,
372, 386.
535
'Guy's Hospital Reports," fractures,
359.
Gutta-percha trial-plates for cleft palate,
293; for interdental splints, 390, 411;
for submental splints, 404.
Gutturals formed without a palate, 459,
462, 464.
"L
H, formation and classification, 451.
Hamilton's bandage, 380.
Hammond's wire splint, 375.
Hanging an artificial palate, 307.
Hard-rubber palate, 269, see also "Ob-
turators."
Harelip, case of double, 204, 461, 463;
and cleft palate, 208; and cleft palate,
articulation with, 460, 463; Little's
case, 463.
Harmonizing teeth with character, 496;
divers colors among tecth, 507.
Hayward's splint, 397.
Head-voice, 418.
Hebrew idiots, 33.
Heister's obturator, 218.
Hereditary type changed by sucking, 10,
11, 106; cases of irregularities, 53, 65,
100, 106, 113.
Heredity influencing development, 9.
Herriott's case of nose, lip, and denture,
348.
Hickory bow used in regulating, 175.
High or selective breeding, 14.
Hill's (Berkley) splint, 394.
History of obturators, 215; of artificial
vela, 259; of the author's palates, 271.
Holmes (Prof. O. W.) on expression of
the mouth, 519.
Hoopes's nose, lip, and obturator, 345.
Houzelot's splint, 393.
Hullihen's obturator, 223; staphylora-
phy, 357.
Human voice, origin of, 415; figure,
proportions and relations, 475.
Hythe Church, skulls, 3.
Ideal arts and mechanic arts contrasted,
468; head, rules for drawing, 478;
type desirable, 489; forms of teeth,
490.
Ideality in dental practice, 468; in an
artificial denture, 472.
Idiocy, Down's examination and diag-
nosis, 26, 27, 38; correlation of irreg-
ularities to, 26-39.
Idiots on Randall's Island, 30; author's
investigation of, 30-34; capacious jaws
of, 32; among the Hebrews, 33'; in
Paris asylums, 34; in Dr. Down's
asylum, 35; jaws of, usual type of,
35; in Pennsylvania Training School,
36.
Illustration of second dentition, 17; of
general disorder of the teeth, 33, 147,
157; of mechanical dentistry, 469; of
facial muscles, 513; of pterygoidei,
517.
Imitation of defects admissible, 503.
Impression-cups, 90; extemporized, 251;
for palates, 291.
}
*
536
INDEX.
Impressions and models, 89; cups for
taking, 90; mixing plaster for, 91;
method of taking, 91, 290; conditions
of success, 92; demeanor in taking,
92; restoration when broken, 92;
morale, 92, 291; of posterior nares,
93, 295; in difficult cases, 93, 322, 383;
compressed sponge in, 94; cups for,
extemporized, 251; of palatal perfora-
tions, 251; difficulties of taking, in
palate cases, 288; distorted, 289; of
cleft palate, 290; cups for palates, 291;
requirements of, 292; detection of er-
rors in, 293; method of proving, 293
correction of errors in, 294; of the
pharynx, 294; of the uvula, 294; of
the nasal cavity, 295, 322, 334, 342,
352; for an artificial nose, 342; for an
artificial nose, Wildman's method of
taking, with paraffine and wax, 352;
for a fractured jaw, 409.
Incisors, upper lateral, extracted, 45, 51,
54, 156, 199; lower, extracted, 49, 142
tipped-up, 100; twisted, 103, 147, 170,
194; flattened, 104; shortened,´ 134,
172; correct presentation insured, 165;
elongated, 171, 178; temporary, ex-
tracted, 197.
Inclined planes, 82, 161, 177; objections
to, 83, 161; for lower jaw, 83; for up-
per jaw, 84; the advantages of, 85.
Indians and Chinese, dental arch of, 4.
India-rubber, first use of, for palates,
260.
Infancy, care of the teeth in, 25.
Inferior dental nerve, injury to, 364;
maxilla, triple fracture of, 402, 405.
Influence on offspring of correcting ir-
regularities, 10; of prolonged nursing,
10; of enlarged tonsils, 11, 99; of
thumb-sucking, 11, 106; of civiliza-
tion on development, 20; of the tri-
geminal nerve, 21.
Inherited irregularity altered by thumb-
sucking, 106; syphilis, effects of, 206,
316; syphilis, prosthetic treatment of,
315.
