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To all those who have been perplexed by cases
of malocclusion of the teeth and have not become
discouraged thereby, but rather stimulated to a
keener interest in, and a broader study of, this
most beneficent, fascinating, and progressive
branch of dental science, this book is respectfully
dedicated.
345753
PREFACE TO THE SIXTH EDITION.
THE issuance of the sixth edition of this work in its
enlarged form, intended by the author as a culmination of
his labor in this line, is inspired by various considerations.
The system of appliances and methods of treatment intro-
duced in the former editions have been well received, as
is evidenced by the number of editions issued and by
their translation into the French, German, Dutch, Scan-
dinavian, and Spanish languages by writers in the coun-
tries in which these languages prevail. As a result of
busy years devoted to teaching and the exclusive practice
of orthodontia, during which the science has been an
absorbing study and the subject of most painstaking
investigation, the author has been more and more im-
pressed with its far-reaching importance and possibilities.
He is actuated in the present instance not alone by the
earnest solicitation of teachers, students, and practition-
ers, but also by an appreciation of the necessities of this
Science and the hope that the principles herein recorded
may be instrumental in promoting its advancement.
The subject is treated far more comprehensively in
this edition than in those which have preceded it, they
having been limited to the mechanical phases of the subject.
Much of this early matter has been re-written, some of
it being eliminated—superseded by better methods, the
object always being to keep simplicity and efficiency fore-
most. There has been a studied effort for condensation
and systematic arrangement. It is believed that lumbering
volumes, like multiplicity of appliances and methods, serve
V
vi PREFACE TO THE SIXTH EDITION.
rather to leave the student in hazy bewilderment than to
equip him for useful practice. On the other hand, a mere
recital of the achievements of others, by divers means,
without System or detail, presupposes a knowledge on
the part of the student which if possessed would render
the slight information imparted but a possible matter of
interest, instead of a necessity for study. That this work
will be found radically different in many particulars from
the usual work on Orthodontia is certain, especially in
that many devices for regulating the teeth, which have
been familiar pictures from the earliest remembrance of
the subject by our oldest practitioners, will be absent; not
that they are eliminated on account of their antiquity, but
because, analyzed never so carefully, they fall so far short
of the present requirements of a regulating appliance. It
is believed that such crudities instead of longer handicap-
ping the student are entitled to only such respect as by
right awaits them in history. -
It has long been the effort of the author to perfect a
system which should be complete within itself—a system
which should include the simplest and best methods, not
Only for the treatment of all forms of malocclusion, but
for the study and diagnosis of cases, as well as for the
teaching of the subject in its entirety. The degree of his
success must be determined somewhat by time and the
intelligent, unbiased judgment of others.
In the illustrations, which are all original, the art of
the photographer and the skill of the engraver have been
severely taxed to accurately represent cases from actual
practice, with the appliances and methods of treatment
employed. No fanciful pen-sketches of imaginary and
improbable cases, created to illuminate theoretical, compli-
cated and impractical devices, will be here found. The
ideas expressed and the lines of practice laid down are
also, except as otherwise stated, original with the author,
and he accepts full responsibility for them. A conscien-
PREFACE TO THE SIXTH EDITION. vii
tious effort has been made to give proper credit for all
inventions of acknowledged merit. To fair minds recorded
dates are usually sufficient evidence of priority.
This work is designed primarily for the instruction of
students in colleges, and secondarily as a guide and ready-
reference book for practicing dentists who have not de-
voted special study to the subject of which it treats.
It has been said that “order is heaven’s first law.”
Order implies exactness, thoroughness. Not only is an
effort made to impress these principles throughout the
following pages, but they have prompted the manner of
doing it. Literary style has been subordinated to clearness
of expression and precision of detail. This may explain
a frequent repetition of terms and methods which would
be inadmissible in a narrative, but which is here indulged
for the convenience of the student, that the necessity for
back-reference may be reduced to the minimum. -
A poverty of terminology has long been felt in the
science of orthodontia, but it has been deemed better to
expand the meanings of terms employed, in many in-
stances, to meet requirements than to increase the vocabu-
lary by introduction of new words. Thus, the term
“malocclusion” is often used for convenience to express
the condition of malposition of a tooth which has no occlu-
sion at all with other teeth. “Elevating” is a term
employed with similar license. We may speak of elevating
a tooth in the upper arch when we really pull it down,
and so with other usage the meaning of which should be
clear. -
The author expresses obligations to Professor Black
for some suggestions in regard to the arrangement of the
Subject-matter, and to Professor Noyes for the use of
Selections from his valuable collection of microscopical
slides of the peridental membrane, and also for actual
Work in the preparation of the new and excellent engrav-
ings prepared especially for this work to illustrate the
viii PREFACE TO THE SIXTH EDITION.
chapter on the Peridental Membrane; also to The S. S.
White Dental Mfg. Co., for the excellent illustrations
which they have cheerfully prepared and for the pains-
taking thoroughness of their work as publishers.
EDWARD H. ANGLE, M.D., D.D.S.
St. Louis, October 20, 1900.
PREFACE TO THE SEVENTH EDITION.
SINCE the publication of the sixth edition of this work
six years have elapsed—years in which very important
steps in the progress of orthodontia have been taken.
Much that was therein enunciated and at that time re-
garded as extreme has become accepted teaching. Much
that was foreshadowed has been verified. The recognition
of occlusion as the basis of orthodontia, therein first made
prominent, seems to the author to mark its real beginning
as a science. In these years there has grown a broader
and deeper conception of the basic principles of occlusion
and their practical application has become of greater im-
portance. At that time the demands in art and occlusion
were still supposed to be distinct and independent, but we
have since learned their intimate relations and entire in-
terdependence,—in other words, that the best balance and
best harmony of the mouth with the rest of the face are
only possible with normal occlusion—the full complement
of teeth in normal relations.”
The author has also aimed to point out a simple, yet
efficient, as well as logical, method of diagnosis of mal-
Occlusion, and also of its treatment in from the simplest
to the most complex cases, also from the basis of normal
Occlusion.
-—
* New York Institute of Stomatology, October 7, 1902; International Dental
Journal, October, 1903. “Art in its Relation to Orthodontia,” Angle, read
before The American Society of Othodontists, October, 1902; published in
Items of Interest, September, 1903.
ix
X PREFACE TO THE SEVENTH EDITION.
A greater perfection of the regulating appliances, to-
gether with a better comprehension of intermaxillary force
and anchorage have made the fulfilment of the demands
of occlusion and art far easier and almost universally
possible, revolutionizing the practice in the treatment of
the second and third classes of malocclusion, as well as
greatly lessening the difficulties of establishing normal
occlusion in many cases of the first great class. A broader
experience and closer study of the alveolar process and
peridental membrane have given a clearer comprehension
of the important changes in these tissues subsequent to
tooth movement. We have learned that at best our efforts
are only to assist Nature and that if we correctly inter-
pret her wishes and intelligently assist her she will com-
plete the growth and development of these tissues normally
in accordance with the type of the individual, so that the
resort to mutilation, as dominated by the individual judg-
ment of the practitioner, is no longer a proper plan of
treatment, but that it must give place to the logical—the
normal—in treatment.
So orthodontia has passed from the empirical of the
“old school” and has become, we believe, more nearly an
exact science than any other branch of dentistry, or pos-
sibly of medicine.
Very naturally such pronounced changes have been
marked by strenuous opposition from a few, but we are
pleased to note that they have been promptly accepted
by the best element in dentistry. In this case, as is usual
in all reforms, the opposition has come from those who
should naturally be first to recognize the soundness and
value of the principles enunciated—the foremost writers
of the “old school.’” Their opposition has taken the usual
form of opposition to progress in religion, science, and
* See articles by Guilford, Case and others of the old school in Items of
Interest, August, 1905.
PREFACE TO THE SEVENTH EDITION. xi
politics, namely, to first ignore; then, “it is not true;”
and finally, “we have always believed.”
These progressive stages have necessitated many
changes in the new edition, such as the entire reconstruc-
tion of the chapter on Facial Art, from the basis of occlu-
sion, as well as of the chapters on Treatment, of cases
belonging to the second and third Classes of malocclusion.
Many devices that were formerly in favor with the author,
and still valued by many practitioners, have been placed
in the Appendix in order to avoid confusion, and for the
reason that in the author’s opinion they are not so ef-
ficient in meeting most of the demands of treatment as the
expansion arch in its present perfected state. Yet for cer-
tain uses many of them are invaluable.
Many minor improvements in methods of treatment
have been added. In fact, practically the entire book has
been re-written in order to make clear the basic principles
of the science as well as their practical application. As
the practical is naturally and justly expected by the student
of Orthodontia, many additional cases are carefully de-
Scribed and illustrated and carried through the various
stages of treatment, which, we believe, will be appreciated
as compared with the time-honored custom followed in
other works of merely suggesting innumerable appliances
without showing the practical results of their use. Indeed
We have not been content with giving the manner of
treatment and establishment of normal occlusion, but have
shown the condition of many cases years after treatment,
Something that will henceforth be demanded in works on
Orthodontia.
In former editions a portion of the work was devoted to
the treatment of Fractures of the Maxillae. As such practice
should not be classified with that of orthodontia it has been
deemed advisable to publish a revision of that portion
of the work separately.
In the preparation of this edition the author has en-
xii PREFACE TO THE SEVENTEI EDITION.
deavored to express his own views, gleaned from his own
extensive experience and observation, and whenever the
thoughts of others have been made use of due credit has
been given in accordance with the true ethics of literature.
He wishes here to express his obligation to Dr. F. B.
Noyes for his assistance in the revision of the chapter on
The Peridental Membrane, and to his former student, Dr.
Norman G. Reoch, for several drawings, and especially to
The S. S. White Dental Mfg. Co., for generously according
him every assistance in the publication of the book.
EDwARD H. ANGLE, M.D., D.D.S.
St. Louis, Mo., November 10, 1906.
CON TENTS.
PA GE
INTRODUCTION . . . . . * * * * * * * * * * * * * * * * * * * * * * * * * - © s - - e - - - e. |
CHAPTER I.
OCCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Key to Occlusion—Line of Occlusion—Nomenclature—Forces Gov-
erning Normal Occlusion.
CHAPTER II.
MALOCCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
S
Forces Governing Malocclusion—Classification of Malocclusion—
Class I–Class II, its Divisions and Subdivisions—Class III, its
Division and Subdivision.
CHAPTER III.
FACIAL ART . . . . . . . . . . . . . * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 60
ETIOLOGY OF MALOCCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SS
Premature Loss of Deciduous Teeth—Loss of Permanent Teeth—
Imperfect Fillings, Crowns, etc.—Prolonged Retention of De-
ciduous Teeth—Tardy Eruption of Permanent Teeth—Super-
numerary Teeth—Transposed Teeth—Disuse—Abnormal Fre-
mum Labium—Habits—Nasal Obstructions.
CHAPTER V.
ALVEOLAR PROCESS AND PERIDENTAI, MEMBRANE . . . . . . . . . . . . . . . . . . . . . . 11S
CHAPTER VI.
TIssuſ. CHANGES INCIDENT TO TOOTH MoVEMENT . . . . . . . . . . . . . . . . . . . . 132
Alveolar Process—Peridental Membrane—The Pulp.
XIV CONTENTS.
CHAPTER VII.
PHYSIOLOGICAL CHANGES SUBSEQUENT TO TOOTH MoVEMENT. . . . . . . . . . 140
CHAPTER VIII.
MODELS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Materials for Impressions—Method of Taking Impressions—The
Trays—Taking and Removing the Upper Impression—Taking
and Removing the Lower Impression—Removing Impressions
from Arches with Spaces, due to Loss of Teeth—Uniting and
Varnishing the Impression—Pouring and Separating the Model
—Trimming the Model—Value of Good Models—Photographs
—Skiagraphs.
CHAPTER IX.
REGULATING APPLIANCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
The Old and the New Methods—Epochs in the History—Requisite
Qualifications—Stability of Attachments—Materials for Con-
struction.
CHAPTER X.
THE AUTHOR'S APPLIANCES * * * * * * * * * * * * g º 'º e º tº e º e º º ſº º e º e º ºs e tº e º e º 'º º tº 182
General Description of-Instruments.
CHAPTER XI.
SOLDERING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 209
Plain Bands and their Attachments—Technique—Soft-Soldering.
CHAPTER XII.
ANCHORAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
Simple—Stationary—Reciprocal—Intermaxillary—Occipital.
CHAPTER XIII.
ADJUSTMENT AND OPERATION OF APPLIANCES . . . . . . . . . . . . . . . . . . . . . . . . 236
Clamp Bands—Plain Bands—Expansion Arches—Wire Ligatures—
Combination Adjusted—Combination for Baker Anchorage—
Combination Reinforced.
CHAPTER XIV.
RETENTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
Time Required—Principles—Temporary and Permanent Devices—
Application of Principles—New Method—Intermaxillary.
CONTENTS. - XV
CHAPTER XV.
TREATMENT.—PRELIMINARY CONSIDERATIONS . . . . . . . . . . . . . . . . . . . . . . . . 305
- Time for Beginning—Time Required—Frequency of Seeing Patients.
CHAPTER XVI.
TREATMENT OF CASES.–CLASS I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
CHAPTER XVII.
TREATMENT OF CASES.–CLASS II, DIVISION 1. . . . . . . . . . . . . . . . . . . . . . . . 448
Class II, Division 1, Subdivision.
CHAPTER XVIII.
TREATMENT OF CASES.–CLASS II, DIVISION 2 . . . . . . . . . . . . . . . . . . . . . . . . 514
Class II, Division 2, Subdivision.
CHAPTER XIX.
TREATMENT OF CASES.–CLASS III. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 550
Class III, Division, Subdivision.
CHAPTER XX.
OPERATIVE SURGERY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 566
Immediate Movement—Alveolar Sections—Resection of Peridental
Fibers—Section of Frenum Labium—Double Resection of Man-
dible.
A PPEND IX.
Jack-screw—Traction-screw—Lever—Miscellaneous Combinations. . . 579
FINAL SUGGESTIONs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610
INTRODUCTION.
MALOCCLUSION of the teeth is found in all races and even
occasionally among the lower animals, and has been one
of man’s afflictions from time immemorial, but that it is
becoming more common as civilization progresses is very
generally conceded. Indeed, it has become so common
that it is now almost the rule, rather than the exception.
Go where we will, wander down the village street or the
crowded avenues of great cities, or wherever humanity
congregates, and we will be confronted by these deform-
ities in such numbers that we are amazed at their preva-
lence. And in proportion as malocclusion exists the func-
tions of the teeth, and speech are impaired, and the facial
lines marred.
The opportunities and possibilities of improvement of
the features by proper treatment of malocclusion are so
great, and the appreciation of the patients and their
friends so genuine when the work has been quickly and
intelligently performed, we wonder that a closer study and
keener interest in the subject by practitioners was not
long ago awakened, and are surprised that so few have
a proper conception of the possibilities of orthodontia for
the improvement of the individual in speech, health and
beauty.
It is not enough to simply move into correct alignment
irregular teeth. We should have a proper conception of
2 1
2 MALOCCLUSION.
the denture as a whole and the art requirements of the
individual type; of the influence of the malocclusion in
arresting or modifying the development of the alveolar
process, jaws, and muscles, and in disturbing the normal
balance of the face. We must consider the numerous
changes which may follow the movement of teeth into cor-
rect positions, with the restoration of the natural func-
tions of the occlusal planes, and the assistance the changes
will lend to Nature as they stimulate her to efforts for the
continuation of normal growth and development of all the
related parts, that they may be in best harmony with
each other in their new relations—in best harmony with
Nature’s plan. In many cases there can be no intelligent
diagnosis or plan of treatment unless the probable changes
through subsequent growth be fully considered.
The real growth of dentistry is of comparatively recent
years, and along branches having little in common with
orthodontia, so that this branch received little attention
until within the last half-century, and it is probable that
more real interest has been awakened and more real ad-
vancement made in the last twenty years, and especially
in the last six, than in its entire previous history.
Much has been written upon the subject of orthodontia,
but mostly from the mechanical standpoint, and only very
recently has it begun to receive that broad and thorough
study which a science of such great importance demands,
for its basic principles are grounded in the mysteries of
embryology, histology and comparative anatomy, linked
with art and physics. x
It has rapidly passed through marked evolutionary
stages until it is now recognized as a distinct science, the
INTRODUCTION. 3
broad possibilities of which are even yet but dimly com-
prehended by those who have not given it careful study.
In the light of our present knowledge most of the theory,
as well as of the practice, of even a few years ago seems
strikingly crude.
Of such theory and practice was the common advice to
young patients to “let the teeth alone and trust to Nature
to straighten them,” or to wait until the permanent den-
tition should be complete before making any effort toward
their correction. Of such was the unfortunate sacrifice
of teeth with a mistaken view of relieving the crowded
condition of the arches, but with the result often of aggra-
vating the malocclusion and giving rise to a serious train
of evils, as shown in the chapter on etiology. So, also,
the use of huge plates combined with springs taken from
clocks and various strange mechanisms as a means of tooth
movement, now seems more in accord with many of the
teachings of medicine during the period of history known
as the ‘‘dark ages.”
Until within a very few years the teachings of ortho-
dontia in dental colleges was very superficial, even ofttimes
being wholly omitted from the curriculum. Now, how-
ever, in all of our best colleges separate chairs have been
established and the subject is more comprehensively taught.
Yet this branch of the science is still made subservient
to all others in dentistry, notwithstanding the fact that
its exactions in teaching and practice are greater than in
any of the other branches of dentistry. There should be
still further radical improvements in its teaching, for it is
an historical fact that no student has yet acquired at a
dental college proficiency in this branch sufficient to enable
4 MALOCCLUSION.
him to succeed in its practice as a specialty. In fact, so
exacting are its requirements, that, unlike the general prac-
tice of dentistry, the mere Smatterer can never hope for
even moderate success, for often apparently very simple
cases of malocclusion are in reality only symptoms of con-
ditions whose management requires the broadest knowl-
edge and mature judgment.
Orthodontia is a subject so great, so important, with
such possibilities and rewards, that it is ample in itself
for the life work of the best minds. For years it has been
the author’s firm conviction that it should be classed as a
distinct specialty—taught and practiced as such ; that it
should be freed from the handicapping influences of gen-
eral dentistry and given an opportunity to develop
normally along lines which are so distinctively its own,
lines which define it as a specialty as clearly as do those
that define the specialty of ophthalmology, and more
clearly than those that define the specialty of rhinology.”
And it is gratifying to note that it is at last rapidly taking
its place among the great specialties of medicine as its
importance demands.
At the time of the publication of the last edition of this
work there were but two or three at most who could be
regarded as specialists in orthodontia. At this writing
there are over sixty giving their exclusive attention to
this branch and limiting their practice to it. One school
has been established for its exclusive teaching, and two
societies formed for the promotion of its interests, with
an unusual number of articles appearing in the literature in
* Angle. Dental Review, March, 1896.
INTRODUCTION. 5
which has been reported more and better work than is prob-
ably to be found in all preceding literature. Orthodontia
when mastered, and practiced as a specialty, becomes one
of the most fascinating of the professions and gratifying in
its practice, having, as it does, a clientèle far more nearly
ideal than is to be found in any other branch of medicine,
composed of patients in health and in the flower of youth
—and that, too, of the cultured and affluent. Yet its
exactions on the student and practitioner are so great that
only those highly qualified in the science can ever hope to
truly succeed; but for such there awaits a field almost
limitless in extent and in which they will receive prompt
recognition.
C H A P T E R I.
OCCLUSION.
“SUBSTANTIAL progress in any science is impossible in
the absence of a working hypothesis which is universal
in its application to the phenomena pertaining to the sub-
ject-matter. Indeed, until such a hypothesis is dis-
covered and formulated, no subject of human investiga-
tion can properly be said to be within the domain of the
exact sciences. . . . It enables one skilled in that
science to practice it with a certainty of results in exact
proportion to his knowledge of its principles and his skill
in applying them to the work in hand.”—HUDSON.
ORTHODONTIA* is that science which has for its object
the correction of malocclusion of the teeth.
Occlusion is the basis of the science of orthodontia. The
shapes of the cusps, crowns, and roots, and even the
very structural material of the teeth and their attachments
are all designed for the purpose of making occlusion the
One grand object, in order that they may best serve the
chief purpose for which they were intended, namely, the
cutting and grinding of food. We will define occlusion as
being the normal relations of the occlusal inclined planes
of the teeth when the jaws are closed.
Malocclusion of the teeth is but the perversion of their
normal relations. It can be studied intelligently only
from the basis of the normal, and to begin its study
without first being familiar therewith would be as unfruit-
ful as the study of the pathology of any other of the
*=–
* From the Greek, opóós, straight; oãots, tooth.
8 MALOCCLUSION.
structures of the body without first mastering their
anatomy and physiology.
There must be, then, clearly fixed in the mind of the
student of orthodontia not only Nature’s plan of the nor-
mal denture when complete, but also its beginnings, the
growth and development of parts, which is a most intricate
and beautiful process, and their co-relations.
The normal human denture in its completeness includes
not only the jaws, alveolar process, dental arches, and
especially the teeth and peridental membrane, which to
us are of prime importance, since on them chiefly our
operations are performed, but also the muscles of lips,
cheeks, tongue, and mouth, the nasal passages, palate,
and throat, as these assist the teeth in performing their
functions. They are also powerful factors in establishing
and maintaining either harmony or inharmony in the
development and arrangement of the teeth, and this just
in proportion as they are, singly or collectively, normal
or abnormal in their own development and functions.
It is, of course, not within the province of a work on
orthodontia to teach as minutely and thoroughly as is
necessary to a complete understanding thereof, the em-
bryology, histology, and anatomy of the human denture.
The reader is therefore strongly recommended to their
study elsewhere, and especially to the works of Drs. Noyes,
Black, Broomell, and Cryer. A thorough knowledge of
the individual teeth is of such inestimable value to the
orthodontist that the student is urged to carve, or model
in clay, the different tooth forms, as in no other way will
there be such a vivid impression stamped upon his mind
of the correct outlines of their crowns and the positions
and relative proportions of their cusps, together with
their marginal, triangular, and oblique ridges, their
grooves and sulci, and their relations to their antagonists.
Nature, in building the dental apparatus, requires a long
period of time—twenty years or more—and from the be-
OCCLUSION. 9
ginning of the formation of the first dental follicle and
the tissues that support and precede it to the eruption of
the last third molar, she works in accordance with a definite
plan toward a definite end, viz., the production of a type
that has been the type of man’s denture as long as man
has been man.
FIG. 1.
Normal occlusion. (Broomell.)
By referring to Fig. 1, which represents the teeth in
normal occlusion, it will be seen that each dental arch
describes a graceful curve, and that the teeth in these
arches are so arranged as to be in greatest harmony with
their fellows in the same arch, as well as with those in
the opposite arch.
In their normal relations the external curve of the lower
arch is slightly smaller than that of the upper, so that in

10 MALOCCLUSION.
occlusion the labial and buccal surfaces of the teeth of the
upper jaw slightly overhang those of the lower. The
mesio-buccal cusp of the upper first molar is received in
the buccal groove of the lower first molar. The teeth pos-
terior to the first molars engage with their antagonists
in a precisely similar way; those anterior interlock with
one another in the interspaces until the incisors are
reached; of these the upper usually overhang the lower
about one-third the length of their crowns, though the
length of overbite varies, being greater in the teeth indica-
ting the bilious and nervous temperaments, and less in the
sanguineous and lymphatic types. ." .
The upper central incisor being broader than the lower,
it necessarily extends beyond it distally, overlapping in
addition about one-half of the lower lateral incisor; the
upper lateral occludes with the remaining portion of this
tooth and with the mesial incline of the lower canine; the
mesial incline of the upper canine occludes with the distal
incline of the lower, the distal incline of the upper occlu-
ding with the mesial incline of the buccal cusp of the lower
first premolar. In the same order the series of buccal
cusps of the premolars occlude—the mesial incline of each
upper occluding with the distal incline of the correspond-
ing lower tooth.
The distal incline of the second upper premolar occludes
with the mesial incline of the mesio-buccal cusp of the
lower first molar. The mesial incline of the mesio-buccal
cusp of the upper first molar occludes with the distal incline
of the mesio-buccal cusp of the lower first molar; the dis-
tal incline of the mesio-buccal cusp of the upper first molar
Occludes with the mesial incline of the disto-buccal cusp
of the lower first molar; the mesial incline of the disto-
buccal cusp of the upper first molar occludes with the
distal incline of the disto-buccal cusp of the lower first
molar, and the distal incline of the disto-buccal cusp of
the upper first molar occludes with the mesial incline of
OCCLUSION. 11
the mesio-buccal cusp of the lower second molar. The
same order is continued with the buccal cusps of the second
and third molars, the distal incline of the disto-buccal cusp
of the upper third molar having no occlusion.
It will thus be seen that each of the teeth of both jaws
has two antagonists or supports in the opposite jaw
except the lower central incisors and upper third molars.
FIG. 2.
Normal occlusion, lingual aspect. (Turner.)
As the inclined planes match and harmonize most per-
fectly in the bucco-occlusal relations of the teeth, so there
is a similar arrangement in their linguo-occlusal relations,
except that the lingual cusps of the lower buccal teeth
project beyond those of the upper into the oral space, as
shown in Fig. 2.
Likewise in the transverse arrangement, the buccal
cusps of the lower molars and premolars rest between the

12 MALOCCLUSION.
buccal and lingual cusps of the uppers, and the lingual
cusps of the upper molars and premolars rest between
the buccal and lingual cusps of the lowers, as in Fig. 3.
The grinding surfaces are thus enormously increased
in extent and efficiency over what would be possible if they
consisted of a single row of cusps or of plane surfaces.
But increase of masticating surface is not the only
reason for this complex interdigitation of the cusps and
inclined planes of the teeth, but it is of equal importance
Normal occlusion of molars, transverse view. (Cryer.)
in providing for the teeth a mutual support. The sizes,
forms, interdigitating surfaces, and positions of the teeth
in the arches are such as to give to one another, singly and
collectively, the greatest possible support in all directions.
This is the pattern, the form, the type of the normal in
occlusion,-the normal denture.
In building the human denture, Nature has worked
toward a definite end to produce the most efficient parts
with the most efficient arrangement of these parts that they
may in function be most efficient. Each tooth is not only
in harmonious relation with every other tooth, but helps
to maintain every other tooth in these harmonious rela-

OCCLUSION. 13.
*
tions, for the cusps interlock and each inclined occlusal
plane serves to prevent each tooth from sliding out of
position, and further, to wedge it into position if slightly
malposed, that is if not beyond the normal influence of the
inclined planes. s
A careful study of the relations of the inclined occlusal
planes and the marginal, triangular, and oblique ridges,
in connection with the movements of the jaw, cannot fail
to impress thoughtful persons not only with the influence
which these exert in maintaining each individual tooth in
correct position, but as well their wonderful efficiency for
incising and triturating the food required by omnivorous
man, and with their marvelous forms and arrangement
for self-cleansing and consequent self-preservation. So
perfect is the plan in the relations of the teeth as a whole
that each cusp or part of a cusp contributes perfectly to
the balance, harmony and efficiency of all, and consequently
the mesio-distal diameter of a tooth, or any portion of it
cannot be sacrificed without proportionately disturbing the
delicate balance and integrity of form and function of the
whole. To one versed in occlusion no argument is needed
to impress the importance of the complete and perfect res-
toration to contour of missing portions of teeth, or of the
adjustment to harmony of those teeth that have become
inharmonious during their eruption. -
Not only are the individual tooth-patterms and the rela-
tion of the teeth most perfectly designed for performing
their functions, but probably no other forms or relations
could produce so beautiful and artistic an effect as an
individual feature, or give so much of beauty in lines and
expression to the face. The denture, with the teeth in
normal occlusion, is a marked element of beauty to any
face, however imperfect in other respects.
There is great harmony in the lines of the teeth, though
all vary, the result being most pleasing. How the beauty
of the central incisor would be impaired if its mesial lines
14 MALOCCLUSION.
were the same as its distal lines. How much less pleasing
would be the result if the lateral incisor were of the same
size as the central, or even of the same pattern, instead of
possessing the majesty of a pattern and relative size all
its own. It is like the central, yet how beautiful in its
difference. The canine, though resembling both central
and lateral, adds much beauty to the whole in the lines
peculiar to its own pattern, and how much the general
effect is enhanced by the lateral incisor being shorter and
slightly less prominent in the line of occlusion than either
the central or canine. As in architecture, the columns of
the corners must not be smaller than the intervening
columns, so in orthodontic operations, or in unanatomically
fashioned dentures, when the lateral is made prominent
or of the same length as the other teeth the result is pro-
nouncedly unpleasing. Again, how unpleasing is the effect
when these beautiful lines are impaired by grinding any
of the marginal surfaces—a fact that should lend caution
to the hand of the orthodontist.
The same artistic harmony of the remainder of the teeth,
both upper and lower, might be pointed out. We would
call further attention here, however, only to that most
noticeable unbalancing effect of the mouth in its relation
to the other features resulting from the loss of a premolar
and retraction of the canine, or, equally bad, the loss of a
lateral incisor, and how the great beauty of harmony of
the whole is impaired by a space in the premolar region
resulting from extraction.
That no two normal human dentures have ever been
created that were exactly alike it is reasonable to suppose,
since it has never yet been demonstrated that Nature ever
duplicates her forms. Three beautiful types or patterns
of the teeth in normal occlusion are illustrated in Figs.
4, 5, and 6. None is absolutely perfect. Probably Nature
never makes the truly ideally perfect type in every par-
ticular. It will be seen that each of these dentures slightly
OCCLUSION.
15
Fig. 4.
FIG. 5.
(Summa.)


16 MIALOCCLUSION.
differs from the others: in the position of the denture as a
whole in its relation to the skull, in the angles of inclina-
tion of the incisors as well as of the other teeth, in the
sizes and typal patterns of the teeth, in the length of
cusps and consequent overbite of the incisors, in the sizes,
widths, and curves of the arches, as well as in the com-
FIG. 6.
(Turner.)
pensating curve of the plane of occlusion. Yet these
variations are but natural and doubtless in perfect keeping
with the distinctive individual type, and we insist that in
the main the dentures are exactly alike in Nature's plan
of the normal in human dentures. If all were alike in every
particular it would necessitate that the three individuals
represented by them also be essentially alike in every other
particular.

OCCLUSION. 17
Key to Occlusion.—According to Nature’s plan of the
human denture all of the teeth are essential, yet in function
and influence some are of greater importance than others,
the most important of all being the first permanent molars.
They are the largest of the teeth and the firmest in their
attachment, which, together with their location in the
arches, makes them the most important of the teeth in the
function of mastication. By the lengths of their crowns
they also determine the extent of separation of the jaws
and length of bite, and in this, as well as in many other
ways, are factors in the artistic proportions of the face.
Being the first of the permanent teeth to take their posi-
tions in the arches, they exercise great control over the posi-
tions which the other teeth anterior and posterior to them
shall occupy as they erupt at their respective periods and
take their respective positions in the arches. As they are
already developed and firmly attached in the alveolar pro-
cess when the other teeth appear, the latter are built into
the dental apparatus around them, as it were. They are
not only the most constant in the time of taking their
positions, but by far the most constant in taking their
normal positions.
A better understanding of the reason why these teeth
take correct positions is gained if we will but remember
that theirs are the first permanent tooth germs formed,
and also that they are the first of the permanent teeth to de-
velop and erupt, which they do unhampered immediately
posterior to the twenty teeth comprising the deciduous set,
and that the deciduous teeth are free to erupt normally
according to Nature’s plan, under the most favorable con-
ditions, and do so nearly always in normal occlusion and in
perfect accordance with the requirements for harmony and
beauty of the developing child’s face. So the first perma-
ment molars in erupting are not only unhampered in taking
their positions, but on the contrary they are, as it were,
guided into and guarded in correct positions by the usually
3
18
MALOCCLUSION.
FIG. 7.

OCCLUSION. 19
•º
normal child denture anterior to them, Fig. 7, and by
their normal locking on eruption is made possible the
normal eruption and locking of all the other teeth both
anterior and posterior to them in both lateral halves of
each arch. - - -
So important is the influence of these teeth in the build-
ing of the dental apparatus that we believe Nature ex-
ercises the greatest care in locating them, especially the
upper first molars,”—which we call the keys to occlusion,--
and so places them that the rest of the dental apparatus
may be completed normally; and if so completed it will,
we are convinced, be in best harmony not only with these
teeth, but with the physical type of each individual, just
as the ears, eyes, the brain, the sphenoid bone, etc., are
located to make, when complete, one harmonious whole,
distinctive from all other individuals, with a face, a dental
apparatus, and all other anatomical characteristics in
harmony, not necessarily perfect as a whole or in any
particular part, but with the best harmony of parts.
The fact that the upper first permanent molar varies
considerably mesially or distally as to its location in dif-
ferent individuals, which is always noted in anything like
an extensive study of the subject, has led superficial
students to regard these positions as abnormal, taken by
chance, and out of harmony with other principles in the
anatomy of individuals, but in reality these variations are
to be expected, and are necessary in the creation of differ-
ent types and different individuals. As, for example, this
molar is found to be located farther anterior in its relation
to the skull in some of the lower orders of man and the pri-
mates, than in the highly developed civilized man, which is
necessary in the typal requirements.
Theoretically the first upper molars may differ in posi-
* Angle, “The Upper First Permanent Molar as a Basis of Diagnosis.”
Items of Interest, June, 1906.
20 MALOCCLUSION.
tion slightly, even in each lateral half of the dental arches
of an apparently normal individual, just as the eyes or
ears, slightly differ as to height or location in the same
person. Probably they are never exactly constant as to
the two sides, but we insist that this is but natural and in
keeping with the rest of the anatomy, and should no more
be regarded as an abnormality when slight than the almost
universal slight difference in the positions of the eyes or
the ears. -
And, finally, that Nature may err in the locating of these
molars is doubtless possible, for we know, the unfortunates
classified as “freaks” are the result of her anatomical
errors, but we must remember that freaks are very rare,
and we believe that Nature so very rarely errs in the loca-
ting of the first upper molars—the very cornerstones, as it
were, in the foundation of the structure of an organ so es-
sential to the whole physical economy as the dental appa-
ratus, as to make it a matter of little or no concern to us ex-
cept, possibly, in research work. The author has been
unable to find, after much study, a single case in an unmu-
tilated denture where it would seem to him that Nature had
erred in not locating these most important teeth so as to be
in best keeping with the remaining typalanatomical factors.
* So it will be seen that we have the most logical and con-
clusive of reasons for regarding these teeth as the keys
to occlusion, and on their positions and the relations of
their antagonists with them, to base the classification and
diagnosis of malocclusion.
The author is well aware of the criticisms to the accept-
ance of the first permanent molars as a basis for diagnosis
of cases of malocclusion, in contra-distinction to the only
heretofore known plan, which is entirely empirical and de-
pends upon the judgment of the operator,” but he feels sure
that an unbiased and more thorough study of the subject
* Cryer, Dental Cosmos, September, 1904; Case, Items of Interest, July,
1905.
OCCLUSION. 21
will demonstrate that the first permanent upper molar
furnishes more nearly than any other tooth or point in
the anatomy an exact scientific basis from which to reason
on malocclusion.
It is to be understood that the sense in which we here
speak of the upper first permanent molar is its mesio-distal
relations, and independently of slight migrations mesially
or distally which may have resulted from mutilation, the
extent of which migrations, if occurring, can be easily
detected and allowances made therefor.
The author has lately become convinced of the wonder-
ful constancy also as to the correct location linguo-buccally
of these molars when they have succeeded in locking
normally with their antagonists. He believes that when
they are found lingually or buccally to their normal po-
sitions it is practically always due to mechanical influences
resulting from their mal-relation with the opposing molars.
Naturally the arch is narrower between these teeth when
they first erupt than at the time the denture is completed,
as must follow the normal growth of the jaws and other
bones. Lack of recognition of these facts has led to the
erroneous belief by many that the upper arch should
usually be widened in the region of the first molars, even in
the cases of young children. -
Line of Occlusion.—Writers on Orthodontia have long been
in the habit of making use of an imaginary line, known as
“the teeth in alignment,” and the “line of the arch,” from
which to note regular or irregular alignment of the crowns
of the teeth. It has most often referred to the general line
of each individual arch, as outlined by the crowns of the
teeth regardless of their number or position, or of the
relations of such lines to the skull. In this way two lines
of occlusion are often inferred, one for each arch, which
may or may not have direct relation one to the other. In
reality, as used, it has been vague and indefinite. So far
as the author is aware, none has comprehended its full
meaning or importance.
22 MALOCCLUSION.
That we should have a line from which to note variations
from the normal in the positions of the teeth is important,
but that its meaning is deeper and that it has a far greater
significance to the student of orthodontia than above in-
dicated, the writer is fully convinced. In the sixth
edition of this work he used the term ‘‘the line of occlu-
sion” which he defined as being ‘‘the line of greatest
normal occlusal contact.” Yet after a much greater con-
sideration of the subject he believes that this definition,
though more nearly expressing the true condition than the
sterms previously employed, is still inadequate, and he
would now define it as being the line with which, in form
and position according to type, the teeth must be in har-
mony if in normal occlusion.
There can be, then, but one true line of occlusion, and
it must be the same as the architectural line on which the
dental apparatus was constructed. This ideal line was
intended to govern not only the length, breadth, and pecu-
liar curve of the dental arches, but the size and pattern of
each tooth, cusp, and inclined plane composing these
arches. And more than this: that as the dental apparatus
is only a part of the great structure—the human body—
each part and organ of which was fashioned according to
lines of design, it must have been intended that the line of
occlusion should be in harmony in form and position with,
and in proper relation to, all other parts of the great
structure, according to the inherited type of the individual.
Hence its majesty, and according to our conception of it
must be our ability to comprehend not only the art require-
ments in each case we treat, but as well must it govern
our conception of the requirements of the position of the
teeth in occlusion and the various operations in treatment.
The line of occlusion then, is more than the tangible or
material. It may be regarded as the basic ideal of the
dental apparatus, the comprehension and appreciation of
which will grow in proportion as our knowledge of the
science of occlusion unfolds.
OCCLUSION. 23
We may speak of moving a tooth of the lower arch into
the line of occlusion, or of moving a tooth of the upper
arch into the line of occlusion, but it must always be
remembered that there can be but one true line of occlusion,
or the line with which each tooth must be in perfect har-
mony if in normal occlusion.
This line describes more or less of a parabolic curve,
and varies within the limits of the normal, according
to the race, type, temperament, etc., of the individ-
ual. It is difficult to determine exactly what the form
of this line should be in each given case. We have already
seen with what great care Nature locates the first perma-
ment molars in this line, and by taking advantage of the
positions of these teeth, and of the diameters of the
incisors and canines, Dr. C. A. Hawley” has ingeniously
made use of the Bonwill law in order to determine the
proper form of the line of occlusion. Doubtless this
method of approximating the true line of occlusion may be
valuable, yet that the line may thus be accurately located
the author does not believe, for the reason that the form
of the line must be modified according to type, while follow-
ing this plan its form is governed by the diameter of the
six anterior teeth, which may accurately determine its
length, but cannot determine its curve. It seems to the
author that the best the orthodontist can do is to secure
normal relations of the teeth and correct general form of
the arch, leaving the finer adjustment to individual typal
form to be worked out by Nature through her forces which
must, in any event, finally triumph.
All teeth found out of harmony with the line of occlusion
may be said to occupy positions of malocclusion, and each
tooth may occupy any of seven malpositions or their
various deviations and possible combinations.
The malpositions of teeth consist principally in the
variation of the positions of their crowns from the normal,
* See Dental Cosmos, May, 1905.
24 MALOCCLUSION.
with usually little displacement of the apices of their roots,
so that they incline at an angle more or less oblique from
the normal. In some instances, however, there is some
displacement of the apices as well as of the crowns, they
having either developed in malpositions, or, as in most
instances, having been forced from their normal positions
by the eruption of more powerful teeth in juxtaposition,
as for example, the crowding lingually of the lateral in-
cisors by the development and eruption of the canines, as
in Fig. 320. Yet even in such cases the displacement is
not so great as appears, the malpositions of the crowns
magnifying this appearance.
Nomenclature.-A definite nomenclature is as necessary in
orthodontia as in anatomy. The vagueness of descriptive
terms often used renders them very inadequate. The
terms for describing the various malpositions should be
so precise as to convey at once a clear idea of the nature
of the malocclusion to be corrected. The author therefore
suggests the following, which, while perhaps not perfect,
still seems to be a great improvement on common usage.
For example, a tooth outside the line of occlusion may
be said to be in buccal or labial occlusion; when inside this
line, in lingual occlusion; if farther forward, or mesial,
than normal, in mesial occlusion; if in the opposite direc-
tion, in distal occlusion; if turned on its axis it would be in
torso-occlusion. Teeth not sufficiently elevated in their
sockets would be in infra-occlusion, and those that occupy
positions of too great elevation, in Supra-occlusion.
These different malpositions in their modifications and
combinations comprise the variations of all cases of mal-
occlusion, from the simplest to the most complex, in which
may be involved not only all of the teeth, but even the
jaws as well. These terms used in connection with the
author’s classification make possible the conveying of a
very complete picture of any given case of malocclusion
in very few words.
OCCLUSION. 25
Forces Governing Normal Occlusion.—The inclined planes of
the cusps of the teeth already in normal position play
an important part by directing the teeth that are erupting
to take their normal positions in the arch, but if their in-
fluence be perverted they may become mischievous factors
in the production of malocclusion.
When the teeth first emerge from the gums their con-
siderable displacement is often noticeable, but this need
occasion no uneasiness provided, as eruption progresses,
their cusps pass under the influence of normally placed
opposing cusps. But if they pass beyond this influence into
abnormal relations, they will not only be deflected from
their own proper positions, but may displace the opposing
teeth and those subsequently to erupt, as well, even to the
extent of the disarrangement of the entire thirty-two teeth,
as is possible from the mal-locking of the first permanent
molars. So there may be times when the dividing line be-
tween harmony and inharmony is very slight, hence the
importance of careful attention during the important
period covering the eruption of the permanent teeth, es-
pecially the beginnings.
Harmony between the complete upper and lower arches
is also powerfully promoted by their normal action and
reaction upon each other through the teeth. As the teeth
of the lower arch erupt before their antagonists of the
upper arch and are consequently to an extent fixed in their
positions before the latter appear, it follows that the lower
arch is the form over which the upper is molded. In other
Words, the lower arch exerts a modifying influence on the
form of the upper. Of course, the upper reacts upon the
lower, but it is unquestionable, in the author’s opinion,
that the lower arch is the more important factor in deter-
mining the form of the dental arches than the upper, as has
hitherto been taught.
From what has been said it may be readily seen how
greatly each arch contributes to the other in maintaining its
26 MALOCCLUSION.
form and size when the teeth are in normal occlusion, and
how pressure abnormally exerted on any tooth or teeth
would be resisted by all the other teeth. For example,
pressure exerted on the labial surfaces of the upper in-
cisors would be resisted not only by all the upper teeth
acting as blocks of stone do in an arch of masonry, but
also by the teeth of the lower arch acting through occlusion.
Inversely, then, one arch cannot be altered in shape
without modifying that of the other, nor can it be altered
FIG. 8.
in size without soon exercising a marked effect on the
other.
Harmony in the positions of the teeth and in the sizes
and relations of the arches is further assisted by another
force—namely, muscular pressure—the tongue acting upon
the inside, and the lips and cheeks upon the outside, of the
arches. The latter, if normal in development and function,
serve to keep the arches from spreading, as do hoops upon
the staves of a cask; the former prevent too great en-
croachment upon the oral space, and each, if normal in

OCCLUSION. 27
function, contributes in like proportion to the harmony
of balance. This muscular pressure is far more important
than is generally recognized.
Fig. 8 represents the teeth of a child aged eight years,
where the jaws and teeth are developing normally. It
will be noted that all of the permanent lower incisors have
erupted and occupy their normal space in the arch, com-
pelling the lower canines to occupy positions the requisite
distance apart. Of special importance is the influence that
these teeth exercise on the opposing deciduous canines
through their inclined planes, each blow that the upper
canines receive from the lower tending to widen the arch,
or at least to prevent it from becoming narrower through
the pressure of the lips.
So it will be seen that normal occlusion of the teeth is
maintained, first, by harmony in the sizes and relations
of the dental arches through the interdependence and
mutual support of the occlusal inclined planes of the teeth;
and second, by the influence of the muscles labially,
buccally, and lingually.
C H A P T E R II.
MALOCCLUSION.
Forces Governing Malocclusion.—In beginning the considera-
tion of malocclusion let us remember that it is but the per-
version of the normal in the growth and development
of the denture—the side-tracking, as it were, of Nature in
some of her normal processes of building, and we repeat,
that as a basis from which to determine its extent and
complexity we must have firmly fixed in our minds a
thorough knowledge of the normal denture complete and
its co-related parts.
We know that every case has a simple beginning in its
variation from the normal, and that very often a single
tooth, from slight cause, being deflected from the normal
may and usually does involve others. The dividing line,
then, between the normal and the abnormal in the begin-
ning is very slight, but always clearly defined, so the
normal in occlusion is the only logical basis for determin-
ing the variation therefrom and the extent of the abnormal
—malocclusion—and, as we shall see, the same forces that
contribute to maintaining the teeth in their normal posi-
tions and harmony in the sizes of the arches, are equally
powerful in maintaining inharmony in the sizes and rela-
tions of the arches and malocclusion of the teeth when once
established.
In a large percentage of cases of malocclusion the arches
^are more or less contracted, and as a result we find the
teeth crowded and overlapping. In these cases the lips
serve as constant and powerful factors in maintaining
this condition, usually acting with equal effect on both
arches, and effectually combating any influence of the
28
MALOCCLUSION. 29
tongue or any inherent tendency on the part of Nature
toward self-correction. In other words, the arches, nar-
rowed and diminished in size, are so maintained by force
from the lips, equal in power to that exerted for their
normal maintenance when of normal size and relation,
with the teeth in normal occlusion. Likewise each in-
clined plane of the cusps once out of harmony serves not
only to maintain the inharmony, but to increase it, upon
each closure of the jaw. It is interesting and instructive
to note the result of these forces even in very early indi-
cations of malocclusion.
FIG. 9.
*f;::::, ; , , , ,
# !
º
: º !
\
º
|
º
E. F. A
!
i
|
f
Fig. 9 illustrates a very common and familiar form of
developing malocclusion. The case is that of a child where
the four lower permanent incisors are fully erupted, but
one of them (the left lateral) has been deflected lingually,
Fig. 10. The arches being thus deprived of the wedging
and retaining influence of this tooth, the external pressure
of the lips has closed the space and diminished the size of
the arch. At the same time pressure, principally from the
lips and cheeks, aided by the occlusal planes of the lower
deciduous molars, is gradually molding the upper arch to
conform to the diminished size of the lower.
It will thus be seen how effectually the malocclusion will
| | }}}}}|{{!!}}. ſº
#|| | #
#| ||
: , ; ; , l; | #: | {H}. t #Hillie