Innervation of the trigeminal nerve,
22.
Instruments for carving, 292.
Interdental splints, 384 (see "Splints").
Intermaxillary bone, loss of, 204, 271,
461, 463.
Investigations of skulls by Cartwright
and Coleman, 2; by Mummery of the
type of jaws, 3; into the cause of ir-
regularities by author, 29; into the
mechanism of speech by author, 430.
Irregularities of the teeth, and idiocy, by
Down, 26, 38; by Tomes, 27; by au-
thor, 30-34; by White, 36'; by Pierce,
37; by Stellwagen, 37.
Irregularities of the temporary teeth, 1;
etiology of, 1; developmental causes
of, 4; accidental causes of, 4, 8; pres-
ence of temporaries a cause of, 7;
extraction of temporaries a cause of,
7; nursing a cause of, 10; thuml-
sucking a cause of, 11; general causes
of, 24; prevented, 25; foretold, 25;
correlation of, to idiocy, 26-39; meth-
ods of investigating, 29; observations
of, in private practice and in public
schools, 29; observations of, in asy-
lums, 34; in diagnosis of idiocy, 38
diagnosis and prognosis of, 40-56;
questionable treatment of, 44, 51, 114,
117, 155; in an underhung jaw, 52;
from mal-occlusion, 52, 110, 123; in
protruding upper jaws, 52, 131; treat-
ment of inherited cases of, 53, 65, 100,
106, 113; age for treatment of, 61;
possibilities in adults of correcting,
62, 160; V-shaped arches, 97, 100,
113, 122; prognostication of, 114; sad-
dle-shaped arches, 115, 198; in pro-
truding lower jaws, 127-136; in facial
features, 486; in artificial teeth, 503;
cases of, from practice, see "Regulat-
ing cases from practice."
Irregular union of fractures, 370.
Jack-screws, first use of, by Dwinelle,
70; different forms and application
of, 71, 73; adaptation of, to a plate,
102; in widening the arch, 102, 107,
116.
Jaw, John Rowse's, 33; artificial, 331,
339.
Jaws, ancient and modern, 3; and teeth,
growth of, independent, 5, 19; diverse
types mixed, 15; of cretins, 30; of
idiots, 31-36; of an absolute idiot, 34;
protruding upper, 52, 122, 131; retreat-
ing lower, 52, 122, 144; closed by ap-
paratus, 119, 137; protruding lower,
127, 136.
John Rowsc's jaw, 33.
Jumbled-up teeth, 146, 156.
Jumping the bité, 53, 124; apparatus
for, 84.
Key for tightening ligatures, 374.
Keystone of an arch, 76, 98.
Kinloch's method of wiring a fracture,
373.
Knots, Flagg's use of, 166.
Knowledge of natural philosophy re-
quired, 68.
Krackowizer's surgery, 332.
Language divided into vowels and con-
sonants, 433.
Larynx, anatomy and function of, 417.
Laughter, action of the muscles con-
cerned in, 523.
Laws of harmony in facial features,
486.
INDEX.
Letters of the English language repeat- |
ed, 455.
Levator muscles, use of, 269; illustration
of, 461.
Levers for regulating teeth, 85, 86.
Lifting a sunken nose, 320, 327.
Ligatures for fractures, 373; Buck's use
of, 373; Kinloch's use of, 373; Thom-
as's method of, 374; key for tight-
ening, 374; Wheelhouse's method of,
375.
Ligatures, linen, 81; silk, 81; attached
to temporary molars, 190; used by
Tomes, 193; silver-wire, 374.
Lines of character in the face, 519.
Lips, artificial, 345, 350.
Liston's splint, 385.
Little's (Prof.) case of harelip, 463.
Lonsdale's splint, 394.
Loss of the intermaxillary bone, 204,
271, 461, 463; of superior maxilla,
333; of part of lower jaw, 333, 403.
Malgaigne's splint, 393.
Malocclusion of teeth, 52, 110, 123.
Malposition of teeth, see "Irregulari-
ties."
Mastication and articulation restored in
gunshot case, 338; on a splint, 400.
Match-stick used in regulating teeth,
125, 144.
Maxilla, tardy development of, 6; con-
tracted, 27.
Maxillary and malar protheses, 335, 340.
Max Müller on vowels, 423.
McGrath's obturator, 230.