30 MALOCCLUSION.
be maintained and how hopeless it is to expect Nature to
correct this deformity unaided. These same influences
may be traced in a similar manner in any case of maloc-
clusion. -
Recognizing the potency of these influences, it must be
apparent that cases of this kind, instead of being self-
corrective, will become more and more complicated as time
goes on and as each succeeding permanent tooth is erupted.
How absurd and unfortunate, then, is the common daily
FIG. 10.
advice from dentists to anxious parents to “let the teeth
alone and Nature will correct them unaided.”
In all such cases the positions of the erupting permanent
lower incisors should be guarded with zealous care, and
should be forced to take correct positions and be main-
tained therein, and thus assist in directing the teeth of the
opposing arch into correct relations and be compelled
to fulfill their important part in the full normal develop-
ment of the alveolar process. This is the golden oppor-
tunity for beginning intelligent interference for the pre-
vention of what might otherwise become complicated cases
of malocclusion. This also applies with equal force to any
other lower tooth that may erupt into abnormal position,
especially the lower first molars. Then, unless there be

MALOCCLUSION. 31
unusual tendencies toward malocclusion, the positions of
the teeth of the upper arch will be directed normally.
For the reason previously stated, if the teeth of the
lower arch be permitted to remain in malposition even
to the slightest overlapping of one or more of the incisors
or canines, the arch will be diminished in size just to that
extent, and as a result of pressure of the lips there will
be a corresponding contraction in the upper arch and some
form of bunching of the teeth.
* The influence of the lips in modifying the form of the
dental arches is an interesting study, and almost every
case of malocclusion offers some noticeable and varying
manifestation of it. In those cases where there is normal
occlusion of the teeth it will be noticed that the lips and
cheeks are also normal and perform their functions nor-
mally. The upper lip will be found to rest evenly in contact
with the gums and upper three-fourths of the labial
surfaces of the upper incisors, leaving, however, about
one-fourth of the occlusal ends of the central incisors and
laterals, and the points of the canines, to be covered by the
edge of the lower lip, so that normally there is a restraining
force exerted upon the upper incisors and canines by both
upper and lower lips. This force is exerted automatically
in response to almost every emotion, and results in main-
taining the teeth in harmony with the graceful and beau-
tiful curve of the normal individual arch.
In cases of malocclusion strikingly characteristic abnor-
malities in lip function are often noticeable, leading to the
Suspicion that more often than is recognized the peculiari-
ties of lip function may have been the cause of forcing the
teeth into the malpositions they occupy. The lack of the
requisite amount of pressure from the lip is strikingly
noticeable in the positions the incisors assume in cases
belonging to Division 1 of Class II, in which the upper
lip but partially performs its function, exércising little
restraining influence upon the labial surfaces of the upper
|
8
2
MALOCCLUSION.
incisors, the result being that these teeth move forward
and protrude in a more or less pronounced manner. In
these cases the over activity of the lower lip assists in
augmenting the protrusion, for in closing the lips the
inner edge of the lowerſ’ſs forced against the lingual sur-
faces of the upper incisors instead of their labial surfaces.
In cases belonging to Division 2 of Class II the upper lip
is found to be well-developed, exerting its full force upon
the upper incisors, and as we shall see, causing their
bunching and the lingual position of their crowns, and thus
establishing and maintaining a comparative harmony as
to the sizes of the two arches, though in abnormal rela-
tions. * *
The abnormally frequent contraction of the upper lip,
manifest in the cases of patients suffering from Snuffles,
forces the upper incisors more or less inwardly, produc-
ing an end-to-end bite and an abnormal wearing of the
cutting edges of the upper incisors. Doubtless, also, pecu-
liarities of disposition, and their manifestations in the
movements of the lips, in many instances so modify the
force exerted upon the teeth as to influence the form of the
dental arches.
Another striking instance of the lack of the requisite
amount of force exerted by the lips and cheeks upon the
external Surface of the arch is presented in certain cases
of patients suffering from cleft palate which involves the
intermaxillary bones and upper lip. The lateral halves
of the arch spread abnormally to a greater or less degree,
in some instances the teeth of the upper jaw closing com-
pletely outside those of the lower, as in Fig. 11.
Dr. Black reports a case in which a portion of the cheek
was lost from carcinoma. The normal external force being
thus released from the molars, they were forced outward
as a result of normal pressure of the tongue.
The result of pressure from the tongue in exerting force
upon the inside of the arch is also a factor, we are con-
MALOCCLUSION. 33
vinced, of great importance in determining the form of the
arches and the positions of the individual teeth. …
That when normal in size, tone, and function, itſexercises
a gentle force upon the inside of the arch, which is in per-
FIG. 11.
fect harmony with the force exerted by the muscles upon
the outside in maintaining the correct balance in muscular
influence upon the teeth, cannot be doubted; and so, it is
reasonable to suppose that when abnormal in size and
function, it may and does exert a modifying influence on
the size of the arches and positions of the teeth. As yet
We know very little as to the extent of this influence,
but we have many proofs of its existence.
That tongues vary considerably in size in different in-
dividuals is well known, yet owing to their peculiar mus-
cular arrangement and their variability in size and form
When being examined, it is difficult to study them accu-
rately. The author has seen instances of the arch being so

4
34
MALOCCLUSION.
'81 º 0101


MALOCCLUSION. 35
enlarged by the influence of the tongue as to create a space
between many of the teeth, as in the case shown in Figs. 12
and 13. He has also seen instances where the abnormally
narrow form of the arch seemed to him to be due to the
lack of proper size and activity of the tongue. It would be
interesting to know how the arches have been modified in
those rare cases where the tongue has been lost.
Classification of Malocclusion.—As we have seen, there are
seven distinct positions which teeth in malocclusion may
occupy, indicated by their deviation from the line of occlu-
sion. These different malpositions form combinations in
cases of malocclusion which are practically limitless in
their variations.
The same rule that holds good in the dissimilarity of
normal dentures is equally true of cases of malocclusion,
for not only do we find the same typal differences in forms,
sizes, color, etc., of the teeth, and in form and size of dental
arches, but we further find that, although the number of
cases is legion, in no two is the arrangement of teeth in
malocclusion just alike, even in those strikingly similar
cases of Division 1, Class II.
Yet notwithstanding this endless variation which has
led to endless confusion in diagnosis and treatment among
the old-school writers and practitioners, as we shall see all
cases of malocclusion fall naturally into a very few distinct
and easily recognized groups, or three great Classes, with
their Divisions and Subdivisions, and when so classified the
extent of the variation from the normal in each case is
easily comprehended and the requirements of treatment
made manifest. *.
These classes are based on the mesio-distal relations of
the teeth, dental arches, and jaws, which depend primarily
upon the positions mesio-distally assumed by the first per-
manent molars on their erupting and locking. Hence in
diagnosing cases of malocclusion we must consider, first,
the mesio-distal relations of the jaws and dental arches,
36 MALOCCLUSION.
as indicated by the relation of the lower first molars with
the upper first molars—the keys to occlusion; and second,
the positions of the individual teeth, carefully noting their
relations to the line of occlusion.
Class I is characterized by normal mesio-distal relations
of the jaws and dental arches, as indicated by the normal
locking on eruption of the first permanent molars, at least
in their mesio-distal relations, though one or more may be
in buccal or lingual occlusion. When the first permanent
molars erupt and lock in normal mesio-distal relations it
makes possible, as we have seen in our study of the normal,
the normal locking of each subsequent tooth that erupts,
and only under such conditions is this possible. But, as
we have also seen, even with a normal beginning, that is,
with normally occluded deciduous teeth, normally locked
first permanent molars, and jaws and dental arches normal
in their mesio-distal relations at the time of this locking,
Some one or more of the anterior permanent teeth, from
a great variety of causes, may be deflected from their
normal course, carrying with them to varying degrees both
approximating and antagonizing teeth until possibly they
may all be involved in malocclusion, yet without disturbing
the mesio-distal relations of the first molars, arches, or
jaws. -
In the average case the arches are more or less shortened
and reduced in size, with a corresponding crowding of the
incisors, as shown in Fig. 14.
It will be seen that the complicated malocclusion, illus-
trated in Figs. 15 and 16, also naturally belongs to this
large class. The first permanent molars have erupted and
locked in normal relations, the malocclusion being confined
principally to deviations from the line of occlusion of the
incisors and canines, the two arches being much shortened
from their full normal contour in front, especially the
upper, which is complicated by the procumbent lingual
impaction of the right upper canine. -
MALOCCLUSION. 37
Fig. 17 represents a less complicated and very common
form of malocclusion belonging to this class—the result
of the premature loss of the right upper deciduous canine
which has disturbed the normal process of development
of the denture. The upper incisors on the right side have
been forced by the lip to occupy positions lingual to the line
Fig. 14.
of occlusion, thereby compelling the right permanent
canine, upon its eruption, to occupy a position of much
labial prominence, but as the jaws and the molars are
normal as to their mesio-distal relations, the case is easily
diagnosed as belonging to this great class.
Fig. 18 illustrates what at this age of the patient is a
simple case belonging to this class, but which, if not treated,
must develop into one of complexity similar to the one
shown in Fig. 14.

"9I "ĐINHºg I *BIJI

MALOCCLUSION. 39
FIG. 17.
FIG. 18.


40 MIALOCCLUSION.
-
Figs. 19, 20, and 21 illustrate another case of pronounced
malocclusion in which the incisors, already in positions of
marked lingual and torsal occlusion, are being carried still
farther out of harmony with the line of occlusion by the
eruption of the canines. By noting the relations of the
FIG. 19.
first molars the case is easily distinguished as belonging
to this class.
Fig. 22 illustrates a rarer type of malocclusion belonging
to this class. Although the mesio-distal relations of the
jaws and first molars are normal, yet the lower first perma-
nent molar, as well as the deciduous lower molars and the
canine on the right side, have locked in buccal occlusion,
and thus is established the beginning of that pronounced
and complex type of deformities which, when fully devel-
oped, are characterized by the lateral displacement of the
mandible and twisting of the mouth, as illustrated in
Figs. 408 and 406.

MALOCCLUSION. 41
It must be borne in mind, however, that the condition of
buccal occlusion of the lower teeth is only an incident in
malocclusion and may also be found in cases belonging to
any other class.

42 MALOCCLUSION.
Fig. 23 shows another case in which all the teeth are
locked in malocclusion. The mesio-distal relations of the
FIG. 22.
jaws and first molars are normal (indicating the class to
which the case belongs), but the molars of both lateral
halves of the lower arch, together with the premolars and
FIG. 23.
===|º
-
º
–
canines, are locked in buccal occlusion, with much lingual
displacement of the upper molars, premolars, and canines.
All of the incisors are also involved.










MALOCCLUSION. 43
Fig. 24 shows a case where there is infra-occlusion of
both upper and lower incisors, with probably slight supra-
occlusion of the molars. Although these conditions may be
found in cases belonging to any class, yet the normal
FIG. 24.
mesio-distal relations of the molars place this case in this
class.
Fig. 25 shows still another variation in malocclusion
which also obviously belongs to Class I, as the first molars
and jaws are in normal mesio-distal relations. As the up-
per incisors are in marked labial positions, the case, if but
superficially examined, might easily be wrongly diagnosed,
as is often done with similar cases, as belonging to that dis-
tinctive and pronounced type of malocclusion, Division 1 of
Class II, the distinguishing characteristics and plan of
treatment of which are radically different.
We might give almost without number illustrations of
the various forms which teeth in malposition may assume
in cases belonging to this great class, for the variations
are limitless; yet they would all agree in the essential

44 MIALOCCLUSION.
characteristics, namely, normal mesio-distal relations of
the jaws and first permanent molars.
The effect of malocclusion upon the facial lines is always
to disturb their balance and harmony, and this in direct
proportion to the extent of the malocclusion. This phase
of the subject will be discussed at length in the chapter
on Facial Art, as well as in the chapters on Treatment.
Fig. 25.
Class II—When from any cause the lower first molars
lock distally to normal with the upper first molars on their
eruption to the extent of more than one-half the width of
one cusp on each side, it must necessarily follow that every
succeeding permanent tooth to erupt must also occlude
abnormally, all the lower teeth being forced into positions
of distal occlusion, thereby causing more or less retrusion,
or lack of development, or both, of the entire lower jaw.
This condition of distal occlusion is the determining char-
acteristic of this great Class, of which there are two
Divisions, each having a subdivision. The great difference
in the occlusion of the teeth in these two Divisions is man-
ifest in the positions of the incisors, the one being protrud-

MALOCCLUSION.
45
'13 "ĐIJI
'92 （ĐIJI

46 MALOCCLUSION.
ing and the other retruding, as shown in Figs. 26 and 27.
Each of these Divisions has a Subdivision.
Division 1 is characterized by distal occlusion of the teeth
of both lateral halves of the lower dental arches, the lower
molars having taken this position on their eruption and
locking; a narrowed upper arch, lengthened and protrud-
ing upper incisors, short and practically functionless upper
lip, lengthened lower incisors, and thickened lower lip
which rests cushion-like between the upper and lower in-
cisors, increasing the protrusion of the former and the
FIG. 28. FIG. 29.
retrusion of the latter. This form of malocclusion is
always accompanied and, at least in its early stages, ag-
gravated, if indeed not caused, by mouth-breathing due to
some form of nasal obstruction.
The occlusion of a typical, fully-developed case is shown
from the right and left sides in Figs. 28 and 29, where it
will be seen, by examining both lateral halves of the den-
tal arches, that all of the occlusal characteristics are mani-
fest. Not only are all of the lower teeth effectually locked
in distal occlusion in these cases, but the mandible is also

MALOCCLUSION. 47
distal in its relation to the maxilla and usually smaller than
normal. It is quite normal in form, although the compen-
sating curve of occlusion is greater than normal, due
principally to the elevation of the lower incisors from lack
of function, while in some instances the lower molars
occupy a plane lower than normal in the line of occlusion.
The upper arch is always abnormally lengthened and nar-
rowed, as shown in Fig. 30.
It seems unnecessary to add illustrations of other cases
belonging to this Division, as there is such remarkable
similarity between them, the malocclusion differing prin-
cipally in the degree of the prominence of the upper in-
cisors, and this depending largely upon the age of the
patient, all cases being progressive from the time of the
eruption and abnormal locking (into distal occlusion) of
the points of the cusps of the lower first permanent molars,
as shown in Figs. 31 and 32. -
The marring effect on the facial lines of cases belonging
to this Class are as constant, noticeable, and pronounced
as the degree and peculiarities of the malocclusion. Fig.
33 shows two faces typical of the inharmony of the facial
lines caused by this form of malocclusion. We shall, how-

48 MALOCCLUSION.
FIG. 31. FIG. 32.

MALOGCLUSION. 49
ever, discuss this phase of the subject more at length in
the chapters on Facial Art and Treatment.
Subdivision, Division 1 has the same characteristics as the
main division, except that the distal occlusion is unilateral,
as shown in Fig. 34. The lower left first permanent molar
on erupting has locked in normal mesio-distal relations, per-
tº 46s 46s
*46sº LEFT
mitting the premolars and canines on this side also to
assume normal relations on taking their positions in the
arches, while on the right side the lower first permanent
molar has erupted and locked in distal occlusion, thereby
compelling the lower premolars, canines and incisors also
to lock in distal occlusion, and necessitating the distal lock-
ing of the lower second and third molars on this side when
they erupt. The result of this malocclusion is inharmony

5
50 MALOCCLUSION.
in the relations of the dental arches to the extent of the
width of one premolar tooth.
The lines of the face are of course marred correspond-
ingly to the extent of the malocclusion, and in a manner
similar to the cases of the main division.
FIG. 35.
Division 2 is characterized specifically also by distal occlu-
sion of the teeth in both lateral halves of the lower dental
arch, indicated by the mesio-distal relations of the first
permanent molars, but with retrusion instead of protru-
sion of the upper incisors. In this division there are no
complications from pathological conditions of the nasal

MALOCCLUSION. 51
passages, hence the mouth is kept closed the normal
amount of time, and the lips perform their functions
normally, which causes the retrusion of the upper incisors
during their eruption until they come in contact with the
already retruded lower incisors, resulting in the crowding
of the upper teeth in the canine region. Such a case is
illustrated in Fig. 35. •
In cases belonging to this division there is much similar-
ity, although more variation than in the first division of
this class. The width of the arches is more nearly normal
and there is less abnormal elevation of the lower incisors,
probably on account of their better opportunity for per-
forming their function. There is usually an abnormal
overbite of the upper incisors, naturally resulting from
their being tipped downward and inward from their
normal outward incline, with the teeth of the lower arch
usually quite even and regular as to arrangement.
In the harmonizing of the anterior part of the upper
arch with that of the lower through lip pressure the mal-
arrangement of the incisors varies considerably, which,
not infrequently, however, assumes one of two different
and more or less constant types, as well illustrated in Figs.
27 and 35.
Naturally the marring effect on the facial lines, due to
malocclusion, in cases coming under this division is notice-
able and characteristic, as illustrated in Fig. 68, the re-
treating jaw and compressed upper lip alone often making
diagnosis easy.
Subdivision, Division 2 has the same characteristics as the
main Division except that one of the lateral halves of the
dental arches only is in distal occlusion, the other being
normal, as in the Subdivision of Division 1. A fully de-
veloped typical case of this kind is shown in Fig. 36. It
will be seen that the molars on the left side have, on
erupting, locked distally to normal, compelling a distal
locking of all the other lower molars and the premolars
52 MALOCCLUSION.
º
on this side, and the crowding and bunching of the incisors
and canines of the upper arch, thereby approximately
harmonizing the sizes of the two arches.
The effect of this form of malocclusion on the facial lines
is shown in Fig. 70.
FIG. 36.
Class III, Division 1 is characterized by mesial occlusion in
both lateral halves of the dental arches. The extent to
which the mesial occlusion must exist in order to place the
case in the division of this class is slightly more than one-
half the width of a single cusp on each side, as in Figs. 37
and 38, but in cases that have been allowed to develop—and
these cases are always progressive—the mesial occlusion
becomes greater, even to the full width of a molar, or more,
as in Figs. 39 and 40.
In cases belonging to this class the teeth in their respec-
tive arches vary from quite regular arrangement to con-

MALOCCLUSION. 53
siderable crowding, especially in the upper arch. There
is usually a lingual inclination of the lower incisors and
FIG. 37.
canines, which becomes more pronounced as the case pro-
gresses, and which is due to the pressure of the lower lip
in the effort to close the mouth and disguise the deformity.
FIG. 38.
Other characteristics are considered in the chapters on
Treatment.
In this class the marring of the facial lines is more
noticeable and unpleasing than in either of the other


54 MALOCCLUSION.
classes, in advanced cases amounting to a striking deform-
ity, as shown in Figs. 608 and 609.
Subdivision, Division 1 differs from the principal Division
only in degree, one of the lateral halves of the arch only
FIG. 39.
being in mesial occlusion, the other being normal, as shown
in Fig. 41, the arches crossing in the region of the incisors,
which often occasions much loss of their tissue by abra-
sion. -
That this classification will be found to embrace all cases
met with is more than probable. There still remains, how-
ever, one possible class, viz., where one of the lateral halves
of the lower arch is in mesial occlusion while the other is in
distal occlusion, but cases having these characteristics are
so very rare that further reference to them seems unneces-
sary, the writer having seen but two or three cases.
In diagnosing cases according to the above classification

MALOCCLUSION. 55
it will be seen that the occlusion of each of the lateral
halves of the arches is important, and must be considered
separately and with equally careful attention, always begin-
ning with the first permanent molars and assuming, for
FIG. 40.
the reasons previously given, that the uppers are in correct
position mesio-distally.
In developing cases of the second and third classes when
the teeth of the lower jaw have not locked into distal or
mesial occlusion the full width of a cusp on one or both
sides, the beginner may be a little puzzled as to the proper
classification, but upon careful inspection a majority of
the inclined planes will be found to favor one particular
Class, Division, or Subdivision, the co-relation of the first
molars being, of course, the most important factor, but the
other characteristics receiving due consideration.
The loss of a tooth or teeth by extraction is shortly

56 MALOCCLUSION.
followed by such marked changes in the positions of the
crowns of the remaining teeth as to sometimes render diag-
nosis more difficult. By the determination of the extent of
FIG. 41.
the tipping of teeth, due to this loss, the case is resolved
into its original condition, from which it can be easily
diagnosed.
It would be easy to imagine other groups into which
cases having similar characteristics in appearance might

MALOCCLUSION. 57
be assembled, which has been done recently to a confusing
number by some writers of the old school, who, basing
classification upon superficial symptoms instead of funda-
mental principles, have arranged cases in classes variously
named for one or other conspicuous symptoms, such as
“open bite,” “saddººshaped arch,” “V-shaped arch,”
“narrowed upperºrth on one side,” “narrowed upper
arch on both sides,’’ ‘‘prominent canines,’’ ‘‘inlocked
laterals,’’ ‘‘protruding upper incisors,” “retruding lower
incisors,” etc., etc. But such classifications are erroneous
and doubtless arose from a superficial study of one or
the other of the dental arches, without due consideration
of their relations, or of the dental apparatus as a whole
from the basis of normal occlusion, for these are not true
classes but usually only symptoms of causes and may be
an accompaniment of cases found in any of the true classes.
A brief recapitulation of the classification is here given
for convenience of study and for ready reference:
Class I–Arches in normal mesio-distal relations.
Class II-Lower arch distal to normal in its relation to
the upper arch.
DIVISION 1-Bilaterally distal, protruding upper in-
cisors. Primarily, at least, associated with
mouth-breathing. \ -
Subdivision.—Unilaterally distal, protruding upper
incisors. Primarily, at least, associated with
mouth-breathing. -
DIVISION 2.—Bilaterally distal, retruding upper in-
cisors. Normal breathers.
Subdivision.—Unilaterally distal, retruding upper
incisors. Normal breathers.
Class III.-Lower arch mesial to normal in its relation
to upper arch. \
DIVISION.—Bilaterally mesial.
Subdivision.—Unilaterally mesial.

58 MALOCCLUSION.
Out of several thousand cases of malocclusion examined,
the proportion per thousand belonging to each class was as
follows:
Class I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 692
Class II.
Division 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Subdivision . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Division 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Subdivision . . . . . . . . . . . . . . . . . . . . . . . . . 100
Class III.
Division . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Subdivision . . . . . . . . . . . . . . . . . . . . . . . . . 8
1000
A writer of a recent text-book, in making use of the
author’s classification, has abridged it by omitting to name
the Classes, Divisions, and Subdivisions, using only the
terms “unilaterally mesial or distal,’’ ‘‘bilaterally mesial
or distal,” etc. A moment’s reflection should convince any
thoughtful person of the grave error of such an incomplete
classification in treating of a subject involving such great
variations and complexities as malocclusion of the teeth,
for if a case is spoken of as simply in unilateral or bilateral
distal occlusion it would convey only a very imperfect de-
scription of its true condition, as under such a classifica-
tion it might belong to one or the other of a great group of
deformities whose general characteristics differ greatly in
other respects and call for widely differing plans of treat-
ment. In other words, it would not classify with any defi-
niteness and would necessitate a lengthy description in
order to convey to the listener’s mind its true condition;
while under the author’s classification if a case be spoken
of as belonging to a certain Class, Division, or Subdivision,
MALOCCLUSION. 59
there is at once created in the mind a quite perfect under-
standing of the case—not only the peculiarities of the oc-
clusion, and the relations of the jaws, but also the art rela-
tions, condition of the throat and nose, habits of the pa-
tient, etc., and nothing further is needed to complete the
picture except minor individual peculiarities.
C H A P T E R III.
FACIAL ART.
THE study of orthodontia is indissolubly connected with
that of art as related to the human face. The mouth is a
most potent factor in making or marring the beauty and
character of the face, and the form and beauty of the
mouth largely depend on the occlusal relations of the teeth.
Our duties as Orthodontists force upon us great respon-
sibilities, and there is nothing in which the student of
Orthodontia should be more keenly interested than in art
generally, and especially in its relations to the human face,
for each of his efforts, whether he realizes it or not, makes
for beauty or ugliness; for harmony or inharmony; for
perfection or deformity of the face. Hence it should be
one of his life studies.
As Orthodontists we must ever place foremost in im-
portance the normal occlusion of the teeth, for only in
normal occlusion is their greatest usefulness possible. But
many of our patients would never reach us were it not
for the inharmony of their facial lines resulting from mal-
occlusion, and if our efforts are intelligently directed we
can do far more to render plain or even distorted facial
lines pleasingly symmetrical, or even beautiful, than any-
one else who has to do with the human face. Indeed the im-
provement in the proportion and artistic effect which may
often be wrought by intelligent effort on the part of the
Orthodontist is marvelous and almost incredible, but his
efforts may also result in producing or enhancing ugliness
and deformity if unintelligently directed.
But that our efforts may be intelligently directed toward
the ideal, some rule, some principle, must guide us. If
60
FACIAL ART. 61
there be not some grand principle as a basis from which to
reason we must be but gropers in the dark—experimenters,
guessers, with results which may cause embarrassment or
even bitter regret.
We know that while all human faces are greatly alike,
yet that all differ. Lines and rules for their measurement
have ever been sought by artists, and many have been the
plans for determining some basic line or principle from
which to detect variations from the normal, but no line, no
measurement, admits of anything nearly like universal
application.
The beautiful face of the Apollo Belvidere has been
very largely used as a guide toward the ideal and from
which to judge variations, but this is impracticable and
misleading, for, notwithstanding the beautiful harmony
of proportions of that face, with its straight line touching
the frontal and mental eminences and the middle of the
wing of the nose, its range of application has been found
to be very limited in gaging the harmony or inharmony
of other faces.
And this is not surprising when we realize that the
Apollo face represents the ideal of the Greek type and the
Greek type only, and that we today see not only very few
faces of a purely Grecian type, but for that matter, very
few of any pure type, unless it be an occasional Roman.
In the early days artists dealt wholly with pure types,
as is unmistakably shown in their works that have come
down to us. In Grecian art, both painting and sculpture, the
faces all conform to the Apollo type, and the type was
constant because the blood of the people was pure, that is,
comparatively free from admixture with races of different
types. w
“The ideal of the Roman type, though markedly differ.
ent from the Grecian, was also closely followed by their
painters and Sculptors, and where types and religious
ideals were so distinctive and so closely adhered to there
62 MALOCCLUSION.
could be certain standards and laws to govern them,
especially in creative art; but to use the Grecian or the
Roman standard as a gage for the types of the present day,
especially in America, is impracticable, for our inheritance,
Our Occupations, our mental activities, our habits of
thought, our social and climatic conditions, etc., etc., differ
So radically, and all these play such vital part in the mold-
ing of the mental, moral and physical, as expressed in our
whole bodies and especially in our faces, that a standard
type is an impossibility. The tendency of modern civiliza-
tion seems to be to create a law for each individual, and in
the face of complex and constantly changing conditions a
fixed type as a basis or standard to govern the molding of
the human face cannot be established.”—(Wuerpel.)
This may all seem discouraging to the orthodontist, but
there is a principle, which if intelligently applied brings
us the nearest to an ideal result possible with each given
patient—that of balance, of symmetry. We should be able
to detect not whether the lines of the face conform to some
certain standard, but whether the features of each in-
dividual—that is, the forehead, the nose, the chin, the lips,
etc.—balance, harmonize, or whether they are out of bal-
ance, out of harmony, and what concerns us most as Ortho-
dontists: whether the mouth is in harmonious relations
with the other features, and if not, what is necessary to
establish its proper balance.
Now, the ability to determine the proper balance of the
features is rare. One of our foremost teachers of art, Mr.
E. H. Wuerpel, says that only one in two or three hundred
of even art students ever succeed in mastering it, and these
only after much observation and practice in sketching and
modeling the human face. Yet discouraging even as this
seems we believe there is a law for determining the best
balance of the features, or at least the best balance of the
mouth with the rest of the features, which artists probably
know nothing of, and one which for our work is far more
FACIAL ART. 63
unvarying and more reliable than even the judgment of the
favored few. It is, furthermore, a law so plain and so
simple that all can understand and apply it. It is that the
best balance, the best harmony, the best proportions of the
mouth in its relations to the other features require that
there shall be the full complement of teeth, and that each
tooth shall be made to occupy its normal position—normal
occlusion.”
The correctness of this rule will be better appreciated if
we will but remember that in those cases where Nature has
succeeded in building a normal denture—teeth in normal
occlusion—she has also succeeded in building it so as to be
in best harmony with the lines of the face, or, conversely,
the lines of the face to best harmonize with this denture,
and that the teeth in these cases are noticeable marks of
beauty. And as malocclusion is but the perversion of
normal occlusion, it invariably will be noticed that inhar-
mony in the balance of the mouth with the rest of the lines
of the face exists just in proportion to the extent of the
malocclusion.
This law may be regarded as one of the corner-stones .
of the new school of orthodontia in contradistinction to
the teaching that has always dominated the practice of the
old school—that of leaving to the individual judgment of
the operator, without any standard or law, the determina-
tion of the requirements in Orthodontic operations in each
given case.
To satisfy this individual judgment extraction was
often, and in complex cases always, resorted to. Its un-
fortunate and inartistic results may be seen in every com-
munity. It is gratifying to note, however, that this
fallacious teaching and pernicious practice are rapidly
passing and will doubtless soon become mere matters of
history.
*Angle, Items of Interest, September, 1903.
64 MALOCCLUSION.
* Fig. 42 shows the face of the Apollo. The face is a study
of symmetry and beauty of proportion in the fully de-
veloped nose and nostril, the full rounded, finely curved
lips, squarely chiseled chin, etc. Every feature is in bal-
ance with every other feature and all the lines are wholly
incompatible with mutilation or malocclusion.
Fig. 42.
Fig. 43 shows another face which is also one of much
beauty and fine proportions. It somewhat resembles the
Greek type and the lower half of the face shows lines which
could only have been molded over teeth normal in size, type,
number and position, and accompanied by normal condi-
tions of development, and normal nasal function. Had
but slight malocclusion existed, or had one tooth only been
sacrificed during the development of this face the effect

FA CIAL ART. 65
inevitably and unmistakably, to the experienced eye, would
have been felt in the marring of these beautiful lines.
When we thoughtfully consider all that enters into the
final production of a face beautiful in balance and pro-
portion, that is, how there must have been the normal
growth and development of the different peculiar bones
and muscles, the normal growth and functionating of nose
and throat, palate, tongue, lips, cheeks, and especially of
FIG. 43.
the teeth, upon which the lines of the mouth so largely
depend and which by slight deviation from the normal in
eruption of a single tooth, the whole system of occlusion
may be impaired, the wonder is not that they are so few,
but that they are not still more rare. Such perfect pro-
portions and such fine lines as are shown in this face are
rare indeed, but be the lines fine or otherwise the principle
will hold good, that the full complement of teeth in normal -
occlusion is essential to the proper typal proportions of
any face.

6
66 MIALOCCLUSION.
Fig. 44 shows a face greatly in contrast to those shown
before. It is neither purely Greek nor purely Roman in
type, but is a blending of the two, and yet it also is in fine
balance. The features are large and prominent and the
head is large, but there is harmony of size, relation and
proportion of features that makes a most pleasing whole.
The face, while in fine balance, is perhaps not beautiful
from a physical standpoint, but it is more. It is beautiful
from an intellectual standpoint, possessing strength, no-
FIG. 44.
bility, majesty, that in the author’s opinion, are lamentably
lacking in the Apollo face. Such fine contour and balance
are incompatible with malocclusion, either through mal-
position or loss of teeth.
Figs. 45 and 46 show the faces of two North American
Indians, vastly different in type, and yet how perfectly the
law of balance applies to these faces. It will be noted that
the mouths are in perfect balance with the rest of their
features, making certain that their dentures must have
been normal.

FACIAL ART. 67
Pig. 45.
3 |
- - - - in wº
ºr F tº º ºr C tº º
ºr tº " . . . . . . - º º
º

68
MALOCCI,USION.
FIG. 46.
-
L --
--
- - - - - - - nºt nºt
ſae
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，
：
T.
，
， ！
ſae
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FACIAL ART.
69
FIG. 47.

MALOCCLUSION.
FIG. 49.
FIG. 50.


FACIAL ART. 71
The same law of occlusal relations applies to all races
and tribes. Where teeth are missing how promptly it is
reflected in the contour of the mouth. How noticeable is
this in the intelligent, kindly, and well-known face shown
in Fig. 47.
It will be noticed in the case shown in Fig. 48 that there
is a depression below the wing of the nose which is due to
Fig. 51.
the lack of development of one lateral incisor, Fig. 49, and
if the reader will study the proportion of the lines of the
mouth with the other facial lines it will be very easy for
him to detect how marked is the inharmony resulting from
the loss of but this one diminutive tooth, and how greatly
the balance of the face would be improved by the restor-
ation of this tooth, its alveolus, etc. And this case is not
exceptional, but we insist that the violation of the law we
have laid down will in all cases, unless possibly in those of

72 MIALOCCLUSION.
freaks, be promptly reflected in the disturbed balance of
the features.
Figs. 50 and 51, and 52 show the faces of two normally
developing children, though it will be observed that they
are of strikingly different types. The proportions of the
faces, the balance of the features, and the harmonious lines
of the mouths tell as truthfully that the teeth are develop-
FIG. 52.
ing into normal occlusion as do the models of the teeth
themselves, shown in Figs. 53 and 54.
In these cases Nature has been able to work unhampered
by detrimental pathological conditions, as is apparent in
the results.
Of course it must be understood that changes in the con-
tour of these young faces must take place with further
development. The noses and chins will develop and become -
more pronounced, and after the eruption of the permanent
canines there will be more of an acute angle between the

FA CIAL AIRT. 73
nose and the upper lip, especially in the face shown in
Fig. 52. But the point we would emphasize is the normal
FIG. 53.
FIG. 54.
development of the mouths of these children, due to the
normal development of their dentures, and the consequent


74 MALOCCLUSION.
normal balance of the mouths in their relations to the other
features. And if we will notice any child so developing,
or any person who has reached maturity with the teeth
in normal occlusion, we will find an equal harmony of bal-
ance of the mouth with the other features, irrespective of
their individual types. Dr. Anema has well said that the
uniformity of harmony in the facial lines of young children
is probably due to the fact that their teeth (the deciduous)
are practically free from malocclusion.
The author would not be understood as intending to
imply that every face with lines and features in harmony
of balance must necessarily be beautiful, nor even that
placing maloccluded teeth in normal occlusion will estab-
lish harmony of balance of every face in its entirety.
. There may be other defects such as the lack of development
of the nose or chin, or unequal development of the two
malar bones, or of any of the bones of the face, etc. These
defects of course could not be remedied by the correction
of malocclusion, but the best harmony of such faces or
of any face is only possible when the teeth are in normal
occlusion. It is also the belief of the author that mal-
occlusion, and the loss of teeth by extraction or non-
eruption, or a combination of these two causes are respon-
sible for the lack of balance and inharmony in a far greater
number of faces than any other cause or combination of
causes, and that this inharmony and lack of balance of the
mouth must exist just in proportion to the degree of mal-
occlusion. *
For a true understanding of what is meant by harmony
of proportion and balance of faces, a careful study must
be made of faces that are out of balance, as well as of those
that are in balance. -
An interesting fact, which the author also believes to be
convincing proof of what has already been said relative to
harmony of facial lines depending upon harmony of occlu-
sion, is the wonderful harmony of facial types with the
FACIAL ART. 75
types or patterns of the teeth: how the broad and Squarish
type of tooth harmonizes with a similar type of face; how
the long and narrow type of tooth is found to accompany
a similar type of face; and our own belief is that the
sharpness of definition of the cusps and developmental
lines is in direct keeping with that of the facial lines, and
vice versa. The proof of Nature’s wonderful harmony of
the tooth patterns with the type of the individual may
be strikingly impressed upon anyone who will try to match
a tooth lost from a skull with teeth of other skulls.
Notwithstanding that the effect on the facial lines of the
varying forms of malocclusion found in the three different
classes varies not only with the degree of malocclusion, but
somewhat with the individual type of face, yet the facial de-
formity produced by the malocclusion in each class is so
distinctive and constant that after some practice the ortho-
dontist may even classify with considerable accuracy the
malocclusion of the people he meets without an actual ex-
amination of their teeth. So, also, the loss of teeth
produces such distinctive disturbance of the facial lines
as to make diagnosis from them alone often easy. One in-
terested soon finds himself making mental diagnoses of
malocclusion and classifying facial deformities whenever
and wherever he sees new faces.
In Class I, the jaws being normal as to mesio-distal
relations, the chin and nose will usually be found in rela-
tively normal balance with the forehead and general con-
tour of the face, with the lines of abnormality principally
confined to the mouth itself.
Figs. 55 and 56 show such a case in the profile and front
face of a boy fourteen years of age, and the lack of balance
in the flat and sunken lines of the mouth clearly indicate
diminished sizes of the dental arches. This lack of normal
contour of the mouth will be more impressive when it is
remembered that at this age a boy’s mouth should be rel-
atively more prominent than that of a man, for the reason
76 MALOCCLUSION.
that his face has not yet reached its full growth, while the
teeth are full sized at eruption. Upon reference, in Figs.
307, 308, and 309, to the excessive malocclusion, the reason
for this lack of normal contour becomes apparent. There
is very pronounced crowding of the teeth both upper and
lower, and as must naturally follow, lack in the develop-
ment of the alveolar process which is developed only to
accord with the positions of the teeth.
FIG. 55. FIG. 56.
How beautifully our rule applies—that is, the full com-
plement of teeth retained and each made to occupy its
normal position—is shown in Figs. 57 and 58, which repre-
sent the face of the same boy three years later. The
greatly improved contour of the face and restored balance
of the features will be observed. Even greater prominence
of the lips would improve the face still more, and this will
probably follow with further development of the alveolar
process which has been so long arrested. The corrected
occlusion is shown in Fig. 315.
Fig. 59 shows the profile of another boy, aged eleven,
whose facial lines were also thrown out of balance by
malocclusion (Class I). Again it will be noticed that the
chin and nose are in good harmony with the general con-
tour of the face and that the lack of balance is confined
to the mouth, and that in this case the lips, both upper and

FACIAL ART.
77


78 MALOCCLUSION.
lower, instead of being flat and sunken, as in the last case,
are too prominent. By referring to the malocclusion,
shown in Figs. 275 and 276, we see at once the reason. The
teeth instead of being bunched in the canine region and flat-
tened in front, are bunched, rotated, and prominent in
the incisor region. Another point will be noted in this
FIG. 59.
connection—that it is the unnatural position and prom-
inence of the upper teeth that causes the lower lip to pro-
trude. When the lips are closed naturally over teeth in
normal occlusion the lower lip rests against the labial
surface of the upper incisors (approximately the first
third), as has before been stated, and it is the upper teeth,
not the lower, that establish the curve of the lower lip.
In this case, however, there is also another reason why
the lips are so prominent, namely, that owing to the ex-
cessive overbite the space for the lips is too short for their

FACIAL ART. 79
natural closure, and when brought together they are pro-
truded unnaturally giving an expression as of pouting to
the mouth.
Figs. 282 and 283 show the occlusion after each tooth
had been normally placed, which also resulted in the length-
ening of the bite and the placing of the features in fine
balance, as shown in Fig. 60.
Fig. 60.
The disagreeable fulness and overprominence of the lips
has been reduced and instead we now have beautiful and
artistic curves in the lines of the mouth.
It seems unnecessary to give in this connection further
evidence of the trustworthiness and universal application
of our law, or rather, Nature's law, as we believe, in
cases belonging to this great class, as other instances will
be noted in the chapters on Treatment.
Figs. 61 and 62 show the profile and front views of the
face of a young girl whose malocclusion belongs to Divi-
sion 1, Class II, shown in Figs. 462 and 463, and the lines of

80 MIALOCCLUSION.
inharmony shown in this face are characteristic of all cases
FIG. 61. - FIG. 62.
FIG. 63.
of this division, and also of its subdivision, except that in
the latter they are usually less in degree.


FACIAL ART. 81
In cases belonging to the first Class, as we have seen,
the mouth is the only feature greatly out of harmony, but
since in the cases under consideration the mandible and
lower dental arches are distal to normal in their relations
with the upper, with consequent malocclusion of all of the
teeth, the mouth as well as all the lower part of the face is
involved and greatly out of harmony with the general con-
tour of the face. There are also other noticeable character-
istic points in the lack of balance or harmony in the facial
lines of patients belonging to this Division. As they are
mouth-breathers the face has usually a dull and listless ex-
pression, as illustrated in the face on the left in Fig. 67,
and the nose is usually undeveloped, with more or less
flattened alaº. As the upper arch is narrower than normal
and the incisors protruding, a corresponding inharmony
in the contour of the upper lip is noticeable, intensified by
its shortness and lack of function, and in connection with
the weak and receding chin is noticed the abnormal curve
and thickness of the lower lip.
These characteristics are quite constant and vary prin-
cipally in degree, but upon the whole, create lack of balance
of the features, and, in accordance with the rule laid down,
in direct proportion to the deviation from the normal in
the development of the dental apparatus.
The attempt to restore balance and harmony of propor-
tion to this face by placing all the teeth in normal occlusion,
as shown in Figs. 466 and 467, seemingly puts the rule to
a Severe test, but the result on the facial lines is shown in
Fig. 63, and while the face may still not be beautiful, or
perhaps even in perfect balance, that it is wonderfully im-
proved cannot be denied, and we believe that by no other
means could so perfect a balance have been established
to be in accordance with the demands of this pronounced
Semitic type.
Since we now have established normal relations of the
muscles and of the inclined planes of the teeth, and normal
7
ſ



FACIAL ART. 83
nasal respiration, the further development of this face
must be toward the normal—toward harmony of balance.
That such has occurred is shown in Figs. 64 and 65,
from photographs taken two years later than the picture
last shown.
Fig. 66.
In this connection let us note the great contrast between
the type of this face and that of the Apollo, in which the
profile line is straight. To have attempted to straighten
the profile line of this patient by sacrificing some of the
teeth and reducing the sizes of the dental arches would
have been to irreparably deform the face and to produce
lines of the mouth inartistic as incongruous and out of
keeping with the typal demands.
In this class of deformities there is occasionally noticed
a type of chin characterized by pronounced lack in the


84 MALOCCLUSION.
development of the mental eminence, which, since the chin
is already greatly receded on account of the diminished
size and distal position of the mandible, greatly augments
the inharmony of the facial lines, as will be seen in the
pronounced case illustrated in Fig. 66. Fortunately this
accompaniment is somewhat rare.
In cases belonging to the Subdivision of Division 1,
Class II, we notice a disturbance of the normal balance
of the mouth with the rest of the features similar in char-
acteristics to those of the main division, but usually less
FIG. 67.
in degree, as might be expected, since one of the lateral
halves of the dental arches only is in distal occlusion, the
other being normal. In these cases the chin is more nearly
in correct mesio-distal relation with the rest of the face,
and the author has yet to see a case belonging to this
subdivision accompanied by the type of chin illustrated
in Fig. 66.
The disturbance of the normal balance of facial lines
from malocclusion belonging to Division 2, Class II is
characteristic and quite uniform, and naturally follows the
receding mandible, distal occlusion, crowded and retruding
upper incisors, with normal development of lips, normal
breathing, etc. It is illustrated on the right of Fig. 67.


FACIAL ART. 85
and made more noticeable by contrasting with a typical
case belonging to Division 1, Class II, as shown on the
left of the same figure. Fig. 68 shows the profile of a
young man’s face which is fairly typical of these cases.
The malocclusion is shown in Figs. 534 and 535. It will be
seen that while the head is large and well-shaped, and the
forehead and nose strong and in good balance, there is a
weakness about the mouth and chin that is greatly out of
keeping with the general contour.
FIG. 68.
In treatment the rule was again applied and each tooth
made to occupy its normal position, with the most grat-
ifying result on the facial lines shown in Fig. 69. The
weak inharmonious lines have been changed to those of
strength and harmony of balance, in great contrast to what
must have resulted from extraction had it been resorted
to according to the old plan of treatment. The restored
normal occlusion is shown in Figs. 536 and 537.
The disfiguring effects on the face caused by malocclu-
sion in cases belonging to the Subdivision of Division 2
are similar to those just shown in the main division, but

86 MALOCCLUSION.
usually less in degree, as the teeth are in distal occlusion
only on one side, those on the opposite side being normal,
yet so marked is the lack of balance of the mouth with the
rest of the face in all of these cases that they are easily
recognizable in the weakness of the chin and pronounced
abnormal curve of the lower lip, as will be noticed in a
typical case shown in Fig. 70. In marked contrast are
these lines of inharmony with the same lines after treat-
ment, as shown in Fig. 71, the change resulting from the
FIG, 70. FIG. 71.
application of the law enunciated—the establishment of
normal occlusion.
Fig. 72 shows the profile of a girl, aged thirteen, whose
facial lines were thrown out of balance by reason of mal-
occlusion peculiar to Class III, as shown in Figs. 600 and
601. A very superficial study is sufficient to show the rea-
son for the flat upper lip and unnatural prominence and
heaviness of the chin and lower lip.
The correctness of the law is again proven by the result
produced on the facial lines, Fig. 73, through the establish-
ment of normal occlusion.
Although the inharmony in facial lines reaches its max-

FA CIAL ART. 87
imum in cases of malocclusion of this class, it will be
unnecessary to give more illustrations of it at this time
since they are always just alike in general characteristics,
varying only in the degree of the malocclusion, or the
mesial inharmony in the relation of the lower dental arch
to the upper, and of the mandible to the maxilla, and this
usually in proportion to the time which has elapsed in its
development from the beginning.
FIG. 72. Fig. 73.
Thus far we have considered the marring effect on the
facial lines from malocclusion of the teeth only; but the
loss of teeth through extraction or non-development is
another potent and all too common factor in disturbance of
the normal balance of the face, and it is a matter greatly
to be deplored that mutilation is still such common prac-
tice, even among some of the better class of dentists, and it
can be accounted for only by the lack of appreciation of the
laws of occlusion and their relation to facial art. So sat-
isfied is the author that the law herein enunciated is correct,
that before closing this chapter he wishes to make a proph-
ecy concerning it, namely, that its truthfulness will soon
be so well recognized that in the report of cases in works
like this, pictures of the faces of patients will not be re-
quired, it being well understood that if normal occlusion be
established the best possible balance will have been given to
the facial lines.

CHAP TER IV.
ETIOLOGY OF MALOCCLUSION.
A LONG period of time—twenty years or more—is re-
quired by Nature to complete the building of the human
denture, and during this time not only are all of the beau-
fiful and wonderful structures of the teeth and the rest
of the tissues of which the dental apparatus is composed
being unfolded in development, but all the other organs
and structures of the body are likewise passing through
the mysteries and marvels of growth, all, under normal
conditions, proceeding continuously and harmoniously
toward the final complete development of a normal, if not
a perfect, whole, that when completed each may best
perform its function—its allotted part in the work of the
whole.
Unfortunately these years during which Nature is thus
so greatly taxed in her normal processes of growth are
years prone to accident and especially to certain forms
of disease which interfere with her delicate work. It is
indeed very exceptional that she is permitted to complete
the growth of any human being without interferences more
or less serious. That she may and does frequently over-
come most or all obstacles is manifest in the many fine
specimens of young manhood and womanhood we see all
about us, but that she often in a greater or less degree fails
to react from the handicapping effect of disease or acci-
dent is also apparent. t
All parts of the anatomy are liable to abnormalities in
development, as medical literature bears abundant witness,
but that no one part is more frequently at variance with
the normal in its development than the dental apparatus
88
ETIOLOGY OF MALOCCLUSION. 89
is evinced by the fact that malocclusion of the teeth in
Some form is almost the rule rather than the exception.
We are able to better understand the reason of this when
we remember that the dental apparatus is not an organ
with but a single function, like the eye or the ear, but that
it is a very complex structure, with many functions, into
which enter not only the jaws, dental arches, and teeth,
but the muscles of mastication, the lips, tongue, nasal
passages, palate, and throat, and that in addition to the
function of mastication these are also concerned in the
vital function of respiration, and also in Speaking, singing,
whistling, laughing, crying, in short, in the expression
of all the various emotions. The different parts and com-
binations of parts entering into the performance of these
various functions and acts are so intimately associated that
even slight inharmony in the growth and development of
any one may ultimately involve the whole apparatus, in-
terfering with the normal functions of all, and even pro-
ducing repulsive deformities, for the influence of these
parts on each other is always continuous and progressive,
-—toward the maintenance of harmony and the normal if
normal, and toward the increase of inharmony and the
abnormal if abnormal.
The causes of malocclusion, then, to be intelligently
comprehended must be studied from the basis of the normal
growth of the denture and its co-related parts. Most of
the immediate causes are mechanical, yet whatever acts
as a hindrance to Nature in performing her delicate offices
in the unfolding of the various tissues composing the
dental apparatus during its growth, will be operative as a
cause in producing malocclusion.
In deciduous dentures we rarely find malocclusion, but
this is easily accounted for from the fact that the foods and
habits of the child are quite normal and very simple during
the eruption of the deciduous teeth. Neither do these teeth
meet with interference during their eruption from any
90 MALOCCLUSION.
remnants of a previous dentition, which are often such
disturbing factors to the placing of the permanent teeth.
Their cusps on eruption are well defined and their locking
such as to maintain themselves in normal occlusion and the
jaws in their harmonious relations, very important as the
development of the bones of the head and face progresses.
But as the teeth become comparatively flat from the wear-
ing away of their cusps as they approach the last period
of their existence, this restraining influence becomes
lessened, permitting such freedom in the relations of the
jaws to each other as may and doubtless does in many
instances lead to the beginning of abnormal locking of the
first permanent molars. -
Occasionally there is found malocclusion in the decid-
uous teeth themselves, usually slight, however, and con-
fined to the incisors, but sometimes extensive even to
involving the entire denture, and may be caused by forces
acting previously or subsequently to their eruption. These
we shall discuss later. Usually the irregularities are so
slight that it is rarely advisable to interfere for their cor-
rection, yet the deciduous teeth exercise such a marked
influence on the further growth and development of the
jaws and dental arches and the placing of their permanent
successors, and through these on the molding of the facial
lines, that they should always be objects of the keenest
interest to the orthodontist. The shedding of the decid-
uous teeth through the absorption of their roots being
physiological, it should take place normally and without
interference with the incoming of their successors, but if
the process is abnormal, as is often the case, they may
become fruitful causes of malocclusion of their successors.
Premature Loss of Deciduous Teeth.-Nature has designed
for the deciduous teeth not only the important function of
incising and masticating the food required by the child up
to the normal period of their loss and replacement by the
succeeding permanent teeth, but also that of assisting in a
ETIOLOGY OF MALOCCLUSION. 91
mechanical way in the development of the alveolar process,
and probably, the development of the jaw. -
The permanent teeth being larger and more numerous
than the deciduous, the greater space required by them is
provided by the broadening of the dental arches in the
region between the canines, and the lengthening of their
lateral halves posterior to the deciduous molars. This is
influenced largely by the development and eruption of the
permanent molars posterior to the deciduous molars. If
the mesio-distal diameters of the deciduous teeth be not
impaired by caries and the teeth remain the normal period,
the first permanent molar in taking its position in the arch
must force its way between the second deciduous molar and
the ramus of the jaw, if below, or the maxillary tuberosity,
if above.
Coincident with the growth of the jaws the deciduous
teeth are carried forward, and the normal mesio-distal
lengthening of the alveolar process takes place. If, how-
ever, one of the buccal deciduous teeth be prematurely lost,
as for example the lower first molar, the wedging influence
of the erupting first permanent molar will be felt only
distally to the lost tooth, and instead of the normal length-
ening of the lateral half of this arch through the pushing
forward of all the teeth, the second deciduous molar only
will be pushed forward to occupy a portion of the space
left vacant by the first deciduous molar. Thus this lateral
half of the dental arch will be shorter than normal and if,
meanwhile, no teeth have been lost on the same side of the
opposing arch the wedging force from the erupting upper
permanent molar will have carried forward the deciduous
teeth and lengthened the arch normally, whereupon there
will be inequality in the length of the lateral halves of the
arches on the affected side, with the establishment of
malocclusion. And this is not the only evil, for the space
occupied by the lost tooth having been greatly diminished,
or even closed, the eruption of the succeeding permanent
*:::::::...
92 MALOCCLUSION.
tooth (first premolar) will be prevented entirely, or the
tooth will be forced into buccal or possibly lingual occlu-
sion, as in Fig. 74. The shortened lateral half will not
develop and the lower arch will as a consequence be smaller
than normal, which must result either in protrusion of the
upper incisors, or in their irregular arrangement through
the effort of Nature by lip pressure to restore harmony
in the sizes of the two arches. Cases belonging to both
Fig. 74.
divisions and subdivisions of Class II are undoubtedly
often produced in this way, as will be hereinafter shown.
Results of the premature loss of the deciduous canines
may be seen in Figs. 352 and 367. While probably the
greatest harm results from the premature loss of the sec-
ond deciduous molar or canine in either arch, yet the prin-
ciple applies to the loss of any of the deciduous teeth, the
difference being only in degree.
The mechanical influence of the deciduous teeth in the
development of the dental arches is so important that they
should by all means not only be retained their full normal
period, but, if they become affected by caries, their full

ETIOLOGY OF MALOCCLUSION. 93
mesio-distal diameters should be restored by suitable fill-
ings after sufficient separation.
Likewise, if a deciduous tooth be lost through the pre-
mature absorption of its root, the full space Occupied by
it should be maintained by some suitable retaining device.
This may be easily and quickly effected by making Small
pits in the approximal surfaces of the teeth mesial and
distal to the space and inserting the ends of a section of
the wire G therein, after which the wire may be lengthened
by a few pinches of the regulating pliers to gain tension,
and, if necessary, needed space, as in Fig. 224.
Loss of Permanent Teeth.-What we have already said in
regard to the mechanical influence of the deciduous teeth
in assisting the normal development of the dental arches
and promotion of harmony of the facial lines is equally
applicable to the teeth of the permanent set up to the
period of their full eruption, or until the last of the molars
have taken their positions. This is a point of such impor-
tance that it should be carefully considered by all teachers
and students. If one or more of the permanent teeth
anterior to erupting molars be extracted, the wedging pro-
cess, so necessary in developing the arch, serves only to
close the space thus made, and there will be no carrying
forward of the teeth and alveolar process anterior to the
space, nor the consequent proper contouring of the face.
The evil effects already enumerated as arising from un-
equal development of the two arches will follow.
It should also be borne in mind that the interdependence
of the teeth is so great at all times that the loss of one or
more at any period of their history must have a marked
influence upon the remaining teeth. Each tooth is such an
important part of occlusion that its loss should be seriously
considered before deciding upon its removal. Occasionally
we hear of someone advocating the sacrifice of the first
permanent molar (one or more), as a prevention of or cure
for malocclusion. The author has yet to see a single case
94 MALOCCLUSION.
where the loss of this tooth has not been followed by mal-
occlusion, or aggravations of it if formerly existent, often
of a far-reaching and serious nature. The loss of no other
tooth is followed by so many and so marked evil effects.
Its size, position in the arch, and relations to the other
teeth are such as should entitle it to the greatest care with
a view to its longest possible preservation. If unavoidably
lost it should be immediately replaced by some form of
artificial substitute.
FIG. 75.
The author has seen several cases where all of the first
permanent molars had been extracted at about the age
of nine years, with a view of preventing development of
malocclusion of the incisors. The result was the shorten-
ing of both of the arches anterior to the spaces, thus
robbing the faces of their normal contours and producing
an undeveloped, sunken appearance about the mouths
similar to that of edentulous persons, while apparently
giving no relief to the crowded incisors. Such a case is
reported in the first chapter on Treatment.
Fig. 75 shows a case of malocclusion, the cause of which
was directly traceable to the unwarranted extraction of
several of the permanent teeth. The two lower first molars
were extracted at about the age of nine with the inevitable

ETIOLOGY OF MALOCCLUSION. 95
©
result. The wedging influence for continuing the normal
lengthening of the mandible being lost, the second and
third molars were tipped forward as they erupted, without
exerting any force in carrying forward the premolars,
incisors and canines, so there rapidly followed inharmony
as to the sizes of the two arches and the relations of the
remaining teeth. The removal of the main support of the
jaws caused the shortening of the bite and arrested the
normal lengthening of the face, and also forced the cutting
edges of the lower incisors against the disto-lingual in-
clines of the upper incisors, thus rapidly pushing them into
marked labial prominence, which, in turn, also tended
to force the mandible distally and further assisted in
arresting its normal development. This condition was
further intensified by pressure of the lower lip, which,
owing to the establishment of conditions favoring its
malposition and relation, rested habitually between the
upper and lower incisors.
Later followed the loss of other teeth by extraction,
which only augmented the untoward conditions already
enumerated, the result being the establishment of such
marked malocclusion as to make the dental apparatus al-
most useless, as well as causing a marked deformity of the
face, and this, too, with facial lines originally in fine har-
mony, and form and structure of teeth naturally much
above the average. Similar cases with like results are,
alas, only too common.
The evil effects arising from extraction of the upper
lateral incisors in order to provide space in the crowded
arch for the canines are so apparent that arguments
against the practice seem out of place in a modern text-
book. The abnormal appearance given the face in the
region of the nose consequent upon the diminished size
of the upper arch, together with the carnivorous appear-
ance of the mouth by the resultant prominence of the ca-
nines is as repulsive as it is inexcusable. -
96 MALOCCLUSION.
Still greater deformities are caused by the more inex-
cusable practice of sacrificing the permanent canines. The
face of a patient so deformed is shown in Fig. 76.
FIG. 76.
Indeed the enormous prevalence of the practice of ex-
traction of teeth by dentists of this and other countries
is a reflection upon the degree of their comprehension of
the science of dentistry. Radical reform in this respect
ought to be instituted. The trivial excuses often given by
men of high standing in dentistry for extraction of teeth
are amazing.
We have elsewhere pointed out the interdependence of
all the teeth, and the author would strongly insist that the
responsibility should not and does not end with the simple
extraction of a tooth for any cause, but that unless the
space of the sacrificed tooth be immediately supplied with
some suitable artificial substitute, malocclusion of the re-
maining teeth will follow.

ETIOLOGY OF MALOCCLUSION. 97
Imperfect Fillings, Crowns, etc.—The laws of occlusion are
not less binding on the dentist than on the orthodontist.
We have already noted that teeth are largely maintained
in their correct relations by reason of the forms of their
crowns, and, especially, the occlusal planes of the cusps.
and if in the restoration of lost portions of teeth by means
of fillings or crowns the demands of occlusion are ignored.
malocclusion must in some form follow. The author daily
FIG. 77.
From the collection of Dr. D. Willard Flint.
sees cases where imperfectly shaped fillings or crowns are
exercising a marked influence in causing or maintaining
malocclusion. Fig. 77 shows a case where complete distal
occlusion in one of the lateral halves of the arches has re-
sulted from a large filling in the first molar that was left in
the form of a flat inclined plane; and many illustrations
might be given where diminutive and very badly shaped
crowns have produced an equally disastrous effect. Some
of these are shown in the chapters on Treatment.

8
98 MALOCCLUSION.
Prolonged Retention of Deciduous Teeth. For reasons not yet
understood the normal process of absorption of the roots
of the deciduous teeth is sometimes delayed. In this event
the succeeding tooth will either be prevented from erupt-
ing, or it will be deflected into malocclusion. Deflection
may also be caused by even a small portion of the root.
Many cases of malocclusion belonging to Class I have their
beginnings in this way. Cases are occasionally met with
where the permanent canine has erupted between the
lateral incisor and deciduous canine. It is, however, more
commonly held in impaction, or deflected lingually as a
result of the non-absorption of the root of the deciduous
Canine. In rare instances a permanent successor is not
developed, for reasons as yet unknown. In such cases the
deciduous teeth usually remain much longer than the
normal period before being lost through the absorption of
their roots, which is of course desirable. They rarely,
however, last longer than the twenty-fifth year, the canine
being the most enduring. When the indications are clear,
however, that a deciduous tooth is actually interfering with
the eruption of its successor, it should be removed regard-
less of the time, as the correct placing of its successor is
of great importance. Usually, however, the absorption of
the one and the eruption of the other goes on simultane-
ously, though ofttimes considerably before or after the
time prescribed in our text-books. We would strongly cau-
tion against interference with the normal process by pre-
mature extraction in the desire to expedite matters.
Tardy Eruption of Permanent Teeth.—Occasionally a tooth,
with or without apparent cause, fails to erupt and remains
imbedded in the alveolar process for months, or even
years. Usually the space is partially or wholly closed
by the adjoining teeth. The impaction of the canine
is the most common of that of any of the teeth, since its
eruption is subsequent to that of both its mesial and distal
associates, so that in all cases it must meet more or less
ETIOLOGY OF MALOCCLUSION. 99
resistance from them. Later, if efforts toward eruption
occur and the space be closed the tooth must necessarily
be itself deflected or force other teeth into malposition.
It is quite probable that so-called “third dentitions” are
only instances of tardy eruption of some one or more of
the permanent teeth.
Supernumerary Teeth.-Supernumerary teeth, as their
name implies, are anomalies, or extra teeth above the
normal number of thirty-two. In outline they rarely re-
semble any of the typical tooth forms, being most com-
monly peg-shaped or conical. Although they may occur in
any part of the dental arches, or even nearly cover the
FIG. 78.
entire vault of the upper arch, as shown in a model in the
author’s collection and also in two or three other well-
known cases, their favorite location is between the central
incisors, as shown in Fig. 78 (from Dr. Ketcham's collec-
tion), in the region of the laterals, or in the bucco-em-
brasial spaces between the molars. The reason for their
appearance is not clearly established. It is now, however,
quite commonly attributed to atavism, or Nature’s effort
to re-establish original conditions. The typical number
of mammalian teeth is forty-four, man in his evolution
having lost four incisors and eight premolars. It is sup-
posed that these supernumeraries are some of these sup-
pressed teeth re-appearing in a rudimentary form.

100 M.A.LOCCILUSION.
These teeth frequently take their positions, especially in
the incisive region, just before the eruption of the per-
manent teeth, resulting in the deflection of erupting per-
manent teeth from their normal course.
Fig. 79 represents a model in the author’s collection in
which two supernumeraries are shown, one between the
centrals and the other distal to the canine and somewhat re-
sembling it. Another irregularity is also here shown in
that the right central is greatly oversized.
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These anomalies seem not to be uncommon as they
appear in almost every collection of models of the teeth.
Sometimes they remain imbedded in the alveolar process
and are revealed only by the probe or skiagraph. Fig. 80
shows a fine specimen of supernumeraries in a skull from
the collection of Dr. W. Booth Pearsall of London.
Transposed Teeth.--Though far more rare than super-
numeraries transposed teeth are also occasionally found,
and when occurring often offer perplexing problems in
treatment which cannot be dealt with according to rule, but
must be solved according to the exigencies of the case.
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ETI () LOGY OF MALOCCLUSION. 101
Fig. 81 shows a case, from a model in the collection of Dr.
Bosart, where the upper centrals and laterals are trans-
posed, and the author has had one case in which the lower
FIG. 80.
left canine and lateral incisor were almost completely
transposed. In treatment it seemed best to effect their
complete transposition. This was decided upon, however,
FIG. 81.
only after full consideration of the difficulties and dangers
attendant upon such extensive disturbance of the tissues
as would follow their normal placing.


102 MALOCCLUSION.
Disuse.-According to a well-known physiological law, the
use of an organ or muscle tends to stimulate its growth
and development, as illustrated in the well-known example
of the blacksmith’s arm, while disuse tends toward lack of
development, or even atrophy, as illustrated in the wings of
domestic fowls when contrasted with those of wild fowls.
The structure and history of the jaws and teeth show that
they were intended for much use. There can be little
FIG. 82.
doubt that the modern methods of food preparation tend
to such disuse of the jaws and teeth as to have a marked
general effect in causing malocclusion.
Fig. 82 shows an upper dental arch and teeth beautiful
in form and structure, with the vault of the arch also most
perfect. It is that of one of the ancient Hawaiians, and
it tells its own story of heredity and use. Let the reader
compare with this beautiful specimen, which illustrates the
harmony of growth and function, the cases of child den-
tures, so common in this country, where the deciduous teeth

ETIOLOGY OF MALOCCLUSION. 103
and the probably already erupted four first permanent
molars, together with the gums, are greatly diseased, ren-
dering normal use impossible, and this, too, at the im-
portant period when the denture should receive the stim-
ulus of full normal use, and he will have no difficulty in
understanding at least one of the important reasons why
modern dentures are so defective in size and in arrange-
ment of teeth.
Abnormal Frenum Labium—A somewhat common form of
malocclusion is distinguished by a space between the upper
central incisors, Fig. 83, and occasionally, though very
Fig. 83.
rarely, between the lower centrals. This space varies in
width, the distance being from one to four, and even five
millimeters, always presenting an unpleasing appearance
and interfering with speech in proportion to its width.
The cause of the deformity is abnormal development and
attachment of the frenum labium, which, instead of being
normal in size and ending in its attachment to the gum
about five millimeters above the gingiva, not only reaches
the gingiva, but passes directly between the teeth and is
attached to the likewise overdeveloped mesio-lingual tuft.
This strong fibrous ligament keeps the teeth separated, not
only by its passive presence, but as well by its action
mechanically, as may be easily proven by gently grasping

104. MALOCCLUSION.
the lip between the thumb and finger and moving it from
side to side in imitation of its normal movements.
At the time the author first described this cause of mal-
occlusion” it seemed to him probable that the abnormal
frenum might be due to an abnormal suture. This question,
however, has now, he thinks, been quite definitely settled
by Dr. Ketcham, of Denver, who has, during the past two
years, conducted an extensive and systematic study of this
Subject by means of the X-ray and the examination of
skulls in museums. He has made skiagraphs of both
normal and abnormal frena, and of twenty-six that were
normal, eight showed normal sutures and eighteen more
or less separation between the intermaxillary bones at the
median line. Of twenty-two that were abnormal, eight
showed perfect union of the alveolar process between the
central incisors, while fourteen showed greater or less
Separation. -
In the skulls examined he found about the same pro-
portion of normal and abnormal sutures.
Fig. 84 shows a normal frenum and normal suture. Fig.
85 shows a normal frenum and abnormal suture. Fig. 86
shows an abnormal frenum and normal suture, and Fig.
87 shows an abnormal frenum and abnormal suture.
Fig. 88 shows the skull of a primate in which there had
been an abnormal attachment of the frenum. The suture
was normal, but accompanied by a pronounced depres-
sion, probably for the better attachment of the frenum.
The conclusion of Dr. Ketcham is that the attachment of
the frenum, whether normal or abnormal, is in no wise
governed by the normality or abnormality of the suture.t
Habits.-The habits of sucking the thumb, lip, or tongue,
so frequently formed by young children, while rarely caus-
* Dental Cosmos, November 1899.
f See the excellent paper by Dr. Ketcham published in the transactions
of the First Annual Meeting of the Alumni Society of the Angle School of
Orthodontia. .
ETIOLOGY OF MALOCCLUSION. 105
FIG. 84. Fig. 85.

106 MALOCCLUSION.
ing displacement of the deciduous teeth, will, if persisted
in during the eruption of the permanent incisors, cause
marked malocclusion.
Fortunately the habit of thumb-sucking is usually
broken before any marked evil effects result, so that cases
where malocclusion has really resulted therefrom are rare
and easily recognized. The upper incisors and canines are
FIG. 89.
drawn forward and to one side, according as the thumb
of the right or left hand has been used, while pressure from
the back of the thumb upon the lower incisors causes their
displacement lingually. These cases are frequently con-
founded with those of protrusion belonging to Division 1
of Class II. The conditions and results, however, are very
different, the latter being mouth-breathers, the former
never, as such action would be a physical impossibility.
This is illustrated in the difficulty which infants experience

ETIOLOGY OF MALOCCLUSION. 107
in nursing while suffering from temporary obstruction of
the nasal passages resulting from colds.
The pernicious habit of biting the lower lip, or pressing
the occlusal edges of the upper incisors against its outer
Fig. 91.
surface, as in Fig. 89, will always, however slightly per-
sisted in, move the upper central incisors forward thus


108 - MALOCCLUSION.
lessening their natural resistance to the narrowing of the
lateral halves of the arch. The effect of this habit on the
occlusion is shown in the typical cases, Figs. 90 and 91.
This habit is more common than seems to be generally Sup-
posed, is often extremely difficult to overcome, and prob-
ably accounts for many ultimate failures in orthodontic
treatment. We know of nothing in orthodontia that causes
more annoyance and discouragement to the practitioner.
Often after long retention when he believes his work sat-
isfactorily completed, he finds the habit has never been
broken and that a few weeks have been sufficient to re-
establish the old conditions, or conditions even worse.
The habit is almost invariably a marked accompaniment
of cases belonging to Division 1 of Class II and its Sub-
division, and unless it be overcome and the normal func-
tions of the lips regained the incisors can never be kept in
their normal positions.
The habit of sucking the lower lip, though quite rare,
must, if persisted in, produce marked malocclusion. The
most repulsive deformity due to malocclusion that the
author has yet seen is that shown in Figs. 92 and 93, which
was caused by this habit. The upper lip was short and con-
tracted, the gums highly colored, and the lower lip was
larger than normal. The lower incisors inclined lingually
more than normal and rested in depressions they had
formed in the mucous membrane high in the vault of the
arch, as shown on the left in Fig. 94. The nose was amply
developed, with no indications of nasal obstructions.
Another habit, though more rare—that of resting the
tongue between the upper and lower incisors, or frequently
protruding it more or less—produces the effect shown in
Fig. 95. The pressure upon the incisal edge prevents full
eruption and holds the teeth in infra-occlusion, while the
molars, being held apart much of the time, lengthen into
positions of supra-occlusion from lack of resistance.
It will be found, however, that there are as many vari.
ETIOLOGY OF MALOCCLUSION.
109

110
MALOCCLUSION.
ºf6
"ĐIJI

ETIOLOGY OF MALOCCLUSION. 111
ations in the habit as there are cases met with, with result-
ant corresponding variations in the malocclusion. The
difficulty of breaking the habit is even greater than that of
overcoming the pernicious lip habits, resting, as it does,
almost wholly with the patient and very few having suffi-
cient character and persistence to overcome it.
With our present knowledge of orthodontia these cases
are the most difficult to treat successfully. The orthodon-
tist should be thoroughly conversant with their peculiar-
ities, and with the obstacles to be overcome in their treat-
Fig. 95.
ment, before beginning which he should have a complete
understanding with the patient and his parents as to the
responsibilities of both.
Nasal Obstructions.”—Of all the various causes of mal-
occlusion mouth-breathing is the most potent, constant, and
varied in its results. It is most prevalent between the ages
* See the excellent article by Dr. W. J. Brady in the Transactions of the
American Society of Orthodontists, 1902, from which we have here freely
drawn, with Dr. Brady's permission.

112 MIALOCCLUS).() N.
of three and fourteen years, or during the most important
period in the growth of the dental apparatus, and is oper-
ative indirectly upon the teeth by causing asymmetrical
development of the muscles, as well as of the bones of
the nose and jaws, and derangement in the functions of the
lips, cheeks, and tongue, while the extent of the general
derangement is manifest in proportion to the degree of
mouth-breathing and the time it has been practiced. Al-
though it may be lessened or discontinued at the age of
puberty, its evil effects may last through life.
In normal breathing an ample amount of air for the
needs of the child enters the nasal passages to be warmed,
moistened, and strained of impurities on its way to the
lungs, where it must give oxygen to the blood. The air
while passing through the nose contributes by its presence
and temperature to the health of the mucous membrane
covering the walls of the nose, the turbinated bones, and
frontal, ethmoidal, and maxillary sinuses. Yet it in no way
interferes with the delicate balance of pressure between
the tongue on the inside and the lips and cheeks on the
outside of the dental arches, but allows the normal closure
of the mouth and permits the jaws and inclined occlusal
planes of the teeth to act for their mutual maintenance in
their harmonious relations. Thus function and growth are
undisturbed.
If, however, the necessity for mouth-breathing becomes
established, all of the beautiful harmony of balance in
growth and functions of parts is seriously disturbed, with
derangement certain. The air is received directly into the
lungs without being cleansed, warmed and moistened. As a
result of this imperfect preparation the lungs receive it in
insufficient quantities to fully oxygenate the blood, the child
becomes pale, anemic, listless, and deficient in size and
weight. The lungs lack normal expansion, and the child
often becomes flat-chested. Thus weakened, a predisposi-
tion to pulmonary and other diseases is established.
ETIOLOGY OF MALOCCLUSION. 113
The baneful effects of mouth-breathing are always mani-
fest in the face. The nose is small, short, with wings
flattened; the cheeks pale and more or less Sunken; the
mouth is held open almost constantly; the upper lip is
short and drawn up in the effort to breathe and fails to de-
velop; the mandible is drawn back and also fails to develop,
being almost always smaller than normal, although usually
regular in form; the upper arch becomes narrower than
normal, and is usually lengthened, probably largely the
result of unequal pressure from the muscles. Normally,
with the mouth closed, the tongue rests in contact with
the vault of the upper arch and the upper teeth, exercising
no inconsiderable influence in molding the vault of the
arch and maintaining its width.”
As we have seen, the balance of pressure between it and
the external muscles is equal, while with the mouth held
open, as is necessary in mouth-breathing, this balance is
disturbed, more than the normal amount of pressure being
exerted on the outside from the muscles of the cheeks
which are on slight tension, and little or none being given
by the tongue on the inside, it being made to rest between
the lateral halves of the lower arch, which probably ac-
counts for the fact that in these cases the lower arch is
rarely narrower than normal.
The causes of mouth-breathing are many, but are always
pathological, and are manifest in the posterior, middle, or
anterior nares, or in all at the same time. A thorough
discussion of the etiology and pathology is clearly not
within the scope of this work, but more properly belongs
to works on the science of rhinology, to which we would
refer the reader, and especially to that by Kyle. Yet it
will not be amiss to here consider briefly and in a general
way some of the more common causes of mouth-breathing.
*J. Sim Wallace, D.Sc., M.D., L.D.S., in his “Essay on the Irregular-
ities of the Teeth” has given this subject much thought. The work is worthy
of most careful reading.
9
114 MALOCCLUSION.
The mucous membrane which lines the nasal cavity is
very extensive, covering as it does, all of the cartilage and
surfaces of the bones forming the nasal tract, as well as
extending into and forming the lining of the frontal, eth-
moidal, and maxillary sinuses. Now anything that will
act as an irritant to this membrane sufficient to produce
engorgement of the bloodvessels with which it is very
richly supplied, and consequent thickening of the mem-
brane, will restrict the normal size of the nasal passages,
thereby obstructing nasal breathing and necessitating in
a corresponding degree a resort to mouth-breathing. This
congestion of the membrane may be but temporary, as
when caused by slight coryza necessitating partial or com-
plete mouth-breathing for a few days only, and then pass
entirely away; or the congestion may take on a chronic
form, more or less continuously obstructing the nasal pas-
sages and causing chronic mouth-breathing, as in chronic
hypertrophic rhinitis, or atrophic rhinitis with polypi,
which growths may completely close the nasal passages.
Whatever form the inflammation of the mucous mem-
brane assumes, if protracted in youth, it will seriously
interfere with normal growth and development of the
bones over which this membrane extends, and indirectly
interfere with the growth of other bones causing
asymmetrical development, so it is common to find
more or less malformation of the septum, with de-
flections, depressions, bony or cartilaginous enlargements.
From like cause we will commonly find great vari-
ations from the normal in the turbinated bones, character-
ized by atrophic conditions, prolongations and enlarge-
ments. The floor of the nose may become modified from
the same cause, resulting in abnormal shape and probably
height of the palatine arch, as well as abnormal form of the
dental arch. The arrest in the development of the bones
in the intermaxillary region, causing crowding of the in-
cisors, so common in Class I, is in many instances directly
ETIOLOGY OF MALOCCLUSION. 115
traceable to pathological conditions of the middle or an-
terior nares. From the same cause the normal form and
size of any of the sinuses tributary to the nasal cavity
may be and doubtless are often modified and contribute
to the impairment of the voice.
But a result far more common is hypertrophy of the pha-
ryngeal tonsil, usually called adenoid vegetation or simply
adenoids. This especially interests the orthodontist on ac-
count of the marked and certain malocclusion resulting
therefrom. It is distinctively a trouble of childhood and
is most active during the growth and development of the
denture, beginning at about the age of three years, or
even earlier, and, for reasons not known, usually termin-
ating in atrophy at about the age of puberty, although in
some instances continuing much later in life.
Malocclusion when resulting from adenoids alone is
usually distinctive in that the upper arch is narrowed and
lengthened, with little or no crowding of the teeth, but with
bilateral or unilateral distal occlusion.
As the evil effects of mouth-breathing are so pronounced,
how important it becomes that it should have thorough
and prompt attention from the most skilful rhinologist
only, and that normal nasal respiration be established,
otherwise the work of the orthodontist must be futile. On
the other hand, how utterly useless is it for the rhinologist
to treat the nasal air passages without the co-operation of
the competent orthodontist, so that the teeth, jaws, and
lips may functionate normally, making possible the normal
closure of the mouth the requisite amount of time. The
work of the rhinologist and the orthodontist should, then,
go hand in hand, for each is equally dependent upon the
other. -
It is easy to understand the beginning of malocclusion
of the teeth in this class of cases, and the various stages
are readily followed. At the time of the eruption and
locking of the first permanent molars which marks the
116 MALOCCLUSION.
true beginning, the conditions for the mal-locking of these
teeth is most favorable. The occlusal surfaces of the
crowns of the deciduous teeth are comparatively flat, their
cusps having largely disappeared through natural wear so
that they can no longer exercise much control over the
proper relations of the jaws when closed. The mandible,
instead of being held forward by the cusps in their locking,
is allowed to close more or less distally to normal. This dis-
tal movement of the mandible is further made easy by the
as yet shallow and imperfectly developed glenoid fossa,
permitting the condyle of the mandible much freedom of
movement.” So, as the first permanent molars erupt and
the cusps feel their way into occlusion, the lower molars
may easily lock in distal occlusion,-not always in full dis-
tal occlusion at once, for very often only the minute points
of the cusps touch for some time as if hesitating as to
which side of the planes of the cusps they will follow.f
Probably only a few hours in many cases decides the po-
sition they will ultimately assume, whether it shall be nor-
mal or abnormal, but when once established their course is
progressive until their full normal or distal occlusion ulti-
mately takes place. -
In some instances the molars in only one of the lateral
halves succeed in locking in normal occlusion, while those
of the other lock in distal occlusion. This is easily under-
stood when we remember that the eruption of the teeth in
the two lateral halves of the dental arches rarely proceeds
simultaneously, those on the side of the greatest functional
activity being in advance of the others weeks or even
months.
* Angle, “The Upper First Permanent Molar As The Basis of Diagnosis.”
Read before the American Society of Orthodontists, Sept. 28, 1905. Published
in the Items of Interest, June 1906.
# Angle, “Some Basic Principles in Orthodontia.” New York Institute of
Stomatology, Oct. 7, 1902. Published in the International Dental Journal,
Oct. 1903.
ETIOLOGY OF MIAI, OCCLUSION. 117
Asymmetrical locking of the molars is further explained
by the fact that climatic changes and systemic conditions
favor mouth-breathing at different periods of their erup-
tion. The fact that mouth-breathing is but temporary in
many cases and can therefore exert a pernicious influence
in the locking of the molars but a part of the time, may,
it is believed, account for the beginnings of malocclusion
in some cases of the second division of Class II, as well as
its subdivision. Mouth-breathing may continue only long
enough to wrongly divert the points of the cusps of the
molars, thus establishing their ultimate complete distal
Occlusion, when normal breathing may be resumed as the
result of treatment, change of climate, or be overcome by
more normal systemic changes; and as normal breathing
and normal lip functions become re-established all of the
characteristics peculiar to this division would naturally
follow in development. The majority of such cases are,
however, in the author’s opinion directly traceable to the
premature loss of the upper first or second deciduous
molars, or even of the teeth anterior, as may be often noted.
Although many cases of mouth-breathing are found in
Class I, some of them may be accounted for, as Dr. McKay
has suggested, by the fact that mouth-breathing may have
developed in them subsequently to the eruption and normal
locking of the first permanent molars.
In conclusion, the author would not be understood as
implying that he believes he has exhausted this subject.
On the contrary, he feels as all students of the subject must
feel—that there is much concerning the etiology of mal-
occlusion that is as yet unknown.
C H A P T E R V.
ALVEOLAR PROCESS AND PERIDENTAL MEMBRAINE.
BEFORE entering upon a consideration of tooth move-
ments in the correction of malocclusion it will be necessary
to consider in a general way the alveolar process and
peridental membrane, as their comprehension is more es-
sential in orthodontia than in any other branch of den-
tistry, in fact, it is only secondary in importance to the teeth
themselves, and it is through our intelligent management
of these tissues that we are enabled to successfully correct
inharmonious positions of the teeth.
The alveolar process, Fig. 96 is that portion of the
maxillary bones formed for the reception and support
of the roots of the teeth. It seems to be wholly subservient
to the uses of the teeth, as it does not appear before their
eruption, and slowly disappears by absorption after their
removal. It conforms to whatever position the teeth ar-
range themselves in, regardless of regularity, so that if
tooth movement be undertaken at the proper age an arch
greatly diminished in size through crowding of the teeth
may be much enlarged and the alveolar process will become
rearranged to conform to the requirements of the roots of
the teeth in their new positions. The peculiarities of the
tissues involved and the richness of their vascular supply
admit of their considerable disturbance with a very reason-
able assurance that Nature will completely restore them,
provided tooth movements be properly conducted.
The alveolar process has an external and an internal
plate. The outer plate forms the external surface of the
bone. The inner plate forms the alveoli or sockets of the
teeth, and though quite loosely formed about the teeth
during their eruption and for some time thereafter thus
118
ALVEOLAR PROCESS AND PERIDENTAL MEMBERANE. 119
permitting their considerable movement, gradually with
advancing age it becomes diminished in size and fits the
roots and necks of the teeth more closely thereby greatly
limiting tooth movement without displacement of the
process.
FIG. 96.
Cryer.
The structure of both plates is quite compact, but is
freely perforated by minute openings for the transmission
of nutrient vessels. Between the external and internal
plates the bone is far less compact, being very cancellous
and similar to the internal structure of the larger bones.
This cancellated structure, Fig. 97, admits of considerable
bending of the process without breaking, especially in the
case of young patients. But as age advances the bone
becomes more dense and unyielding.

120 MALOCCLUSION.
In health the alveolar process surrounds the roots of the
teeth to nearly the height of the gingival line. The thick-
ness of the process on both the labial and lingual surfaces
varies greatly over different portions of the roots and in
different individuals, but in each case the distribution is
FIG. 97.
Cryer.
such as to best resist the strain upon the teeth incident to
mastication.
It is usually very thinly distributed over the labial sur-
faces of the roots of the upper incisors and canines and
upper third of the premolars and molars, always present-
ing more or less of a fluted appearance (very noticeable in
carefully made models) which is readily detected by pres-


ALVEOLAR PROCESS AND PERIDENTAL MEMBBANE. 121
sure of the finger, enabling us to trace quite accurately the
exact positions of the roots of these teeth, as shown in
Fig. 98.
Fig. 98.
Broomell.
The process at its immediate margin is thin, but abruptly
thickens on the buccal surfaces of the upper molars and
premolars amounting to a well-defined ridge fully one-
eighth of an inch in thickness in some instances, then grow-
ing very thin as the apical third of the root is approached,
portions of the roots being sometimes wholly uncovered.
On the lingual surface of the upper teeth it is also very
thin at the margin, gradually and evenly thickening toward
the ends of the roots, and forming the curve of the vault
of the arch. That portion, however, covering the roots of
the second and third molars assumes quite a uniform
thickness in order to form the groove and fossa for the
posterior palatine artery.
That portion covering the buccal roots of the lower teeth
is thin at the margin, gradually and evenly becoming
thicker toward the center of the body of the jaw to form
the external oblique ridge, while the labial plate covering
the roots of the incisors and canines is thickest near the
margin, the remainder being very thin and sometimes

122 MIALOCCLUSION.
even missing in portions especially if the root be markedly
prominent.
Its distribution over the lingual surface of the roots
of the lower teeth is thin at the margin, gradually thick-
ening toward the mylo-hyoidian ridge.
Strongly adherent to, and closely covering, the external
plate of the alveolar process is the periosteum, which in a
modified form dips down into the alveoli to form the peri-
dental membrane.
Peridental Membrane.—The peridental membrane is a
strong, fibrous membrane forming a close, cushion-like in-
vestment of the roots of the teeth, and is the medium of
attachment between the alveolar process and cementum.
It is composed largely of fibers of inelastic connective
tissue, and is richly supplied with nutrient vessels, nerves,
cells, and glands. Its function is three-fold:
First, vital, for the formation of the alveolar process
On one side and the cementum on the other. l
Second, sensory, through which the most delicate touch
of the tooth is felt.
Third, physical, holding the tooth in position in the alve-
olar socket and resisting the movements of the teeth in the
various directions. It also supports the soft tissues about
the teeth.
Cells.-There are five kinds of cells found in the peri-
dental membrane:
First, the fibroblasts, for formation of fibers of the
membrane. These are spindle-shaped cells lying between
the fibers. -
Second, osteoblasts. These are cuboidal cells for for-
mation of the alveolar process, and are found close to the
layer of bone or imbedded therein. -
Third, cementoblasts, or formative cells of the cemen-
tum. These flattened and irregular cells are in close con-
tact with the surface of, and imbedded in, the cementum.
Fourth, osteoclasts, or cells whose function it is to dis-
ALVEOLAR PROCESS AND PERIDENTAL MEMBRAINE. 123
integrate calcified tissue, and which vary greatly in num-
bers and location. -
Fifth, glands, the function of which is as yet imperfectly
understood.
Arrangement of Fibers.-The arrangement of the fibers of
the peridental membrane is very complex. More than a
general description is here impossible. The course which
the fibers take varies greatly in different portions of the
root. Figs. 99 and 100 show a longitudinal section of the
tooth, membrane, alveolar process, and gum, which will
give a general idea of the arrangement of these fibers.
It will be seen that those about the neck of the tooth
pass outward more or less at right angles, some blending
with the gum, other branches curving up to support the
gingiva, while others blend with those at the beginning
of the alveolar process. Still others anastomose with those
from the gingival portion of the adjoining teeth, forming
a tough ligament known as the dental ligament.
The manner of attachment of the fibers to the alveolar
process at its beginning is noteworthy. Not only are they
united to it at points nearest the cementum, but some are
attached at the top of the bone, while others pass over to
form a union with the alveolar process on its outer surface
(well shown in the microscopical section illustrated in Fig.
100), thus making the strongest possible attachment for
the resistance of strain.
At the beginning of the alveolar, process, and a little
below, the fibers are at right angles to the long axis of the
tooth. They soon, however, begin to incline, and a little
farther down their course is oblique until near the apex of
the root. These serve to suspend the tooth in its socket.
We will call them the suspensory fibers. As we near the
apex of the root the fibers again assume a direction more
or less horizontal, while at the apex their course is at right
angles with the surface. -
Fig. 101 shows a transverse section of the alveolar por-
124
MALOCCLUSION.
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The thinness of the labial
(Noyes.)
tion, in which the general arrangement of the fibers from
al section of an incisor of a kitten with crypt
of permanent tooth. . The labial is to the right and the lingual to the left.
g of a longitudin
A drawin
The bone is represented in the light stippling.
plate of the process is shown, with the periosteum and the muscle attached.
The lingual plate of the bone is much thicker.
this aspect is well shown, and it will be seen that some of
the bundles of fibers pass out from the cementum at right








































ALVEOLAR PROCESS AND PERIDENTAL MEMBRANE. 125
.
-
-
-
Longitudinal section of the peridental membrane, showing the gingival
and upper third of the alveolar portion.
B, dentin, showing the light band at the outer border. C, cementum,
showing at the occlusal extremity a thickening where the fibers which
pass up to support the gingivae are attached. D, bone of the alveolar process.
The short, strong fibers which support the tooth against lateral strain are
seen stretching from the cementum to the bone. A blood vessel cut lon-
gitudinally is seen crossing these fibers. (Noyes.)

126 MALOCCLUSION.
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Drawing of a transverse section of the peridental membrane in the upper
third of the alveolar portion, showing the thickness of the labial plate, with
periosteum and muscle attached, and the fibers resisting rotation.
The tooth shows two layers of cementum. The bone is represented by the
lighter stippled part, which shows its spongy character. On the mesial
side (to the left) the septum is not complete and the fibers pass to the distal
of the incisor, which is not shown. The labial plate of bone (above) is very
thin, and shows the periosteum with its two layers and the muscle attached
to it. (Noyes.)






