McQuillen's cases, 158; cross-bar, 158;
methods of regulating, 159; remarks
on diagnosis, 187.
Mechanical forces in regulating teeth,
68; dentistry, illustration of, 469.
Mechanic art, definition of, 468; and
ideal art contrasted, 468.
Mechanism more reliable than surgery
for cleft palates, 213; of palate for ac-
quired lesions, 254-258; of palate for
congenital cases, 260-305; for restor-
ing mastication and specch, 338; of
speech, 412; of the vocal organs, 415;
of vowels, 424-430; of consonants,
435-455; of gutturals, 442.
Medusa, head of, 479.
Mental splints, 381-407.
Metal plates instead of vulcanite, 193.
Method of investigating irregularities,
29; of mixing plaster, 91; of making
models, 94; of making bulb, 243; of
making artificial palate, 288; of prov-
ing impressions, 293; of taking a bite,
473.
Mistaken prognosis in regulating teeth,
154.
Mixing diverse types of jaws, 15.
Mixing plaster, 91.
537
Models, study of, 52, 95, 123; and im-
pressions, 89; method of making, 94;
articulating, 95.
Molars extracted for regulating teeth,
48, 109, 151, 155.
Molding in sand, 301.
Molds for palate, see "Palate-molds."
Moon, his splint, 395; his criticism on
fracture treatment, 396.
Morale in taking impressions, 92, 291.
Motion the origin of sound, 412.
Mouth the chief focus of expression, 519.
Movement of teeth frequent during life,
57; not inconsistent with health, 57;
not dependent upon absorption, 59;
dependent upon elasticity of the alve-
oli, 60.
Moving teeth in adult life, 62, 160.
Mummery, his investigations, 3; on ef-
fects of civilization, 22.
Muscles, levator palati, 269, 461; mis-
use of compressor nasi, 311; of the
larynx, 417; of the pharynx, 419; of
the eye, 518; of expression, 518.
Muscular action of the pharynx, 232,
238, 419, 429, 458, 462; with fractures,
366 in laughter, 523; in weeping,
524; in pain, 524; in fear, 526; in
rage, 526.
Nasal, buccal, palatal, and dental pro-
theses, 313-361.
Nasal impressions, 93, 295, 322, 342,
352; fossæ, function of, 418.
Nasmyth's splint, 385.
Natural philosophy, knowledge of, re-
quired, 68.
Necrosis, 369; effects of, 370.
Nerves concerned in expression, 520.
Nervous system, observations of Nathan
Allen on the, 19.
Nichols's observations among Indians
and Chinese, 4.
Non-union of fractures, 370, 372.
Normal type of dental arch, 2, 28, 41.
Nose-elevator, 320; elastics for, 321.
Nose, lifting a sunken, 320, 327.
Noses, artificial, see "Artificial noses."
Number of vowels indefinite, 423.
Nursing, results of, when prolonged, 10.
Objections to extraction, 44; to relaxa-
tion of force, 66; to inclined planes,
83; to plaster for palate-molds, 299
to rhinoplasty, 341; to ligatures, 373;
to bandages, 382.
Obturator, definition of, 214; history of,
215; Ambroise Paré's, 216; Heister's,
218; Guillemeau's, 218; Pierre Fau-
chard's, 219; Delabarre's, 220; Snell's,
221; Rowell's, 222; Hullihen's, 223;
Buckingham's, 226; White's (Dr. J.
D.), 228; McGrath's, 229; Suersen's,
for acquired lesions, 233; Suersen's,
538
for congenital cleft, 236; special use
of Suersen's, 238, 239; replacing an
artificial velum, 239; bulb for artificial
velum, 243; valueless without a bulb,
244; effects of, upon speech, 246, 248,
258; movable (Parkinson's), 269
simple, for congenital clert, 272; and
palates combined, 285; and artificial
jaw, 331.
Old age in youth, 481.
Oral stream, points of interruption of,
INDEX.
434.
Organs of articulate language, 422.
Origin of the contracted dental arch, 11,
12, 27, 98, 99, 111; of abnormalities
of the teeth, 23, 24; of cleft palate,
207; and use of bandages, 377; of the
human voice, 415; and explanation of
vowel sounds, 423.
Overtones and undertones, 413.
Packing palate-molds, 304.
Pain, muscular action in, 524.
Painter's suggestions, 495.
Palatal, dental, and nasal protheses,
313-361.