ALVEOLAR PROCESS AND PERIDENTAL MEMBRANE. 127
angles to its surface and pursue the shortest course to
the alveolar process, while other bundles are sent out at
different angles and cross on their way to the alveolar
process. Others still curve laterally, this course being
more pronounced at the angles of the root, especially the
labial angles, to prevent the turning of the tooth in its
socket. The course of these fibers is especially well shown
in the reproduction of the microscopical section in Fig. 102.
The fibers soon after arising from the cementum break
up into smaller fibers which pursue a more or less parallel
course, or in some instances pass around the numerous
nerves and bloodvessels in their course outward. These
again unite into larger and coarser fibers as they approach
the alveolar process. In young subjects a large portion of
the alveolar process is often missing between the teeth, as
in Fig. 102, in which case the fibers pass directly across
to unite with those of the adjoining teeth.
The attachment of the fibers to the cementum and bone
is most secure, the ends being literally built into the bony
substance, actually penetrating the cementum to its union
with the dentin, while the alveolar portions, in addition
to the strong attachments gained by the numerous bay-like
excavations in its surface, also penetrate the very sub-
stance. In reality the bone has been deposited about the
fibers, or the fibers built into the bone.
Although the fibers are composed of inelastic tissue and
their attachment is most secure, yet it is known that the
teeth admit of a slight movement normally. This wise pro-
vision doubtless often prevents shock or fracture, and per-
mits a better adaptation of their occlusal planes in masti-
cating food, thus rendering them more efficient. This
slight movement is probably due to the bundles of fibers
pursuing different directions in their course, so that none
is on actual tension until the slack, so to speak, is taken up.
No thoughtful person can study the arrangement of the
fibers of the peridental membrane without being impressed
128 MALOCCLUSION.
with their wonderful perfection for resisting the displace-
FIG. 102.
Transverse section of a lateral incisor and its membrane from the occlu-
sal third of the alveolar portion. A, the pulp, showing blood vessels and
nerves. B, dentin. C, cementum, showing two layers. The outer of the two
layers of cementum shows at several points greater thickness, where cemen-
tum has been built up around the fibers to attach the strong bands that
resist rotation. D, bone of the alveolar process. E, dark spots representing
indifferent fibrous tissue surrounding and accompanying the blood vessels
and nerves, or fibers which run in a plane at right angles to the section.
On the right side the fibers are seen passing from the mesial of the lateral
to the distal of the central, the septum of bone not coming between at this
point. At the left the fibers are seen passing from the cementum to the
bone of the alveolar process. (Noyes.)
ment of the teeth incident to occlusion and mastication,
and it is of special interest to the orthodontist, enabling

ALVEOLAR PROCESS AND PERIDENTAL MEMBBANE. 129
him to better comprehend not only the proportionate value
Fig. 103.
Transverse section of the peridental membrane, showing the fibers pass-
ing from the cementum to the bone, taken from the disto-lingual corner
of Fig. 102.
B, dentin. The light band next the cementum shows the first formed
layer, or granular layer of Tomes. C, cementum, showing two layers.
the inner, or first formed, darker and more even in thickness; the outer, or
newer, lighter, and showing a hypertrophy at the disto-lingual corner,
where the cementum is being built up around the fibers to attach the
strong bands which resist rotation and which are seen stretching across to
the bone of the alveolar process, D, D, bone of alveolar process. F, marks
a spot where absorption is going on in the bone. The small dark spots
next to the surface of the bone are osteoclast cells. (Noyes.)
of the fibers for giving resistance in anchorage, but as

10 -
130 . . . " MALOCCLUSION.
well, to overcome the difficulties from their resistance in
the teeth to be moved.
Of the seven possible tooth movements it is well known
that depressing a tooth in its socket is the most difficult.
This is readily explained from the fact that by far the
larger number of fibers—the suspensory fibers—directly
resist this movement of the teeth as is required in masti-
cation. . .
The next most difficult movement is that of rotation.
While probably most of the fibers indirectly tend to pre-
vent the tooth from turning in its socket, there are an
unusual number at the four angles so arranged as to di-
rectly resist such movement. -
The lingual and labial movements, less difficult to per-
form, have less resistance from the fibers, while to the
movement of elevation direct resistance is offered only by
the fibers at the extreme apex of the root and at the border
of the alveolar process, and experience proves that this
is by far the easiest movement to accomplish. i
Thickness.-The thickness of the peridental membrane
varies in different periods of life, being much greater in
childhood and becoming gradually less with age. This
is brought about largely by the deposition of bone around
the entire internal plate of the alveolar process, similar to
the lamellar arrangement in the large bones. The mem-
brane is sometimes further encroached upon by increase
in the thickness of cementum through deposits by the ce-
mentoblasts around the fibers. This becomes especially
marked in that pathological condition, hypercementosis,
and is well shown in Fig. 103.
Blood Supply.—The peridental membrane is freely sup-
plied with blood which is derived from three sources:
First, from branches given off from the gums.
Second, from numerous branches from the alveolar
process. . - .
Third, from one or two large branches entering through
ALVEOLAR PROCESS AND PERIDENTAL MEMIBRANTE. 131
the apical space, which immediately divide and subdivide,
some being given off to the pulp and others to the mem-
brane, forming a rich plexus throughout these structures.
The advantage of these various supplies of blood is
apparent, for if from disease or pressure the supply be
interfered with from one source, that derived from the re-
maining sources may still be ample.
The question is often asked, “In the rapid movement
of teeth is the blood supply to the pulp shut off?” As
minute branches of vessels are supplied to the pulp,
from the peridental membrane, through the foramen, as
well as from the large branch entering the apical space, it
is not probable that strangulation could result unless pre-
ceded by inflammation.
The vessels supplying the peridental membrane are, for
the most part, found midway between the bone and cemen-
tum. In old age, however, they are found nearer to the
bone, even partially embedded in it, so that their course
may often be traced on the surface of the inner plate.
C H A P T E R V I.
TISSUE CHANGES INCIDENT TO TOOTEI MOVEMENT.
WHEN force is exerted upon the teeth to be moved two
principal changes take place in the alveolar process. First,
a bending of the process; second, absorption of the process.
in advance of the moving tooth and deposition of bone
behind it. These changes vary greatly: according to
the age of the patient, in different patients of the same age,
in the direction of movement, and also in the rapidity of
movement. -
In youth, or before the bone has become dense by a pre-
ponderance of inorganic substance, it permits of much
bending, so that incisors may be moved out of inlock in a
few hours, or the lateral halves of the arch widened in a
few days, or before much absorption could have taken place
in advance of the moving tooth. In further proof of this
the process will be found upon examination to be intact
about the roots, not only on the labial side, or in front
of the moving tooth, but on the lingual or opposite side,
as well, it having been carried with the moving tooth. This
is easily explained when we remember the cancellous struc-
ture of the bone, the inelasticity of the fibers of the peri-
dental membrane, and their very strong attachment to it.
Another striking illustration of the bending of the bone
is in the distal movement of the canine into the space
made vacant by the removal of a first premolar. The
author has frequently noted that not only the septum of
bone just mesial to the canine closely follows the moving
tooth, but in some instances even the lateral incisor is
dragged in the same direction to quite an extent, owing
probably, in the main, to the strength of the fibers com-
posing the dental ligament. - .
132
TIssue CHANGES INCIDENT TO TOOTH Movemſ ENT. 133
While more or less springing of the bone is probably
always an accompaniment of tooth movement, yet in pro-
portion as the bone becomes dense with age so the modifica-
tion of the process attendant upon tooth movement prob-
ably changes from springing to the slower action of ab-
sorption and the still slower deposition of bone.
Coincident with the changes in the bone there are also
pronounced changes taking place in the peridental mem-
brane. As force is exerted on the moving tooth the mem-
brane is compressed in front of it, between it and the al-
veolar process, while a greater tension of the fibers of the
membrane takes place on the opposite side. As a result
of this tension and compression the nerves of the mem-
brane are impinged upon, causing more or less discomfort,
which, however, as a result of the slight movement of the
tooth and temporary paralysis of the nerves from pres-
Sure, subsides more or less quickly according to the amount
of inflammation present.
As a result of this pressure the absorbent cells, or osteo-
clasts, are stimulated to increase in number and in activity.
They immediately engage in the absorption of the portion
of the bone most involved in the movement, as well as of
the bone attachments of the fibers on greatest tension.
While these changes are taking place, the osteoblasts
have become active and have begun filling up the depression
and reattaching the fibers by the redeposition of bone; but
as this is a much slower process than that of absorption
the tooth is found to be more or less loose in its socket
at the completion of its movement, as well as long after,
necessitating its being supported by means of the retaining
devices until the deposition of bone shall be complete, the
fibers modified, and a normal socket formed for its support
in its new position.
Rarely is the movement of only a single tooth in one
direction all that is required—as the movement labially, or
the rotation of an incisor. More often the movement in
134 - MALOCCLUSION.
various directions of a number of teeth in both arches
is necessary, and frequently the combination of several
movements of a number of teeth in both arches is required
as, for example, the combined labial and rotary movement
of single incisors, or the elevation, rotation, lingual and
possibly distal movements of a prominent canine.
With a suitable appliance and the proper regard for
the physiological laws governing tooth movement all neces-
sary movements of all teeth may be carried on simultan-
eously and with but little discomfort to the patient, if
undertaken at the proper age.
If a tooth be mechanically elevated in its socket the
change chiefly involves the peridental membrane. The
fibers at the end directly resisting this movement are
severed, and the oblique or suspensory fibers are stretched
and recurved upon themselves. The result of the partial
withdrawal of the conical root is increased space, not only
at the end but also on the sides of the root, so that there
is considerable freedom of movement of the tooth, necessi-
tating the deposition of bone over the entire surface of its
socket, as well as increase of height of margin. Not only
this, but there must be entire reconstruction of all the
fibers, and especially of the suspensory, which experience
proves requires much time, especially when the movement
of elevation is performed after Nature has ceased her
efforts at further eruption.
In the movement of depression the bone must be ab-
sorbed by the osteoclasts over the entire surface of the
alveolus to allow for the advance of the root of conical
form. The fibers of lateral support are stretched,
while the suspensory fibers are also stretched and severed
at their points of attachment to the bone, thereby neces-
sitating more disturbance of tissues and requiring more
force and time than any other of the seven movements.
In the rotation of a tooth in its socket little change by
springing or bending is probable, the principal change
TIssue. CHANGES INCIDENT TO Tooth MOVEMENT. 135
being absorption of the bone and of those fibers along the
entire length of the root that directly resist this movement.
Thus is made plain the necessity for so great an amount
of force in performing this movement.
In all cases of tooth movement a large number of the
fibers of the membrane remain on tension long after its
completion (due principally to the recurrent spring of the
bone), their force tending to draw the tooth back to its
original position, and necessitating considerable support
from the retaining devices until the tissues have become
thoroughly re-established in harmony with the tooth in its
new position.
In accomplishing the movement of teeth lingually, la-
bially (or buccally), mesially, or distally, the principal
change is in the position of the crown of the tooth, it being
tipped into its correct position. The usual supposition is
that the tooth in the alveolar process acts as a lever, the
crown, or long end of the lever, moving in one direction,
and the apex of the root in the opposite direction. To
make clear these supposed changes, and especially the
extent of the movement of the apex, writers have fre-
quently used the illustration of a post driven into the
earth about one-third of its length. If force be exerted
at right angles to the post near its top the post will act
as a lever in the displacement of the soil, the two ends of the
lever moving in opposite directions and the pivotal point
being somewhere near the beginning of the last third of
the embedded portion. -
The illustration is a poor one and very misleading, as
the mechanical conditions are very different. Doubtless
this would be the result if the tooth, like the post, had
but one resistant substance and that equally distributed in
all directions about its root, but as we have already seen
in the study of the alveolar process, the bone varies greatly
in thickness over different portions of the root and in
different teeth, so the amount of displacement of the apex
136 MALOCCLUSION.
depends, ofttimes, upon the location and movement of the
tooth and whether one tooth or a number in the same
region are being moved in the same direction. In reality
there may be little or no displacement of the apex, or there
may be considerable.
In the first place, the alveolar process is not a level
plane, like that in which the post is implanted, but a pro-
jection or high ridge, of elastic structure, admitting of
much bending, its susceptibility to this action increasing
proportionately as we approach the top. The labial move-
ment of the incisors, as necessary in Fig. 104, especially
FIG. 104.
favors this bending, which is also a matter of common ob-
servation in efforts at extraction. "
Again, the mechanical difference between the attachment
of the post to the soil and the tooth to the alveolar process
is such as to produce still further difference in the results
of their movements. As the apex of the root is implanted
deep in the bone, which is greatly thickened in its lingual
direction and reinforced by the strong cortical layer of the
alveolar process, its movement lingually could not well
take place as a result of springing. This movement is
further strongly resisted by the innumerable inelastic
fibers that encapsule the apex, radiating in all directions

TIssue CHANGES INCIDENT TO TOOTH MOVEMENT. 137
to effect the firmest attachment possible to the bone, their
ends being enclosed in its structure.
So in the labial movement of the crown, the lingual
movement of the apex of the root is not only resisted by
the bone in front, but also behind and on each side, by
reason of its attachment, while in the case of the end of
the post little, if any, resistance is offered by the soil be-
hind or on either side, but only by that in front.
Another difference. The force for the movement of the
post is applied remotely from the fulcrum, while the force
exerted on the tooth by the ligature is applied closely to
the fulcrum, or at a point best calculated to facilitate the
bending of the alveolar process in the labial direction.
Again, unlike the single post, several teeth may be asso-
ciated in the movement, which adds still further to the
possibilities of the labial, and correspondingly to the im-
possibilities of the lingual, movement of their apices.
In the lingual movement of incisors there are much
greater possibilities for the movement of the apices of the
roots in the opposite direction, owing to the lesser resist-
ance offered by their thin covering of bone labially and
its much greater thickness on the lingual surfaces of the
roots. The result is often noticed following the reduction
of protruding incisors, as in those cases belonging to Di-
vision 1 of Class II.
In the similar movements of the upper canines and pre-
molars practically the same changes in the positions of
the roots follow.
In the movement buccally of the upper molars there is
bending or absorption of the outer plate, and the palatine
roots are elevated in their sockets to make easier the
tipping of the crown, with probably no movement at the
apices of the buccal roots, unless it be that they are forced
more deeply in their sockets. In the opposite or lingual
movement of these teeth these movements are reversed.
In the buccal movement of the lower molars there is
138 MALOCCLUSION.
greater displacement of the apices of the roots in the oppo-
site direction from which the crowns are moved, owing to
the great thickness of the buccal plate of the alveolar pro-
GeSS. - .
In the movement of teeth mesially or distally there can
be little or no bending of the labial and lingual plates, the
chief resistance now being offered by the septa and the
peridental attachments, and the movement of the teeth
more nearly resembles the movement of the post, the apex
moving considerably in the opposite direction from the
crown, which is always noticed in the unpleasing angle of
the canine after the retraction of its crown. º
The Pulp.–While the pulp of the tooth is a tissue more or
less involved in tooth movement, yet when the operation is
properly performed this tissue is practically undisturbed
and should suffer no real injury. On the other hand, its
normal function may be so interfered with as to cause
it to suffer marked disturbance and even complete devital-
ization, especially if the movement be conducted too rapidly
or the force too abruptly applied. The principal danger,
however, arises from congestion and inflammation of the
tissues of the apical space, causing the partial or complete
strangulation of the vascular supply to the pulp. In view
of these facts it should be our aim to prevent, as far as
possible, all tendency toward inflammation. If the pulp
becomes partially congested, as is usually evinced by much
sensitiveness to pressure and to thermal changes, and a
slight change in color which shows through the enamel,
the tooth should be allowed to remain passive for several
days, when, usually, these symptoms will subside. The
author has noticed several instances where these symptoms
have been markedly manifest and have wholly subsided
under palliative treatment. Sometimes, however, complete
devitalization will follow, and while the death of the pulp
under these conditions is to be regretted, the consequences
TISSUE CHANGES INCIDENT TO TOOTH MOVEMENT. 139
are not of sufficient importance to occasion any more regret
than when it occurs in the treatment of teeth for caries.
The principal evil following the death of the pulp in
these cases is the possible permanent discoloration of the
crown, which is more liable to follow the speedy death from
strangulation than the slow devitalization from the en-
croachment of caries. For this reason, whenever complete
devitalization of the pulp shall be apparent it should be
immediately removed and the tooth treated, and the canal
filled after the best prescribed methods, when the further
movement of the tooth may be conducted without greater
fear of inflammation than if the pulp were intact.
In like manner, if it be desirable to change the position
of a tooth having an already devitalized pulp, it may be
undertaken without hesitancy, provided the surrounding
tissues be healthy and the pulp canal first properly
cleansed and filled.
It is often desirable to perform tooth movement soon
after the eruption of the teeth, or before the root is fully
formed, its end then having a broad, funnel-shaped open-
ing. If the movement be properly performed the pulp
should suffer no greater disturbance than when the root is
fully calcified. In fact there is less probability of strangu-
lation and death than later when the foramen is greatly
diminished in size. - -
C H A P T E R V II.
PHYSIOLOGICAL CHANGES SUBSEQUENT TO TOOTH MOVEMENT.
So far we have considered the physiological changes
which take place in tissues during tooth movement, but we
must remember that certain very important changes which
were practically unrecognized prior to the publication of
the last edition of this work, also occur subsequently to
tooth movement. w
To better understand these changes we must keep in
mind the conditions previously existent. The development
of malocclusion is gradual, and in proportion as the func-
tions and positions of the teeth deviate from the normal
there is necessitated a corresponding deviation in the de-
velopment of the alveolar process, and, to a greater or less
degree, in the bones of the jaws, vault of the arch, the nasal
tract, and the muscles of the face. All being out of har-
mony, the tendency, as we have seen, is usually to favor
still greater inharmony, or departure from the normal,
as growth and development progress.
After the crowns of the teeth have been moved into
correct positions in the line of occlusion, and harmony of
the occlusal planes established, the direction of force has
been so changed as to exert a different and more normal
influence upon the tissues of the alveolar process and bones
of the face. The result of this stimulus is to awaken Nature
to continue the building of the denture in accordance with
her original plan and the type of the individual.
Evidences are common throughout surgery of Nature’s
wonderful inherent power to remedy her defects, and of
her prompt response as soon as favorable conditions are
established. The natural changes following the intelligent
140
PHysiological changes AFTER Tooth Movement. 141
correction of malocclusion are always pronounced and
gratifying, and often even surprising.
The cognizance of these changes reveal greater possibil-
ities in art and in establishing the normal in occlusion,
and should, in many instances, modify our plan of treat-
ment by obviating the apparent necessity for extraction;
and it should also lend greater importance to the question
as to the proper time for treatment.
Very frequently where there has been change of position
of a number of teeth, especially in both arches, some may
occupy planes of greater elevation than others, or the
cusps of some may not occupy exactly normal mesio-distal
relations, but if we have succeeded in placing the teeth
so that their inclined occlusal surfaces sufficiently favor
their normal positions, their proper heights and relations
will become established through use and the growth of the
alveolar process. In some cases the incisors may ap-
parently be too short, but after a few weeks or months
of growth, when the buccal teeth shall have become settled
in their new positions, the length of overbite will gradu-
ally become normal, especially in young patients.
FIG. 105.
Another noticeable and important change is that follow-
ing the labial movement of the crowns of a number of
incisors, as in Fig. 105. The crowded and bunched positions
of the incisors have caused marked arrest in the develop-
ment of the alveolar process in the region of their apices,

142 MIALOCCLUSION.
so that after correction these teeth are found to stand at a
very pronounced angle, with a very abnormal depression in
the region of the apices of their roots, Fig. 106, and an
apparent overprominence of the lip, often suggesting
the impossibility of their being maintained in such
FIG. 106.
positions, but the crowns of the teeth now being in normal
occlusion, Nature is stimulated to continue the development
of the alveolar process, and to shift the apices of the roots
labially to normal positions, so that in due time there will
be the full normal contour of the alveolar process and the
teeth will stand at a normal angle, the result being a cor-
FIG. 107.
responding improvement in the contour of the face in the
region of the base of the nose—a normal result—which
could not have taken place had extraction been resorted to.
The changes here outlined are shown to have taken place
in Fig. 107, which represents a model of the corrected case
made three years later than that shown in Fig. 106.


PHYSIOLOGICAL CHANGES AFTER TOOTH MOVEMENT. 143
The growth of the alveolar process and the shifting of
the roots of the teeth toward normal positions as a result
of the stimulus following the establishment of normal oc-
clusion seems to vary in different individuals and at differ-
ent ages of the patients.
As there are no records of other cases outside of the
author’s practice, this being the first case reported,” the
author is as yet uncertain as to whether there is an age
limit in this growth. He is certain, however, that up
to the time of the eruption of the canines the response
in growth will be most noticeable and gratifying. Prob-
ably there is no age at which Nature would not make an
effort to complete the development of the alveolar process
thus arrested, and succeed to a certain extent. This is an
important point which awaits complete investigation, as,
if there be an age limit, a need for extraction may thus be
furnished, constituting practically the only case to be con-
ceived of by the author outside of deciduous teeth too long
retained, supernumerary teeth, or abnormal conditions so
extensive as not to be amenable to general laws, but which
must be indeed very rare. -
It seems to the author that the rules which govern the
growth of the alveolar process subsequently to tooth move-
ment are in accord with its normal growth under normal
conditions, being most rapid during the period covering
the eruption of the incisors and growing noticeably slower
after the eruption of the canines. -
There are many pronounced changes following tooth
movement and the establishment of normal occlusion, in
the growth of the alveolar process, in the size and form of
the vault of the arch and in the nasal passages and jaws,
and also changes in lips and tissues about the mouth—all
of which is exhaustively discussed in the chapters on
Treatment.
* Angle, MALOCCLUSION, sixth edition. See also the further discussion of
this case—pages 340.
CHA PTE R v III.
MODELS.
Materials for Impressions.—In deciding upon a proper
course of treatment in any given case it is of first im-
portance to obtain very accurate models of both dental
arches. Such models assist in determining not only the
variation from the normal and the class to which the case
belongs, but also the proper plan of treatment, and are
exceedingly valuable as references during its continuance.
From such models accurate measurements may be made
from time to time for comparison with the natural teeth.
In this way may be judged not only the exact movements
of the malposed teeth, but any unfavorable movements
of the anchor teeth may be detected. These models are
valuable only in proportion to their accuracy, and those
most nearly approaching accuracy are made from plaster
impressions. They must show not only both arches and the
relative positions of the teeth and cusps, as well as the
vault of the arch, rugae and gums, but also as much of the
roots and positions of the same as are indicated by the
gums and alveolar process up to the point where the attach-
ment of the muscles renders obscure the further shape of
the jaw.
It is frequently stated by the writers of the “old school”
that models sufficiently perfect can be made from impres-
sions taken in modeling compound or other of the plastics.
There is no fact better known in dentistry, however, than
that an impression of the teeth made with such materials
can only remotely approach accuracy even where the teeth
are in normal position. The shape of the jaw, together
with the shapes and inclination of the teeth, make the re-
moval of a plastic impression, without change of form,
impossible. Of the degree to which arrest of development
144
MODELS. 145
of the alveolar process has taken place, especially in the
region of the roots of the incisors, so important to accu-
rately record in the model, only the merest supposition
can be gained from a model made from a plastic impres-
sion. From the large number of models of this kind which
the author receives each year from dentists, few of which
even approach accuracy, it is evident that the value of
correct models is not sufficiently appreciated. It is quite
probable that those who object to plaster impressions have
never learned the correct method of taking them, otherwise
they would find but little, if any more, trouble to them-
selves, or objection from the patient, than in using the
plastics.
Method of Taking Impressions.—If the student will carefully
observe the following simple plan for taking impressions
and making models he will find, after a little experience,
that the method is not difficult and that the most perfect
results are possible. He must, however, observe extreme
care and accuracy in each stage of the operation. We may
as well remark here that a careless operator could never
hope to be successful, and had better remain content with
the unreliable results from plastics.
First, the teeth should be thoroughly cleansed from all
tartar or soft deposits. For this the little soft-rubber cup
disk used with pumice is excellent. Care should be taken
not to wound the gums, as any bleeding prevents sharpness
in the outline of the gingiva in the impression.
The Trays.-The trays shown at Fig. 108 are essential;
there are five sizes. They were especially designed by
the author in accordance with the anatomy of the parts
for taking impressions of complete or partial dentures,
the rims and vaults being much higher than in the
ordinary trays which were all designed for taking impres-
sions of edentulous jaws. It is very important that they
should always be kept thoroughly smooth, bright, and
clean. When not in use they should be wrapped in clean
11
146 MIALOCCLUSION.
cotton-flannel to prevent marring by contact with each
other.
In taking an impression care should be observed to select
a sufficiently large tray, which should be bent to conform
FIG. 108.
more perfectly to any peculiarity in the shape of the jaw.
This will not injure the tray. The proper size and shape
will be best determined by trials in the mouth.
Taking the Upper Impression.-Good impression plaster is
mixed in the usual way to quite a stiff consistency and

IMODELS. - 147
carefully distributed, as shown in Fig. 109, the shape and
height of the trays making but little impression material
necessary. It will be observed that the greater amount
is placed in the anterior part of the tray, and heaped up
and extended over the outer edge of the rim, none being
allowed in the vault of the tray.
It is now placed squarely in position and the plaster
allowed to rest evenly in contact with the occlusal edges
of all the teeth, but not yet forced up into position. The
lip is then raised and the plaster extending outside of the
rim is carried high up underneath the lip with the finger;
FIG. 109.
this is to insure expulsion of air, as well as a high im-
pression. The patient is now instructed to allow complete
flaccidity of the lips. The tray is then forced up evenly
until the points of the teeth touch the bottom of the tray,
and is steadily supported upon the end of the indea, finger
only. To expel the air from the cheeks they are now gently
manipulated, but not drawn down, as this would expel a
considerable portion of the plaster and prevent one of the
important objects, namely, a very high and accurate im-
pression. -
There being no surplus plaster in the vault of the tray,
little, if any, can be forced in contact with the soft palate,

148 MALOCCLUSION.
to cause nausea. The patient will therefore not be incon-
venienced and the impression may be allowed to remain
until it has become thoroughly set, which is very important,
as the harder the plaster becomes the more perfect will be
the impression. If removed too quickly a film of the
plaster will be found adhering to the surfaces of the teeth.
The tray must now be loosened and taken away, leaving
the impression in the mouth. It is essential that the tray
should loosen easily from the impression, hence the impor-
tance of its being kept clean, bright and smooth.
Removing the Upper Impression.—All superfluous pieces of
plaster should be carefully removed with a pair of pliers,
and the saliva and soft portions of the plaster thoroughly
removed by means of numerous pledgets of cotton of gen-
erous size.
Two grooves are then scraped or cut in the hardened
plaster on a line parallel with the canine teeth, but not cut
quite through. Then with a quick pry with the point of
a pen-knife the anterior plate is loosened and laid, together
with all subsequent pieces, on a clean blotting pad. The
lateral pieces are then broken off with the thumb and
finger, when only the large piece covering the roof of the
mouth will remain. This may be readily worked loose and
if the operation has been carefully performed the impres-
Sion will consist of four pieces, although a much greater
number would in no way injure it. Great care should
be observed to save all Small pieces, and to immediately
place them near their original positions in the large pieces.
The edges of the pieces to be united must be kept free
from all fragments of plaster, which may necessitate the
washing of each piece separately under the faucet.
Taking the Lower Impression.-In like manner the impres-
sion of the lower arch is secured, being careful to observe
the essential points, namely, carrying the impression ma-
terial, which has been built up and outside of the anterior
part of the rim of the tray, well down beneath the lip with
MODELS. 149
the finger before forcing the tray home, then expelling the
air by gradually working the cheeks while the tray is
steadily held by the ends of two fingers of the left hand,
one resting on the top of each lateral half. The handles
of the trays are only used for their insertion and removal.
While thus supported the folding in of the cheeks be-
tween the gums and distal portion of the tray should be
guarded against by gently forcing them outward and back-
ward with the finger.
To guard against the infolding of the tongue it should
be raised and gently drawn forward, then allowed to settle
back into an easy position.
Removing the Lower Impression.—In removing the lower im-
pression, in addition to the labial grooves parallel with the
long axes of the canines, it is often desirable to make two
similar grooves in the lingual portion of the impression.
Sometimes a single groove between the central incisors
will be sufficient. The exact number and location of
grooves in both impressions should vary according to the
positions of the teeth, and should be carefully planned
before inserting the impression material.
Removing Impressions from Arches with Spaces, due to Loss of
Teeth.-In the case of an impression where one or more of
the teeth are missing, the difficulty of removing it by or-
dinary methods is greatly increased. There are two plans,
however, by which this difficulty can be easily overcome
and accurate impressions of the most difficult partial den-
tures secured.
The first is by cutting a deep additional groove in the
impression mesio-distally in the space of the missing tooth.
The lateral halves of the segments are then readily sprung
apart and the pieces dislodged. The peculiarities of these
spaces should be carefully studied before inserting the im-
pression in the mouth.
Another excellent plan for weakening the impression at
exactly the same points is to insert a piece of thin metal
150 MALOCCLUSION.
or tough cardboard in the space of the missing teeth, the
pieces being held by the approximal surfaces of the teeth
at either end, the lower edge resting upon the gum, while
the upper edge should be on a line parallel with the occlusal
surfaces of the teeth. By this method grooving will be
unnecessary.
Uniting the Impression.—After removing the pieces of the
impression, they should be dried somewhat before uniting,
FIG. 110.
never, however, allowing them to become thoroughly dry,
as when drying ununited they seem to warp somewhat, and
when put together after so drying do not form a perfect
whole. If allowed to stand a couple of hours they will
probably be in best condition to unite, which requires pa-
tience and care. If skilfully done the line of fracture
can hardly be detected. The pieces are best held together
by means of wax made quite hot on the spatula and flowed
over the outside, the clean, united ends being held so per-
fectly in contact that none will flow into the fracture. They

MODELs. s 151
should never be united in the tray, as accuracy by this
means is impossible. -
In uniting the impression the smaller pieces should be
first joined to the larger, instead of attempting to force
them into correct position after union of the large pieces.
The minute pieces are best held in position with liquid
celluloid. -
In uniting the pieces should be placed in actual contact
only once, and immediately secured. The habit of fre-
quently trying pieces together should be avoided, as the
fine serrations are thus destroyed. -
This method of taking impressions preserves the fine
points of the interdental spaces. We believe it to be the
only practicable way of making a plaster impression.
After the impression is united it should present the
appearance illustrated in Fig 110.
Warnishing the Impression.”—The impressions being united,
they should be coated very evenly with shellac varnish.
At the expiration of half an hour, or when the varnish has
become hard, a second coat should be applied over the
occlusal surfaces of the teeth and rough points, but not
over the Smooth surfaces, especially the labial gum sur-
faces. After drying again the depressions for the cusps
* It is important that only the best quality of varnishes of the proper
consistency be used, as only from such can we gain that most beautiful,
accurate and artistic surface for our models, so much prized by all skilful
orthodontists. If too thin, the hard glossy surface will be wanting
and it will be difficult to separate the impression without injury to the
model. If too thick all fine tracings of the impression, especially the
stipples of the gum, so important to preserve, will be obliterated.
The ordinary gum shellac procurable at drug stores should never be
used in making this varnish as it is so greatly adulterated as to make it
wholly unfit for this use. A fine grade of the gum may be procured through
The S. S. White Dental Mfg. Co. It should be used in the proportions of
one ounce of gum shellac to three and one-third ounces of the best commercial
alcohol. The sandarac warnish is made by combining the clear, selected tears
of sandarac with the best commercial alcohol in the proportion of one ounce
of sandarac tears to two and one-half ounces of alcohol. . -
152 MALOCCLUSION.
of the teeth should be carefully examined and all rough
portions again varnished so that when dry they will be
very smooth, otherwise much trouble will be given by the
breaking of the delicate cusps during separation. After
again drying apply over the entire impression a very thin,
even coat of sandarac varnish of fine quality.
Pouring the Models.-After the varnish has dried for half
an hour the impression will be ready for filling, which, in
order to secure expulsion of air bubbles may best be accom-
plished by quickly and carefully painting the plaster into
the tooth cavities with a small camel's-hair brush, then
rapidly filling the remainder of the impression and building
it up to generous proportions with a spatula, gently shak-
ing the while, never jarring, after which it should be turned
bottom upward on a glass slab.
FIG. 111.
Rogers.
Separating the Model,-After the plaster shall have thor-
oughly set, say over night, and the impression shall have
been thoroughly grooved, as in Fig. 111, the pieces may
very readily be separated. Should any air cavities be
found in the model they may be filled by packing in white
oxyphosphate of zinc and pressing it home by replacing the
corresponding piece of the impression, which should be al-
lowed to remain until the cement is thoroughly hardened,

MODELS. 153
when it will readily separate, leaving a very perfect sur-
face. A cusp or broken tooth may in like manner be re-
paired, or its contour artistically restored with a delicate
brush in the application of plaster of a creamy consistence
as suggested by Dr. Pullen. None of this plaster, however,
should ever be allowed to touch any other portion of the
model proper, as the dainty lines of the enamel and stipples
of the gum will thus not only be obliterated but an unpleas-
ing, “white-washed” appearance will be given to these sur-
faces. -
Trimming the Models—The models may now be trimmed,
and not only will there be a surface as smooth as polished
marble, but each cusp, all the interdental spaces, and the
rugae, as well as the inclinations of the roots, and even the
minute stipples of the gum and the developmental lines of
the enamel, will all be accurately and beautifully shown.
The frenum and attachment of the muscles, as well as all
of the tuberosity and as much of the gum posterior to the
last lower molar as possible should also be fully and per-
fectly shown in the model, as this not only reflects skill in
the making of the model, but adds greatly to its beauty and
truthfulness. Any coating of Suet, paint, varnish, etc.,
only detracts from the beauty of such models. -
The trimming of the models to graceful proportions,
while requiring a little extra time and some considerable
skill which can be developed only by experience and atten-
tion to details, is well worth while, for a collection of
models so trimmed presents a most attractive appearance
and cannot fail to reflect much credit on its possessor, es-
pecially when taken in comparison with the usual collec-
tion of slovenly made models, with practically no attention
given to trimming. It may be put down as quite a general
rule that the degree of perfection of the models he makes
is indicative of the knowledge, skill, and success of the
orthodontist in the treatment of his patients. -
There is a principle governing the proportions of the
154 MALOCCLUSION.
trimmed portions of the model that is very simple and
natural and gives fine balance and artistic effect.
FIG. I. 12.
>
:
*
*
*
w-
ſ
f
X
G
* *
Şı
For convenience we will call the trimmed portion of the
model the “art,” portion and the untrimmed, or gum and
tooth surfaces, the “anatomical” portion. The following
FIG, 113.
rules for gaining the proper proportions, together with the
diagrams indicated in Figs. 112 and 113 were worked out
by Dr. Martin Dewey.








MODELS. 155
In the finished, occluded model, Fig. 114, the base and
top should be parallel. In order to determine the proper
height of the finished model let the art portion at its thin-
nest point in both upper and lower that is, A B and E F,
equal one-third the width of the anatomical portion at its
widest point, that is, measuring from the cutting edge
of say the lateral incisor to the highest point of muscle
attachment, B D and C E. *
==
==
Bº-s---
Esº
ÉÉ
=#
• -: ſ
ºf [.
I
*=-
'#
I t |
| O
E. H. A
Trim the line F H, in Figs. 112 and 113, at right angles to
the base lines, or top and bottom of the model, and in such
a manner as to preserve all anatomical parts.
Trim the lines E F and I H parallel with the line of
occlusion as indicated by the first molar and camine.
Establish points E and I over center of normal posi-
tions of the crowns of the canines. Let the distance E I
equal the distance E X and I X, and with the center X de-
scribe the arc E D I. In the lower model trim to this arc,
and in the upper trim to plane surfaces, letting D E equal
D I regardless of whether or not D comes between the cen-

156 MALOCCLUSION.
tral incisors. Following this plan any variation from the
median line is shown.
The lines F. F" and H' H", Figs. 112 and 113, are run
at right angles to IF and E H respectively, and each is
one-third the length of the line E D or D I. -
The more truly mechanically these proportions are car-
ried out the more beautiful will be the model. Each sur-
face should be smooth and exactly at right angles to the
base line. This is now easily accomplished after a little
experience with the author’s plaster plane, which is a great
convenience, the square and rule making the correct pro-
portions easy of accomplishment.
FIG. 115.
º
ºº::===º:
º
*4
| § *::::
| a_ |S
-
º
FF-º º 2. º
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The author is indebted to Dr. F. S. McKay for the sug-
gestion of using a plane for trimming the models, which led
to much experimenting, resulting in the style of plane com-
bined with square and rule shown in Fig. 115. It is com-
posed of brass, with bronze blade to avoid corrosion and
discoloration of models, and in connection with a strong
sharp knife for roughly trimming the model, it is the only
instrument necessary. Use of the plane soon develops skill
in planing to fine accurate measurements.
There are two important points in the care and use of
the plane which are highly essential and without which no
one can succeed in its use. First, the blade must be kept
exceedingly sharp, a good clean oil-stone being always at


















MODELS. 157
hand for the purpose and frequently made use of. Second,
the blade must be set to cut the very thinnest possible shav-
ings as the desired line is neared. Coarse shavings are
permissible and desirable only in the general shaping of the
model.
The models should now be carefully occluded after com-
parison with the natural teeth, and the occlusion indicated
by two or more very delicate pencil markings at conven-
ient places—usually on the lingual surfaces of the molars
—so that the proper points of contact may afterward be
readily found. It is also well to mark in India ink what we
might term the “landmarks,’’ viz., a point on the mesio-
buccal cusps of the upper first molars and the buccal
grooves of the lower first molars. The practice of placing
models in articulators is obsolete. The lines serve the pur-
pose much better than an articulator of any form. The
models should also be neatly labeled and placed in a
suitable cabinet for protection from dust and injury, to
serve for study and reference, and, on occasion, be valuable
as legal evidence. Fig. 116 shows a very convenient form
of mahogany case for this purpose.
As soon as the teeth have been completely moved another
impression should be taken and models made. This is done
after all appliances have been removed and the teeth thor-
oughly cleansed, and immediately prior to adjusting the
retaining devices. These models are valuable for com-
parison with the natural teeth during the period of reten-
tion, as well as for future reference.
Another style of model is also occasionally necessary.
It is made from an impression taken of the labial and
buccal Surfaces of the teeth when the jaws are closed by
pressing plaster, mixed to the usual consistency, on these
surfaces of the teeth and allowing it to harden, after which
it is treated as already described for the making of models.
Such models are shown in Figs. 416 and 480.
It is also of advantage to have “study models” occa-
158 MIALOCCLUSION.
sionally made during treatment and retention, by pressing
a piece of softened wax about one-fourth of an inch thick
on the occlusal edges of the teeth, to show only their occlu-
sal surfaces and the appliances in situ.
Fig. 116.
º º
- lºº-ºº-ºº:
- TT T.
ºlººlºº
* † T.
*
TITTTLºº T.
Tº
Tº
HREE
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Value of Good Models.-A collection of fine, accurate
models is not only an incentive to keener interest and bet-
ter work, but is a most valuable form of “library” in itself,
in which many valuable phases of the subject are recorded
that can never be reduced to writing.
Models should never be mutilated by the fitting of bands
and appliances. While they may serve as a basis for gen-











MODELS. 159
eral measurements for the appliances, the fitting should
always be done to the natural teeth.
Photographs.-Very important, also, are good photo-
graphs of each patient at the beginning of treatment.
While such pictures are not so valuable as the face itself
for determining the true condition as to harmony and in-
harmony of the facial lines, they are essential to note
by comparison the changes that follow as the result of
treatment. Photographs should also be taken at the close
of treatment; and also, whenever possible, two or three
years after completion of treatment.
Pictures, also, of dental models, though not so valuable
as the models themselves as a means of study, make, if ar-
tistically mounted in connection with the pictures of the
face in a suitably made album, a volume highly interesting
to patients and of inestimable value to the true student of
orthodontia. Even the simplest cases should not be
omitted, for each case teaches some lesson and it is often
from the apparently unimportant cases that valuable
lessons may be learned both in art and occlusion.
Our requirements in facial photography are very dif-
ferent from those usual in portrait photography, and it
is extremely difficult to find photographers of sufficient skill
who can comprehend and will fulfill our needs. The modern
photographer aims to idealize his work—to bring out the
poetical of the face as much as possible. He aims through
the possibilities of pose, focus, high lights and deep shad-
ows to obscure all blemishes and inharmonies of balance
and proportion, and intensify that which is most beautiful
in the features.
Again the term “profile” means to the photographer a
Quartering view of the face; a “front view” means more
or less variation from full front. A smile is also usually
insisted upon. Such treatment for their purpose is doubt-
less proper and such pictures may be very beautiful and
reflect the great skill of the photographer, but they are of
160 MALOCCLUSION.
little or no scientific value in orthodontia. What is re-
Quired by the Orthodontist is absolute truth and accuracy,
both as to inharmony and harmony in the contour and bal-
ance of the features, as well as the greatest possible detail
as to all fine lines, with no deep shadows or high lights.
On the contrary the lights and shadows must be just as
evenly distributed as possible, the pose must be natural and
not for effect, and the teeth lightly closed in their habitual
positions. Two pictures of cabinet size or larger are re-
quired, a full front and a full profile, that is, for the latter
the line of focus must be parallel with a line which touches
equally the crest of each supra-orbital ridge. This only
can give a full normal view of the profile outline. If turned
a little from this position, as photographers will usually in-
sist upon, the opposite eye-brow, or portion of the forehead
above it, if it be prominent, will show, and overbalance the
lower part of the face and consequently make the picture
useless as a likeness of the real proportions.
The difficulties in photographing the colorless models
are much greater than in photographing the face, for the
same reasons we have given relative to gaining detail and
avoiding high lights and deep shadows. In the author’s
collection, numbering several thousand photographs—the
work of thirty or more photographers—there are but few
truly fine results. He is glad to say, however, that Mr. P.
J. Knapp of Buffalo, N. Y., has, after much experimenting,
succeeded in producing the best results of anyone in his
experience.
Skiagraphs.--Skiagraphs, now so easily and quickly made,
are often of great value in settling doubts as to whether
teeth be missing, or as to their location if merely im-
bedded. These points may be determined in the majority
of cases by careful observation of the contour of the al-
veolar process and digital pressure, together with the use
of the exploring needle, yet where there is any doubt as
to the existence or location of a tooth in the alveolar pro-
MODELS. 161
cess no careful orthodontist would omit for a moment avail-
ing himself of the skiagraph for determining these points,
though it is greatly to be regretted that on the points on
Fig. 117.
Ketcham.
which we need the most light the skiagraph is often un-
reliable, for it leaves the shape, length, and exact position
of the root often a mere conjecture, yet that the perfect
form and outline of the teeth can be shown by it if proper
skill be employed is seen in Fig. 117.
Skiagraphs having become a necessity to the specialist
in orthodontia it becomes a question whether he should
Fig. 118.
undergo the necessary discipline and expense for doing the
work himself or intrust it to others.
Fig. 118 illustrates a case as revealed by the skiagraph


12
162 MIALOCCLUSION.
where the canine is so deeply imbedded in the alveolar
process as to baffle the ordinary methods of diagnosis.
Fig. 119 shows the rare case of a missing permanent
canine. The deciduous canine is shown with its root al-
most wholly absorbed. The first premolar is about to
erupt. The skiagraph showed that in the opposite side of
FIG. 119. FIG. 120.
the arch the permanent canine and first premolar had
failed to develop, and that the deciduous canine, like its
fellow on the opposite side, was also about to be lost
through absorption of its root.
Fig. 120 shows another case, that of a young lady aged
sixteen, where the left lateral incisor is missing. Addi-
tional interest is given to this case in the fact that in a
cousin of this patient on the father's side the left upper
lateral also failed to develop, while a sister and the pater-
mal grandfather of the patient have diminutive, malformed
laterals, the father's teeth being normal in development.

C H A P T E R IX.
REGULATING APPLIANCES.
- i
REGULATING appliances are devices for exerting pressure
upon malposed teeth in order to move them into harmony
with the line of occlusion.
Two plans are now followed in the designing and con-
structing of regulating appliances. The first is based upon
the belief that each case so radically differs from all other
cases that an appliance must be invented and constructed
from raw material to meet its special requirements. The
second plan recognizes the division of malocclusion into
a few clearly-defined classes, with requirements of treat-
ment clearly indicated by each class, and having fixed
standard forms of ready-made regulating appliances act-
ing upon definite principles, which amply provide for all
requirements of all cases belonging to each class.
The first plan is the one that has been most universally
employed, and has come down to us from the earliest
history of orthodontia; indeed the greater part of the lit-
erature of the science consists of descriptions of appliances
which have been invented to accomplish tooth-movements
in special cases, until some thousands are recorded, one
author alone boasting of many hundred. Although much
may be accomplished in skilful hands following this plan,
it should require no argument to prove that for many
reasons it is most defective and unscientific.
First, it necessitates that each dentist shall be an inven-
tor, and it is well known that the inventive faculty is
rather a natural gift than an acquirement, and that it is
possessed by only a very few. Then, as all inventions, if
perfected, must be experimented with, it must follow that
163
164 MALOCCLUSION.
the treatment of each case must be largely in the nature
of an experiment, often necessitating many changes in the
plan of treatment, and the invention and construction of
new appliances. Hence all treatment upon such theory
must be and in fact has ever been, tedious and costly and
often resulting in failure.
Second, another objection to following this plan is that
the appliances so constructed must necessarily be more or
less crude and lacking in requisite proportions, for any
instrument reaches perfection as to size, proportion,
temper, strength, and finish only after much experimenta-
tion and repeated efforts toward perfection in manufac-
ture.
Finally, another objection more serious than all is that
as the plan is empirical, with only a vague and indefinite
basis from which to reason, the difficulties in teaching and
practice become very great and the resultant good very
limited. After a life of practice the dentist following this
plan must still be in a maze of experiments and unable to
impart much information that could be of assistance to his
successors. This, we think, is abundantly proven by all
the works which have been written on the subject based on
this plan.
Such teachings may be said to “begin nowhere and end
nowhere,” and the attempted correction of malocclusion
with such appliances has been most appropriately termed
‘‘tinker regulating.” *
The second plan, as we have stated, recognizes the prac-
ticability of fixed, standard forms of devices for perform-
ing the different tooth movements necessary in all the va-
rious classes of malocclusion, the proper forms having
been arrived at as a result of careful experimentation and
close observation in a very large number of cases, embrac-
ing the greatest variety of malocclusion. Instead of hand-
made productions by the dentist, which, with his limited
experience and meager facilities must always fall far short
REGULATING APPLIANCES. 165
of the ideal in delicacy of proportion, temper, accuracy of
fit and interchangeability of parts and in finish, they are
made upon elaborate machinery, like fine watches or high-
class dental or surgical instruments, by the most skilled
workmen who have become experts, not only through
natural ability but from close study and long experience,
insuring the most perfect product at the minimum of
expense.
Dr. Farrar long ago predicted the possibility of this
plan, for he says in Vol. XX, page 20, of the Dental
Cosmos:
‘‘It has for some time been evident to me (though by
most people thought to be impracticable) that the time
will come when the regulating process and the necessary
apparatus will be so systematized and simplified that the
latter will actually be kept in stock in parts and wholes,
at dental depots in readiness for the profession at large,
so that it may be ordered by catalogued numbers to suit
the needs of the case; só that by a few moment’s work at
the blow-pipe in the laboratory the dentist may be able,
by uniting the parts, to produce any apparatus, of any size
desired, at minimum cost of time and money.”
If such appliances are practicable, it must become ap-
parent to all thoughtful minds that the advantages from
their use over the first plan must be very great, for, instead
of being confronted by a confusing and almost limitless
number of devices which can at best serve only as general,
vague, and often delusive patterns for him, the dentist has
but to thoroughly familiarize himself with a few standard
devices and their combinations, which he may ever keep
in stock in readiness for immediate demands, and which
may be quickly and easily applied, thus obviating the great
disadvantage of delays, so often necessary in the former
plan.
Again, familiarity with the standard appliances adds
greatly to the possibilities of development of skill and
166 MALOCCLUSION.
judgment in their use, as in the case of the frequent use of
favorite patterns of pluggers or excavators.
Finally, instead of being compelled to experiment with
inventions until a suitable and efficient instrument has been
devised for the case in question, he has the advantage of
being able to thoroughly rely upon standard forms of
devices as he does for other operations in dentistry. He is
thus enabled to direct his energies to a more thorough and
intelligent study of the case in hand, such as the problems
of occlusion, art relations, anchorage, retention, physiol-
ogy, etiology, etc., the consideration of which has in the past
been almost wholly sacrificed to the devising and construc-
ting of appliances. And whether or not ideal standard
regulating appliances have yet been reached, the possi-
bilities and positive advantages of the principle over the
first plan are so marked that we think all progressive
dentists interested in this branch should make efforts
toward developing orthodontia along these lines, rather
than to perpetuate a plan that is so obviously wrong and
a positive hindrance to the real progress of Orthodontia.
In no other branch of medicine, nor in any other Science
so far as known to us, is there such inclination to perpet-
uate a principle so antiquated, defective and antipodal
to progress. Even machinists, finding it impractical,
long ago abandoned the practice of making their own tools.
Then imagine a modern surgeon teaching his students to
invent, forge, and construct from raw material instru-
ments for each operation, or an up-to-date dentist grinding
the clays and pigments for the artificial teeth he shall use,
or “designing and forging a special instrument for each
case or operation.” Such was once the practice, but it is
now well known that most of the real progress in dentistry
and surgery has been made since the dentist and Surgeon
were relieved of this impractical task by experts, who have
produced instruments so perfect in design, construction and
finish as even to be often far in advance of the comprehen-
REGULATING APPLIAN CES. 167
sion and skill of those who are to use them; and the author
feels sure that Orthodontia has made its greatest progress
since the introduction of fixed, standard forms of ready-
made regulating appliances. A few of the writers and
teachers, it is true, are still linking the present with the
past in commending to dental students the acquirement of
skill in the construction of regulating appliances, which
can only be very crude at best. The custom is archaic and
illogical, and the long, tedious hours which students are
usually compelled to devote to their making, should by a
more advanced standard of teaching be directed to pur-
poses more in keeping with the requirements of true ortho-
dontia. The successful, up-to-date orthodontist classes
himself on a different plane from that of a mechanic.
The author’s regulating appliances, the description, plan
of application, and operation of which will be given later
are in direct keeping with the second plan, just described.
In fact, the second plan practically originated in the intro-
duction of this system some twenty years ago. They are
now standard in all countries where dentistry is practiced,
and their efficiency and universal application are recog-
nized. Like most valuable and popular pieces of mech-
anism, they have numerous imitations, but if intelligent
comparison be made with all others from the basis of
efficiency, simplicity, and delicacy, their superiority is at
Once apparent. The differences will be found to be steps
backward instead of in advance, and usually necessary
for legal reasons.
Naturally it is gratifying to the author to know that
all of the few standard forms of appliances introduced by
him have been accepted by the profession and are in
popular use wherever dentistry is practiced, yet recog-
nizing the great advantages of simplicity, he has found
that some of even these few in many instances with ad-
vantage give place to the expansion arch, the practicality
of which is increased by reason of the recent improve-
168 MALOCCLUSION.
ments in the latter appliance. The jack-screw, once a
favorite with the author and still an almost universal fa-
vorite with dentists generally, has been entirely eliminated
from the author’s practice. In fact he has found that it
is practicable to perform all orthodontic operations with
the expansion arch, although other appliances may occa-
sionally be used to advantage. -
Epochs in the History.—To the real student of Orthodontia
the history of regulating appliances is a most interesting
and instructive study. It shows that their beginnings, as
in most sciences, were crude; the unfolding slow, and
ofttimes marked by retrogression as well as advance, with
the perpetuation of much even to the present time that
should have been discarded.
Of necessity, the history of appliances is closely con-
nected with the history of orthodontia and largely
measures its progress. One surprising feature of the his-
tory is the frequency of rediscovery of identical principles,
their materialization differing only in minutiae of manufac-
ture. While the study is of much interest to the student
of orthodontia, the limits of this work will not permit of
more than the brief mention of such steps in the history
as may be regarded as epochs in the evolution of appli-
ances. This will involve the consideration of principles
only, and of those whose value is attested by their survival.
Mere improvements in methods of applying these prin-
ciples, however ingenious and valuable, cannot here be
noted. The actual principles embodied are few. •
The form of the first regulating appliances, or by whom
they were employed, is not known. It may have been, like
the substitution of the natural by artificial teeth, far back
in the history of man, but the first appliance that was
destined to mark a distinct step in the written history
of orthodontia was that given to us by Fauchard, of
France, in 1726, and which we will call the expansion arch,
for its chief function is to expand the dental arch. Its
REGULATING APPLIANCES. 169
form in the main is that of the ideal dental arch, and it
has been variously named as bandeau, bow, long band,
bandelette, etc. Unquestionably the conception of this
device, which, in its greatly improved form we rely on so
largely in modern practice, was the one greatest step in the
invention of appliances. r
That which may easily take rank as Second in importance
was the invention of the tooth band, or the medium for the
attachment of appliances to the teeth. Of bands there are
two kinds; first, the adjustable clamp band, or one that is
held in position by means of a screw with which it is firmly
FIG. I2].
zº
Fs
|
% a/ \s
%
*h
º
º
º: S 4:
* * : A
* * Sº º º
- N. §
*-
clamped about the crown of the tooth, and second, the
plain or brazed band, always made to fit each tooth in
question and held in place upon it by means of cement.
The first was the invention of J. M. A. Schangé, also a
Frenchman. We find it illustrated, as in Fig. 121, in a book
of one hundred and eighty pages published in Paris in
1841.” He seems to have used it chiefly upon the malposed
teeth, rather than for anchorage. It is only fair, however,
that the honor of the invention should be accorded to him,
* “Précis sur le Redressement des Dents.” Par J. M. A. Schangé, Med-
icin-Dentiste, membre de plusieures sociétés savantes. Troisième édition.
Paris, 1841.


170 MALOCCLUSION.
as its inception has been claimed by others at a much later
date." It consisted of a ribbon of metal in length sufficient
to nearly encircle the crown of the tooth, each end bent
OutWard Sharply at right angles, and both thickened and
perforated, one threaded, the other smooth. A threaded
shaft with perforated head was made to engage these
perforations in the band. By turning the shaft the band
was diminished in circumference and securely clamped
upon the crown to prevent displacement, as shown in the
engraving, in principle identical with Farrar's of 1876.
To all students of orthodontia another very important
epoch in the history of regulating appliances should be
mentioned in connection with Schangé's clamp band, for it
is in this connection that the screw first makes its ap-
pearance in regulating appliances, the honor of the intro-
duction of which has been erroneously divided between
Dwinelle, of New York, and Gaines, of England.” Their
recorded dates of using the screw were, however, eight
years later than that of Schangé's.
The plain band consisted of a ribbon of metal fitted to
the circumference of the crown, the ends being united by
brazing. Although such bands, of gold, were used by the
ancients for securing artificial crowns and bridges, it is
not clear by whom they were first used for regulating pur-
poses. Desirabode (1726) speaks of them as “bracelets”
or “little rings.” Thomas Evans, of Paris, mentions
them in 1854, and Dr. A. H. Fuller, in the Missouri Dental
Journal, January, 1872, describes a novel form of plain
band. It was constructed by closely wrapping a plaster
model of the tooth to be banded with fine platinum wire,
over which was flowed 20-carat gold, to which the desired
attachments were made.
The real value of the plain band, however, dates from its
attachment to the tooth crown by means of oxychlorid of
* Farrar, “Irregularities of the Teeth,” first volume.
REGULATING APPLIANCES. 171
zinc cement, which was accomplished at about this time
by Dr. Magill,” of Erie, Pa. This effectually prevented its
displacement under the ordinary strain necessary in
tooth movement. Magill’s method of making the band was
to encircle the crown with a thin ribbon of platinum,
slightly overlapping the ends and uniting by brazing. He
was probably not at this time aware of previous use of
either plain or clamp bands. By the use of bands the
direct, firm attachment of appliances to the teeth was
effected, so that loss of power by slipping was reduced to
the minimum and an important step in the progress of
orthodontia gained.
The regulating jack-screw was invented in 1848 by Dr.
Dwinelle, of New York.f. It is shown in Fig. 122. This
FIG. 122.
invention marks two important steps. First, the introduc-
tion into Orthodontia of one of the most compact, yet
powerful forms of mechanism for exerting force known
to mechanics; second, the beginning of fixed, standard
forms of regulating appliances with interchangeable parts
kept in stock at the dental supply houses. It consists of
a threaded steel shaft with comical head, perforated for
the reception of a turning tool, and a rounded nut, also
of steel, with long, parallel flanges joined at their extrem-
ities in the form of a fish-tail. Although difficult to keep
* At the meeting of the Western Pennsylvania Dental Society, Pittsburg,
March, 1896, in a conversation with the author, Dr. Magill said he could
not remember the exact date at which he first began attaching the bands
by means of cement, but believed it was in 1871, or 1872.
† Some attempt has recently been made to change the name of this ap-
pliance to screw-jack, but as it has been known since 1849 as jack-screw,
and is so named in Webster's and the Standard dictionaries, being illustrated
in the latter in position against the teeth, and as the term seems more
appropriate, this innovation is not regarded with favor.

172 MALOCCLUSION.
in position and somewhat expensive, three sizes being re-
quired, it was at the time regarded as a boon to the pro-
fession, and is still in favor with many dentists.
Lee and Bennett, some time in the 80’s attached a washer
of elliptical form with perforated ends below the head
of the jack-screw, and, attaching ligatures to this and the
fish-tail, used the appliance for pulling instead of pushing.
The author’s traction screw was suggested by this adapta-
tion of the jack-screw, as were probably various other de-
vices that have been used for traction. The traction screw”
may, in any event, be regarded merely as a modification of
the jack-screw, and not as the application of a distinct
principle. -
The force derived from the elasticity of rubber has been
extensively used in tooth movement. Rubber for this pur-
pose was introduced by Dr. E. A. Tucker, of Boston, in
1846. Although an immense amount of harm has resulted
from its improper application, and it is now far less
commonly used than formerly, it is, and doubtless will
long remain, a valuable adjunct to regulating appliances
under suitable conditions.
Occipital anchorage, gained through the use of the head-
gear, for the reduction of the mandible, as well as pro-
truding upper anterior teeth, was introduced by Dr. Nor-
man W. Kingsley, of New York, in 1866. It was of much
value, but since the introduction of the Baker Anchorage
is far less commonly employed than formerly.
The introduction of piano wire for use in orthodontia
by Mr. Walter Coffin, of England, some forty-five years
ago, marks another step of considerable importance. On
account of its great elasticity, it has been extensively used,
but far less now than formerly, as it has been largely sup-
planted by nickel silver.
* This has been denominated “drag-screw,” but the name seems neither
so appropriate nor euphonious as the other, and has not been adopted.
HEGULATING AFPLIANCES. 173
The introduction of vulcanite for the construction of
regulating plates is, in the author’s opinion, of question-
able importance, for the reason that the same results by
means of far more delicate forms in metal were previously
accomplished.
The introduction of delicate metal tubes" by the author,
in 1886, may, we hope, not immodestly, be said to have been
another step in the evolution of appliances, as they provide
a simple, compact, and ready means of attachment between
bands and working appliances. Their value is attested by
the fact that since their introduction they have entered
into the formation of all appliances of note.
The advent of a complete system is of such great im-
portance, in comparison with the fragmentary methods
previously employed, that it is believed to be worthy the
distinction of being classed among the epochs in the history
of regulating appliances. After a careful consideration
of the countless number of appliances that appear in the
literature, the author, in 1886, recognized the fact that
they must all exert force on moving teeth in one of three
ways, namely, by pushing, pulling, or twisting, and it oc-
curred to him that a very few simple forms would admit,
through proper interchangeable attachments, of almost
universal application, and that thus we might with great
advantage dispense with the confusing mass of recorded
appliances, many of them extremely crude, complex, bulky,
and unhygienic. His system was first described in a paper
before the Ninth International Medical Congress, in 1887.
The introduction of nickel silveri (the valuable prop-
erties of which are more fully discussed elsewhere) by
the author in 1887 for the manufacture of regulating ap-
pliances has to such a large extent revolutionized their
* Transactions of the Minneapolis Dental Society, December, 1886; of the
Minnesota State Dental Society, May, 1887; and of the International Medical
Congress, September, 1887. Also Ohio Dental Journal, October, 1887. Angle.
# Archives of Dentistry, September, 1888.
174 MALOCCLUSION.
manufacture that it must take rank as an important step
in their history.
The introduction of soft brass wire for ligatures by the
author is of such great practical value that he believes it
should here have honorable mention.
REQUISITE QUALIFICATIONS OF APPLIANCES.
Efficiency.—As the object of the regulating appliance is
to perform tooth movement, efficiency should take prece-
dence over all other qualities. The reason for this is ob-
vious, for at best the correction of malocclusion is to a
greater or less degree an unpleasant and protracted oper-
ation, and unless the appliance be efficient so that the
various tooth movements may be accomplished as rapidly
as is consistent with the physiology of tooth movement,
the operation will be unnecessarily long and tedious, sacri-
ficing valuable time of both patient and operator, and
frequently leading to discouragement and failure.
A very large number of the appliances recorded in the
literature are so obviously defective in the plan of con-
struction and operation—distribution of force, manner of
gaining anchorage, and manner of attachment—as to
greatly lessen their efficiency and to necessitate their being
worn far longer than would be necessary with efficient
appliances. Indeed we know that many of them could
not possibly have accomplished what is claimed for them.
Simplicity.—Next in importance to efficiency is simplicity.
The regulating appliance should be simple in principle and
plan of operation. It is well known that the best forms
of mechanism are those freest from complication, simplest
in design, and most direct in application of force.
It is also known that some of the most valuable machines
possessed limited utility until they had passed through cer-
tain evolutionary stages in which the original plans of great
complexity gradually gave place to those of simplicity.
For example, the electro-magnetic mallet and the sewing-
REGULATING APPLIAN CES. 175
machine. In fact, many modern inventions are but the dis-
covery of simpler methods in the application of long-known
principles; and where complexity may be admissible in
some machines, as for example, the printing-press, we must
remember that it performs numerous functions, and the
limits of space and weight are very broad, with the freest
scope for application of mechanical principles. But in the
regulating appliances the restrictions of the lips, cheeks,
tongue, gums, and occlusion make simplicity and freedom
from bulk of the highest importance.
FIG. I23.
R P R
#6 j6 °

f
M & ‘ā ā g ...ſº
2. T Tº Asºº
D
T - E §
: º Q (H E
º º R a R’ſſ) * 2
: fºº # 1 if ºğº 3
2. n J # #$# # N F (ſ E
B º
l,
<!-- * —,
The invention of a simple yet efficient machine is a more
difficult achievement than the invention of a complex one.
It should be remembered that each additional piece com-
posing a regulating appliance usually augments in a more
than proportionate ratio its liability to derangement, as
well as the care and time required in its operation, the
expense of its construction, and the inconvenience to the
patient. And yet the complexity of design and number
176 MALOCCLUSION.
of parts of many of the regulating appliances that have
come down to us through the literature are such as to
create the impression that their originators must have be-
lieved this quality to be of the first importance. Many
of these appliances are mechanical curiosities, and doubt-
less in the future will be pointed out as such. Two such
are shown in Figs. 123 and 124.”
FIG. 124.
\ -
º {{
º
P ‘
-*§
f§#
ti.-
:ºº:
|-£º%
|ºº
W\º%
N:
§
t&
º:§º
W
ſ \!...Y º * º lºº º * *
Fºº W
º º
Wº%
º %
Vº /
* ſº
T. Tº -
; º º º º º
" .
%. §: |||||W * -
- º ! º # º
㺠tºº.
\
w
Delicacy.—An appliance which is delicate in size and pro-
portion, and from which all unnecessary material has been
eliminated, possesses such important advantages as should
be readily appreciated, for in proportion to the bulk of the
appliance are the functions of the mouth interfered with.
Another serious disadvantage from a bulky appliance
is the difficulty of cleansing it. It affords ready lodgment
for particles of food, which, at the temperature of the
mouth, soon undergo fermentation rendering the breath
most offensive and necessitating the frequent removal of
the appliance (either by the patient or dentist, according to
its plan of construction) for the purpose of cleansing.
* Transactions Ninth International Medical Congress, Vol. V, p. 577,
Washington, D. C., 1887. -


























REGULATING APPLIANCES. 177
Thus the operation is prolonged, but worse than all, the
alternate forward and backward movements from the re-
linquishment and reapplication of pressure so interferes
with the tissues involved as to act as an incitant to in-
flammation—the principal cause of pain in moving teeth.
For these reasons a skeleton form of appliance, with
direct, stable attachments to the teeth by means of plain or
clamp bands, should invariably be used in preference to
devices in combination with plates, a remarkable illustra-
tion of which is shown in Fig. 125.
FIG. 125.
The use of such crude, bulky, inefficient, and most un-
cleanly appliances during the evolutionary stages through
which orthodontia has passed does not create so much
wonder, but why they should still form such an important
part of the latest works on orthodontia it is difficult to
comprehend. We are glad to note, however, that they are
rapidly passing and that they are entirely obsolete in the
practice of all members of the new school of orthodontia.
Inconspicuousness—As any devices upon the teeth attract-
ing attention are, to patients of sensitive nature, a source
of more or less annoyance, it is important that the reg-
ulating appliance shall be made as inconspicuous as pos-
sible; and yet we insist that efficiency in an appliance is
of so much greater importance that it should be kept fore-

13
178 MALOCCLUSION.
most in view even though the form of appliance best suited
to the case be conspicuous.
The wearing of appliances, however, has become so com-
mon as to no longer attract much attention.
The degree of unsightliness depends largely upon the
manner in which a given appliance is constructed and fitted
to the teeth. If gracefully proportioned, with skilfully
made attachments and the most perfect finish of parts, the
appliance, although noticeable, may not be really objection-
able in appearance. But if, as is too often the case, an ap-
pliance, though constructed on the same principle, be un-
necessarily bulky, badly proportioned, unskilfully attached,
with little attention given to finish of parts, its appearance
will be repulsive.
Stability of Attachments.-No matter how perfect the de-
sign and construction of an appliance, if the attachments
to the anchor and moving teeth be not such as to insure
its stability it becomes worthless, for if it slip or give at
the point of anchorage or deliverance it will become either
entirely inoperative or the force will be wrongly directed
according as the power is derived from a screw or spring,
thus prolonging the operation and sacrificing the time of
both operator and patient, with the added pain, annoyance,
and expense necessitated by the removal and repair of
the appliance.
Owing to the irregular and slippery surfaces of the teeth,
the gaining of firm attachment to them has always been one
of the problems in tooth regulation. Since the introduc-
tion of properly made plain and clamp bands firmly ce-
mented or clamped upon the teeth, and of the wire liga-
tures, the certainty of firm, immovable attachments is as-
sured, with consequent perfect control of the appliances,
and direction and intensity of force, making it possible to
compute with considerable accuracy the time necessary for
tooth movement in each given case. The great advantages
of this form of attachment have rendered practically ob-
REGULATING APPLIAN CES. 179
solete attachments by means of cribs, plates, clasps, etc.,
and it again becomes difficult to understand why such
forms of appliances, with their crude and necessarily un-
stable attachments, should still find advocates.
Materials for Construction.—Gold, silver, platinum, plat-
inous gold, platinous silver, iridio-platinum, platinoid (so-
called), aluminum, and several of the baser metals and
alloys, as brass, copper, aluminum bronze, steel, and iron,
and also vulcanized rubber, may all be used in the construc-
tion of regulating appliances, and each possesses proper-
ties of more or less value; yet, after experimenting with all
of these, the author is thoroughly convinced that the ma-
terial most nearly filling all requirements is nickel silver.”
Since its introduction for the manufacture of regulating
appliances by the author some twenty years ago, it has
largely supplanted all other metals for this purpose. Its
great practical value becomes more and more apparent to
the unprejudiced practitioner as the peculiar working
properties and possibilities of this nearly ideal material
are revealed by familiarity of use. In its manufacture
great strength and rigidity may be developed, as demanded
by the jack and traction screws. Again, it may be given
great elasticity, as required by the expansion arches.
When properly annealed, it is very malleable, yet suffi-
ciently rigid to give it the excellent qualities so necessary
in retention and reinforcing anchorage, as exemplified in
the wire G. But its excellent qualities are perhaps best
shown in its adaptation to the making of plain bands to
be placed upon the teeth for securing the attachments of
the appliances. Rolled into a flat ribbon, if it be of the
proper quality and properly treated in manufacture, it
may be drawn by the band-forming pliers so tightly about
the tooth as to conform to its surface with great accuracy,
* Nickel silver, or “German silver,” is an alloy of copper, nickel, and zinc,
prepared in varying proportions according to the use for which it is intended.
180 MALOCCLUSION .
even though it be but three-thousandths of an inch in thick-
ness (C), and yet it will be sufficiently rigid to withstand
being driven into place upon the tooth without crimping
or changing form if care be used—in striking contrast to
gold, silver, platinum, or other metals of the same thickness
used for this purpose.
Dr. C. A. Hawley in conducting some experiments in
order to determine the comparative strength and stretch
of nickel silver, iridio-platinum, and some other metals,
found that nickel silver, while possessing great tensile
strength, yet admitted of considerable stretching before
breaking, which accounts for its beautiful adaptability in
banding teeth, making it superior for this purpose to plat-
inum or gold, which while possessing valuable qualities,
the most important of which being freedom from oxidation,
are yet inferior in this respect.
The surfaces of nickel silver may be readily united with
solder, and its fusing point is so high that any of the
various grades of gold or silver solder may be employed,
if the proper flame be used and care be taken, without fear
of injuring the band by overheating.
So slow a conductor of heat is it that the excellent method
of soldering” by holding many of the pieces with the
fingers may be employed, again in sharp contrast to any of
the other metals we have enumerated.
It is susceptible to a high degree of polish, which should
always be given the band after setting, and which in most
mouths will remain durable, often assuming a delicate
bronze-like color pleasing in appearance. The wearing of
bands of this metal for three consecutive years without
detrimental change has been noted by the author. In a
Small percentage of mouths, however, it is true that it does
become discolored, even to unsightliness. This fact has
given rise to the only prejudice against the use of this
* Introduced by the author in the second edition of this work.
REGULATING APPLIANCEs. 181
metal that we know of, but this objection seems trivial in
view of its many points of superiority. If the orthodontist
will insist upon a reasonable degree of cleanliness on the
part of the patient while wearing the appliances, or will
occasionally devote a moment or two of attention to them
himself with the soft rubber disk and pumice, followed
by a burnisher, there need be no occasion for complaint.
And lastly, its inexpensiveness brings it again in sharp
contrast with gold and platinum; yet we insist that it is
its excellent qualities more than its inexpensiveness that
makes it so preferable a metal for orthodontic purposes.
The oft-repeated fallacy that gold is the one suitable
metal for the construction of regulating appliances is
rapidly passing, as it ought, for undoubtedly it has been a
real hindrance to progress.
C H A P T E R X.
THE AUTHOR’s APPLIANCEs.
“In art—in all things, the supreme excellence is simplicity.”
WHILE giving a course of lectures on the subject of
orthodontia to a class of dental students in 1884 the author
for the first time made an extensive research into the his-
tory and literature of the science and he was amazed to find
such a vast number of appliances recorded therein. Indeed
most of the literature then consisted of descriptions of
regulating appliances which had been constructed for
Special cases, and the plan being still in vogue several
hundred more were recorded in the next few years. Most
appliances being invented to meet the requirements of in-
dividual cases (and often only hypothetical cases), and
usually a special appliance being designed for each mal-
posed tooth, their range of application to other cases was
very limited. With the exception of the Dwinelle jack-
Screw all were constructed by hand from raw material.
In connection with them there was simply no system or
order, and the difficulties and discouragements in teaching
Orthodontia at that time can at this date hardly be com-
prehended. - -
As already noted, the author, after much consideration,
became convinced that notwithstanding this vast number
of appliances, each one must act, if at all, by exerting
force upon malposed teeth in one of three ways, namely,
by pushing, pulling, or twisting. It then occurred to him
that it might be possible to construct a few instruments of
simple form and standard pattern which would meet the
requirements of all cases. More study convinced him that
the plan was practicable, and, that if so, the difficulties in
teaching and practice would be greatly lessened.
182
THE AUTHOR’s APPLIANCEs. 183
The problem, then, was to devise three instruments, one
for pushing, one for pulling, and one for twisting, each of
form to admit of almost universal application, and all to
be of standard pattern; delicate yet efficient, with inter-
changeable parts, to be attached to teeth used as anchorage
as well as to the teeth to be moved, by means of plain
bands made from ribbons of band material, these ribbons
or coils of band material also to be of standard width and
diameter.
It seemed to the author that the requirements of the in-
strument for pushing could be best met in some form of
jack-screw. The well-known Dwinelle jack-screw, shown in
Fig. 122, was, as we have said, then in use, it being com-
posed of steel and three different sizes being required. It
Soon became apparent that, owing to its peculiar form,
difficulties of attachment, and the metal from which it was
made, its range of application was far too limited to bring
it within the proposed requirements. As a result the
author’s jack-screw was invented and its construction by
any dentist was at that time thought to be practicable.
At first it was somewhat crude and consisted of a threaded
shaft with a needle-like point. On this shaft was fitted a
nut to be turned with a wrench in order to exert force. The
shaft of the screw was made to telescope within a base
consisting of a square bar of silver which was usually
forged from about one-half of a silver twenty-five-cent
piece.
The advantages of this jack-screw over the old form lay
in the fact that it was far more delicate and admitted of
great range in length—from one-fourth of an inch to any
desired length—gained by varying the length of the base
or sheath. Furthermore, as the threaded shaft was not
required to turn, as in the Dwinelle form, the whole screw
could be bent to crescent form if desired, as might be of ad-
vantage when placed across the vault of the arch. Still
another great advantage, the base could be securely held to
184 MALOCCLUSION.
the anchor attachments by solder as well as by a variety
of other means, as shown in Fig. 623.
While possessing these advantages it still had certain
defects which had to be overcome before it would com-
pletely meet the great diversity of requirement. It being
difficult to bore a hole of uniform diameter in the square
base, it was thought a round tube would possess advan-
tages, and after much inquiry a crude form of tubing
known as “joint wire” was found in use among jewelers.
This was an improvement, though still defective, as the
shell was of far greater thickness than necessary and the
bore much too small, still requiring boring for its necessary
enlargement. Moreover, the tubing not being seamless
would spread under strain, and being a crude alloy of
silver, it lacked rigidity, so that more metal was required
than was consistent with the desired delicacy. Further-
more, the threaded shaft being steel, it gave much trouble
from corrosion. So it became necessary to find a more
suitable metal from which to make not only this, but if
possible, all regulating appliances.
Gold or platinum had previously been almost wholly
relied upon, but it seemed to the author that their great
expense as well as their malleability was a serious
handicap. After tedious experimentation he was delighted
to find that a fine quality of nickel silver, or “German
silver,” as it was then generally called, met the require-
ments for the construction of not only the regulating but
the retaining appliances. We have discussed the desirable
Qualities of this metal elsewhere.
The trouble of getting manufacturers of tubing to ex-
periment until an ideal seamless tube of nickel silver was
produced need not here be dwelt upon. Much credit, how-
ever, is due to the Ellwood Ivins Tube Co. for carrying to
completion the solution of the difficult problem.
The first improvements of the jack-screw over its orig-
inal form, then, were in the change of metal, and making
THE AUTHOR’s APPLIANCES. - 185
the sheath of tubing and that seamless and of the minimum
thickness consistent with strength. Next, it was found that
two lengths of tubing would give the screw sufficient range
of application, and by making its delivery end flat so that
it could be pointed or notched at the will of the operator,
its range of attachments was extended. Later another
valuable improvement was added in the friction sleeve mut
which effectually prevents its displacement by the tongue.
As perfected it is shown in Fig. 126.
FIG. 126.
Illustrations of a few of the many uses to which it is
applicable are shown in the Appendix.
Traction Screw.—To devise an instrument that would be
universal in its application for exerting a pulling force
was not an easy problem, and after experimenting much
with a spring it was abandoned for the power derived from
the Screw. After much thought it became apparent that
a Screw for pulling that would have quite as wide a range
of application as the jack-screw for pushing could be made
by simply modifying the latter. Metal tubing being now
at our command, this was made much easier. So a section
of wire that had been bent sharply at right angles near one
end was threaded and made to telescope a long sheath
(similar to the jack-screw), and a nut engaging the threads
Worked against the end of the sheath opposite to the angle.
The short, bent end of the shaft engaged a short section
of tubing, all as shown in Figs. 127, 128, 129, and 130. The
tubes, being soldered to bands on the anchor teeth and those
to be moved, furnished a medium of attachment for the
Screw and a means for the distribution of the force. By

186 MALOCCLUSION.
using two or more of the screws, combinations could be
formed whereby a number of teeth might be moved by
pulling, so that with it practically all of the requisite move-
ments could be accomplished, while as in the use of the
jack-screw, simple, stationary and reciprocal anchorage
could be gained. - r -
- FIG
. 127.
ſº w
% ſº º ****
"SA
... Nºw Ee
=NYº
# º -
At first it was thought that two sizes of this screw were
necessary. Later it was found that the larger size only
was sufficient and the smaller size was abandoned. A few
of its many possible combinations are shown in the
Appendix. e
Lever.-An instrument for exerting a rotary force upon
a tooth, which could be applicable in all cases, was next
considered, a lever being the only instrument that
could meet this requirement. Already we were making










THE AUTHOR’s APPLIANCEs. 187
use of this principle in a crude way, namely, by a rigid
lever in the form of a finger of metal soldered to a band
cemented on a tooth, the long end of the lever being tied to
some suitable anchor tooth (see Guilford, American Sys-
tem of Dentistry, 1885); but the range of force thus to be
gained was very limited, requiring frequent removals and
reapplications of the band in order to bend the lever and
continue the force. But the author’s device consisted of a
very short section of tubing soldered to a band on the tooth
FIG. 131. FIG. 132.
§:..? ###
* | º
to be rotated, into which one end of the lever was inserted,
the other end being sprung around and attached by a liga-
ture to some suitable anchor tooth, as in Figs. 131 and 132.
Sections of the very elastic form of steel known as piano
wire were used as levers, L, Fig. 135, so that a great range
of movement could be given to the tooth and any degree
of force exerted simply by substituting a lever of greater
or less diameter, four different sizes meeting all require-
ments. By this means any single tooth, or a number of
teeth, could be given continuous rotatory force. A few of
the almost limitless possible combinations are shown in
the Appendix.
As auxiliaries to these three devices were added a



188 MALOCCLUSION.
number of short sections of small tubing, R, Fig. 133, and
a section of smooth, soft wire, G, Fig. 134, which accurately
Fig. 133.
; :
FIG. 134.
telescoped these small tubes, the principal uses of these
auxiliaries being the reinforcement of anchorage and the

THE AUTHOR's APPLIANCEs. 189
final retention of the teeth, for which we have since found
no substitutes. They are very useful.
The jack-screw E and J, the traction screws A and D,
and B and C, and the levers L, together with their auxilia-
ries, wire G, tubes R., band material F and H, and the
wrench, are shown in Fig. 135.
After much difficulty in the manufacture of these devices
they were finally made on fine machinery by skilful ma-
chinists with great accuracy in the fit, and beauty in the
finish of parts, as well as the greatest strength possible
consistent with delicacy.
The simplicity, efficiency and range of ready adaptability
of these three devices and their auxiliaries were quickly
recognized, and they soon largely superseded the limitless
number of old, made-to-suit-the-case forms of appliances,
and they had and are still having an extensive use by
dentists in all countries, but for reasons that we shall
note later they are far less used by the author than for-
merly.
Another special type of appliance seemed necessary to
meet the requirements of treatment of a distinctive type
of cases which has always given the dentist much trouble.
They were formerly loosely designated as “protrusion
cases,” or “cases of protruding upper incisors,” but are
now classified as belonging to Division 1 of Class II.
Until recently the plan of treatment of these cases, after
extracting the upper first premolars, was to reduce the
prominence of the incisors and canines by retracting them
(using the molars for anchorage) to close the Spaces thus
made, and great force being necessary to accomplish this,
much unfortunate displacement of the teeth used as an-
chorage often resulted. In order to avoid this and gain
more stable anchorage Dr. Kingsley had made use of oc-
cipital anchorage by covering the back and top of the head
with some form of cloth or leather cap, and a pulling force
was given to the protruding teeth by heavy elastics at
190 MALOCCLUSION.
tached to this cap on both sides and distributed to the teeth
through various contrivances.
This very original plan was variously modified by
Farrar, Goddard and others. Most of the modifications,
FIG. 136.
however, were very bulky, clumsy, and some of them
absurdly complicated. In 1888 the author devised
an appliance for this special class of cases,” also making
FIG. 137.
ſº sº º . º º º
/ sº º
º |||ſ, | " ... | | |
* 7. º º \
º
&
Q
º
W
|
\ -
ſºlº In 1 | \ W
º º
º
/º/, º * Hi}!
º
º
ſ
|
, , , ,
|
|
ſ
t
1:...º.
use of this form of anchorage. It consisted of a delicate
round bar of metal bent to conform to the shape of the
* Angle, International Dental Journal, June, 1889.





THE AUTHOR’s APPLIANCES. 191
ideal dental arch. It was made to encircle the dental arch,
its ends being supported by loosely telescoping tubes
FIG. 138. FIG. 139.
:
2
Á
º
()
;
;
O
:
:
C
:
ºº
º
*
º
º
º
Öº
º
º
§
tº:-
à
s
Z
E.H. A.
:-
ū
Ž
3
Soldered to bands on the upper first
molars. The center of this curved bar
i e e * s
# º rested in contact with the labial surfaces
º of the prominent central incisors and
j was held in place by notches formed in
| plain bands cemented upon these teeth,
| all as shown in Figs. 136 and 137.
Force was received upon the center of
this spring arch through a traction bar,
A, Fig. 138, having a standard in its cen-
ter with a socket in the end of the stand-
ard, which socket engaged a ball sol-
dered to a delicate sheath that in turn
was soft soldered to the center of the
N spring arch, thus forming a ball and
tº YA socket joint.
W The author’s headgear for Securing oc-
cipital anchorage in connection with the
above device, is shown in Fig. 139. It is an improvement
over the ordinary form in that it consists of an adjustable,
S. ;










192 MALOCCLUSION.
non-collapsible rim, to which is attached by a silk lacing-
cord a silk met which fits the back of the head, the rim
FIG. 140.
being large enough not to come quite in contact with the
head. By attaching elastic bands, one above and one below

THE AUTHOR’s APPLIANCES. 193
the ear on each side, which engage the hooked ends of the
traction bar, any desired degree of force can be directed
against the protruding teeth. The device in position upon
the head is shown in Fig. 140. The non-collapsible rim dis-
tributes the force equally over the patient’s head, so that a
much greater amount of force can be borne without incon-
venience than with the caps formerly employed, which lo-
calized the pressure thereby restricting the circulation
and causing headache.
By studying this device in its entirety it will be seen
how nearly ideal the plan is for the distribution of force
for the reduction of the prominent teeth; how as the spring
arch receives pressure from the ball and socket joint it
is moved distally, not only carrying the protruding teeth
with it, but compelling their regular arrangement, all being
retracted until the spaces made vacant by the extraction
of the first premolars are closed, without any displacement
of the posterior teeth.
The headgear and traction bar of course cannot be worn
constantly but they are easily removed and replaced by the
patient. While the teeth are thus released from heavy
pressure they are prevented from springing back by means
of delicate rubber ligatures, as shown in Fig. 137, which
are made to act constantly. It will be seen that they en-
gage the distal ends of the tubes on the anchor bands, are
stretched forward and tied in front of delicate metal
collars, thus automatically holding all that is gained in
tooth movement by the greater force from the heavy elas-
tics. Later hooks were attached to these collars (sheath-
hooks) which directly engage the delicate rubber ligatures.
The arch by its own elasticity also constantly exerts con-
siderable force in the desired direction upon the moving
teeth. This is effected by giving the arch considerable
lateral spring before slipping its ends into the sheaths of
the anchor bands, whereby the spring arch in its effort to
assume its normal pose manifests a strong tendency to
14
194 IMIALOCCLUSION.
slide distally through the tubes, giving a corresponding
pressure to the incisors. Too great lateral pressure, how-
ever, should not be exerted upon the anchor teeth, as in
time they would be displaced. Various modifications of
this method are shown in the Appendix.
Notwithstanding the great efficiency of this appliance,
the present demands of orthodontia are best fulfilled in
these cases by the Baker form of intermaxillary anchorage,
later to be considered, by means of which extraction is
avoided and normal occlusion established instead of merely
“improved’’ occlusion as in the former plan of treatment.
For this reason this appliance has been superseded in the
author’s practice, and though it may occasionally be used
as auxiliary to intermaxillary anchorage, yet the necessity
for its use will become lessened as greater skill in the
employment of intermaxillary anchorage is developed.
Fig. 141 shows the use of the headgear in connection with
the chin retractor—a combination principally relied on for
reduction of prominence of the mandible in cases belonging
to Class III until the advent of the intermaxillary anchor-

THE AUTHOR’s APPLIANCEs. 195
age, which has almost entirely superseded it, although it
is still regarded with favor as an auxiliary to intermaxil-
lary anchorage by a few practitioners.
Although, as we have said, these appliances with their
auxiliaries are no longer relied upon by the author to the
extent formerly, yet many of their simple combinations are
still in daily use, chiefly in performing very simple move-
ments of teeth or in certain cases for the readjustment of
some teeth that have partially relapsed from their cor-
rected positions. To make the reason for their general dis-
continuance clear let us remember that the requirements
in orthodontia as we understand it today differ greatly
from those existing at the time of invention of these de-
vices. Then there was no classification of malocclusion, no
standard or basis from which to correctly determine the ex-
act direction or extent of tooth movement other than the
One fixed, in each case, by the individual judgment of the
Operator, which often decreed that where the teeth were
crowded room should be provided by the sacrifice of one or
more and the pushing, pulling, or twisting of the remainder
simply into alignment, and usually limiting this to the up-
per jaw regardless of the higher requirements of facial
art and of the functions of the teeth through occlusion, that
according to modern standards completely govern the di-
rection and extent of all tooth movements in each given
case. In other words, normal occlusion and facial balance
now being the basis from which to reason, consideration of
the entire denture instead of only the mere symptoms or
the “crooked” teeth, as formerly, is necessitated and often
calls for the movement of all of the teeth in one or both
arches. This being true, a device to meet the requirements
should be able to exert the desired amount of pressure, not
only on a single tooth to accomplish any of its required
movements, but as well on any or all of the other teeth of
the same arch or of both arches in any necessary direction
simultaneously.
196 MALOCCLUSION.
To compass these exactions would at first thought seem
impossible, even with a large number of devices, but it has
been found not only possible, but possible with only a single
appliance. That appliance in its perfected condition has
FIG. 142.
FAUC HARD'S
1728
been named by the author the expansion arch, from its
chief function, although no name can adequately describe
it. - -
For the inception of this valuable device, as we have
said, we are indebted to the great French dentist, Fau-
chard. Without doubt its introduction marks by far the
most important step in the history of regulating appli-
ances. Originally the appliance was very crude, clumsy,
unsightly, and its uses greatly limited. It was composed
of a flat ribbon of metal, perforated for the reception of





THE AUTHOR’s APPLIANCEs. 197
fibrous ligatures by means of which attachments were made
to the teeth used as anchorage as well as to the teeth to be
moved. The principle has been made use of in many
FIG. 144.
#t.
}}
3%
"...º.
ſº
jº." F. : |
*| | | || - f. *NW l
Ulm. º 32/E. 3. ! º ſ
lſºs º
\
\\
modified forms by many practitioners since Fauchard’s
time, only a few of which have we here space to consider.
Four of the chief of these are represented in Figs. 142,
143, 144, and 145. It is doubtful whether Fox’s plan of
nearly a century later was any improvement over


198 * MALOCCLUSION.
Fauchard's. It differed from his principally in the addi-
tion of that most useless absurdity, the gag, in the form
of blocks of ivory, to prevent the closure of the jaws and
interference with the moving teeth.
A marked improvement in the anchorage of the arch was
given us by Schangé in 1841, in the form of a skeleton crib
attachment to the molars. -
Harris’s modification consisted in improvement of the
manner of attachment for securing anchorage. Metal caps
were swaged to cover the crowns of the molars, to which
the arch was soldered, and in order to keep these caps in
position upon the anchor teeth they, in turn, were soldered
to a metal plate covering the vault of the arch. This
necessitated the frequent removal of the device for the
purpose of cleansing—a fatal weakness in any appliance,
as the moving teeth are thus often sprung back and forth
by the relinquishment and reapplication of force, which
action is a certain means of inciting inflammation. Desir-
abode's modification was very similar to that of Harris.
To describe any considerable number of the later mod.
ifications would require too much space. They differ
chiefly in their proportions and in their manner of attach-
ment, being combined usually with some form of plate.
The author’s improvements of this appliance may briefly
be said to consist in change of metal (nickel silver), modifi-
cation of form and proportions, greater length of thread-
ing of sides for universal adjustment of size, in the
material, style, and proportions of the parts entering into
the anchor clamp bands, and in the various attachments,
some of which are modified and others newly devised. Im-
portant among these is the addition to the clamp band of
the long tubular sheath for the reception of the ends of the
arch, which not only protects the cheeks from abrasion
by the threaded portion of the arch, but gives greater
stability to the anchorage. Still others deemed very im-
portant are the friction sleeve of the sheath of the clamp
THE AUTHOR’s APPLIANCEs. 199
bands, and extension flange of the arch nuts, as shown
(enlarged) in Figs. 146 and 147, the extension rib on the
ribbed arch E, as in Fig. 147, the sheath hooks, Fig. 151,
for use in the Baker anchorage, and last and very import-
ant, the brass wire ligatures, Fig. 154, descriptions of all
of which follow in connection with instructions for their
U1S62.
|
For convenience there are three styles of the expansion
arch. Fig. 146 represents the plain arch E which is a very
elastic round bar bent to conform approximately to the
shape of an ideal dental arch. The sides of this arch are
threaded and provided with nuts. One end of these nuts is
elongated to form an extension flange, which accurately
telescopes the friction sleeve of the sheaths of the D and X
bands, as shown in the engraving.
This form of nut adds another truly valuable improve-
ment to the expansion arch, as it enables us to make the

200 MALOCCLUSION.
exposed part of the nut very short and compact, at the
same time giving greater length of thread and conse-
Quently greater strength. Its greatest value, however, lies
in the fact that this extension flange prevents the loosening
of the nut by unscrewing through friction with the tongue
or cheek—a common annoyance since screw devices have
been used in the mouth. This improvement is also made
use of in the author's jack and traction screws.
FIG. 147.
Fig. 147 shows the ribbed expansion arch E, a later mod-
ification of the arch last shown and differing from it only
in being provided with a delicate rib on the periphery of
the unthreaded portion, in which hook-like notches are to
be made at desired points to prevent slipping of the wire
ligatures. By this means the direction of force on the
moving teeth is accurately controlled. It is further valu-
able in that it greatly increases the strength and lateral
spring of the arch, thus adding measurably to its efficiency
in widening the dental arches.

THE AUTHOR’s APPLIANCES. 201
The author has recently added a smaller size of each of
these arches, which are especially advantageous in treating
FIG. 148.
E. H. A.
the cases of very young children. They are shown in Figs.
148 and 149.
Fig. 150 shows the third form of the arch as used by the



202 MALOCCLUSION.
author, known as the arch B. It is smooth and threadless,
similar in form and temper to the plain expansion arch E,
though more limited in use. It is especially designed for
shortening and widening the anterior part of the arch and
FIG. 151.
has a sheath-hook on each side for the reception of the
rubber ligatures. The delicate ball in front makes it appli-
cable for attaching the standard of the traction bar when
it is desired to use occipital anchorage singly, or as auxil-
iary to the intermaxillary anchorage.
FIG. 152.
The sheath-hooks (enlarged), shown separately in Fig.
151, are to be attached to either of the other arches when-
ever it is desired to employ them in connection with the
Baker anchorage.
Fig. 152 represents six adjustable clamp bands. Nos.
1 and 2 are plain, and are used both in regulation and in
retention. Nos. 3 and 4 are provided with strong, headed
pins soldered to their screw-heads. These were especially
designed for the treatment of fractures of the maxillae.
The X and D bands are provided with smooth-bore tubes
soldered to their sides into which the ends of the arches
and the extension flanges of the nuts accurately fit. The
X bands are for premolars and the D bands for molars.”
* For the varying sizes of molar teeth there are three sizes of D bands,
although in the author's practice the medium size alone meets all require.


THE AUTHOR’s APPLIANCEs. 203
Fig. 153 shows three coils of band material, already re-
ferred to, from which plain brazed bands for incisors, ca-
nines, or even premolars may be made, that serve as me-
diums of attachment to the arch through wire ligatures.
They are also very largely used in retaining devices. C
and F are of the same width, being narrower than H, and
F and H are of the same diameter, being thicker than C.
C is used only where a very thin, delicate band is required;
F where a stronger band is needed, and has much more
universal use; H is principally used for canine bands.
Fig. 154 represents the ligature wire, which is very soft,
Smooth, and strong, and especially prepared for the use
FIG. 154.
of the orthodontist. It comes in three sizes. The largest
size is preferable for performing most tooth movements.
The medium size is used where less force is required, or
where the teeth are so close together that the larger wire
could be passed between them only with difficulty. The
Smallest size is principally used to hold teeth passively to
ments of the permanent molars. The smaller size, however, is occasionally
found to be an advantage when the deciduous molars are used as anchor
teeth.


204
JMALOCCLUSION.
FIG. 156.
. . . . .
É----
X.
|:| =-
X
|| -i -
-i
{{[[: | -
|º º
|
FIG. 155.
-
\
;:
|
\
W
º




























THE AUTHOR’s APPLIANCES. 205
the arch after their movement is completed and while the
FIG. 159. - FIG. 160.
ºf
"H IT
| -
in-d \
º
ſº '. "
movements of other teeth are being completed by means of


206 MALOCCLUSION.
the heavier ligatures. It is also sometimes used in con-
nection with the retaining devices.
FIG. 161.
Fig. 155 represents strips of rubber from which wedges
are made to exert pressure on some tooth of overprom-
inence, or to assist in rotation.

THE AUTHOR’s APPLIANCEs. 207
Instruments.--For uniting the different parts of the ap-
pliances to form the various combinations, and for plac-
ing them in position upon the teeth, only a few instruments
FIG. 163. FIG. 164. FIG. 165. FIG. 166.
are necessary, but it is important that they should be of
the best selection and some of them of special design.
Fig. 156 shows the author’s soldering pliers. Their del-

208 MIALOCCLUSION.
icate proportions and peculiar form making them
especially suited for holding bands and small pieces.
Fig. 157 shows another pair of pliers for placing pieces
of solder in position, picking up small pieces, etc.
The author’s band-forming pliers are shown in Fig. 158.
These were designed especially for making bands, their
plurality of operating edges making them equally appli-
cable to any surface of any tooth. They are provided with
grooves for holding the small square nuts and round wire,
and are also very useful for most other orthodontic pur-
poses for which the usual flat-beaked pliers are employed.
A good pair of wire cutters is essential, the style shown
in Fig. 159 being the most satisfactory of the many makes
the author has tried.
The author’s regulating pliers are shown in Fig. 160.
These are used for exerting force in moving teeth by
lengthening or shortening wire, and for numerous other
purposes—a very valuable instrument.
A pair of Scissors for trimming bands, clipping liga-
tures, etc., is shown in Fig. 161.
The How pliers are best for tightening ligatures and for
general uses. They are shown in Fig. 162.
An ordinary hand mallet and band driver, shown in
Figs. 163 and 164, are also requisite. The beveled end
of the band driver is for the purpose of restoring to proper
form the friction sleeves of the sheaths of the D bands
when by accident they become bent.
The two wrenches shown in Figs. 165 and 166 are for
use in turning all the nuts of the various appliances; one,
a short single-end wrench, and the other a double-end, or
right and left, wrench especially designed for the adjust-
ment of nuts of the clamp bands on lower molars, which are
practically inaccessible to a straight wrench. Both are
made of steel, nickel-plated and finely finished.
And last, and very important, a suitable lamp for Solder-
ing. The author prefers the Lane blowpipe, shown in
Fig. 167. -
C H A P T E R XI.
SOLDERIN G.
IT is safe to say that no one will ever acquire much skill
in orthodontia unless he attains proficiency in soldering.
Efforts have been made by some to construct regulating
and retaining appliances so that all unions of parts shall be
effected by mechanical attachments, as Screw-, hook-, or
FIG. 167. FIG. 168.
clamp-joints. In principle this is commendable, but in
fact, carried beyond certain narrow limits, is impracti.
cal, for it necessitates needless bulk, useless complex-
ities, and unnecessary expense, a brazed joint being far
stronger, far more compact, cleanly, and inexpensive.