Falate, congenital lesions of, 203; ac-
quired lesions of, 205; treatment of
acquired lesions of, 248; treatment of
congenital fissure of, 278; movement
of, in sounding M, 437; movement of,
in sounding N, 440; movement of, in
sounding Ng, 443; compensation for
the loss of, 458.
Palate-molds, objections to plaster for,
299; type-metal for, 300; sectional,
300; and flask, 302; latest form of,
303; packing with rubber, 304.
Palatine defects (see also "Artificial
palates"), 203.
Paralysis from fracture, 365.
Paré's obturators, 216.
Paris asylums, inmates of, 34.
Parkinson's palate, or movable obtura-
tors, 270.
Pasteboard splints, 381.
Pathological absurdity, 65; inquiry
(Tomes's), 121.
Pattern for artificial palate, 296.
Pennsylvania Training School, 36.
Perforations of the palate, 250.
Period for wearing fixtures in regulat-
ing, 64.
Peters's (Dr. George A.) operation on
palate, 286.
Pharynx, impression of, 294; function of,
418; muscles of, 419; action of, 462.
Philosophy of the movement of teeth,
126; of the action of wedges, 130; of
resonance, 414.
Physiognomy, importance of a knowl-
edge of, 511, 529.
Physiological and pathological action in
shortening teeth, 135.
•
Physiology and pathology, 57; of the
vocal organs, 417.
Pierce (C. N.) on idiots, 37.
Pitch of voice, 413, 418.
Plaster of Paris, 99, 91; method of mix-
ing, 91; extraordinary impressions of,
93, 322, 333; quality of, 94; soap for
parting, 94; coloring, 94; first use
of, in palate cases, 273; used with a
brush, 294; objection to, for palate-
molds, 299.
Points of interruption in the oral
stream, 434.
Porcelain teeth, manufacture of, 504.
Posterior nares, impression of, 93, 295.
Premature extraction, 5, 6.
Pressure, kind preferred in regulating,
65, 69; derived from a spiral spring,
180; causing extensive absorption,
249.
Principal vowels in English, 4.4.
Production of voice, 419.
Profile, rules for drawing, 476; Greek
type of, 478; American type of, 480;
alteration of, 480; of the upper teeth,
499; of the lower teeth, 500.
Prognosis in treating irregularities, 40–
56; mistaken, 154; in fractures, 369.
Prognostication of irregularities, i14.
Prolonged nursing, results of, 10.
Proportions and relations of the human
figure, 475.
Prosthetic treatment of syphilis, 315,
342, 346, 351; dentistry as a science,
467; dentistry requiring æsthetic cul-
ture, 469; dentistry as an art, 471.
Prothesis, palatal, dental, and nasal, 320;
for facial deformity, 324; maxillary,
335; malar, 335.
Protruding upper jaws, 52, 122, 131;
lower jaws, remarkable cases of, 127,
136.
Pterygoidei, illustration of the, 517.
Public schools, children of, 29.
Race degeneration, 19.
Rage, muscular action in, 526.
Ramus, fracture of, 363, 407, 411.
Rapidity of absorption or reproduction,
61.
Rapid movement in regulating, 97, 125,
128, 152.
Ravages of syphilis, 205, 316, 318, 341,
349, 351.
Recognition by dental societies, 275.
Reconstructing a broken impression, 92;
a model of a fracture, 409.
Reducing an upper arch, apparatus for,
77, 78, 84, 87, 97, 108, 123, 125, 145,
152; a lower arch, apparatus for, 80-
83, 141, 164.
Reduction of thumb-sucking case, 107
of dislocations, Ribes's method, 368;
of fractures, 398.
INDEX.
Reenforcement of sound by resonance,
414.
Regulating apparatus, care of, 66; for
expanding an upper arch, 70, 100, 107,
129, 163, 180, 183, 184, 200; for ex-
panding a lower arch, 71, 72, 79, 145;
for twisting teeth, 74, 85, 103, 147, 170,
196; for reducing an upper arch, 77,
78, 84, 87, 97, 108, 123, 125, 145, 152;
for reducing a lower arch, 80-83, 141,
164; for closing jaws, 119, 137; for
shortening teeth, 133, 172; neglected,
136; travesty on, 186. (See "Ap-
paratus for regulating Teeth.")