15 209
210 MIALOCCLUSION.
The soldering required in orthodontia may be accom-
plished easily, and almost instantly, by the operator who
will devote a little time to mastering the method here
described.
FIG. 169.
One of the first essentials to correct soldering is a clean,
meat, convenient place to work; and another of very great
importance is a proper blowpipe.
As many of the parts of these appliances are very deli-
cate, it is important that a very fine, sharp, steady flame
be used in effecting their union by solder. A large or
uneven flame would injure and might ruin them. The Lane
blowpipe, Fig. 167, operated with the ordinary foot-bellows
is especially well suited, as it produces the requisite flame,

SOLDERING. 211
Fig. 168, of most instense heat, yet under the most perfect
control, while both hands of the operator are left free.
Fig. 169 shows the bracket table used by the author as
a convenience in this work. On this table, three feet long
by fourteen inches wide, ample convenience is offered for
all the necessary operations preliminary to the adjustment
of the appliances upon the teeth. It is covered by a glass
slab and holds the blowpipe, connected by tubing with the
foot-bellows. The drawers are receptacles for tools and
appliances.
FIG. 170.
Notwithstanding the many ingenious spring clamps
and other devices that have been invented for holding such
small work, the plan introduced by the author in the second
edition of this book, if once mastered is far preferable in
most cases. It consists in holding the two pieces in contact
while soldering by means of the fingers or pliers. The metal
of which these appliances are made is most favorable for
Soldering in this way, it being so poor a conductor of heat
that most of the attachments can be made while held with
the fingers without any perceptible communication of heat
to them, provided the flame be suitable.
Where union of a small tube with a band is desirable,
as in Fig. 168, the tube is best held in contact with the
band and flame by means of some delicate instrument that

212 MALOCCLUSION.
will absorb but little heat. One of Gates’ nerve-drills with
the point broken off is nearly ideal for this purpose.
Where two small tubes are to be united, as in Fig. 170,
the pliers may be used to support one of them.
This method of soldering is not difficult, most students
learning it readily. The only point that may seem at all
difficult to the beginner is the holding of the pieces in fixed
position just at the time the solder is congealing. This
is accomplished by touching one or more of the fingers
of one hand with those of the opposite hand, as in Figs.
168 and 170, to steady them, holding the pieces gently,
not rigidly, just as a good penman holds a pen. After a
little practice any of the soldered attachments may be
easily and quickly made. All of those shown in Figs. 623
and 624 are made in this way. -
Where the end of a small tube is to be united to a band,
it is best to fuse the solder upon the band, then hold the
small tube by means of the small pliers in contact with
the solder and again apply heat, as otherwise the solder
will usually be drawn into the tube.
The solder” best adapted for uniting the different parts
of these appliances is silver, although any of the various
carats of gold solder may be used, with cream of borax
for a flux. No more solder than is necessary should be
used, especially in all small attachments—just enough to
make a firm union.
Always avoid injuring the metal by overheating, or
bringing it to more than a bright red color. Apply only
sufficient heat at the right point to thoroughly fuse the
solder. In every instance avoid overheating the Screws
and nuts. This is to be especially observed with the jack
and traction screws. Great care is observed in the manu-
facture of the arches E and B to preserve their stiffness
* The author recommends a silver solder prepared for the use of Ortho-
dontists by The S. S. White Dental Mfg. Co. -
SOLDERING. 213
and strength, and we would impress the fact that heating
them would ruin their fine temper and render them worth-
less. -
Plain Bands.-As the plain bands form such an important
part of the regulating appliances, and especially in this
system, it is important that proper methods be employed,
not only in their making, but in their setting as well.
So erroneous are many of the directions given by authors,
and so crude are some of the different methods of making
these bands that it may be instructive to here point them
Out. . -
First, it is the plan of some to adjust the appliance to
the plaster model, forming the bands over the plaster teeth,
and then to transfer it to the mouth. A more crude or
inaccurate method could hardly be devised, as it is impos-
sible to pinch or burnish band material about a plaster
tooth so that its final fit to the natural tooth will be at all
accurate, and so made it must soon loosen under the neces-
sary strain of tooth movement. -
Another but slightly less crude method in which much
unnecessary time is consumed is to cast the form of the
tooth in metal, around which the band is hammered and
molded to the desired form. The fit of such a band can be
but little more accurate than when made after the method
last described.
Another method is to make a band in a similar way and
then to cover it, forming an entire crown for the tooth.
This of all methods is the most absurd, for unless the tooth
be mutilated such a band must be imperfect of fit, bulky,
and occupy valuable space, and also often directly interfere
with occlusion, while the firmness of attachment is no
greater, but probably less, than with a plain or clamp band
correctly made and properly set with suitable cement.
One author directs that the band shall be made larger
than the tooth in order to provide space for the cement—
another error, for with a band larger than the tooth its
214 - MALOCCLUSION.
attachment will be far less firm than if the fit were accurate
and it will be almost sure to loosen under the strain neces-
sary in tooth movement. The most accurately fitted band
admits of the requisite amount of cement if the latter be
properly mixed, which may be due in part to the slight
stretching of the band when it is driven into place.
Another author recommends that the band on its inner
surface be corrugated or roughened by scratching in order
to make the cement adhere more firmly. The folly of such
practice ought to be apparent when we remember how
firmly cement adheres even to the polished surface of agate
or glass. Again, note the inconsistency of roughening the
band and not the enamel. Such practice is wholly un-
necessary, besides being injurious to the band,
Another method is the use of a strip of metal in length
not quite sufficient to encircle the crown of the tooth, and
having soldered upon its outer surface, near the ends and
at right angles to them, two small buttons around which
ligature wire is wound in the form of the figure 8, thus com-
pleting the union of the ends of the band by tying. This
form of band possesses no advantages over the brazed
band, but on the contrary has many disadvantages. It is
bulky and uncleanly and under the strain of tooth move-
ment will loosen far more easily, besides being more expen-
sive and requiring more time in tying than is needed in
brazing.
We have already stated our reasons for preferring
nickel silver for the making of regulating appliances, and
especially for the making of bands, in Chapter IX, yet this
metal varies greatly in quality, not only on account of
differences in the formulae, but also on account of the man-
ner of manipulation in manufacture. -
It is important that it be of the proper fineness, diameter,
and temper, or it will be harsh and unyielding and difficult
or impossible of proper adaptation to the form of the
tooth, in which case it will loosen more readily under the
SOLDERING. 215
strain of tooth movement, will occupy unnecessary Space
between the teeth, and present a less pleasing appearance.
The method of making plain bands employed by Dr.
Magill, who must always be regarded as the father of this
most valuable adjunct to orthodontia, was to burnish a short
piece of band material (platinum) about the tooth, overlap
the ends and solder. This method, though much better
than those already described, falls far short of the possi-
bilities in band making. -
By the author’s method” a ribbon of band material of
sufficient length to firmly grasp with thumb and fingers is
slipped around the tooth to the desired point, and pinched
with the band-forming pliers to conform to the shape of
the tooth.
By this means there is sufficient pressure brought to
bear to stretch the metal and make it adapt itself with the
greatest accuracy to the surface of the tooth around which
it is drawn. The author wishes to make clear the necessity
of having not only a firm grasp of the band material, but
exerting a strong pulling force on it with the fingers, to be
counterbalanced by a pushing force from the pliers. If
these two forces are properly balanced, although they
may be considerable, even to the extent of breaking the
band material, they may be employed so skilfully as not
to cause pain even to a tooth that is already tender on
pressure from tooth movement. -
A band so formed and ready for soldering is shown at
Fig. 171.
Simply pinching a short piece of band material about
the tooth, as has been recommended by some authors,
makes a loose fit and an imperfect band. Fig. 1727, taken
from one of the modern works on orthodontia, shows a
fair sample of such bands.
* Notes on orthodontia. “A New System of Appliances,” Transactions
Ninth International Medical Congress, 1887. Angle.
+ Essig’s “American Text-book of Prosthetic Dentistry.”
216 - MIALOCCLUSION.
No one should expect other than a very crude band if
rough and loose-fitting pliers be used for pinching, for the
FIG. 171,
FIG. 172.
A. B
junction of the pinched portion will then be rounded, as
in Fig. 172, instead of sharp and at right angles, as in Fig.
171.
FIG. 173.
Many advantages will be found in the use of the author's
band-forming pliers, Fig. 173. The peculiar shape of the


SOLDIERING. 217
instrument and form of the jaws make it equally adaptable
to all of the various surfaces on any of the teeth where the
union of a band is desirable.
In banding the centrals, laterals, or canines the union
may be made either on the labial or lingual portion of the
tooth. If made on the labial surface that portion of the
band crossing the lingual surface of the tooth should be
properly burnished to a fine adaptation just before the final
strain with the pliers. The canine is the most difficult of
any of the teeth to band, but by forming the seam on the lin-
gual incline and firmly burnishing the outer surface while it
is being pinched, an accurate fit can in most instances be
made. Another plan is to pinch a fold in the band on the
lingual incline, while it is being firmly pinched and drawn
with the fingers on the opposite side. The band is then
removed and a little solder flowed into the fold. It is
then replaced and the seam made upon the labial surface
by pinching, burnishing, etc., in the usual way.
FIG. 174.
SOLDER--
In soldering a band either gold or silver solder may be
used. A portion about one-eighth of an inch square wet
with borax cream is placed between the angles of the band
and held by the band-soldering pliers, Fig. 174, over the
sharp flame of the Lane blowpipe. With these pliers uni-
form pressure is exerted at the exact points necessary to
insure a smooth unbroken joint when soldered, Fig. 175.

218 MALOCCLUSION.
And as only the minimum amount of heat is absorbed by
the pliers no change of form or injury to them is possible.
A further advantage is that their points rest in contact
with the band material in such position as to be shielded
from the solder, so that none will be fused upon the points,
thus avoiding an annoyance of no small moment that is
often encountered in the use of ordinary pliers, their con-
tact with the solder being almost a necessity.
FIG. 175.
To insure the flowing of the solder in the seam only,
plenty of borax should be placed there, but none on the
inner surface of the band, as otherwise the solder would
be drawn from the seam and there would be faulty union
or a thickening of the band, either of which would render
it entirely useless. When soldered the band should present
a continuous, even surface, otherwise the union will be
imperfect and the band should be condemned. If the
surplus ends of the band be cut off leaving them still united,
as in Fig. 175, there will be very little waste to the strips
of band material, and ample length for a firm grasp be-
tween the thumb and finger, while pinching, will always be
insured. The band being properly fitted, it is ready for
any attachments that may be required. -
Let us again insist upon the importance of a very hot,
fine, sharp-pointed flame in the making of all these attach-
ments, as neatness in such delicate soldering is impossible
with a coarse flame. With the proper flame such attach-
ments may be made almost instantly without injury to


SOLDERING. 219
the delicate pieces of the appliances, and before the heat
can be transmitted to those portions held by the fingers.
The flame from the ordinary blowpipe, such as dentists
generally use in the various processes in crown and bridge
work, is wholly unsuited.
FIG. 176.
H
The principal soldered attachments to the plain bands
are spurs, staples, etc., from the G wire; tubes, planes of
metal, etc., etc. Not a large variety of soldered attach-
ments is necessary, yet the beginner should so discipline
himself in the technique of soldering as to be able to make
all attachments with great skill and accuracy.
220 MALOCCLUSION.
It is often necessary to solder a tube or spur close to
the union of a band or other attachment, which must be
done without unsoldering the first joint. Fig. 176, shows
Some delicate Soldering, one of the requirements in the
course of technique in the Angle School of orthodontia.
In A short sections of G wire are placed in pairs at
regular intervals opposite each other and at right angles
to a longer section of the same wire, each attached by
silver solder and independently of all the others. Any
student may soon acquire this proficiency in soldering
which, although evincing skill, is still crude compared with
the soldering in what is known as “filigree work.”
B, shows short sections carefully mitered with a file and
joined, also by silver solder, using the smallest amount
of solder consistent with perfect union.
TIG. 177.
The attachment of a spur to a band is best accomplished
by heating the smoothened end of the wire G, touching
it to a large piece of borax, holding it in contact with a
small piece of solder in the flame until the solder is par-
tially fused, then bringing it in contact with the band at
the desired point and again holding in the flame which
should be so applied that the heat will be distributed
equally between band and spur up to the point of fusion of
the solder. After it is fused, Fig. 177 or K, Fig. 623, it is
clipped off with the wire cutters to the desired length,

SOLDERING. 221
which should not be greater than one thirty-second of an
inch, and the roughened end made smooth with file. But
little solder should be used, as a large amount would form
an incline that would not so well hold the ligature. This
spur should always be attached at such an angle as will
best prevent the ligature from slipping off, and usually, for
reasons which we will note later, close to the gingival
margin of the band.
It is desirable that all attachments, both for moving the
tooth and in anticipation of retention, be made, if possible,
before setting the band, in order that the pain and trouble
of removal and substitution of a new band, after the teeth
have become tender, may be avoided.
The untrimmed ends of the band serve the useful pur.
pose of a handle for holding it in the flame and in contact
with the piece to be attached, as in Fig. 177. After the
attachments have been made the ends of the band are
trimmed, leaving them long or short as desired.
If a notch” is to be formed, as in C C, Fig. 136, into
which the arch is to rest for its better support, the ends
should be left about one-sixteenth of an inch long, but, if
not, they may be trimmed still shorter, though it is never
desirable to trim them even with the surface of the band.
The sharp corners should be rounded by means of a fine
flat file. - -
The band is now deoxidized by boiling in a few drops
of dilute sulfuric acid in a small test-tube or other suitable
vessel, or it is dipped in phosphoric acid and held in contact
with the flame until the fluid is partially evaporated by
boiling, then washed and dried.
The band is then ready to be cemented upon the tooth,
* Forming a notch in a band, formerly thought to be so necessary, is now
rarely deemed advisable by the author, the band and spur being placed
at such a point on the tooth that the ligature alone will hold the arch in
the desired position.
222 MALOCCLUSION.
which will be considered in the chapter on Adjustment
and Operation of Appliances.
Soft-Soldering.—It is frequently necessary to attach
sheath-hooks, and occasionally to make other attachments,
to the arches E which are manufactured in such a way
as to give them the greatest possible amount of spring. If
the sheath-hooks are attached by means of the ordinary
soft solder with which they come provided, the temper of
FIG. 178.
the arches need not be injured. We would, however, im-
press the importance of using the very smallest possible
flame procurable with the Lane blowpipe, and slowly rais-
ing the temperature to the melting point of this low-fusing
soft solder. *
It is sometimes desirable to attach spurs to the plain
arches E or the arches B. They also should be attached
by means of soft solder in order not to injure the spring
of the arches. f
The best plan for making these spurs is to fuse a very

SOLDIERING. 223
small piece of this solder upon a section of ligature wire,
then hold it in contact with the arch in the flame. This
gives a fine conical spur with brass center, which is very
strong, yet inconspicuous. Fig. 178 shows the arch with
spurs both before and after the surplus wire has been cut
off. The spur should be no higher than the diameter of
the ligature it is intended to support, as, if higher it will
be unsightly and will abrade the lips or interfere with
their movements. Dr. Lourie has invented an ingenious
form of forceps for raising a barb or spur from the metal
of the arch which may obviate the necessity for soldered
spurs. Since the introduction of the ribbed arch in which
notches may be made to prevent the slipping of the liga-
tures, without removing the arch from the mouth, the use
of spurs is rarely necessary.
Jewelers’ soldering fluid (nitro-muriate of zinc) is used
as a flux in making these attachments.
C H A P T E R X II.
AN CHIORAGE.
THE movement of one or more teeth in any of their
Several directions is possible only by the exercise of force
and its intelligent application in accordance with the laws
of mechanics and dynamics. -
According to the well-known law of physics, action and
reaction are equal and opposite, hence it must follow that
the resistance of the anchorage must be greater than that
offered by the tooth to be moved, otherwise there will be
displacement of the anchorage and failure in the move-
ment of the teeth to the extent, or, possibly, in the direction
desired. 4.
The sources at our disposal for securing anchorage or
resistance are, first, the teeth themselves, and second,
Sources external to the teeth, and anchorages may be classi-
fied as simple, stationary, reciprocal, intermaxillary and
occipital. -
An accurate knowledge of the forms and surfaces of the
teeth and their occlusion, the surfaces, lengths, and inclina-
tions of their roots, and the structure, density, and dis-
tribution of the alveolar process and peridental membrane,
is essential to an intelligent application of the principles
of anchorage. The degree of resistance offered by dif-
ferent teeth varies greatly, according to their position, size,
length and number of roots, the direction from which force
is exerted, and in the manner of mechanical attachment
to them. -
Of the many improvements in the methods of tooth regu-
lation perhaps none has been greater than the modern
devices for gaining and applying anchorage. The former
bulky and insecure devices for this purpose in the form
224
AN CHIORAGE. 225
of vulcanite or metal plates or cribs, have become practi-
cally obsolete since the introduction of the method of ce-
menting and clamping bands upon the teeth, by which far
greater stability and control of anchorage is gained.
The force should be as direct and positive as may be
possible with the conditions at our disposal. The ideal
anchorage would of course be an immovable base. This,
however, it is probably never fully possible to obtain in
the mouth owing to the elasticity of the alveolar process
and cushion-like function of the peridental membrane.
Some displacement of anchor teeth is admissible and some-
times even desirable, provided these teeth be kept within
the limits of final restoration by means of the inclined
planes of the occluding teeth; but if greater displacement
than this occur, malocclusion of the anchor teeth, most
difficult or even impossible to overcome, may be established.
Hence they should be closely watched and careful measure-
ments and comparisons with the original models be fre-
quently made. Any unfavorable movement perceived
should be promptly combated. The embarrassment fol-
lowing any considerable displacement of the anchor teeth
is so serious that ample anchorage should always be se-
cured in the beginning.
Simple Anchorage” is that form in which, first, the resist-
ance is overcome by means of an anchor tooth or teeth of
larger size or more favorable location, as in Fig. 179; and
second, the form of attachment to both anchor tooth and
teeth to be moved is hinged or pivotal, admitting of the tip-
ping of both in their sockets, as in Fig. 180.
In Fig. 179 the central incisor is being moved labially by
means of a section of the G wire made to rest in a socketed
band encircling its crown, the opposite end of the wire
engaging a pit in the anchor tooth. As force is exerted by
* It is impossible to trace the origin of simple anchorage. It was the first
and until recent years the only form cmployed in orthodontia.
16
226 - MALOCCLUSION.
lengthening the wire by means of the regulating pliers,
the central incisor, offering less resistance than the larger
and more favorably placed molar, is moved outward,
FIG. 179.
Qa
gº
|
|
§
ſº
ºSS
zº
\"",
although the form of attachment admits of the tipping of
both.
Fig. 180 illustrates an example of simple anchorage
where a firmly implanted canine is being moved labially by
FIG. 180.
"If...?
means of a jack-screw, the base of which loosely engages
a spur attached to the anchor band upon the first premolar.
This anchorage by itself would be insufficient, but, as
illustrated, all of the incisors are made to assist in over-
coming the resistance of the moving canine. It will be


A N CHIORAGE. 227
observed that the mechanical attachment to both is prac-
tically a hinge.
Of course this principle of anchorage, with its hinge-
like attachments, admits of application in exerting a pull-
ing force equally as well as in those cases just illustrated
where a pushing force is exerted.
Stationary Anchorage” is that form in which the attachment
to the anchor tooth is essentially rigid so that its tipping
is impossible, and if moved at all it must be dragged bodily
through the alveolar process in an upright position. Fig.
181 shows an illustration of stationary anchorage for the
retraction of a canine. The long sheath of the screw is
soldered to a clamp band rigidly cemented and clamped
upon the molar, while the angle of the screw engages a
tube soldered horizontally to a plain band on the canine.
The attachment to the canine is hinged and designed to
facilitate tipping, while that to the molar is rigid to prevent
tipping. Should any displacement of the molar occur, both
root and crown would be moved equally and in the same di-
rection. It will thus be seen that the resistance in this form
of anchorage is many times greater than in simple anchor-
age. So efficient is it that the retraction of a canine has
been accomplished by anchorage to a premolar alone, with
* This form of anchorage was introduced in its perfect form by the author
in the second edition of this work. See, also, Items of Interest, December
1887. Full credit must, however, be given Dr. Barrett who first made use of
this form of anchorage, though in an imperfect manner, by means of a vul-
canite plate entirely covering the vault of the arch and molars, but this, of
course, did not admit of strict rigidity of attachment.

228 MALOCCLUSION.
but little displacement of the latter, while in the effort to
accomplish the same thing by simple anchorage all three
molars and one premolar have been displaced.
In making use of stationary anchorage skill and judg-
ment are necessary, for its efficiency depends on the
absolute rigidity of the appliance and its attachment to the
anchor tooth. Care must be exercised that the amount of
force exerted shall at no time be so great as to strain or
FIG. 182.
injure the attachment. This is of vital importance, for
any loosening or straining of the attachment would im-
mediately greatly weaken its resistance, or even transform
it into ordinary simple anchorage, with possibly embar-
rassing results. The effect of continuing force after the
anchorage has become defective is forcibly illustrated in
Fig. 182, which represents the condition of the teeth of a
young lady who called on the author for consultation after
the irreparable injury shown had been accomplished. In
the effort to retract the lower incisors and canines to close
the space of the extracted first premolars, the first molars
and second premolars were drawn forward and the molars

ANCEIORAGE. 229
nearly out of their sockets, and apparently without in the
least effecting the desired distal movement of the anterior
teeth. Yet the movement of these teeth could easily have
been accomplished without displacement of the molars by
the proper application of the principles of stationary an-
chorage.
This valuable form of anchorage in its range of use-
fulness is more limited than simple anchorage because it
is not always possible to secure complete rigidity of both
appliance and attachment. It has, however, great use in
modern orthodontia and we shall illustrate its application
in its partial or complete form many times in the pages
that are to follow, and we would call special attention to
the directions for adjusting the attachments on page 587.
Reciprocal Anchorage, strictly speaking, is not a distinct
form of anchorage, yet its value, and possibilities in appli-
cation are such that it may with propriety be so regarded.
It is that form in which one malposed tooth is pitted
against another, the force, if correctly applied, being re-
ciprocated from one to the other, moving both into normal
occlusion. It admits of the widest range of application
and is the most valuable form of anchorage. Each case
should be studied carefully with a view to its use whenever
possible, either in its simplest forms, as in Figs. 183 and
184, or when a greater number of teeth are to be moved, as
in widening the arch, Fig. 199, or in combination with other
forms of anchorage, or in its most extensive application,
in the reciprocal movement of the teeth of opposite jaws,
as in Fig. 190. It will be found applicable in a very large
percentage of cases and is an important principle made
use of in the treatment of many of the cases that will be
shown later.
Fig. 183 illustrates the use of reciprocal anchorage in
its simplest form where two inlocked canines are being
moved in opposite directions into the line of Occlusion by
means of a jack-screw, the attachment at each end being
230 MALOCCLUSION.
such as to admit of tipping of both teeth. The force
exerted by tightening the nut upon the screw is recipro-
cated to both of the teeth, the result being, as both teeth
are of the same size and offer equal resistance, that both
are moved with equal rapidity into harmony with the line
of occlusion. - - -
FIG. 183.
º
ºil. º º
| º º
|º
º |
{ f} jº |
º
ºffilº
|
º º º
º |
|
|
|
The extra tubes shown upon the bands are in anticipation
of reinforcing the anchorage and for retention.
Fig. 184 shows where two central incisors are being ro-
tated in opposite directions, force being exerted by the
occasional tightening of a wire ligature engaging tubes or
spurs on their mesio-labial angles, while an intervening
FIG. 184.
wedge of rubber exerts force on these teeth in the opposite
direction, thus the force is reciprocated from one to the
other, the effect being to rotate both into harmony with the
line of occlusion. -
Intermaxillary Anchorage is that form in which anchorage
is secured by attachments to teeth in the opposite arch. It
is the newest form of anchorage, having been introduced by

























ANCIHORAGE. 231
the author in 1890.” (See Dental Cosmos, September 1891,
page 743, from which Figs. 185, 186, and 187 are taken.)
FIG. 185.
It may or Imay not be used reciprocally. As here illus-
trated it is not used reciprocally, the elevation of the up-
* These three pictures, in the form of lantern slides, were first shown
before the Illinois State Dental Association at Bloomington, Ill., May 1891,
to illustrate a paper given by the author, entitled “Efficiency and Simplicity
in Regulating Appliances.” The paper was discussed by Drs. Case, Matteson,
Black, A. O. Hunt, Garrett Newkirk and others.
There were about forty additional slides used, and it may be worthy
of mention that these were the first lantern slides ever used to illustrate
plaster models of cases of malocclusion. They were made by Dr. W. J.
Brady and are still in the possession of the author.

232 MALOCCLUSION.
per canines in Figs. 186 and 187 being accomplished by
means of rubber ligatures attached to anchorage devices on
the lower teeth, and the lower teeth prevented from elevat-
ing by the irresistible force of direct occlusion.
The principle of intermaxillary anchorage has often been
further extended by the author to those cases where eleva-
tion of a number of teeth is desired, either in one or both
of opposing arches, as in Fig. 188, by first securing the
teeth by means of ligatures or bands to the expansion arch
FIG. 188.
from which hook-like spurs project at desired points, over
which are engaged rubber ligatures of various strengths.
One of the most valuable modifications of this anchorage
is what is now known as the Baker Anchorage, by means
of which the teeth of opposite arches may be reciprocally
moved collectively—the uppers distally and the lowers
mesially, or vice versa. This marks an important step in
the progress of orthodontia, for with this anchorage the
entire plan of treatment of cases belonging to both Classes
II and III has been revolutionized, making their treatment

ANCHORAGE. 233
simple and easy with patients of proper age. This form
of anchorage, as used by Dr. Baker,” is shown at Fig. 189,
Fig. 189.7
Fig. 190.1
and the author’s modification of it is shown in Fig.
190.
* To the best of my knowledge and belief we are indebted to Dr. H. A.
Baker of Boston, for this idea, he having used it in the retraction of the
protruding incisors of his son a number of years ago, and it was from
him I received the idea. I have hence called it the “Baker anchorage.” Dr.
C. S. Case of Chicago, also employed this form of anchorage, probably at
about the same time as Dr. Baker, not, however, as anchorage complete in
itself, as did Dr. Baker, but only as auxiliary to occipital anchorage in a
case belonging to the third Class. It is reported in the Transactions of the
Columbian Dental Congress.
#Angle. Sixth edition.
#Angle. Dental Cosmos, March, 1903.


234 MIALOCCLUSION.
For a more thorough understanding of intermaxillary
anchorage we would refer the reader to the chapters on
FIG. 191.
Treatment of practical cases of malocclusion belonging to
Classes II and III, and their Divisions and Subdivisions.

AN CEIORAGE. 235
Occipital Anchorage is that form in which the resistance is
borne by the top and back of the head and force transmitted
to the teeth by means of the headgear and heavy elastics
connected with attachments upon the teeth, as in Fig. 191.
This well-known form of anchorage, heretofore principally
applied to the treatment of cases belonging to Division
1 and its Subdivision of Class II, and to Class III, has
in the author’s practice been largely superseded by the
Baker anchorage, just described. Although it is still highly
prized by many and will undoubtedly long hold a place
in Orthodontia, probably chiefly as an auxiliary to other
forms of anchorage, the author feels sure that in propor-
tion as skill in the use of the Baker anchorage is developed
occipital anchorage will be less and less relied upon.
Finally, the variations in the application of the various
forms of anchorage are so many and important that they
should be constantly considered in the treatment of each
and every case. To the thoughtful orthodontist the possi-
bilities in the delicate shadings of force and anchorage,
like that of harmony to the artist in music, are ever widen-
ing. With the novice much of importance in anchorage
might be lost sight of altogether, or possibly recognized
only too late, but as his skill develops he will learn to weigh
the problems of anchorage in each case most carefully,
seeking to utilize every possible advantage which he will
anticipate far in advance of his immediate needs, and
in proportion as he is capable of comprehending and skil-
fully taking advantage of the possibilities of anchorage,
so, to a very large extent will ease of treatinent and cer-
tainty of success be developed. The strings of the violin
are but four, but their possibilities in music are immeas-
urable. -
C H A P T E R XIII.
ADJUSTMENT AND OPERATION OF APPLIANCES.
Adjustment of Clamp Bands,--In adjusting the expansion
arch with its auxiliaries, all of which have been previously
described, the first step is the fitting of the anchor clamp
bands, either D or X. The use of the D bands on the first
molars is usually preferable, as these are the largest and
firmest of the teeth, thereby affording the firmest anchor-
age. Occasions may arise, however, in which it may be
desirable to adjust these bands to the second or third
molars, or it may sometimes be desirable to use the X
bands on the premolars, either on one or both sides, but
their use is only occasionally demanded.
In adjusting a clamp-band the nut should first be loos-
ened sufficiently to allow ample size for the crown over
which it is to slip. The band should then be shaped be-
tween the flat beaks of the band-forming pliers until it
conforms approximately to the shape of the crown of the
tooth, the shaft of the screw, which should always point
forward unless for some special reason, being bent also
if necessary. The band should then be worked carefully
Over the crown with the fingers and made to slide between
gum and enamel to the desired point, and then alternately
clamped and burnished until made to conform accurately
to the shape of the crown. -
One of the greatest blunders made in adjusting these
bands is to trim or file the band on its edge to prevent
supposed interference with the gums. Such procedure
only ruins the band. Besides, it is essential that this por-
tion of the band shall pass beyond the swell of the crown
and be clamped and burnished to the neck of the tooth
236
ADJUSTMENT AND OPERATION OF APPLIANCES. 237
to prevent its slipping off. This is the most valuable
part of the band. g *
Another blunder frequently made is to begin the clamp-
ing or burnishing before the band is well over the crown.
In this case part of the band must bear the entire strain
and will be stretched or torn, or the band will loosen
and come off.
It is a mistake to allow the screw to stand out at too
great an angle. The band should be turned before clamp-
ing until the screw is in close contact with the adjoining
teeth. It is then not only out of the way and will give
no annoyance to the tongue or lips, but on Occasion the
projecting end may be of great value for the attachment
of auxiliary devices. If the screw should be drawn away
from the tooth while tightening the nut it should after-
wards be bent back by a burnisher or piece of wood.
The bands are made to endure the greatest strain con-
sistent with their nearly ideal proportions, and far more
than ever actually required in tooth movement. They will,
therefore, bear considerable tightening of the nut, yet if
this be carried too far they will be broken. It is usually
best not to clamp the band tightly at first, but to wait
until the second or third sitting for the final clamping
and burnishing, when there will be more room between the
approximating teeth for its better adaptation.
The clamping of the bands is ample to secure them in
position without cement except in effecting stationary an-
chorage, as in the use of the traction screw, shown in Fig.
181. We have elsewhere pointed out that no injury to the
tooth will result by not cementing the clamp bands in
position.
Fig. 192 shows a D band that has been properly adjusted
to the crown of a molar. It will be noted that it accurately
conforms to the swell of the crown. A small portion of the
upper edge has been burnished over the distal marginal
ridge. This is important to prevent the possibility of the
238 - IMALOCCLUSION.
band working too far over the crown. A band so adjusted
offers the firmest anchorage, and cannot be loosened with.
out breaking, or unturning the nut.
If the teeth to be banded are crowded, care and patience
are necessary to work the band into position. This is
usually easy with young patients, as their teeth admit of
considerable movement. The band is worked between
the teeth on one side and allowed to remain for a few
minutes, then the other side is gently rocked and pressed
with the finger, or better, with a flat piece of wood, until
started into place between the teeth. It is then well to
allow it to rest for a few minutes, beginning the same
operation with the band for the tooth on the opposite side
of the mouth, after which, sufficient separation will usually
have taken place to readily permit of the further adjust-
ment of the first band.
An excellent method of providing space is shown in Fig.
193, in which a ligature of wire is made to engage the
approximal surfaces of the teeth to be separated and
tightly twisted. Such a ligature will not give annoyance
from displacement, so liable in the use of wedges, and if
worn a few hours it will be found that ample space has
been gained for the accommodation of the band. This
method of separation is equally valuable in gaining space
between incisors, or incisors and canines for the plain
bands.

ADJUSTMENT AND OPERATION OF APPLIANCES. 239
Sometimes after adjustment of the anchor band it is
found that the mesially adjoining tooth inclines buccally
to such a degree as to prevent the passing of the end of
the arch into the sheath. This is readily remedied by
unsoldering the sheath from the band and resoldering it,
with a piece of metal of sufficient thickness intervening.
Usually a portion of a ten-cent piece is ample. By this
FIG, 193.
means the sheath is sufficiently projected buccally for the
ready insertion of the end of the arch.
Occasionally a case may be found where the tooth which
it is desired to use as anchorage inclines forward at such
an angle that the sheath of the D band will not properly
line with the expansion arch (see Figs. 421 and 422). In
this case the band should be removed and the sheath de-
tached and resoldered at the proper angle. This may be
readily effected by placing a small piece of solder and
borax at the union of the band and sheath, applying heat,
and turning the band as desired. It is, however, rarely
necessary, as by slightly bending the arch and shifting
the position of the band it can in most instances be

240 MIALOCCLUSION.
properly adjusted without changing the position of the
tube. -
What has been said regarding the adjustment of the D
bands will, of course, also apply to the adjustment of the
X, plain adjustable, and fracture bands. - - -
Adjustment of Plaim Brazed Bands. In adjusting the plain
brazed bands the tooth to be banded is first cleansed, then
dried and protected from moisture. The band is filled
with oxyphosphate of zinc of creamy consistence, then car-
ried on the end of the finger to the tooth, upon which ce-
ment and band are pressed. With the fingers alone the
band is carefully worked nearly to its desired position, and
then driven down by a few gentle taps from the mallet and
band driver. The burnisher is now quickly applied to the
edges of the band only, and the surplus cement wiped off.
When the cement has thoroughly hardened the band should
be polished and burnished, as it is well known that a
smooth, polished surface is far less liable to discoloration
than a rough one. - -
A band made as described in the chapter on Soldering,
and set as above, will fit with the most glove-like accuracy,
will present a very neat appearance, and will not loosen
under necessary strain. If it is defective in any particular,
as too large, weakened by crimping, or slightly torn when
driven into position, it should be condemned immediately
and a perfect one substituted, for sooner or later it will
Surely fail and cause annoyance.
In banding a tooth where there is much crowding it may
be necessary to provide space in advance. Usually, how-
ever, by exercising a little care and patience the banding
may be done at one sitting.
Adjustment of Expansion Arches.—In adjusting the expan-
sion arch to a given case of malocclusion it can rarely at
once be given the form of an ideal dental arch, or as we
wish the teeth to be arranged when completed, especially
if the malocclusion be extensive, as in Fig. 201, for the
ADJUSTMENT AND OPERATION OF APPLIANCES. 241
reason that much unnecessary space would thus be oc-
cupied by it, with consequently much inconvenience to the
patient. For this reason it should first be given a form
roughly approximating the form of the dental arch, and
after the form of the latter has been improved somewhat
through the elasticity of the expansion arch, and the lig-
atures, it should be removed and bent to more nearly
resemble the ideal form, and in this way gradually approx-
imate the ideal in both expansion and dental arches.
If adjusted correctly the expansion arches become guides
and patterns for the proper alignment of the teeth and
'finally temporary retainers.
In changing the form of the arch by bending, much care
should be exercised not to break it. Let it be remembered
that the arch is made from the best obtainable metal and is
necessarily quite hard in temper in order to give it the
proper strength and Spring, and that if carelessly handled
it may be easily broken in the threaded portion, and es-
pecially at the point where the threaded and unthreaded
portions join. But by holding it in the groove of the band-
forming pliers and bending it but slightly at any given
point, extending the area, if need be, to a number of points
in near relation, any desired form may be given it without
injury. Whenever broken it reflects carelessness.
The adjustment of the size of the expansion arches for
the requirements of the teeth to be moved into proper align-
ment is controlled by the nuts in front of the anchor tubes.
The tendency of beginners is to depend principally on the
tightening of the nuts for applying pressure on the moving
teeth. This, however, is a mistake, as the principal force
should be derived from the ligatures and the elasticity of
the arch. .
Adjustment of Wire Ligatures.—Unquestionably the greatest
modern improvement in connection with the use of the arch
is the substitution of brass wire ligatures” for the fibrous
* Fourth edition of this work.
17
242 MALOCCLUSION.
ligatures, on account of their great strength, cleanliness,
and freedom from stretching or slipping, making their
force direct and positive. With them the possibilities in
the use of the arch are greatly extended, shortening the
time of treatment, and making easy much that was im-
practicable or even impossible with the fibrous ligatures,
Owing to the giving of the knot, stretching of the fiber, and
its great tendency to slip. The wire not only entirely over-
Comes these defects, but, in addition, it has a great advan-
tage in that it may be tightened by additional twists with-
out removal, possessing thereby, in addition to its primary
usefulness, the ideal power of the screw, and obviating"
the necessity for the frequent relinquishment and reappli-
cation of pressure on the moving teeth necessary with other
ligatures—the principal source of pain and inflammation
in moving teeth. It is very important, however, that only
a very fine quality of brass wire, of the proper temper,
size, and finish be used. Wire of spring temper is entirely
useless. -
When applying a wire ligature a piece of ample length,
at least a foot long, should be used, so that it may be
firmly grasped by both hands and strong tension exerted
when twisting it. This should never be more than three-
fourths of a turn at first. The surplus ends are then
clipped off, leaving projections one-sixteenth of an inch
long. These ends are then curled under the arch, usually
one on each side, as correctly shown in Figs. 195 and 199,
the tension on both strands of the ligature being thus
equally distributed, as well as providing a smooth surface
to the lips. This is the author’s favorite way of disposing
of the ends, although Drs. Lourie and Brady prefer to bend
both ends of the wire either above or below the arch, as
shown in Fig. 194.”
It is a mistake to suppose that greater stability is given
* Brady, Western Dental Journal, May 1906.
ADJUSTMENT AND OPERATION OF APPLIANCES. 243
to the union of the wire by a number of twists. In reality
all over three-fourths of a turn is superfluous bulk, as any
one may easily verify by exerting pressure with the two
FIG. 194.
hands on a large loop of wire the ends of which have been
united by twisting. The twisted portion will simply re-
volve in the untwisting if sufficient force be used, all of the
strain being borne by the primary portion of the twist.
In tightening the ligature, firmly press the tooth and
arch between the thumb and finger of one hand while giving
it another half-turn with suitable pliers. It should be re-
membered that the spring of the expansion arch, when used
in connection with the wire ligature, is constantly acting,
so that, as a rule, a ligature need only be tightened occa-
sionally.
Although the uses of the wire ligature in orthodontia are
limitless, there are three principal ways of applying it in
ligature form: First, the simple ligature, as in AA, Fig.
195, where it is made to engage a single tooth and the


244 MALOCCLUSION.
expansion arch, when direct labial or buccal movement is
required; second, where rotation and possibly labial move-
ment is required the ligature is made to engage the ex-
pansion arch and a spur upon a band cemented to the
tooth, as in B; third, the double-loop ligature, as in C, to
effect the same movement. The ligature applied in this
manner is more uncertain in its results than when applied
as last shown, and should only be used occasionally. Its
greatest use will be found in the temporary retention of an
incisor to the arch after rotation, while the movements
of other teeth are being completed.
If the molars or premolars are to be rotated, Fig. 196,
the movement is effected in the same manner as in B, Fig.
FIG. 196. FIG. 197. FIG. 198.
195, by means of spurred bands, ligatures, etc. As here
shown the wire ligatures are intensified by means of strips
of rubber which have been stretched between the arch and
the angles of the crowns opposite to which the ligatures
operate. This is often an advantage. Where two teeth are
to be rotated in opposite directions, as in Fig. 197, a single
ligature made to engage both the Spurs is quite as effica-
cious as two ligatures, each made to engage a spur, and oc-
cupies less space. Fig. 198 shows a method suggested by
Dr. Reoch for use of a single wire ligature in double rota-
tion. The wire ligature is made to engage a short section
of the wire G drawn firmly against the mesio-lingual angles
of the teeth. This plan is rarely efficacious on account of
the shapes of the teeth and the liability of the toggle to
displacement, yet where the shapes of the teeth are favor-
able it may be used with advantage. The author would
suggest, however, that if a small bit of soft solder be used

ADJUSTMENT AND OPERATION OF APPLIANCES. 245
in uniting the ligature and toggle, the liability of the appli-
ance to loosen would be greatly lessened.
Combination Adjusted.—That the reader may better com-
prehend the uses and great possibilities of the expansion
arch let us now carefully consider it in combination with
its auxiliaries adjusted to the teeth of the upper arch,
Fig. 199, in the very complicated case shown in Fig. 398,
FIG. 199.
requiring the movement of all the teeth in both arches
and offering the severest test to a regulating appliance,
and at the same time offering us the best of opportunities
for its study with a view to its proper adjustment and
operation, not only in this case, but for all general uses.
Its more extended uses in special cases will be noted later
in the treatment of individual cases. In this case the upper
dental arch requires much widening, while both centrals
and both laterals are to be carried forward and outward
and rotated, and the canines are to be elevated in their
sockets.
Plain spurred bands and ligatures are adjusted to all
the incisors for their combined labial movement and rota-
tion, the spurs on the plain bands having been so placed
that pressure exerted by reason of the elasticity of the

246 MALOCCLUSION.
arch through the wire ligatures will bear most heavily on
the angles of those teeth that are turned lingually, and
as they are rotated they will also be drawn labially. By
using the ribbed expansion arch and notching the rib for
the more stable attachment of the ligatures, the degree
and direction of force for moving these teeth is absolutely
controlled. A knife-edge file is best suited for making these
notches, and much care should be exercised in order to
make them effective. They should be fully as deep as the
diameter of the rib or even slightly deeper, and slanting
so that they will be in the form of a hook: to prevent any
waste of force by slipping of the ligatures. An enlarged
section of the ribbed arch so notched is shown in Fig. 200.
The first molars, attached to the expansion arch through
the clamp-bands, are moved buccally by reason of the
lateral spring of the expansion arch. The first premolars
are moved in the same direction through their attachment
to the arch by plain wire ligatures, and the second pre-
molars through contact with the screws of the D bands.
Pressure on the canines to move them lingually may be
intensified by rubber wedges stretched between teeth and
arch and the superfluous ends cut off, as shown in Fig. 201.
By carefully studying the picture (Fig. 199) it will be
seen how perfectly force is distributed to accomplish the
various necessary tooth movements, and how, as in all
perfect mechanisms, each part not only performs its func-
tion, but assists, and is in harmony with, all other parts.
For example, note how perfectly the force is reciprocated
from one moving tooth to another; from one lateral half
of the dental arch to the other, and how this is intensified

ADJUSTMENT AND OPERATION OF APPLIANCES. 247
by the pressure on the center of the expansion arch in
front, the tendency being when pressure is exerted at this
point, as in all arches, to spring the ends farther apart.
As the central incisors are rotated much force is exerted
FIG. 201.
upon them at their diagonally opposite corners, in reality
the arch operating on each as two levers combined, the
power ends acting in different directions. No tooth can
resist this force. At the same time, by tightening the
nuts all four incisors are carried forward by the irresist-
ible force equal to that exerted by what is practically two
jack-screws combined. .
In the anterior teeth one lateral incisor reciprocates its
force to the other, one central to the other, all in perfect
harmony. Note, also, what complete control we have over
the movements of the teeth both singly and collectively
through the ligatures, with the anchorage practically
derived from all of the teeth in the arch, and representing
simple, reciprocal, and, to a considerable degree, stationary
anchorages. -
With this appliance we may not only expand the arch in
all directions, as required in this case and here shown, but
as we shall see in the chapters on Treatment, we may
widen or narrow either or both of the dental arches on
one or both sides, or we may lengthen or shorten one or

248 MALOCCLUSION.
both of the lateral halves. We may move teeth singly in
any direction, or we may elevate the teeth, and to a limited
extent depress them.
In adjusting the arch as here shown (Fig. 201), it will
be seen that it is placed high up toward the gum, as is
necessary in all cases in order to keep intense, rigid ten-
sion upon the moving teeth, for if the arch be allowed
to work towards the points of the teeth, its natural ten-
dency, it will lose much or all of its force, and become a
wobbly, inefficient encumbrance.
The tendency of amateurs is often to bend the arch so
that it will be too narrow in the anterior part and bind on
the canines, preventing the proper adjustment of the
incisors. It should be bent so as to afford ample room.
Another common failing of the inexperienced is to give
the arch so much lateral spring as to cause buccal displace-
ment of the anchor teeth in cases where no buccal movement
of these teeth is necessary. -
FIG. 202.
Fig. 202 shows the combination adjusted to perform
tooth movements in a case similar to the one just described
and affords another study of the arch in operation. The

ADJUSTMENT AND OPERATION OF APPLIANCES. 249
premolars are being moved outward by plain wire ligatures
occasionally tightened by twisting. The tension on these
teeth is made more continuous by blocks of rubber which
are enclosed between ligatures and the lingual surfaces of
the teeth—a plan which may often be employed with ad-
vantage. Force in the opposite direction is being exerted
upon the canines also by a block of rubber drawn tightly
between arch and tooth. Two ligatures are shown in
Operation upon the left lateral incisor—one for effecting
its lateral and the other its forward movement. This
will later become more effective as the tooth is carried
forward by tightening the nut in front of the sheaths of
the anchor bands. It is often useful. Ligatures are shown
on both central incisors, bands being unnecessary on these
teeth unless their rotation is desired, especially if the ap-
pliance is firmly adjusted and made to lie well up toward
the gingiva.
FIG. 203.
In cases where much widening of the arch in the region
of the canines is necessary, as in Fig. 203, care should
be exercised to give the expansion arch plenty of lateral
spring, and so shape it as to allow for the movements of the
teeth, and what is also very important is to so locate the

250 MALOCCLUSION.
notches for the reception of these ligatures as to exert
full force in a lateral direction.
:
Very often when the incisors are protruded it becomes
necessary to shorten the dental arch in front and to widen

AD.J. USTMENT AND OPERATION OF APPLIANCES. 251
it in the region of the premolars and canines. Such a case
is shown in Figs. 204 and 205. A favorite plan with the
author for accomplishing this is to exert force reciprocally
from the front of the dental arch to the two lateral halves
by means of the threadless arch B, as shown in Fig. 206.
Fig. 206.
Before slipping the arch into the sheaths of the anchor
bands seen upon the molars, much lateral spring was
gained by flattening the arch considerably in the middle.
Now, by carefully springing it into position in the sheaths,
in its efforts to straighten it will move distally, exerting
much force in a lingual direction upon the central incisors.
By lacing the first premolars to this arch, as shown in the
engraving, this force is at once reciprocated from the
incisors to them. The second premolars may also be
moved outward by ligatures in the same manner, or, by
means of strips of rubber drawn between their lingual
surfaces and the screw of the anchor bands, as shown in
the engraving. The arch must not bind upon the canines
but allow ample room for their outward movement, which
will usually follow the lateral, wedgelike force received

252 MALOCCLUSION.
from the incisors as they move lingually. If this is not
sufficient their movement may also be accelerated by liga-
tures. It will be seen that a ligature is made to encircle
each lateral incisor and the arch. This is to prevent their
displacement by the moving centrals.
Another instructive lesson in the use of the expansion
arch and ligatures may be gained by a careful study of
Fig. 207.
FIG. 207.
It will be seen how completely we may control the degree
and direction of force necessary to effect the various move-
ments. The anchor bands have been carefully clamped and
burnished upon the first molars, with the ribbed expansion
arch placed in position and bent to correct form so as to
give considerable lateral spring and yet not bind upon the
canines.
In order to move all of these malposed teeth into har-
mony with the line of occlusion it will be necessary to move
all of the teeth anterior to the second premolars forward,
and it will be noted how directly force is applied toward
this end. Hook-like notches have been made in the rib of
the arch directly anterior to the canines. The ends of

ADJUSTMENT AND OPERATION OF APPLIANCES. 253
ligatures united are shown at this point resting in these
notches. These plain ligatures extend back on each side
and firmly embrace the first premolars and canines. By
tightening the nuts of the expansion arch anterior to the
sheaths on the anchor teeth the arch is moved forward
and a powerful force exerted on the canines and first pre-
FIG. 208.
molars for their forward movement. Each lateral incisor
is also embraced by a similar ligature and its labial move-
ment effected by an occasional additional twist or renewal
of the ligatures, the twists for renewing force always being
made before the nuts are tightened.
As the teeth anterior to the second premolars are moved
forward and each lateral half of the arch thus lengthened
the second premolars are moved outward by the occasional
twisting of the ligatures shown in position.
On the right side is shown a small block of rubber which
was inserted in the form of a rubber strip between arch
and ligature before the latter was twisted. This, although
slightly bulky, insures more constant force and is often

254 MALOCCLUSION.
taken advantage of. Another plan is to include the rubber
Wedge between the tooth on its lingual surface and the
ligature.
Gradually by this means the teeth are moved into correct
alignment. Later it may be necessary to modify the form
of the ribbed arch to prevent binding upon the canines.
It will also be necessary to rotate the central incisor by
means of band and spur engaging a ligature, as in B, Fig.
195. -
Later it will also be necessary to rotate both left pre-
molars, which should not be attempted until they have
gained their correct mesio-distal positions, as the fibers of
the peridental membrane will then have been so broken up
that the rotation will be more easily accomplished. This
should be done with bands and spurs and wire ligatures, as
in Fig. 196. It will also be necessary to rotate the left
canine and the right second premolar, as in Fig. 321.
What we would especially impress in connection with
this engraving is the manner of lengthening the lateral
halves of the dental arches, as this will often be employed
in the treatment of cases described in the chapters on
Treatment.
By the addition to this combination of sheath-hooks and
rubber ligatures we may enlist the Baker anchorage, when
all of the upper teeth may be moved distally and all of the
lower teeth mesially, as illustrated in Fig. 209, or these
movements may be reversed, as shown in Fig. 210, and all
this simultaneously, with any other tooth movements that
may be required in either or both arches."
The modification of form and directions of spring, plus
the modifications in ligature attachments, make it possible
to meet all the requirements of tooth movement, and in
its use it is possible to cultivate a very high degree of skill.
* Angle, “The Importance of the First Molars in Their Relation to Ortho-
dontia.” Dental Cosmos, March 1903.
ADJUSTMENT AND OPERATION OF APPLIANCES. 255
It typifies efficiency and simplicity. It is easily applied
and is so stable in its attachments that there need be no
slipping or loss of power. It is cleanly and occupies a posi-
FIG. 209.
tion in the mouth that causes the least inconvenience to the
patient. If this device be intelligently managed it need
interfere but little with the normal functions of the mouth.
FIG. 210.
Iſº
On the contrary, however, if improperly managed it be-
comes a constant annoyance, as has been said, and one of
the most useless of devices.
In its proper use the widest range for reciprocal anchor-







256 MALOCCLUSION.
age is possible. We may also gain simple and a consider-
able degree of stationary anchorage with it by reason of
the tubes and firm attachment of the anchor bands to the
teeth used as anchorage, and also, as we have seen, the very
valuable intermaxillary anchorage.
The necessary direction and distribution of force should
be carefully studied in each case, as well as the effect upon
the anchor teeth and all that are in proper position.
The arch should always be made to lie approximately
close to the teeth so as to interfere as little as possible
with the functions of the lips.
It should be remembered that as its force in tooth move-
ment is usually exerted by its elasticity, its careful bending
in order to secure the proper degree and direction of force
is of much importance. To make the most of this pos-
sibility and at the same time avoid interference with de-
sired movements by binding, or with teeth already in cor-
rect position, is the most difficult problem in its manage-
ment, and yet it is easily solved if intelligently studied in
each case.
After years of experimenting it is believed that as shown
here, with its improvements and attachments (Fig. 208),
the expansion arch has for its intended uses, like the violin
in music, reached perfection.
The tendency of all appliances upon the teeth at first is
to excite more or less inflammation which, however, soon
subsides. In order that the patient may become gradually
accustomed to the appliances the various parts should be
adjusted at different sittings. The tension should be very
light at first in order that their wearing may be attended
by no pain and with but the minimum of inconvenience.
Later, much greater pressure can be borne.
Although in cases met with for treatment the malocclu-
sion always differs, the adjustment of the expansion arch
and its auxiliaries, as shown, is practically always the
same, the principal difference being in the form given it by
ADJUSTMENT. 257
bending in order to exert force in the desired direction, and
in the manner of manipulating the ligatures used in connec-
tion with it for the movement of the teeth.
Adjustment of Combination for Baker Anchorage.—Fig. 209
shows a very important combination of the expansion
arches in which the Baker anchorage is used in the move-
ment distally of the teeth of the upper, and mesially those
of the lower, arch in the correction of the malocclusion of
cases belonging to Class II. .
The arches are adjusted as above described and sheath-
hooks are attached to the upper at points opposite the
lateral incisors. Either the plain or ribbed arches may be
used, the ribbed being preferable in this combination only
where deflection of force through the ligatures is necessary
in the lateral movement of incisors and canines. The force
is exerted by means of one or more small rubber ligatures
which engage the sheath-hooks on the upper expansion
arch and the distal end of the sheaths of the anchor bands
on the lower molars.
The nuts anterior to the sheaths of the bands on the
upper first molars are occasionally tightened, as the molars
are moved distally, so as to exert all of the force upon them,
instead of expending any of it upon the prominent incisors
for the time being.
After the upper molars have been moved distally into
full normal occlusion with the mesially moved lower
molars, it will be found that a space exists between them
and the second premolars. The D bands on the upper first
molars are then removed, and X bands are placed on the
second premolars. The nuts on the expansion arch are
moved forward and the arch again adjusted, and the force
from the rubber ligature again exerted in order to move
the upper premolars distally. A wire ligature is made to
engage the upper first and second premolars in order to ef-
fect the movement of the first premolars at the same time.
As previously in moving the molars, the nuts are kept tight
18
258 MALOCCLUSION.
against the sheaths of the X bands so as to exert all of
the force on the premolars and none on the incisors. When
these teeth are well back in correct mesio-distal relations
with the lower, the nuts are gradually loosened to allow
force to be received by the incisors and canines, which, in
turn, are soon moved into correct relation with their an-
tagonists.
If care and judgment be exercised the operator will often
be surprised by the ease and rapidity with which teeth in
these pronounced deformities are adjusted.
It is well known to those experienced that teeth move
mesially more readily than distally. Hence the tendency
is for the lower teeth to move more rapidly than the upper.
This is easily controlled by lacing the lower incisors to the
lower expansion arch with wire ligatures, having pre-
viously given the arch a downward bend so that when it is
lifted by the ligatures it is made to bind in the sheaths of
the bands on the first molars, or to exert the same strain
upon the apex of their roots as upon their crowns, thus
enormously increasing their resistance by establishing
stationary anchorage. Thus the degree of movement en
masse of the teeth of each arch may be completely con-
trolled.
Plain bands are not required on any of the incisors unless
their rotation is necessary, the wire ligatures alone being
sufficient.
As the upper molars move distally the tendency of the
anterior part of the upper expansion arch is to move
downward toward the cutting edges of the incisors. It is,
therefore, necessary to occasionally loosen the bands on
the upper molars (or premolars) and adjust them to
proper alignment of the sheaths so that the anterior part
of the expansion arch will be kept well up toward the gum.
In the treatment of cases belonging to Class III the same
combination of appliances is used, but the plan of operation
is reversed, as shown in the diagram, Fig. 210. The sheath-
ADJUSTMENT AND OPERATION OF APPLIANCES. 259
hooks are attached to the lower expansion arch, well for-
ward, and rubber ligatures stretched between them and
the distal ends of the sheaths of the anchor bands on the
upper molars.
Fig. 211.
E. H. A.
Figs. 211 and 212 show a modification of this anchorage
which may occasionally be used to much advantage in those
FIG. 212.
E. H. A.
cases, fortunately rare, where the teeth of the lower arch
have moved laterally in front and mesially on one side.


260 - MALOCCLUSION.
While the intermaxillary ligature is carrying the molars
and premolars into correct mesio-distal relations on
the right side, this is assisted by one acting in like
manner in the region of the incisors. These movements are
further assisted by the spring of the two expansion arches,
the upper one being bent outward in the region of the left
lateral incisor, canine, and first premolar, then forced back
against the teeth and firmly held by the ligatures, notches
being made in the rib of the arch to prevent their slipping.
In like manner the lower expansion arch is used on
the opposite side. In the few cases so treated by the author
the result was prompt and most satisfactory. &
FIG. 213.
Fig. 213 shows another modification in the application of
intermaxillary anchorage and rubber ligatures for the re-
traction of a single canine. The tooth has been most care-
fully banded and a bar of metal soldered at right angles
to its labial surface on a line parallel with the axis of the
tooth, its lower end being shaped in the form of a hook and
engaging the rubber ligature. It will be seen how greatly
the leverage on the crown of the tooth is thus increased.
This combination is very valuable for effecting the re-

ADJUSTMENT AND OPERATION OF APPLIANCES. 261
traction of individual teeth and may be used separately or
with expansion arches, but of course acting independently
of them. .
From the foregoing it will be seen that cases of all
classes may be treated with the expansion arch. It most
naturally meets the demands of occlusion, for with it we
can have control of the entire dental apparatus—some-
thing impossible in the use of the innumerable appliances
that have been devised for the correction of symptoms
chiefly, regardless of the laws of occlusion. He who will
study its possibilities will be more and more impressed
with its wonderful efficiency. In the chapters on Treat-
ment we shall show further modifications in its use in
the great range of malocclusion treated.
Combination Reinforced.—The elasticity of the arch, es-
pecially of the ribbed arch, is sufficient to exert ample force
FIG. 214.
for widening either of the dental arches; yet in very rare
instances, where the patient has reached maturity, the force
may not be sufficient to accomplish the desired movements
as rapidly as may be wished. To meet this limitation the
arch may be reinforced by one of the levers L which should
be adjusted to exert pressure upon the lingual surfaces
of the anchor bands, as in Figs. 214 and 215, and attached

262 MALOCCLUSION.
on each side by uniting two short tubes, R and D, at right
angles, the longer one slipped over the end of the screw
of the D band, and the ends of the lever bent sharply at
right angles and made to engage the short tubes. Any
desired degree of force may easily be gained with this
simple method of reinforcement.
A simpler way of securing the reinforcement spring is
to insert its finely pointed ends, bent sharply outwards at
right angles, into very delicate perforations made in the
anchor bands at their mesio-lingual angles, as in Fig. 404,
the ends passing through the band and extending between
enamel and band. See also Dr. Edmond’s method of se-
curing the ends of the reinforcement spring, Fig. 661.
FIG. 215.
In Fig. 215 the threaded ends of the arch are seen to
project through the distal ends of the sheath. These ends
should be clipped off, otherwise abrasions of the cheeks will
follow. .
It seems almost useless to caution dentists against their
persistent habit of making the nuts of the expansion arch
operate against the distal ends of the sheaths of the anchor
bands in the effort to reduce prominence of the incisors.
This should never be done, as complication from the dis-
placement of the anchor teeth are usually the only results.
For this movement the Baker anchorage with force derived
from the opposite jaw should be relied upon.

C H A P T E R XIV .
RETENTION.
AFTER malposed teeth have been moved into the desired
position they must be mechanically supported until all of
the tissues involved in their support and maintenance
in their new positions shall have become thoroughly
modified, both in structure and in function to meet the
new requirements. It cannot be too strongly insisted
upon that the permanency of the teeth in their new
positions cannot be hoped for, regardless of the length of
time the retaining devices have been worn, unless such
occlusion has been established as will enable the inclined
planes of the cusps to ultimately act in perfect harmony
for mutual support, which also means perfect harmony as
to sizes and relations of dental arches. -
Dr. Dewey has well said,” “The normal interproximal
contact is of equally great importance as those (forces)
before mentioned (inclined planes). It has scarcely been
Spoken of in the past because writers have failed to recog-
nize its independence from the force of the inclined planes.
By the force of interproximal contact is meant the force
One tooth in an arch exerts upon those approximating it.
This force is passive to a certain extent. It may be illus-
trated by the blocks of stone in an arch of masonry. The
contact point, being only a point on a nearly round surface,
is to a great extent like the point of contact between two
spheres. If force is brought to bear from one to the other
directly parallel in line with their diameters they will re-
main stationary, but if applied at different angles they
will roll. If once the interproximal contact points of the
teeth are moved out of line, the teeth tend to move further.
* Dewey, Transactions American Society of Orthodontists, 1904.
263
264 IMALOCCLUSION.
The tendency of the lower cuspids to return to old posi-
tions of torsal occlusion can be explained in this way.”
Retention is too often lightly considered. The problems
involved are often so great as to tax to the utmost the skill
of the most competent orthodontist, often being greater
than the difficulties encountered in the treatment of the case
up to this point. It is far easier to lay down rules for
the governing of tooth movements than for retention. In
this field great patience is required, and ample opportunity
is offered for originality and skill in technique.
Time Required for Retention.—The time required for me-
chanical retention varies, according to the age of the
patient, occlusion gained, causes overcome, tooth move-
ments accomplished, length of cusps, health of tissues, etc.,
from a few days to a year, or two years, or often longer,
while in the case of unconquered lip or tongue habits, re-
tention may be required for an indefinite period. Upper
incisors that have been moved from lingual to normal
occlusion, as in Fig. 274, require mechanical retention for
a few days only, after which their permanent retention is
effectively maintained through normal occlusion or the
favorable action upon them through the lower incisors
upon each closure of the jaws. &
Again, teeth that have been directed into correct posi-
tions during the period of eruption need support for a few
months only, while much longer retention (for at least two
years) would be required for the same teeth if moved after
the full development of their alveoli.
Again, the rotation of a tooth causes such great disturb-
ance of the fibers of its peridental membrane that it must
be retained far longer than in case of its labial or lingual
movement.
As a general rule, with the same tooth movements, the
period of retention in the case of a patient aged twenty-one
would be about three times as great as in the case of a
patient but nine years of age.
RETENTION. 265
Yielding to the temptation to remove the appliances be-
fore the teeth have become thoroughly established in occlu-
sion is the cause of many failures in cases probably other-
wise well conducted. As so much depends upon this part
of the operation, the wearing of the appliances possibly
longer than necessary is far better than their too early re-
moval. It must also be borne in mind that unless the causes
which have been operative in producing or maintaining
malocclusion be removed or modified, the establishing of
permanent normal occlusion can rarely be hoped for; for
example, if the malocclusion has been caused by pathologi-
cal conditions of the throat or nose it is very improbable
that the teeth will remain in correct occlusion after the re-
moval of the retaining device unless normal breathing be
established so that the mouth may be closed the requisite
amount of time and the inclined occlusal planes of the teeth
may act in harmony for their mutual support. (See chap-
ter on Normal Occlusion.)
Or, if the malpositions of the teeth be due to pathological
conditions of the peridental membrane, unless restoration
to normal conditions be effected by proper treatment (the
possibilities for which are very doubtful in most cases)
permanent normal occlusion without mechanical retention
cannot be hoped for. Yet in these cases the wearing of
delicate and efficient retaining devices indefinitely may
be far less objectionable than the malocclusion. These
points should be thoroughly understood by the patient
before treatment is commenced. -
Or, if by the loss of some one or more teeth, as for ex-
ample the first molars, faulty occlusion result from the
tipping of the remaining teeth, the further unfavorable
movement of these teeth must be permanently arrested by
crowns or bridges, or other methods of replacing missing
teeth by artificial substitutes.
We have elsewhere pointed out the forces that maintain
the teeth in normal occlusion, hence it seems needless to
266 MIALOCCLUSION -
say here that to defy these forces and correct and retain
the teeth of one arch only without equal attention to the
opposite arch, as is still frequently done by the novice, is
to court certain failure upon the removal of the retaining
devices.
Principles of Retention.—As the tendency of teeth that have
been moved into occlusion is to return to their former
malpositions, the main principle to be considered by the
designer of a retaining device is to antagonize the move-
ment of the teeth only in the direction of their tendencies.
Very slight antagonism is required, but its exercise must
be constant. If the reader will keep these facts in view he
will realize that only delicate devices are necessary, and
will be impressed with the utter uselessness of much of the
bulk and material composing so many of the retaining
devices shown in our literature.
To determine the necessities in retention each corrected
case should be carefully studied in connection with the
original models, noting the various directions in which the
teeth are inclined to move, the difference in their sizes,
and the proportionate force they will exert.
To secure retention we have at our disposal support
or anchorage from the following sources: first, reciprocal,
or the pitting of one tooth against another, their tendencies
being to move in opposite or different directions; second,
teeth already firm in the arch; third, occipital, as shown
in Fig. 191; and fourth, intermaxillary retention, or where
teeth in the opposite arches are made to act reciprocally
for their mutual support through mechanical devices; and
finally, the normal occlusion of the teeth which is of course
the ultimate retainer in all cases.
We must remember that the patient is already wearied
with the inconvenience of the regulating appliances, so it
should be the aim to make the retaining devices as delicate,
compact, and inconspicuous as possible, always, however,
consistent with the main object—perfect support. The
RETENTION. 267
more securely the teeth are held, the more rapidly will they
become firm in their new positions. For this reason, and
that they may be as little as possible under the control of
the patient, whenever practicable the appliances should be
made stationary by the attachment of accurately fitted and
cemented bands. They should also be readily cleansible
by the patient with the brush, that they may in no way
injure the teeth. The devices necessary for retaining the
teeth need never be bulky nor complicated, nor comprise
a large number of pieces. It is remarkable how compact,
simple and yet efficient they may be made, and still meet
all requirements of the most complicated cases.
With accurately fitting bands properly cemented upon
the teeth no possible injury can come to the tooth under-
neath but on the contrary the band is a protection to the
tooth. Yet those attachments which bear against the teeth,
such as spurs, and bars connecting bands, should, of
course, have as minute a point of contact as possible. For
this reason the round wire is decidedly preferable to flat
surfaces in the form of bars or clasps—the usual devices
in the past.
As the retaining device is to be worn for a considerable
time, some prefer its construction from gold or iridio-plat-
inum instead of nickel silver on account of the tendency of
the latter to discolor in some mouths, which may be advis-
able, but it is a fact that may be verified by experiment
that if the bands be made of nickel silver there will be far
less danger of their loosening.
Devices for Temporary Mechanical Retention.—Before adjust-
ing the retaining device it is often best to allow the regu-
lating appliances to remain passively in position upon the
teeth for several days or even weeks, in order that the
tenderness of the teeth may subside. Yet upon the removal
of the regulating appliances there is usually found to be
more or less Soreness, as well as mobility, in the teeth.
It is, therefore, difficult to form and fit bands with any
268 MALOCCLUSION.
considerable degree of accuracy without occasioning pain,
and yet pain may and should be avoided. So it is best to
adjust a temporary device on exactly the same principles
as if it were to be permanent, with looser fit of bands, which
may be gently worked into position with the fingers alone.
If a good quality of cement be used the device will be held
firmly in position for a few weeks, until all soreness has
subsided and the teeth have become more firm, when a
device with bands and all other parts of the most perfect
fit and finish may be substituted.
Another simple plan for temporary retention may, when
the conditions are favorable, be employed with much satis-
faction. It is to make use of the bands and spurs already
upon the teeth, having removed the expansion arches, en-
gaging the spurs with strands of the wire ligatures and
lacing them about the teeth in such a way as to exert a
reciprocal force and antagonize their movements in the
directions of their tendencies. In this way the pain caused
by removal of old bands and fitting of new ones to the
tender teeth is avoided. With experience, judgment and
skill in the use of this plan are developed, and the oppor-
tunities for its successful employment increased propor-
tionately. -
FIG. 216. FIG. 217. FIG. 218.
Figs. 216, 217, and 218 show a case retained after this
method.” In moving the teeth from their torso-mesial posi-
tions bands were made to encircle their crowns, with Spurs
placed at the gingival edges of the bands at their disto-
lingual angles to operate in connection with the expansion
* Angle, “American Text-book of Operative Dentistry,” third edition, page
775.

RETENTION. - 269
arch, wire ligatures, etc. In the temporary retention three
ligatures were employed. First, one ligature was made
to engage the spurs on the central incisors, both ends
brought forward and tightly twisted at the mesio-labial
angles of the centrals. Thus it will be seen that reciprocal
force is exerted that will effectually resist the movement
of these teeth in the direction of their tendencies. Second,
another ligature was made to engage the spur on the disto-
lingual angle of the left lateral incisor, the ends brought
forward across its labial surface, one end being passed
between the left central and lateral and made to engage
the spur upon the central, brought back between these teeth
and firmly twisted with the other strand of the ligature
at a point on the labial surface of the lateral incisor, as
indicated. In precisely the same manner a ligature was
made to engage the Spurs upon the right lateral and cen-
tral, all as shown in Fig. 217. By studying the original
positions of the teeth in Fig. 216, it will be seen how direct
and positive is the reciprocal force exerted by these liga-
tures in resisting the movement of the teeth.
. After a few weeks of temporary retention the teeth were
permanently retained, as shown in Fig. 218, by other bands
placed upon the laterals and connected by a section of the
G wire in the usual way, as described elsewhere.
FIG. 219. FIG. 220.
Molars or pre-molars which may have been rotated with
the arch, spurred bands and ligatures as in Fig. 196, but
which may have partially relapsed, as in Fig. 219, may be
readjusted and retained by means of a ligature made to
engage the Spurs and tightly twisted upon the buccal sur-
face. By engaging strips of rubber between spur and .

270 MALOCCLUSION.
ligature before tightening the latter by twisting, as in Fig.
220, the readjustment may be effected more speedily, after
which a fresh ligature, without the rubber wedges, may
be used as a retainer.
Devices for Permanent Mechanical Retention.—The simple
band and the short projecting wire, which for convenience
we call a spur, embody a principle which may be made
applicable to nearly all the requirements of permanent
retention in all the various classes. It is surprising to
find in what number of combinations they may be em-
ployed.
If a single tooth has been rotated its movement in the
direction of its tendency may be antagonized by the band
and spur, the spur being so placed as to bear against an ad-
joining tooth, as in Fig. 221, the spur being attached to the
FIG. 221. FIG. 222.
Fºsºsº.
º
|
|
i ºl
ºltii
band by means of a small tube" and key pin. However, as
the utmost simplicity in all devices worn in the mouth is so
desirable, it is usually better to have the spur soldered
directly to the band. Greater efficiency resulting there-
from, it is usually preferable to use a band having two
spurs, as in Fig. 222. Unnecessarily long spurs should
never be used, as they are cumbersome and unsightly.
Even shorter spurs than those shown in the engraving may
be employed. t
Much care should be exercised in placing the points of
the Spurs which bear against the adjoining teeth so that
they will not cause displacement of the tooth retained. As
represented in the engraving they are wrongly placed.
* Transactions Ninth International Medical Congress, September, l887
and Ohio Dental Journal, October, 1887, Angle.





RETENTION. 271
The spurs being made to rest on inclined planes down
which they will slide through the force exerted by the tooth
in its effort to regain its former position, it would be forced
partially out of its socket resulting in its partial relapse.
This point may be taken advantage of, however, in some
cases where it is desirable to force the eruption of a tooth
slightly, for example, a canine after its rotation. The
points of the spurs in the case shown should bear upon the
gingival ridge of the central, and above the swell of the
crown of the canine. The fine adjustment of the spurs
should be left until the cement has hardened after setting
the band, when they may be bent until their ends touch at
the exact points required.
In some instances where the period of retention is
to be protracted, or where bands would be unpleasantly
conspicuous, spurs may be set in fillings, as in Fig. 223,
drilled for the purpose, or newly placed if any convenient
cavities exist. In rare instances it may even be desirable
to form minute cavities in the enamel, to be properly filled
upon the removal of the spur. In the case of deciduous
teeth, soon to pass away, the drilling may be considered
merely a matter of convenience, and is in many instances
preferable to the setting of bands.
FIG. 223. FIG. 224.
fºs
A method often desirable when the space of a lost tooth
is to be preserved is to connect two bands by a short section
of wire G, the ends being engaged in tubes R soldered to
the bands, as in Fig. 224. •
Another excellent modification of this plan is shown in
Fig. 225,” in which one band is dispensed with, one end of
* Angle. Sixth edition.

272 MALOCCLUSION.
the section of wire G being bent in the form of a goose-neck
to engage the mesial surface and sulcus of the first pre-
molar, the other end being soldered directly to a plain band
on the lateral incisor.
FIG. 225.
Fig. 226 shows a modification of this plan in which the
D bands are made use of for holding the spurs which are
to span the regained spaces of lost first molars. Lateral
displacement of the spurs is prevented by short sections
FIG. 226.
of the wire G bent to crescent form and soldered to the
spurs and made to bear against the lingual and labial
angles of the second premolars. The bands in this case had
been used in effecting the tooth movements.
If two approximating teeth were rotated the firmest
support would be given them by uniting a spur to the
lingual surfaces of both bands by solder, in which case the
device becomes two bands and two spurs united. The

RETENTION. 273
spring of this spur makes possible greater precision in
the adjustment of the bands, with less liability of subse-
quent loosening, than when the bands are directly united by
solder. -
The tendency to rotation of the right central and lateral
incisors, plus the lingual tendency of the left central and
the mesial tendency of all, are effectually resisted by two
bands connected by a spur, with an additional spur made
to bear upon the mesio-labial angle of the lateral, as in
Fig. 227. The engraving shows the ends of the wire G
secured by engaging tubes soldered to the lingual surfaces
of the bands. Direct attachment of the ends of the wire
to the bands by solder may, of course, also be used, and is
usually preferable.
It will be seen that the amount of metal forming the de-
vice is reduced to the minimum, and is distributed so as to
resist the movements of the teeth only in the direction of
their tendencies.
FIG. 228. FIG. 229.
^.
E. H. A.
Fig. 228 shows the union of two bands by a section of
wire G, employed to antagonize the lingual tendencies of
two lateral incisors that have been rotated and moved
labially into the line of occlusion—another instance of two
bands and spurs united. Another combination of bands
and spurs, Fig. 229, attached to the centrals would have
accomplished the same result. e


19
274 MALOCCLUSION.
Fig. 230 shows a combination of bands and spurs of
great simplicity used to resist the tendency of the incisors
to return to their original positions as shown in Fig. 231.
- .* º ? - E. -
º - º -- -
* … º: sºy. - º r º
6 º' wº *\!\Sººn º
& si-sºº ºr cºes, & gº º
- Sºº-ºr &
§ º f º, "
sº º ł.
/- Nº º # ... : : -; & º
* º :*::. . . {
>Sº º ºffſhººtº
- - Fºſs
-, *il,
shºt
ºr .* ...ſilhoſſ"Wºº ſº º, ºff.
Neatly fitting bands upon the central incisors are con-
nected on their lingual surfaces by a section of the wire G,
the ends of which project and bear against the disto-lingual
surfaces of the laterals, while two spurs are soldered to the
disto-labial angles of the bands on the central incisors and
bear against the mesio-labial angles of the lateral incisors.
FIG. 231.
By studying the device carefully it will be seen how
effectually all of the various movements are resisted
and especially the lingual and torsal movements of
the laterals. It is probably the simplest and most compact
device that could be constructed for resisting the various
movements in question, and is a favorite with the author.
It is important that it be adjusted with accuracy, and also




RETENTION. 275
that the ends of the wire be carefully placed, for reasons
given in connection with the description of Fig. 222. In
some instances it may be an advantage to provide a suit-
able resting place for the lingual spurs by slightly grooving
the marginal ridge of the laterals.
FIG. 232.
Still another plan, one of the author's latest in the
retention of this type of cases, is to employ bands on the
lateral incisors only, these bands being provided with spurs
which bear upon the disto-lingual angles of the centrals,
and also having two longer spurs soldered to the disto-
labial angles of the bands which cross the labial surface of
the canines and first premolars, and are ligated to the latter
by means of neatly twisted wire ligatures. Thus are not

276 MALOCCLUSION.
Only the lingual and rotatory movements of the lateral ef-
fectually antagonized, but also the labial movement of the
canine and lingual movement of the first premolar, as in
Fig. 232. -
FIG. 233.
Fig. 233 shows the union of two bands by a section of
G wire, which would also resist the lingual movements of
FIG. 234.
the lateral incisors, and the torsal and lingual movements
of the canines—the conditions most frequently met with in
FIG. 235.
retention. An additional spur soldered to the long spur,
as in Fig. 234, forms another combination for antagonizing
the various tendencies of the incisors and canines.
By the addition of two spurs to this combination, as in
Fig. 235, the lingual and buccal movements of the first



RETENTION. 277
premolars are also resisted in a complicated case of mal-
occlusion. .
Fig. 236 shows where this principle has been employed
in resisting the torso-lingual movement of the canines, as
well as the lingual movement of the incisors; also the lin-
gual movement of the first premolar on the right. The left
canine has been elevated and to prevent its depression a
spur has been soldered to the disto-lingual angle of the
band, which extends upward and engages the mesio-lingual
sulcus of the first premolar. An intervening wedge of
rubber is also shown, used to regain the full normal height
of the canine which had slightly relapsed. As soon as this
is accomplished the rubber is to be removed and the spur
bent to rest firmly in contact with the sulcus of the tooth.
Space has been regained for the missing right first molar,
and is effectually retained by the claw, spur, and band
device, as illustrated, also shown in Fig. 226.
So it will be seen that any or all of the incisors and
canines may be firmly supported by combinations of the
band and spur, and that the premolars and molars may
be included by extending the principle.

278 MALOCCLUSION.
Retention of upper incisors that have been reduced from
protrusion, as in Division 1 and its Subdivision of Class II,
may be successfully effected by the plan shown in Fig. 228,
made to extend to bands that have been placed upon the
canines or first premolars.
Another plan is to make use of a vulcanite plate covering
the vault of the arch, cut short in front and thickened,
and perforated for a screw and nut, the screw being flat-
tened between the central incisors and provided with a
Small T-bar soldered at right angles to it, and made to bear
against the labial surfaces of the central incisors. This
device was given to us long ago by Dr. Kingsley, and is
occasionally made use of by the author with much satisfac-
tion. It is illustrated at A, Fig. 251.
FIG. 237.
The demands of treatment according to the modern plan,
or from the basis of normal occlusion, have rendered the
practice of retracting the canine, once so common, now
rarely necessary. For the retention of canines that have
been so retracted, of course nothing could be more efficient
than to allow the traction-screws to remain in position as
retainers, as shown in Fig. 237, which should usually be
done for at least two months. This, however, is only an-
other form of the principle of two bands and spurs united.
As the device is more bulky than necessary it may be
removed after the time stated, and the following plan for
protracted retention of these teeth be employed. A delicate
plain band is made to encircle the second premolar, having
two tubes R soldered to the band, one to the mesio-lingual

RETENTION. - 279
and one to the mesio-buccal angle of the band. Ends of
the largest-sized wire ligature are passed through these
tubes, and the wire drawn tightly against the mesial sur-
face of the canine, when the ends are bent sharply around
and clipped off. Twisting is unnecessary. The device is
correctly shown in the engraving, Fig. 238.
FIG. 238.
By its use ample support is gained and the bulk and
conspicuousness reduced to the minimum. It is important
that the tubes shall be close to the gum so the wire loop
cannot slide off the canine crown.
A simpler modification of this plan, though very efficient
if properly applied, is to dispense with the band on the
premolar, extending the wire ligature to enclose both pre-
molar and canine. To prevent this ligature from working
beneath the gum a cross ligature passing between the
canine and premolar is made to embrace the labial and
lingual strands of the first ligature and twisted tightly on
either the buccal or lingual side. &
Retention of a number of teeth may be effected by a
union of bands encircling them, as in Figs. 239 and 240,
and this was formerly common practice. The method, how-
ever, is crude and inadvisable, as by applying our rule of
simplicity and the reduction of the retaining device to
the minimum bulk consistent with efficiency, it will be seen

280 * MATIOCCLUSION.
that much unnecessary space between the teeth is monop-
olized, and that superfluous material is required. It has
also other disadvantages. First, it is very difficult to per-
fectly set all of the bands at once; and second, as a slight
springiness is required by all healthy teeth and this attach-
ment is rigid, it will be found that one or more of the
teeth will soon break their attachment with the cement,
thus lessening the efficiency of the retainer and possibly
endangering the enamel underneath the band through
salivary fermentation. - -
In the use of all bands in retention we would caution that
they be inspected at least once in two months, for if they
should become loosened they would act as receptacles for
food particles, the fermentation of which might in time
injure the enamel.
And this may be a good time to discuss the risks or
possible injuries to teeth through banding.
Ever since the introduction of this system which marked
the beginning of anything like an extensive use of cemented
bands upon the teeth, there has been considerable preju-
dice and criticism by dentists through fear of injury to
the teeth therefrom, and as a result many fears and mis-
givings have been fostered in the minds of the laity. For-
tunately as to intelligent dentists these prejudices have
been almost completely overcome, for experience in

RETENTION. 281
numberless cases has proved, what ought to have been
apparent on reflection,--that the tooth is positively pro-
tected from injury so long as the band remains properly
cemented upon it. This truth is further exemplified in
the daily practice of dentists in cementing crowns. The
Only danger to the enamel that can possibly arise is through
wearing an uncemented band for a long period of time.
But unless there is a strong tendency toward caries, this
danger is in reality slight, for the flow of saliva between
band and tooth reduces to the minimum the dangers of dis-
integration, and no injury occurs even though uncemented
bands be worn for many months. In the past twenty years
the author has employed upon the teeth of his patients
many thousands of bands, both plain and clamp, the former
always cemented, the latter never, except in those occa-
sional cases where stationary anchorage was required, or
where they were to be worn as retainers for a protracted
period, etc., and yet he can recall only one instance where
injury resulted to the enamel through wearing the bands.
This was from a treatment band upon a central incisor,
which through an oversight on account of its fine fit was al-
lowed to remain on the tooth without cementing for a num-
ber of months. Great was his surprise and chagrin upon
removal of the band to find a whitened disintegration of the
enamel marking the location of the band upon the tooth. In
this case the teeth of the patient were strongly predisposed
to caries.
In one instance in the author’s practice a band was worn
continuously for four years and at the expiration of this
time the cement attachment was found to be perfect and
so strong that cutting of the band was necessary to effect
its removal. It is needless to say that the tooth was
entirely uninjured. Had it been necessary to wear the
band for ten years, or even longer, the author believes no
injury to the tooth could have resulted.
As the different periods of regulating the teeth should
282 MALOCCLUSION.
not exceed more than a few weeks or months, at most, no
injury to the teeth during the process need ever be appre-
hended. The only danger lies in the long periods necessary
for the wearing of the retaining devices, and if these be
made with the least possible bulk and contact with the teeth
according to the plans we are here outlining, with the bands
carefully fitted and thoroughly cemented, and occasionally
inspected, there is not the least possibility of injury. Of
course that the teeth will be kept properly cleansed by the
patient is understood. -
For the retention of one or two teeth, for example the
second lower premolars that have been elevated in their
sockets, a very simple and efficient plan is to encircle the
tooth with a band and project a spur so as to engage the
sulci of the adjoining teeth. -
This may be also applied to the canines, molars, or, in
the very rare instances in which it is necessary, to the in-
cisors, the form of the spur being modified to gain the
proper bearing, according to the form of the teeth used
as Supports. - -
With nearly all of these various forms of retaining de-
vices we may effect the finer adjustment of the teeth,
especially those that have slightly relapsed after the device
has been worn for some time, by stretching a strip of
rubber between the spur and tooth to be moved. After
the force from the rubber has moved the tooth the desired
distance, the rubber is removed and the spur bent to give
firm support to the tooth in its corrected position. The
bending is best effected by the strong beaks of the regu-
lating pliers.
There is a new and novel method—the author’s latest—
which may be made use of in retaining teeth, and which in
competent hands will prove to be of great value and to
have wide range of application, in which both plain and
clamp bands play but a minor part at best, and are often
entirely dispensed with.
RETENTION. 283
In the application of this principle advantage is taken
of the interproximal spaces between the teeth, these spaces
being occupied by very delicate spurs made to project from
Fig. 241.
a base in the form of a wire variously anchored and made
to lie in contact with either the labial or lingual surfaces
of the teeth, these delicate spurs grasping the flattened
sides of the necks of the crowns, preventing their rotation
and their movement mesially or distally, labially or lin-


284 MALUCCLUSION.
gually, yet in no way monopolizing the valuable space
between the teeth at their points of contact, as is necessary
in the use of bands, clasps, etc. As for example, the lingual
movement of all of the incisors and the labial movement
of the canines, A, Fig. 241, are resisted and all effectually
retained by means of this principle, as shown in B, Fig.
241. The base wire and spurs, in readiness for application,
are shown in Fig. 242. A section of base wire of very soft
material was carefully bent to lie in close contact with the
lingual surfaces of the incisors of the plaster model made
FIG. 242.
after the teeth had been moved labially into correct posi-
tions. Points were then marked upon the wire opposite the
interdental spaces, and delicate spurs were soldered at the
points marked, those intended to lie between the laterals
and canines being of considerable length, all as shown in
the last engraving.
The teeth having been thoroughly cleansed, the device
was slipped into place, the spurs passing through the inter-
dental spaces, and projecting more or less beyond the
labial surfaces of the teeth. The lateral spurs were drawn
tight, bent backward against the labial surfaces of the
canines, and the ends secured by wire ligatures made to
engage them and the first premolars. The spur between
the central incisors was clipped short so as not to interfere
RETENTION. 285
with the lip, while those between centrals and laterals were
bent around the mesio-labial angles of the laterals to resist
their tendency to rotate after the manner shown in Fig.
249.
By studying this device carefully it will be seen how ex-
tremely simple and compact, yet efficient it is for resist-
ing the movements of the teeth, and as the amount of
metal in its construction is reduced to the minimum it
is very cleanly, inconspicuous, and the normal contact of
the teeth is in no way interfered with, a point that all
will appreciate. The firmness with which it is kept in
position and the impossibility of its slipping off the teeth
can only be understood by a close study of the principle
of the device and the forms of the teeth. Let it be re-
membered that the teeth are suspended, as it were, at their
necks between the times of a fork, and not only do the
greater diameters of the teeth toward their cutting edges
prevent the device from sliding off, but the contact of the
teeth with each other doubly locks the device in place. All
can recall how readily a waxed silk ligature may be drawn
between the contact points of the teeth, yet how difficult
or impossible this is with the unyielding wire ligature,
though very delicate, while the spurs of larger size add
proportionately to the firmness of attachment of the device.
B, Fig. 243 shows the application of the device in antag-
onizing the tendency of teeth of a lower arch which have
been moved from the malpositions shown in A, Fig. 243.
In connection with the long spurs which pass out between
the canines and laterals, other spurs pass between the cen-
trals, and the right central and lateral, and are bent to
engage the mesial angles of these teeth in order to resist
their torsal tendencies.
B, Fig. 244 shows the device in position in another case
in resisting teeth that have been moved from their mal-
positions as shown in A, Fig. 244. In this case the spurs
are seen projecting beyond the labial surfaces of the teeth
286 MALOCCLUSION.
as they pass outward from their attachment to the base
wire, through the interdental spaces. These projections
are to be considered later. Near the ends of the base wire
FIG. 243.
are soldered short sections of wire which pass distally in
contact with the premolars and are soldered to the ends of
the screws of the clamp bands No. 2 which have been pre-
viously fitted to the first molars.

RETENTION. - 287
There are various ways of securing the ends of the side
wires, such as resting them in sockets formed by the short
tubes R soldered to the ends of the screws. Or a larger
Fig. 244.
tube may be slipped upon the side wire and after all is ad-
justed the tube may be slid back to cover the union of the
wire and screw ends, but soldering it direct to the screw as
here shown is usually best.


288 - MALOCCLUSION.
Some care is necessary in order to make the side wires
of just sufficient length. This is not difficult if the different
steps in the making and adjusting of the device be followed
in their logical order. First, the base wire is fitted to the
proper curve and position upon the teeth of the plaster
model; second, the side wires are soldered to the base wire,
leaving them longer than will be finally required; next the
places are marked upon the base wire at the desired points
for the attachment of the incisor spurs, but these are not
Fig. 245.
soldered until later; then the anchor bands are most care-
fully fitted to the first molars (natural teeth). The base
and side wires are then tried in position upon the natural
teeth and the side wires cut to the precise length required;
next the spurs are soldered, as in Fig. 245; and finally the
side wires are soldered to the ends of the screws and all
adjusted to correct position upon the natural teeth, and
after most carefully burnishing the base wire to its correct
fit, the projecting ends of the spurs are either cut off close,
as they emerge between the teeth, or bent to engage the
angles of the incisors to prevent their rotation, if neces-
sary. In all such cases the hooks so made should only be
RETENTION. 289
of sufficient length to give a firm bearing against the angle
of the tooth to prevent its turning, Fig. 249. A greater
amount would be an unnecessary encumbrance. As the
Fig. 246.
anchor bands are to be worn a long time in such cases it
is well to cement them in position.
B, Fig. 246 shows another application of the principle

20 -
290 MALOCCLUSION.
used in retaining the teeth of the upper arch shown at A,
Fig. 246, of a typical case belonging to the first division of
the Second class, which have been moved from their mal-
positions, the dental arch having been shortened and
widened.
As here used the base wire is continuous, the ends being
united by solder to the ends of the screws of the anchor
bands, as in the last case. The spurs are shown projecting
from the labial surfaces of the incisors. The two outside
spurs are to be bent to engage the mesio-labial angles of
the laterals and cut off the proper length, as already de-
scribed. Occupying the interdental space between the
central incisors there are two spurs, one above the other.
Only one can be shown in the engraving. One is bent to en-
gage the mesio-labial angle of the right central incisor.
while the other is bent to the left to antagonize a like move-
ment of the left central. Planes of metal are shown at-
tached to the buccal surfaces of the anchor bands which are
to engage the Spurs attached to bands on the opposing
teeth, in the usual way, as in Fig. 512.
By using a base wire of proper rigidity in this case ample
support is given to the lateral halves of the dental arch,
while the spurs effectually prevent any labial movement of
the incisors. In such cases it may sometimes be desirable
to have double instead of single spurs between the centrals
and laterals, as well as between the centrals, the extra
spurs embracing the disto-labial angles of the centrals.
In this way both mesial and distal angles of the centrals
are firmly grasped, yet the spurs are so delicate there
is ample room for them. .
Another plan is to make use of a modification of the T-
bar, A, Fig. 251, in connection with the base wire. The
author prefers the device shown in Fig. 247, which consists
of two loops of ligature wire (largest size), one within the
other, to which is soldered at right angles a short section of
heavier wire, the latter to rest in contact with the mesio-

RETENTION. 291
labial angles of the central incisors. The four ends of the
ligatures are passed between the centrals—two above the
base wire and two below, firmly twisted about the base
wire in the usual way, and the ends cut off, the object of
two ligatures being that in case of one breaking the other
will still give the teeth firm support. Another advantage
is, there being four strands instead of two passing between
the centrals, the T-bar is prevented from twisting and is
firmly held in its proper transverse relation to the incisors.
FIG. 247.
Still another modification in the application of this prin-
ciple is shown in B, Fig. 248, in the maintenance of the
proper length and width of the arch, the teeth of which
have been moved from the positions shown in A, Fig. 248.
In this case much spring is necessary; the base wire
is best made of clasp metal and extends distally on
each side and lies in close contact with the lingual sur-
faces of the premolars and first molars, and also close
down against the gum, and, in connection with the usual
spurs which occupy the interdental spaces between the in-
cisors additional spurs are soldered to the base wire to en-
292 MIALOCCLUSION.
gage the interproximal spaces between the premolars, and
le premolars and first molars, they being sprung into po
the p | l first molars, they being g into po
FIG. 248.
sition and the ends of the spurs being of sufficient length
to pass entirely through between the teeth, when they
may be cut short, or, if need be, bent in hook-like form as

RETENTION. 293
already described in connection with the incisor spurs, and
as shown in Fig. 249 which represents the labial aspect of
B, Fig. 248. Of course the apparatus might be extended
backward to include one or more of the molars, if desirable.
FIG. 240.
It is hardly to be expected that this principle of retention
will supplant that other most excellent form of the band
and spur which we have already considered quite
thoroughly. Indeed in the hands of those of little expe-
rience or the careless it will probably never prove success-
ful, but with the real experts in orthodontia—those pos-
sessing the proper technical skill and minds cultivated for
weighing the finer problems of retention, it will, we think,
meet with great favor. Yet even the skilful orthodontist
must not expect to be successful in its use without grad-
ually acquiring skill in its employment, applying it at first
only in its simpler forms in simple cases, and as his skill
increases he may extend it even to the most complex prob-
lems of retention. We would also recommend, as a means
of discipline, that he construct and apply these retainers to
plaster models of corrected cases. He will thus learn many
things that will be of much benefit to him in applying the
principles to the natural teeth.
In its use the size, quality, and temper of both the base

294 MALOCCLUSION.
wire and that used for spurs is of the greatest importance.
As the base wire must be freely bent in order to permit the
spurs to take their places in the interdental spaces, it must
be very soft so that it may readily be made to re-assume
its original ideal form by gently bending and burnishing,
and in accomplishing this much patience and skill must be
exercised. In cases where the segment of the circle is large
and but few spurs are required, as in B, Fig. 241, the base
wire may be made of the wire G, but in most cases where
the segment of the circle is smaller, as in B, Fig. 244, with
a greater number of spurs to be attached, the wire G is
too heavy—too difficult of restoring to its correct form—
therefore the wire used should be much smaller in diameter.
The author now makes use of wire of the same quality as
the wire G, but a little over one-half the diameter, or .028".
The spurs, in most instances, will probably be best made
from hard wire. Iridio-platinum, or platinized gold an-
swers well. If either of these metals are used they may be
of even smaller diameter than the base wire, or .020” or
.025", yet sometimes it is desirable to have the Spurs made
of very soft wire. In this case nickel silver wire is best.
Experience and judgment only will enable the operator to
decide these points. t
Where the interdental spaces are reduced to the mini-
mum size on account of the type of teeth with broad necks
this form of retention is not so favorable, yet even in these
cases, if the spurs be made of hard wire and the diameter
diminished by flattening, it may be successfully employed.
The author would take opportunity early in the history
of this plan of retention to caution care in the use of these
interproximal spurs not to injure the delicate and impor-
tant gingiva. There is no reason whatever why these spurs
should injure the gum if properly used. .
The base wire should always be so shaped and located
and the spurs inclined so as to avoid pressure on the soft
tissues. To guard against undue pressure of the base wire
RETENTION. 295
when used as in B, Fig. 248, additional fingers or spurs
should be soldered to the wire, extended upward and
hooked over the occlusal edges of teeth at points that will
not interfere with occlusion. -
The author also wishes to impress the fact that the
principles here involved are radically different from those
of the ordinary, time-honored clasps made to slide over the
crowns of teeth, which have so long been used as a means
of securing both partial artificial dentures and retaining
devices. It is a principle entirely unique as applied to re-
tention so far as the author is able to learn from the liter-
ature of the past.
Where a number of teeth have been elevated, as for
example the incisors and canines, in those cases known
as “open bite,” the problem of retention has always been
a difficult one, yet even in these cases, with the proper care
and skill efficient retention is rendered comparatively easy.
Our chief reliance is the spring derived from the expansion
arch, with its bearing in the tubes of the D bands which
are firmly clamped upon the molars, or anchor teeth. The
attachment to the teeth to be retained is best effected by
again making use of the principle of the claws or spurs
projecting from the arch into the interproximal spaces and
grasping the teeth on their mesial and distal surfaces, as

296 MALOCCLUSION.
shown in Fig. 250. These spurs are sheath hooks attached
at proper points, the angle of the hook being cut off and the
remaining rounded projections being made thinner by
means of a file. If the spurs are carefully located and the
proper form given to the arch so that gentle spring is ex-
erted downward (or upward if in the lower arch), a very
perfect support in all directions is given to the loosened
teeth. The device will be found to give but little trouble,
although slight modification of its form may occasionally
be necessary.
FIG. 25l.
A. B
If some of the teeth in such cases have been rotated their
recurrent movement should be combated by bands and
spurs in the usual way, and as already described. Or, they
may be retained by the band and spur, with wire ligatures
made to engage the spur and expansion arch, the same as
in effecting their movement originally.
The principle of grasping the teeth by means of inter-
proximal spurs was first employed by the author in connec-
tion with a plate and was exhibited before the first meeting
of the American Society of Orthodontists held in St. Louis,
June 11-13, 1901. This plate is shown in B, Fig. 251.