Regulating cases from practice, au-
thor's, 96-157; Charles Tomes's, 116;
George Allan's, 136; McQuillen's,
157; Flagg's, 160; Richardson's, 169;
H. M. White's, 174; J. D. White's,
179; Westcott's, 181; Gilmour's, 186;
John Tomes's, 189; Angell's, 200.
Regulating teeth, prognosis, 40-56; diag-
nosis, 40-56, 187; in hereditary cases,
53, 65, 100, 106, 113; jumping the bite
in, 53, 124; study of features in, 53,
141; effects of, upon the nervous sys-
tem, 55; age to begin, 61 in adult
life, 62, 160; critical period in, 66; re-
relaxation of strain when, 66, 150;
mechanical forces used in, 68; in-
genuity and invention necessary in,
68, 88; no two cases of, exactly alike,
69; experiments on plaster models,
95; study of the models, 95; crush-
ing the arch in, 97, 100, 127; rapid
movement in, 97, 125, 128, 152; ex-
panding the arch in, 100, 163, 184;
twisting teeth, 103, 147, 170, 186, 194;
flattening teeth, 104; unexpected re-
sults, 108; closing the jaws in, 119,
137; shortening teeth, 134; in three
weeks, 125; by wedges alone, 129;
when jumbled, 146, 156; without a
gag, 150; mistaken prognosis, 154;
discouraging experiments in, 155
lengthening teeth, 171, 178; absurd
method of, 186; without apparatus,
·
197.
Relations and proportions of the human
figure, 475.
Relaxation of strain in regulating, 66,
150.
Remarkable cases of protruding lower
jaw, 127, 136.
Remodeling a living face, 483; the
mouth, 483.
Remuneration considered, 56, 185.
Repetition of letters, 455.
Requisites of artificial vela, 266, 279.
Resonance, philosophy of, 414.
Resonating cavities, 414, 432.
Restoration of a deformed face, 324; of a
sunken nose, 327; of speech and mas-
tication, 338; of features, 481.
539
Results of prolonged nursing, 10; of
thumb-sucking, 11, 108; of mixing di-
verse types, 15.
Retaining plates, 79, 81, 105, 108, 130;
period for wearing, 64.
Retention of temporary teeth, 7; of tem-
porary canines, 7; of every tooth un-
necessary, 42.
Retreating lower jaws, cases of, 52, 122,
144.
Revolving teeth, see "Twisting teeth.”
Rhinoplasty, objections to, 341.
Ribes's method of reducing dislocations,
368.
Richardson's case of irregularity, 169.
Rose pearl for artificial nose, 343.
Rotating shaft used by Dr. Angell, 201.
Rowell's obturator, 222.
Rubber tubing for clastics, 77; shect, for
palates, 268; vela, durability of, 309;
bandage for fractures, 404.
Rules for drawing a head, 476, 478.
Rutenick's splint, 393.
Saddle-shaped arches, 31, 44, 115, 19S.
Sand-molding, 301.
Scrapers for plaster, 292.
Screws, 69; Angell's, 74; Farrar's, 74;
in tooth for twisting, 148; Westcott's,
184; to fasten splints, 389. (See alsó
"Jack-screws.")
Sculpture as related to dentistry, 471.
Second dentition, 17.
Secretary Seward's case of fracture, 371.
Sectional artificial palate, 255, 301.
Selection and arrangement of teeth, 487.
Sequestrum in fracture, 403.
Sercombe's palate, 267; objcctions to,
269.
Shortening incisors, 134, 172; a living
face, 482.
Silk ligatures, 81.
Similar cases of irregularities requiring
different treatment, 50.
Skull-cap, brace, and elastics, 133; and
chin-cap, 138.
Skulls of Hythe Church, 3; of the Cau-
casian, 496; of the negro, 498; com-
parison of, 497; of the gorilla, 498.
Snell-Sercombe artificial palate, 256.
Snell's obturators, 221; palate, 262.
Soap for separating plaster, 94.
Social standing of patients, 55.
Sound the result of motion, 412; vibra-
tions per second of, 412; is composed
of different tones (clang), 413; pitch,
quality, duration, and intensity of,
413; fundamental tone, overtones and
undertones of, 413; reénforcement of,
by resonance, 414.
Spanish brown for coloring plaster, 94.
Speech with cleft palate, 209, 459; imme-
diate effects of an obturator on, 258;
and mastication restored in a gunshot
540
case, 338; mechanism of, 412; with
cleft palate and harelip, 460; with
cleft palate and double harclip, 461,
463.
INDEX.
Spiral spring for widening an arch, 180.
Splints made of wire, 375; paste board,
381; Gunning's, 384; interdental, 384
Bean's, 385; Liston's, 385; Nasmyth's,
385; Suersen's, 386; fastened with
screws, 389; Elliott's use of gutta-
percha for, 390; Moon's, 390; Cho-
part's, 392; Desault's, 392; Bush's,
393; Houzelot's, 393; Malgaigne's,
393; Rutenick's, 393; Berkley Hill's,
394; Lonsdale's, 394; Moon's exter-
nal, 395; Bullock's, 397; Hayward's,
397; author's, 398-410; tin, 399; vul-
canite, 399; mastication on, 400; sub-
mental, 401, 404, 407; duct-com-
pressor, 406; tongue-holder, 406; with
separate arms, 407; adjustment of,
410; universal, 410.
Sponge, compressed, 94.
Spongiopilin, 401, 406.
Springs, spiral, for regulating teeth,
180; as used by Angell, 202.
Staphyloraphy, 210; failure of, 211, 358;
reasons for failure of, 212; operation
of, undone, 286; Huilihen's case of,
357.
Stearn's palate, 263; wooden mold for,
264.
Stellwagen on idiots, 37; on regulating
teeth, 188.
Strain relaxed in regulating teeth, 150.
Study of models, 52, 94, 123; of the liv-
ing face essential in regulating teeth,
53, 141.
Submental compress for fractures, paste-
board, 381; Bean's, 385; Rutenick's,
393; Lonsdale's, 394; Moon's, 396;
Bullock's, 397; author's, 401, 404, 407.
Suersen's obturators, 231; splints, 386.
Sunken nose lifted, 320, 327.
Superficial muscles of the face, 513.
Superior constrictor of the pharynx,
232, 238, 419, 429, 458, 462; maxilla,
loss of, 333; maxillary fractures,
Tomes's case of, 361; maxillary frac-
tures, Salter's case of, 362; maxillary
fractures, treatment of, 362; maxilla,
double fracture of, 405; and inferior
maxilla, fracture of, 405.
Support for an artificial palate, 282.
Surgery of cleft palate, 210; Krackowi-
zer's, 332.
Surgical operation on a nose, 328.
Sutures for fractures, 373.
Syme's directions for fracture treatment,
377.
Syphilis, inherited, 206, 316; prosthetic
treatment of, 315, 342, 346, 351.
Syphilitic effects, 205, 316, 318, 342, 349,
51.
Table of sounds with new classification,
457.
"Taking the bite," method of, 472.
T cross-bar in regulating teeth, 77, 97;
when inadmissible, 101, 107.
Teeth, artificial, author's case of, obtu-
rator, and jaw, 331; author's case of,
obturator, and palate, 358; idealism
in, 472; continuous-gum work, 494;
made by carving, 494; arrangement
of, 499-502; discolorations of, 503
irregularities of, 503; tricks and de-
vices in, 503; criticisms on, 505; color
of, 506; want of individuality in, 508;
culmination of excellence in, 509.
Teeth of ancient races, 3; of modern un-
civilized races, 3; of Indians and Chi-
nese, 4; of dwarfs and giants, 18; of
the future, 25; of children in public
schools, 29; of idiots, 33, 35; in gen-
eral disorder, 33, 147, 156; which
must not be extracted, 54; deformities
resulting from the loss of, 474, 481,
528; expression of the canine, 483,
499; ideal forms of, 490; peculiarities
of form of, 491; an indication of char-
acter, 496. (See also "Arch," "Irreg-
ularities of the teeth," and "Regu-
lating teeth.")
Temporary teeth, extraction or retention
of, 6, 7; molars, use of, in regulating
teeth, 190; molars, ligatures attached
to, 190; incisors, extraction of, 197.
Terror, illustration of, 526.
Thomas's method of wiring fractures,
374; key for tightening ligatures, 374.
Thumb-sucking, Ballard's theory of, 11;
case of, from practice, 106.
Time for wearing retaining plates, 64.
Tin splints, 399.
Tipped-up incisors, 100.
Tomes, Charles, his theory of V-shaped
arches, 11; on enlarged tonsils, 11,
99; his case of contracted maxilla,
116;
his case of maxillary fracture,
361.
Tomes, John, on edentulous gums, 7
his theory of protruding arches, 12;
on regulating teeth, 189–195.
Tom Thumb's teeth, 18.
Tonsils, enlarged, associated with irreg-
ular teeth, 11, 99.
Trachea, function of, 417.
Transmitted peculiarities of the teeth, 9.
Travesty on regulating apparatus, 186.
Treatment of charity patients, 55; of ac-
cidental lesions of the palate, 248-258;
of simple perforations of the palate,
250; of congenital fissure of the pal-
ate, 271-311; of facial deformities, 313
-361; of fractures, 361; of fractures of
the upper jaw, 362; with ligatures,
372, 373; of fractures of the lower
jaw, 398-411; of fractures of the ra-
INDEX.
mus, and of the coronoid and condy-
loid processes, 407, 411; of irregulari-
ties, see "Regulating teeth."
Trial-plates, 295.
Triangular dental arch, 97, 113.
Tricks and devices in artificial teeth, 503.
Trigeminal nerve, function of, 21, 22.
Truman's (Prof.) remarks on extraction,
114.
Twang of the Yankee explained, 212.
Twisting teeth with bands, 74; with
levers, 89, 195; with elastics, 103;
with wooden pegs, 149, 170, 186.
Tyndall's description of vowels, 426.
Type-metal for palate-molds, 273, 300.
Type of dental arch seen in Great Brit-
ain, 36; seen in America, 37.
Underhung jaw, 52.
Undoing a staphyloraphic operation, 286.
Unexpected results in regulating, 108,
155.
Union, irregular, of fractures, 370.
Universal artificial palate, 284; splint of
gutta-percha, 411.
Usual type of idiots' jaws, 35.
Uvula, impression of, 294.
Variations in the resonating cavity, 432.
Variety of normal type of dental arch,
28, 41.
Velum, artificial, see "Artificial pal-
ate"; definition of, 214.
Venetian red for coloring plaster, 94.
Vibration of sounding waves, 412.
Vocal training, 241, 311; chords, 415;
organs, mechanisin of, 415; organs,
anatomy of, 416; organs, physiology
of, 417; consonants, 434.
Voice, training of, 241, 311; duration
of, 413; intensity of, 413; head, 418:
pitch of, 418; production of, 419;
quality of, 419.
Vowels, indefinite in number, 423; Max
Müller on, 423; and consonants, new
table, 457.
Vowel-sounds, Elsberg's explanation of,
423; Bristowe's division of, 424; Tyn-
dall's description of, 426.
541
V-shaped arches, theories of origin of,
11, 12, 27, 98, 99, 111; arches, treat-
ment of, 96-126; or triangular, dental
arches, 97, 100, 107, 113, 122; arches
of hereditary origin, 100, 107, 113;
contracted maxilla (Tomes's case),
116.
Vulcanite palate, 272; for noses, 314;
shell with nasal support, 320; bridge
for a nose, 328; splints, 399; plates
in testing articulation, 431; plates for
regulating, see Apparatus for regu-
lating teeth."
Vulcanizing palates, directions for, 305.
(6
Wedges, use of, 75; failure in the use of,
75; of wood, 118, 170, 189; of rubber,
129, 145; philosophy of, 130; used on
the lower teeth, 145.
Westcott's cases of regulating teeth, 181;
advice on regulating teeth, and fees,
184, 185.
Wheelhouse's treatment of fractures,
375.
Whispered speech, explanation of, 452.
White's (J. D.) method of widening an
arch, 179; obturator, 228.
White's (Dr. J. W.) report on idiots, 36;
remarks on æsthetics, 465.
White's (Meredith) cases or irregularity,
174, 176.
Widening a dental arch, see "Expansion
of a dental arch.”
Width of ancient and modern jaws, 3.
Wiegall's figure-drawing, 475.
Wildman's case of nose and obturator,
351; method of taking an impression,
352.
Wire ligatures for fractures, 373; splint,
375.
Wiring the jaw, 373; Buck's method of,
373; Kinloch's method of, 373; Thom-
as's method of, 374; Wheelhouse's
method of, 375.
Wood, compressed, for wedges, 189, 191.
Wooden pegs for twisting teeth, 149 170.
Woodward's case of gunshot wound, 339.
Yankee twang explained, 212.
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