RETENTION. 297
Gradually the base wire has superseded the plate for the
retention of anterior teeth, thereby obviating the necessity
of a removable device as was necessary for purposes of
cleansing in the use of the plate.
The lingual tendency of molars and premolars, however,
may be resisted by a neatly fitting vulcanite plate, as in
Fig. 252, partially covering the palatal arch and bearing
against the teeth that have been moved.
During the early stage of retention the plate should
not extend far enough forward to rest in contact with the
incisors or canines, for, owing to their sloping surfaces,
the plate is wholly unreliable for their support and would
only interfere with other devices, besides being superfluous
FIG. 252. - FIG. 253.
material. It may be necessary to secure the plate in posi-
tion in some instances, which may be done by springing
each lateral edge under a lug soldered to a band encircling
a molar or premolar, or by means of interproximal Spurs
which engage the molars, or the molars and premolars.
Such bands or spurs may usually be dispensed with after
a short time, when the plate has become better settled in
position and the force exerted by the teeth less marked.
During the last stage of retention, or when the tendency
to resumption of malpositions shall have nearly subsided
the bands and spurs upon the incisors may be removed and
a plate extending forward and accurately fitting their

298 MALOCCLUSION.
lingual surfaces may be used, as in Fig. 253. In this
engraving is shown how a portion of the side of a retaining
plate has been removed and a piece of the wire G bent in
such a way as to bear upon the teeth, the ends of the wire
engaging cavities in the plate. By this means pressure, if
desirable, may be brought to bear upon the teeth by occa-
sionally removing the staple and pinching it with the regu-
lating pliers. -
Some also prefer a vulcanite plate for antagonizing the
lingual tendency of the lower molars and premolars. It
should be delicate but carefully made, and should cover
the lingual surfaces of the teeth, and extend but a short dis-
tance beyond the gingiva laterally, but rather more in the
region of the incisor gum. Hooks of platinized gold, made
to engage the lingual grooves of the lower first molars,
should be vulcanized into the plate to prevent undue pres-
Sure upon the gum by the settling of the plate.
This form of plate is also valuable for retaining the
regained space of lost teeth, as in Fig. 423.
Where the teeth of both arches have been retained, es-
pecially where there has been much crowding and narrow-
ing of the arches, the retaining devices in the lower arch
should be worn the longer on account of the well-known
fact that the lower teeth through occlusion exercise a
greater influence in controlling the positions of the upper
teeth than do the uppers in controlling the positions of
the lowers. - -
Other forms of skeleton apparatus, or cemented bands
attached to a lingual arch wire, as in Figs. 254 and 255,
may also be employed for effecting retention of the lateral
halves of both upper and lower dental arches in similar
Cà.SéS.
Intermaxillary Retention.—Where the molars have been
moved distally in the upper arch and mesially in the lower,
as in the treatment of cases belonging to Class II, their
tendency to return to their former positions is antagonized
RETENTION, 299
by means of that simple, yet very efficient, plan of re-
ciprocating force between opposite arches, first brought
out by the author in the fourth edition of this work, and
FIG. 254. FIG. 255.
º
again, modified and improved, in the sixth edition, as shown
in Fig. 256. It consists of a strong spur made to close in
front of a plane of metal, both spur and plane soldered to
No. 2 bands which are clamped in cement on opposing
FIG. 256.
molars. It is effective only when the jaws are closed. If
the device is properly made and adjusted, only occasional
inspection is necessary to keep it in order, and it will be
seen how effectually the direction of the tendencies of not
only the first molars but of all the molars and premolars of
both dental arches on the same side is resisted.
The spur may be made of brass or of nickel silver, about
three thirty-seconds of an inch in diameter. The plane of
metal soldered to the band upon the upper molar should
be about one-fourth to three-eighths of an inch long and
about one-eighth of an inch wide and the thickness of a
silver ten-cent piece. Great care should be exercised in


300 MALOCCLUSION.
locating and attaching both the plane and spur upon the
accurately fitted bands. Finer adjustment may, if neces-
sary, be effected by bending the spur after the cement has
become thoroughly hardened, the spur being supported
between the strong beaks of the regulating pliers at the
point of its attachment while its projecting end is bent
with the How pliers.
It may be necessary to occasionally remove the upper
band and resolder the plane according to the needs of occlu-
Sion. A point of importance to be remembered is that the
plane should be attached to the lower edge of the band
So that there will be less leverage upon the spur, and con-
sequently less danger of loosening the lower band. This
device is also shown in Fig. 512, the first one used in its
improved form.
In rare instances spurs set in fillings for accomplishing
the same purpose will be found an advantage.
FIG. 257.
E. H. A.
A very simple and efficient retaining device for upper
molars that have been moved from lingual occlusion, is a
band and spur placed upon the upper molar, as in A, Fig.
257, the spur or finger being made to bear against the in-
cline of the buccal surface of the lower molar. These spurs
may also be placed mesially or distally somewhat and bear
on the mesial or distal angle of a lower molar or premolar,
as in B and C, if desirable.
As the strain upon this device is very great and must
be long continued, it is of the utmost importance that it
be most thoroughly and skilfully adjusted, using only the
best cement. With proper care the device will prove very

PETENTION. - 301
efficient, and will remain in position almost indefinitely,
yet where the strain is very great the band may in time
give away at the point where the spur is soldered, espe-
cially if it has been overheated in soldering. If it is de-
sired to strengthen the band, this may be readily accom-
plished by a piece of the heavy band material H made to
intervene between spur and band and thoroughly soldered.
The staple form of spur, shown in B, Fig. 258, has some
advantages over the single spur, as in its use the strain
upon the band is more equally distributed, and it may be
bent to bear either buccally, mesially, or distally upon the
opposing tooth. At present it is a favorite with the author.
A, Fig. 258 represents the staple form of spur attached
to the band transversely, which may be used with advan.
tage to bring resistance on the mesio-proximal or disto-
proximal surface of the opposing tooth. The small spurs
attached to the Staple, as seen in the engraving, were used
in a special case for the finer distribution of force upon
the opposing tooth.
Fig. 258. FIG. 259.
In like manner the plane and spur may be employed, and
are often preferable, upon the premolars, as in Fig. 259
making use of the No. 1 clamp bands. In this case the
spur may be made shorter, and also straight instead Óf
curved. -
Sometimes this principle may be employed in making
attachments to canines. In such case the band and plane
upon the upper canine is dispensed with by taking ad-
vantage of its form, and its mesial inclined plane engaging

302 - MALOCCLUSION.
a flat spur which has been soldered to a No. 1, or a brazed
band cemented to the lower canine, as shown in Fig. 260.
This spur should be about one-eighth of an inch wide where
it engages the upper canine, and rounded at its lower end
to avoid irritation of the lip. To be most effective it should
incline somewhat forward, and may be adjusted occasion-
ally by bending. In this way not only retention, but
the actual movement of the upper canine distally, and of
the lower mesially, may be accomplished to some extent,
and in many cases this is desirable. It is a favorite device
with the author. - -
FIG. 260. - FIG. 261.
It may sometimes be necessary to combine this device
with that shown in Fig. 233, the latter being placed in
position upon the lower canines instead of on the upper,
as shown in the engraving. Owing to the unfavorable
shape of the lower canine for banding there is more liability
of bands upon these teeth loosening under strain than of
those upon the premolars, hence they should be made with
the greatest care, always using H band material, and se-
curing the most perfect fit. This band and spur are illus-
trated in Fig. 261. s .
Dr. Lourie makes use of a modification of this plan.
His method consists in banding the lower first premolar,
with the nut of the clamp band No. 1 on the buccal surface
of the tooth. The band is pinched and burnished on its
lingual surface and made to cover the rudimentary lingual
cusp of the tooth. An upright spur is soldered to the bent
and burnished portion of the band so that when the jaws

RETENTION. 303
are closed this spur engages the mesial surface of the
lingual cusp of the upper first premolar. The full advan-
tage of this principle of retention is not only thus gained,
but in a very compact manner, yet this device does not ad-
mit of subsequent modification as readily as do those
previously described. -
Where the reverse order of force has been employed, as
in cases belonging to Class III, or where the molars and
premolars of the lower jaw have been moved distally and
those of the upper jaw mesially, their movements in the
direction of their tendencies are effectually antagonized by
the same methods as just described, only so attaching the
planes and spurs that the spur shall antagonize the distal
end of the plane of metal instead of the mesial end.
This same principle of reciprocal retention, may be ex-
tended to combat the labial movement of upper incisors
that have been moved lingually, which is accomplished by
placing upon the lower central incisors plain bands, there
being soldered to their labial surfaces strong spurs which
project forward and are bent upward sharply at right
angles to engage the labio-occlusal edges of the upper
incisors, as shown on one incisor in Fig. 262. The stability
FIG. 263.
of the teeth used as anchorage should be reinforced by a
section of the wire G soldered across the lingual surface
of their bands and made to bear against the adjoining
lateral incisors.
Sometimes it may be desired to place the bands upon the

304 - - MIALOCCLUSION.
canines instead of upon the incisors, and connect them by
a bar of metal containing the spurs similar to the device
shown in Fig. 263. - g
This device has the further advantage of preventing the
lower lip from being drawn against the lingual surfaces of
the upper incisors—a habit which seems to be almost
universal in these cases, and very difficult but most neces-
sary to overcome.
So far we have but outlined the principles of the various
devices which the author has found to be most valuable
in retention and daily employed by him in his practice.
Under the chapters on Treatment these principles will all
be subject to test, and in the numerous cases treated their
slight modifications, demanded by the requirements of in-
dividual cases, will be noted. .
C H A P T E R X W .
TREATMENT—PRELIMINARY considerATIONs.
“EVERY art has its own methods of training, its distinc-
tive discipline, its secrets of experience and skill; and mas-
tery depends upon practice of these methods, submission to
this discipline, possession of the fruits of this experience,
and command of this skill. Between the untrained man
and the artist, in every department of creative work, there
must be an educational process severe and prolonged.
This necessity is imposed on men of genius no less rigor-
ously than on men of talent.”—HAMILTON WRIGHT MABIE.
BEFORE beginning the treatment of malocclusion of the
teeth there should be certain well-defined principles fixed
in our minds in regard to the dental apparatus as a whole,
for we must constantly bear in mind the intimate relations
existing between the teeth and all other tissues and parts of
the dental apparatus, and the powerful influences they ex-
ert upon one another. We have seen that Nature builds the
human denture in accordance with her long-tried and well-
established laws, the result being a constant and well-
defined pattern; that this pattern, though varied in form,
is in principle always the same; and that its variations are
slight and always in harmony with the demands of the
type of the individual.
We have already noted that when Nature, through cer-
tain adverse causes, is unable to fully carry out her normal
processes in the building of the dental apparatus, there are
in the result defects or variations from the fixed normal
plan, shown in malocclusion of the teeth, with consequent
impairment of their functions—the extent of the malocclu-
sion being in direct proportion to the extent of the disturb-
ing cause. Also, in the same proportion as malocclusion
21 305
306 MALOCCLUSION.
exists, will there be disturbance in the harmony and balance
of the mouth with the rest of the face.
The longer teeth remain in malocclusion the more fixed
becomes the variation from the normal in all co-related
muscles and tissues. The tongue never having been per-
mitted the normal freedom of a normal arch, doubtless also
fails to develop normally in form and function, and its
muscles, together with the muscles of mastication and those
about the mouth all become correspondingly modified in
order to best adapt themselves to the established conditions
of the teeth. In like manner the nose, in size and function,
is often modified from the normal.
Logically, then, in the treatment of malocclusion our
attention should be directed toward interpreting Nature's
wishes and assisting her to carry out her original plan in
the building of the denture, working hand in hand with her,
for only as we comprehend her wishes in each individual
case and assist her, will our efforts be successful in estab-
lishing the normal in occlusion and the normal in
the balance of the mouth with the rest of the face. It
should be obvious, then, to all thoughtful minds, that the
demand in treatment should be the removal of pernicious
causes, the retention of the full complement of teeth, and
the compelling of their normal locking during or subse-
quent to their normal period of eruption, thus permitting
Nature to complete the denture according to her fixed plan
and the demands of the individual type.
The method so long followed by all of the “old school”
writers of determining an arbitrary course of treatment
for each individual case “according to the judgment of the
operator,” in which extraction is freely resorted to, and the
sizes of arches greatly reduced and their forms modified
from Nature’s intended plan and the demands of the type,
has ever resulted, and can only result, in establishing the
abnormal—deformity. By such treatment, instead of
greater freedom being given to the tongue and normal
TREATIMENT. 307
function to the teeth, the former is often more restricted
and the function of the latter upon the whole rarely im-
proved; and instead of establishing balance, harmony, and
beauty of the facial lines, the deformity is ultimately more
often found to have been only modified, with a result even
far less pleasing than the original condition. Dr. Daven-
port has well said, “In the treatment of our patients, it is
hoped that if we cannot all see our way clearly upon this
matter we may at least see far enough not to make the
articulations worse by our operations than they were when
brought to us.”
While in most instances we may rapidly establish the
normal sizes of the arches and relations of the teeth, much
time will often be required by Nature to effect the normal
development of the other tissues of the dental apparatus,
the development of which has been arrested. Yet even in
this we may often greatly assist Nature by directing our
patients as to the proper and necessary closure of their
lips and teeth, and proper breathing, and by insisting upon
their overcoming pernicious habits of the lips and tongue,
and also insisting upon possibly needed treatment of nose
and throat. These conditions often call for much tact and
persistent patience on the part of the orthodontist.
What we have said presupposes the treatment of cases
with the full complement of teeth, which we have had the
opportunity to treat during their most active period of
growth, development and eruption or during the period in
which lie our greatest opportunities for assisting Nature
in approximating the nearest to the ideal in the results.
Yet many cases are presented for treatment in which there
is a lack of the full complement of teeth, through failure
to develop, extraction, or caries. The demands for the great
object to be accomplished, however, are the same in these
cases as when the full complement of teeth is present,
and necessitates the establishing of normal occlusion, or
as nearly so as the exigencies of the case will permit, by
308 MALOCCLUSION.
enlarging the dental arches to their normal size and re-
placing the missing teeth by artificial substitutes. While
the ideal treatment may not always be deemed advisable,
it is impossible to lay down any rules for such exceptions.
The carrying out of the ideal in the treatment of such
cases presents such apparently great difficulties that it
would probably be almost the last one to which the amateur
in orthodontia would naturally resort. He would be inclined
to compensate for the already diminished size of one arch
by reducing the size of the opposing arch still further
by extraction. Yet the great difficulty of permanently
maintaining the teeth in correct alignment when so treated
must not be lost sight of, for it must be remembered that
inclined occlusal planes, inharmonious as to size and form
are thus brought in contact, with teeth, also, at incorrect
angles of inclination, thus tending toward their displace-
ment from wrongly distributed force in occlusion, instead
of occlusal planes harmonious as to size and relation
with normal angle of inclination of teeth, as intended by
Nature, which favors permanency of normal positions and
relations. Moreover, by the reduction of the sizes of the
dental arches, the tongue and lips must exercise less control
in keeping the teeth in correct positions than when exerting
their full normal influence, as when the full number of teeth
are correctly placed. Furthermore, the invariably detri-
mental effect on the facial lines, the shortening of the bite,
and the impairment of speech, make this plan of treatment
so objectionable that it is rarely indeed that the skilful,
modern Orthodontist would resort to it, for the great per-
fection to which the regulating appliances have been
brought makes easily possible the enlarging of the dental
arches and the regaining of the spaces for the full mesio-
distal diameter of missing teeth. This fact, together with
the ease and permanency with which the missing teeth are
replaced, owing to the great advancement in modern pros-
thetic art, makes this the one plan of practice that will be
TREATMENT. 309
most often preferred by the true orthodontist and more
and more appreciated by him as his knowledge and ex-
perience increase; yet in the cases of very young patients
where there has been mutilation, it is often difficult to de-
cide which of the two plans to follow, the serious problem
hinging upon the result of mutilating sound teeth in order
to restore the missing teeth by artificial substitutes. Still,
if it were always possible to have these restorations made
with a very high degree of skill, with mutilation reduced
to the minimum, the conservative, ideal plan of treatment
would be almost universally desirable.
Time for Beginning Treatment.—Recognizing the importance
of the principle of normal occlusion as a basis in the treat-
ment of malocclusion, it becomes an axiom that the proper
time to begin treatment is as near the beginning of the
variation from the normal in the process of the develop-
ment of the dental apparatus as possible. This may date
from the eruption and locking of the first permanent
molars into distal occlusion, usually as a result of adenoids,
or into mesial occlusion, probably as a result of enlarged
tonsils, or it may in rare instances have an even earlier
beginning—in the mal-locking of the deciduous teeth.
The age at which the correction of malocclusion may be
accomplished extends over quite a wide range of years.
All agree that the positions of the teeth may be more
readily changed in early childhood than at any other
period, yet it has always been argued by the writers of
the “old school” that this is a most unpromising age for
treatment, as, they say, a young child will not endure
suffering or inconvenience, and is unable to appreciate our
efforts in its behalf. Much is recorded in Orthodontic liter-
ature favoring the period of life between the ages of twelve
and seventeen years, it being argued that as the operation
is such a long and painful one it is useless to begin treat-
ment before the child has arrived at the age when pride
begins to assert itself. Then, it is argued, the regulating
310 MALOCCLUSION.
appliance would be worn, the inconvenience tolerated, and
the pain endured, consequently the hope of success would
be greater than with younger children. Again, it is urged
that as the operation is such a painful one this age has
its disadvantages, especially with girls, it being a critical
period in their history, the physical economy being already
severely taxed.
Doubtless in the past there has been much reason for
the above arguments, for the empirical methods employed,
and the awkward, bulky, and inconvenient appliances gem-
erally used always caused much annoyance and often real
suffering to the patient, and owing to their faulty prin-
ciples of construction they were necessarily very slow in
bringing about desired results, often prolonging contin-
uously for many months or even years operations that were
in reality very simple. It is, therefore, but little wonder
that young children refused to endure them, that only
those pushed on by pride could be induced to persist in
their use, and that patients of delicate constitution were
deterred from wearing them altogether, for fear of perma-
ment constitutional injury. There is no longer, however,
any excuse for such arguments or methods, though unfor-
tunately both are still too often employed. Any child may
now undergo an operation for the correction of malocclu-
sion, even though extensive, without fear of impairing its
health; for with a properly constructed appliance, skilfully
adjusted and operated, little more than inconvenience
should be occasioned and the desired tooth movements
should be brought about, usually in a very few weeks. The
inflicting of real pain and suffering is not only unnecessary,
but reprehensible, for it reflects carelessness on the part of
the orthodontist, or ignorance, or both. The author has con-
stantly in his practice a large number of young children,
some of them quite delicate, and he has yet to observe
that they have in any way sustained physical injury or that
they have been made more nervous or irritable by wear-
ing the regulating appliances.
TREATMENT. 311
Instead of the treatment endangering the normal growth
and development of the child, it should be accompanied
by the usual growth and development. In fact in many
cases pronounced improvement in health has been noticed
during treatment, probably largely due to the establish-
ment of normal respiration. And instead of finding young
children lacking in appreciation, if they are not caused
pain and can see satisfactory changes taking place they
become our most tractable, willing, and appreciative pa-
tients, the author preferring them to all others. The ease
and rapidity with which their teeth can be moved at this
tender age should make it the most desirable time of life
for the correction of malocclusion. At this writing the
author has under treatment a little girl but five years old
whose malocclusion is of the third class—typical and well-
defined. A more ideal patient it has never been his
pleasure to treat, and the progress being made is most
gratifying. Dr. Guilhermena P. Mendell has recently com-
pleted the treatment of a most pronounced case of mal-
occlusion belonging to the first Division of Class II, which
we will discuss later, for a child less than four years of age,
making a record as to the early age of the patient.
The author is more and more impressed with the ad-
vantages of beginning the treatment early, just as soon
as malocclusion is manifest. Then Nature is putting forth
her best efforts; then growth and repair are most rapid
and the surrounding tissues most yielding; then slight
force is sufficient to gently direct each erupting tooth into
its correct relation with the line of occlusion. Unless some
unusual physical condition of the patient exist it is un-
questionably a serious mistake, without the least argument
in its favor, to defer the operation until all the teeth shall
have erupted, a time-honored custom still often advocated
and followed by dentists. To such mistaken practice is
directly traceable thousands of cases of pronounced mal-
occlusion, with inevitably distorted facial lines, impaired
312 MALOCCLUSION.
speech, etc. By this time the whole dental apparatus
will have become involved, the teeth firmly fixed in their
malpositions, the facial lines badly marred, and the lips
and muscles modified to work in harmony with the compli-
cated malocclusion, all of which might have been easily
prevented had the operation been begun at the proper age.
There is another reason in favor of early treatment. We
have already seen, in the study of the alveolar process and
peridental membrane, that in young children the sockets
of the teeth are large and the septa of bone often lacking
to a considerable degree, Nature seemingly waiting until
the positions of the teeth shall be determined before com-
pleting this precious structure. Now if the teeth be moved
at this time into correct positions the normal deposition of
bone and development of the socket about the root of the
tooth will follow, while, if delayed until the completion of
Nature’s period of active growth and development of the
alveolar process, extensive absorption must take place,
and the re-deposited bone may possibly be less stable in
quality, or, we believe, even lacking entirely in portions in
Some instances. From experience in a few cases of
attempting to correct malocclusion which had been years
before unsuccessfully treated, the author has been strongly
impressed with the apparently abnormal instability of the
teeth which had been used for anchorage. This fact,
together with the great difficulty in some cases of maintain-
ing in their new positions teeth that have been moved after
maturity, even after a long period of retention, strongly
Suggests the possibility that the secondary deposit of bone
may never be as stable as that deposited during the normal
period of development. Indeed the histological investi-
gations of Dr. Noyes seem to confirm this.
There is still another very important reason why the
treatment of malocclusion should be begun early. It ar-
rests not only increasing complexities of malocclusion of
the teeth but also inharmony in the growth of the bones
TREATMENT. 3.13
of the jaws, and consequent inharmony of growth and
improper functionating of the muscles—always more or
less an accompaniment of malocclusion, especially in
Classes II and III, and in gravity and extent necessarily
proportionate to the age of the patient.
While, as we have noted, the period for the treatment
of malocclusion may extend to maturity, or, in favorable
cases much later, we think it may be regarded as a law that
in proportion to the age of patients is their sensitiveness
to pain, the time required for treatment, the obstacles to
be overcome, the inconvenience, the period of retention,
and the uncertainty as to prognosis increased. The ab-
Surdity of delaying treatment with the hope that Nature
will correct the deformity we have elsewhere pointed out.
Time Required for Treatment.—One of the questions always
asked by patients is how long a time will be necessary to
complete the treatment of their cases. No one can or should
attempt to fix any time, other than in a general way, for
any prognosis as to individual cases can be made only from
the basis of our knowledge of Nature’s normal processes in
building the human denture, and we must remember that
the efforts of the orthodontist are at best only to assist
Nature in placing the teeth in normal occlusion during
this process, and that she may require many years to com-
plete it. A knowledge of the causes that have been instru-
mental in deflecting the normal building, the extent of the
malocclusion, and the age of the patient must all be care-
fully considered. So, also, the disposition of the patient
and the degree to which we may have his and his parents’
co-operation have an important bearing on the time that
will be required, for it is well known that without such co-
operation our best efforts can count for but little. And
we may as well say here that the orthodontist is justified
in promptly dismissing any patient who is persistently
delinquent in keeping his appointments or in obeying in-
structions, as failure in the treatment of cases of such
314 MALOCCLUSION.
patients is only a question of time, and the orthodontist
should take prompt measures to place the responsibility
where it belongs. Fortunately such cases are rare, and if
the orthodontist be skilful and himself very systematic,
so that prompt and gratifying results of his efforts may be
apparent, he will usually receive the hearty co-operation of
both patient and parents. No orthodontist, however, can
or should expect his patients to be prompt unless he him-
self sets the example. Carelessness and lack of system
have no place in the practice of orthodontia. The work
is so exacting that only the best in skill and system makes
the naming of the approximate time at which a case may
be completed even possible. For this reason all attempts
to practice orthodontia under the handicapping annoyances
incident to combining the work with the general practice
of dentistry has ever resulted, and must ever result, in
a large percentage of failures.
Carefulness, thoroughness, and prompt and intelligent
decision and action at each visit of the patient are imper-
ative, doing only what is clearly indicated, and that without
deferring until another time. If an arch is to be changed
in form, anchorage shifted, an over-twisted ligature to be
renewed, a different attachment added to a band, a band
replaced, removed, or a new one added, etc., it should be
done promptly, dismissing the patient only after knowing
with certainty that each and every part of the regulating
appliance is fully performing its work.
Recognizing the time necessary for the development of
the denture it must be obvious that the period of treatment,
if begun early, must extend through a number of years,
especially in cases of marked malocclusal tendency. The
plan of treatment to be adopted is to take each case at as
near the divergence from the normal process in the build-
ing as possible, then assist Nature, as promptly as is
consistent with the physiology of tooth movement, with
delicate and efficient appliances, in the locking of the maloc-
TREATMENT. 315
cluded teeth, say one or more of the first permanent molars,
when the regulating appliances should be removed, the
teeth thoroughly cleansed, effectively retained, and occa-
Sionally inspected. No further treatment may be neces-
Sary, especially if the causes have been removed, but if on
the eruption of other teeth it becomes certain that they shall
require mechanical assistance in order to effect their
normal locking, the regulating appliances may again be
brought into requisition, and after effecting the necessary
movements, again be discontinued.
So treatment may extend over a number of periods,
especially if complex causes be present, even to the time
when the canines shall become fully erupted and firm in
their correct positions, but each time the regulating appli-
ances should be removed as soon as the necessary move-
ments are accomplished, giving as much freedom and rest
from their use as possible. To compel patients to wear reg-
ulating appliances for long periods at a time is needless
and reprehensible. As we have said, a few weeks with the
proper appliance is all that is needed to effect the neces-
sary movements of any given period.
The time required for treatment as so far outlined refers
more especially to cases taken early in their variations
from the normal, yet in those cases in which treatment is
begun at a much later date, or after all or nearly all of the
teeth have erupted more or less completely into malocclu-
Sion, as in Figs. 307 and 367, there should also be periods
of rest and retention, and the reason is obvious. The al-
veolar process has been arrested in development and re-
quires much time for the growth necessary to accommodate
the teeth in normal occlusion. In such cases all the teeth re-
Quiring movement should be moved simultaneously and as
far each time as is consistent with the arrest in the alveolar
process. The appliances should then be removed and the
teeth retained for six months, or in complex cases, for a
whole year, when there may be another period of activity
316 MIALOCCLUSION.
followed by another period of rest and retention, and in
some cases even a third period may be desirable. In this
way, the alveolar process having been stimulated and given
time for growth, better ultimate results will be gained with
FIG. 264.
less probability of injury to the tissues. In the case shown
in Fig. 264 three years were found not too long a time for
the development of sufficient alveolar process for the needs
of the teeth in their new positions. Fig. 265 shows the oc-
clusal view of the upper arch in this case, made at a still
later date.
Fig. 202 shows the appliances in position upon the model

TREATMENT. 317
at the beginning of treatment. Appliances were worn
for short periods on three different occasions, followed
by several months of retention in each instance. In
the reported treatments of cases throughout our literature
we often hear mention of the rapidity with which they have
been accomplished, as if that were the principal thing to
be desired. In reality, for the reasons we have given, this
is, generally speaking, something to be especially avoided
FIG. 265.
and can only reflect a lack of comprehension of the require-
ments of the physiological laws that should govern the
great changes and necessarily great disturbance of the
tissues involved.
Frequency of Seeing Patients. During the treatment of mal-
occlusion it is far better to see the patient at regular in-
tervals, and to this end the appointments should be
definitely pre-arranged, for it is obvious that if system be
observed much greater progress will be made in a given

time.
318 MIALOCCLUSION.
The necessary frequency of the visits depends much on
the skill of the orthodontist. The author is convinced that
much unnecessary time of both patient and orthodontist
is often consumed, not only during visits, but in their fre-
quency. With a truly efficient appliance properly adjusted
so that the requisite amount of force may be directed and
constantly applied to the moving teeth, a full week may
usually be allowed to elapse with perfect propriety without
further attention. It is probably better, however, for oper-
ators of but limited experience to see their patients reg-
ularly twice a week in order to guard against unnecessary
delays on account of possible derangement of the appliance.
C H A P T E R XVI.
TREATMENT OF CASES.—CLASS I.
As already noted in the classification of malocclusion, the
number of cases belonging to this class is the greatest and
comprises by far the largest variety, the distinguishing
characteristics of the class being relative normal relations
of the jaws, usually with the teeth crowded and the arches
diminished in size, but with the keys to occlusion—the
first molars—in correct occlusion mesio-distally, although
one or more may be in buccal or lingual occlusion. The
malposed teeth are usually, however, confined to those
anterior to the molars, and more commonly to the incisors
and canines. Both arches are usually involved and often
quite similarly.
As the mesio-distal relations of the lateral halves of the
dental arches are normal in this class, it must follow that
if the teeth of each arch be moved into harmony with the
line of occlusion both arches must then be in perfect
harmony as to size and the teeth be in normal occlusion,
with proper facial balance established. The latter, how-
ever, may not at once be apparent, as we shall see later, but
it must follow ultimately when Nature shall have effected
the full development of the alveolar process and the
muscles shall have become modified in form and function
so as to act normally in their relations with the teeth in
occlusion.
That we may clearly establish in the mind of the reader
these principles, as well as familiarize him with some of
the many forms of malocclusion of the teeth belonging to
this class and with the best methods for their correction
and retention, a number of cases from the author’s practice
will be here reported.
3.19
320 MALOCCLUSION.
Most cases belonging to this class have very simple be-
ginnings. Fig. 266 illustrates a very common beginning
of a type of cases, early and proper treatment of which
may prevent malocclusion of other teeth upon their
eruption. For some cause not always easy to determine
there has not been the normal growth in the alveolar pro-
cess in the region of the lower incisors, which is manifest
in a lack of the normal widening of this arch between the
deciduous canines. In this case while the lower centrals
have erupted in practically normal positions, the laterals
have been forced into labial positions. As elsewhere noted,
FIG. 266.
the pressure normally exerted by the lips upon the canines
tends to augment this crowded condition, the lower dental
arch being thus prevented from exerting its normal widen-
ing influence through occlusion upon the upper. As a
result the way is rapidly being paved for the permanent
narrowing of both arches, and consequent further complica-
tions as more of the permanent teeth shall erupt. A very
simple, yet efficient method of assisting Nature in antag-
onizing this narrowing tendency of the arches is to slowly
widen the space between the lower canines by lengthen-
ing a section of soft wire pointed at each end and made
to rest in pits in the enamel of the deciduous canines, as
in Fig. 267, the lengthening of the wire being effected by
pinches with the regulating pliers. In this way space will
be provided not only for the lower lateral incisors, but also

TREATMENT OF CASES.—CLASS I. 321
for those of the upper arch by the outward pressure
exerted upon the upper canines through the inclined planes
of the lower canines. This method is useless unless intel-
ligently managed. The tendency with a beginner is always
to renew the pressure too often. By a too rapid movement
the influence upon the teeth of the upper arch will soon
be lost by the carrying of the lower canines outside of their
zone of normal occlusal influence. Once a month is quite
often enough to see the patient and extend the movement of
the teeth by one or two pinches of the wire. By studying
FIG. 267.
ſº
º
| | º tº
E.H.A.
this method its efficiency will be readily seen. Gentle pres-
sure and stimulus long continued are needed to accord with
the natural growth of the jaw and as the device is of almost
no inconvenience to the patient it may be worn without
complaint an indefinite time. The method has long been
a favorite with the author and is very useful if employed
early.”
If it be employed before the case has progressed to
pronounced displacement of the laterals, Nature’s inherent
force, together with pressure from the lips, will gradually
move the laterals into correct occlusion as space for them
is made. Or, force may be exerted upon them by means of
wire ligatures embracing the laterals and the pinched wire.
Or if the laterals be misplaced lingually instead of labially
* “A New Force in Orthodontia,” Dental Digest, vol. 1, No. 1, Angle.








22
322 MALOCCLUSION.
as they more commonly are, force may be exerted upon
them by means of rubber wedges placed between each lat-
eral and the pinched wire. In more advanced cases the
pinched wire may be employed on the labial surfaces of the
teeth and soldered to bands cemented upon the canines,
with force exerted upon the laterals by means of wire
ligatures, as shown in Fig. 268.*
Fig. 269 shows a modification of this plan of applying
force which was used with much satisfaction in the case
E. H. A.
here illustrated. At the beginning of treatment the decidu-
ous canines were much closer together than here repre-
sented, with the right permanent lateral lingually displaced
and much closer to the left lateral. The right central was
also turned farther upon its axis. A section of an expan-
sion arch was soldered to the labial surfaces of bands ce-
* Angle. Fourth edition.


TREATMENT OF CASES.—CLASS I. 323
mented upon the lateral incisors, and a spur which had been
soldered to the lingual surface of the one on the left was
made to bear in a notch ground in the lingual surface of the
canine. An occasional pinch from the regulating pliers
widened the distance between the lateral incisors and with
them the canines were carried laterally. At the same
time the labial movement of the right lateral was effected
by a piece of rubber stretched between the right canine and
the end of the section of pinched wire. The movement of
these teeth provided space for the right central, rotation of
which was accomplished in the usual way, as shown, by
spurred band and ligature engaging the lengthening sec-
tion of wire.
The movements of these teeth successfully accomplished
through occlusion the few necessary movements of the
teeth in the upper arch. The device was so simple and
efficient, yet compact, that it gave the patient almost no
inconvenience. He was rarely seen oftener than once in
six weeks. * ,
When the teeth had all been moved into harmony with
the line of occlusion the device was allowed to remain in
place and served the purpose of retention. The rubber
wedge, however, was removed and the end of the wire bent
to bear firmly against the canine.
This form of device has many uses, especially in the
beginnings of similar cases. But in cases further pro-
gressed, as in Figs. 270 and 271, the upper arch has become
so much involved that it is folly to attempt its treatment
indirectly through occlusion. Each dental arch should
then be operated upon, and for this purpose there is noth-
ing else so efficient or that gives so complete control of the
movements of the teeth as the expansion arch, already
described. For its operation in this and similar cases
the D bands should be placed upon the permanent first
molars, or, they (in Smaller size) may be employed upon
one or all of the second deciduous molars. Rarely, how-
324 MALOCCLUSION.
ever, is it advisable to employ all four of the deciduous
molars, or even two in the same arch, as anchorage. The
FIG. 270.
expansion arches are then carefully bent to exert force
in exactly the direction desired when the wire ligatures
FIG. 271.
are employed, yet at the same time to lie as closely as pos-
sible in contact with the teeth without binding or in any way
interfering indirectly with the necessary movements of the


TREATMENT OF CASES.–CLASS I. 325
malposed teeth, so that the patient may experience as little
inconvenience as possible from the presence of the ap-
pliances.
In Fig. 272 is shown a more or less common type of
malocclusion belonging to this class, as will be readily
recognized by the position of the molars. The patient was
a boy sixteen years of age. All of the upper anterior
teeth are in lingual occlusion, while the lower, through
occlusion, have been forced slightly labially. The upper in-
cisors were laced to the expansion arch with wire ligatures,
FIG. 272. FIG. 273.
and all carried labially by tightening the nuts in front of
the tubes on the anchor teeth—the first molars. It will be
seen in the next engraving, Fig. 273, that plain bands en-
circle the lateral incisors to prevent slipping of the liga-
tures, while plain ligatures are used on the centrals. The
engraving illustrates a study model made after completion
of the tooth movements and just before the appliances were
removed.
The upper teeth were moved outward to correct posi-
tions, as shown in the case completed, Fig. 274, in just
seven days. The appliance was allowed to remain upon the
teeth passively for ten days before its removal, when occlu-
sion alone was depended upon for retention.
No effort was made to change the positions of the lower

326 MALOCCLUSION.
incisors, as it was known that the necessary change would
be effected by occlusion. -
In the treatment of all similar cases there is a strong
tendency on the part of many to perpetuate the antiquated
FIG, 274.
practice of applying some form of gag to keep the jaws
apart and prevent the occlusion from interfering with the
FIG. 275. FIG. 276.
movement of the teeth. Such useless encumbrances should
be abandoned. A good appliance will effect the movement,
regardless of the slight hindrance offered by occlusion,


TREATMENT OF CASES.–CLASS I.
327

328 MALOCCLUSION.
which is reduced to the minimum by the patient’s natural
avoidance of irritating the sensitive moving teeth.
Figs. 275 and 276 represent the malocclusion of another
case, that of a boy aged eleven years, and Figs. 277 and 278
show the teeth from the occlusal aspect. The permanent
incisors and first molars have erupted. The lower right
lateral incisor early took a lingual position and the pres-
sure of the lips acting externally to the arch soon closed
the space between the central incisor and the deciduous
canine, thereby diminishing the size of the arch to that
extent. The pressure of the muscles of the lips and cheeks
gradually molded the upper arch to conform to the di-
minished size of the lower.—only an accentuated condition
of that shown in Fig. 9 and of all similar cases allowed to
progress.
It will be seen that the molars have locked normally.
There is, therefore, the normal mesio-distal relation of the
jaws and dental arches, and if in obedience to the law of
occlusion the arches be enlarged anteriorly and each of the
malposed teeth be placed in harmony with the line of
occlusion, there will then be normal occlusion. Although
it would at first appear that there is not sufficient room to
accommodate all the teeth (and, indeed, extraction was
freely advised by several dentists), yet in fact the room
was ample, as we shall see.
Again, by studying the profile of the young man’s face,
Fig. 279, it would seem that to enlarge the arches and place
all of the incisors in their correct relation would be to
exaggerate to unsightliness the protrusion of the lips, al-
ready too prominent, yet in reality this prominence was
not exaggerated, but on the contrary reduced and beautiful
harmony of balance given to the face for reasons given
in the discussion of the art relations of this case in the
chapter on Art.
The treatment was simple and is easily understood. The
four upper incisors were carefully banded, the thin band
TREATMENT OF CASES.–CLASS I. 329
material C being used for the laterals, and the thicker, or
F, upon the centrals. Spurs of wire G that inclined forward
and downward were attached at the disto-lingual angles of
these bands close to the gingival edge. The right lower
lateral was also encircled by a plain band having a spur
attached near the disto-linguo-gingival margin.
FIG. 279.
D bands were carefully fitted to both upper and lower
first molars, and the expansion arches slipped into position,
all this occupying but a few moments at each of three
different sittings, so that the patient might become grad-
ually accustomed to the wearing of the appliances. He
was then dismissed for a week, until all soreness had sub-
sided, after which light pressure through plain ligatures
made to encircle expansion arch and spurs was applied, as
shown in B, Fig. 195.
Now, by studying the positions of the teeth from the
occlusal aspect in Figs. 277 and 278, it will be seen that

330 MALOCCLUSION.
both canines in both upper and lower arches must be moved
laterally in order to provide space for the lateral incisors
as they are moved into their correct positions, or in har-
mony with their proper lines of occlusion; therefore hook-
like notches were made in the ribs of the expansion arches
opposite the canines for engaging the ligatures used in
forcing these teeth in the direction indicated. At the same
time the permanent centrals and laterals were being ro-
tated into their correct positions.
In shaping the upper expansion arch, in order to best
exert force upon the teeth to be moved, and at the same
time to occupy as little room in the mouth as possible,
it was bent to rest in contact with the mesial angle of the
right central, but made somewhat wider in the region of the
canines in order to permit the widening of the dental arch.
In like manner the lower expansion arch was adjusted. As
the molar teeth were already in their correct positions
bucco-lingually as well as mesio-distally, no lateral spring
was given to the expansion arches.
The widening of the dental arches in the region of the
deciduous molars in such cases is often good practice, yet
the movement of these teeth is not so necessary as that of
the deciduous canines, for the reason that the permanent
canines and first molars must govern the width and length
of the arches. They being correctly placed and their posi-
tions maintained, the premolars upon eruption are molded
into harmony with them through the buccal and lingual
action of the muscles.
It may be well to again impress upon the operator of
little experience the great importance of so placing the
bands, spurs, ligatures and arch, that all will act with the
greatest efficiency. A loose band or ligature is, of course,
useless, and its wearing but a waste of time. A loose arch,
or one operating too near the cutting edges of the teeth is
worse than useless.
Figs. 280 and 281 show the positions of the teeth from
TREATMENT OF CASES.–CLASS I. 331
the occlusal aspect after the necessary movements had been
completed. Figs. 282 and 283 show the teeth in occlusion.
and Fig. 284 shows the facial lines.
FIG. 280. FIG. 281.
The expansion arches were allowed to remain in position
for a couple of weeks that all soreness might subside before
the adjustment of the retaining devices, and a novel method
FIG. 282. FIG. 283.
of temporary retention was employed by making use of
the bands and spurs already in position upon the teeth, in
connection with wire ligatures which were wound in
and out between the teeth and made to engage the spurs


332 MIALOCCLUSION.
in such a way as to antagonize the movement of the teeth
in the direction of their tendencies, as fully described on
pages 268 and 269, and shown in Figs. 216 and 217.
FIG. 284.
After several weeks of temporary retention the upper
teeth were permanently retained as illustrated in Fig. 218.
The lower incisors were retained by bands placed upon the
laterals and connected by a section of wire G soldered at
their mesio-lingual angles and made to bear against the
intervening centrals. Spurs were also soldered to the
disto-labial angles of these bands and made to bear against
the deciduous canines, thus preventing the lingual move-
ments of all the lower incisors in the manner indicated in
Fig. 235.
A case similar to the one just reported, although less
complicated, owing to the normal arrangement of the teeth
of the lower arch, is shown in Fig. 285. The effect upon
the facial lines was marked and also similar to that in the
last case, and for like reasons.

TREATMENT OF CASES.-CLASS I. 333
FIG. 285.
FIG. 286.


334 MALOCCLUSION.
In treatment the upper arch was enlarged and each
tooth moved into harmony with the line of occlusion by
force exerted from the spring of the expansion arch.
Neatly fitting bands made from the band material C were
cemented upon the central and left lateral incisors, and
FIG. 287. - FIG. 288.
rotary force applied by means of ligatures engaging the
arch and spurs soldered to the disto-lingual angles of the
bands close to their gingival margins. No spurred band
on the inlocked lateral was necessary, a plain ligature only
being used and all the ligatures being occasionally tight-
ened by twisting or renewal. The corrected occlusion is
shown in Fig. 286.
The teeth were retained as in Fig. 230.

TREATMENT OF CASES.—CLASS I. 335
The fine harmony established in the balance of the facial
lines, as the result of treatment, is shown in Figs. 287 and
288.
Fig. 289 shows a case which has been allowed to progress
until the malocclusion has become somewhat complicated.
The jaws being in their normal relations and the first
molars normally locked, it is easily diagnosed as belonging
to this class. Both arches are much reduced from their
normal size, with the alveolar process developed in accord
with the malpositions of the teeth.
FIG. 289.
|
|
.
X
º
|
fins
| º
- *
||f|| ||
º | | |
i |
s
|
i i. i
The treatment clearly indicated, is to enlarge the arches
and place each tooth in harmony with its line of occlu-
sion. This was accomplished by means of the expansion
arches, ligatures and spurred bands, as described in the
chapter on Adjustment and Operation of Appliances. The
dotted lines seen on the buccal and labial surfaces of the
teeth indicate the positions which the expansion arches
were made to occupy during treatment, and Fig. 290 shows
the case corrected. Each tooth having been placed in
harmony with the line of occlusion the two dental arches
must and do harmonize as to size, offering to each other
mutual support through the harmonious relations of their

































336 MALOCCLUSION.
inclined occlusal planes. Time only is necessary to effect
the full development of the alveolar process and the normal
functions and relations of the tongue and lips with the
teeth in their new positions.
FIG. 290.
A similar case is shown in Fig. 291. The first molars
have locked normally. The deciduous molars are present,
but the deciduous canines have been lost, followed by re-
traction of the incisors of both upper and lower arches
largely through lip pressure. The lower permanent
canine on the right side is just beginning to erupt which
will necessarily cause a still greater bunching of the in-
cisors as well as their movement lingually. The upper
right canine has not yet erupted, but its location is ap-
parent, it being almost directly over the root of the lateral.
Its eruption must be followed by great disturbance of the
upper incisors. Fig. 293 shows the facial lines of the
patient.
The treatment of the case consisted in moving labially all
of the incisors, providing ample space for the canines,

TREATMENT OF CASES.–CILASS I. 337
with firm retention until the complete eruption of the
canines and premolars. The movement of these teeth was
comparatively easy, but the recurrent tendencies of the
:
incisors, owing to the habit of contracting the lower lip
abnormally, were very strong, requiring their retention
for quite a protracted period.

23
338 MIA LOCCLUSION.
Fig. 292 shows the beautiful occlusion that has been
established, and here we would again impress an important
fact to be observed in all such cases, namely, that the re-
tention of the lower incisors and canines in their full mesio-
FIG. 203.
distal relations—even long after the retention of the upper
incisors has been discontinued—is of prime importance,
for, as we have seen in the chapter on Occlusion, the lower
dental arch is the mold over which the upper is formed
and maintained, and without the full normal size of the
lower arch, especially in its anterior part, the normal

TREATMENT OF CASES.-CLASS I.
339
:
:

340 MALOCCLUSION.
positions of the upper incisors in any such case can never
be maintained.
Figs. 294 and 295 show the beautiful balance in the facial
lines that has resulted from placing the teeth in normal
occlusion. -
Fig. 296 shows another case similar to the one just de-
scribed, but more complicated, there being decidedly
N
h
º
º
§§
|
º
greater arrest in the growth of the alveolar process and
jaws, which was probably due largely to the premature
sacrifice of deciduous teeth.
The relations of the first molars being normal, the plan
of treatment clearly required that both dental arches be
enlarged and each malposed tooth moved into harmony
with the line of occlusion, when there must necessarily
follow harmony in the sizes of the arches and Nature’s
intended relations of the teeth of each arch with those of
the opposite arch.
Figs. 297 and 298 show the model of the upper arch from
the occlusal and labial aspects, with the expansion arch
in position at the beginning of treatment. The incisors
were gradually moved labially to conform to the ideal form
given to the expansion arch, and at the same time the
Mºl' . .
º








TREATMENT OF CASES.-CLASS I. 341
dental arch was gradually widened in the region of the
premolars by the lateral spring of the expansion arch and
wire ligatures, all as carefully described in Chapter XIII.
In like manner, also, the lower arch was treated.
Fig. 297.
Fig. 299 shows the occlusion of the case after correction,
with retaining bands upon the canines, those of each arch
being connected by sections of wire G, as in Fig. 401, the
Fig. 298.
result being to antagonize the lingual tendency of the
formerly malposed anterior teeth.
The positions of the teeth in the lateral halves of the
arches were maintained in this case by vulcanite plates, as
shown in Fig. 252.


342 MALOCCI, USION.
There is a bit of history connected with this case that
should give much additional interest to it. By studying
the case in its original condition it will be seen how de-
fective is the growth of the alveolar process, and how nar-
rowed and reduced in size are the arches. It is a very com-
mon and typical case of the first class, demanding, accord-
ing to the plan of treatment hitherto universally followed
by the old school, the sacrifice of teeth, for it was reasoned
that in such cases the jaws were too small to accommodate
the teeth, usually supposed to be on account of the inheri-
FIG. 299.
.
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tance of the small jaws of one parent and the large teeth
of the other; therefore the supposed logical treatment was
to help Nature in overcoming her blunder of fashioning a
Small jaw for the reception of the full complement of well-
developed teeth, by reducing the number of teeth—two
or four of the premolars being sacrificed, or, in accord-
ance with the plan of some dentists hitherto held to be
good practice, all four of the first molars. The argu-
ments for the defence of such practice now seem strange
indeed. They were that extraction would not only provide
space for the remaining teeth, but that as the first molars
were supposed to be more perishable than other teeth and
as their eruption so soon followed the completion of the
child denture, they should be regarded largely in the na-























TREATMENT OF CASES.—CLASS I. 343
ture of deciduous teeth, and their sacrifice of no great
consequence. Indeed such sacrifice was often deemed desir-
able, since, it was argued, their removal would not only fur-
mish room for all the remaining permanent teeth erupted or
to erupt, but, stranger still, would assist Nature in her evo-
lutionary process of shortening the jaws so as to be in
better keeping with the lessened needs of the teeth due to
the change from the coarser foods of primitive man to the
soft and finely prepared foods of the highly civilized man.
It had long been a growing conviction with the author,
however, that the latter plan was not only absurd, but that
the sacrifice of any teeth was unscientific and positively
wrong in most cases, and that it should be employed
only as a last resort and then only after great deliberation,
and failure of the conservative method, for he had already
found that in simpler cases the supposed needs for ex-
traction vanished as intelligent treatment for the enlarge-
ment of the arches and placing of the teeth in normal
occlusion progressed. But in such a pronounced case as
this, where there was such marked arrest in the develop-
ment of the alveolar process, and especially as the patient
was a quite delicate girl, treatment without extraction
seemed almost hopeless. After much thought, however, it
was decided to give the conservative method a thorough
trial. As the arches were gradually enlarged much anxiety
was occasioned by the very abnormal outward inclinations
of all the teeth, and especially of the upper incisors, and
much doubt was experienced as to whether the teeth could
ever be permanently maintained at such abnormal angles.
It seemed to the author that the weight and pressure of
the lips and force of occlusion upon the teeth at such angles
might ever tend to their displacement. He of course at
that time had no realization of the fact that these forces
would prove blessings in disguise in stimulating the growth
of the tissues, and that we would ultimately have the full
growth of jaws and alveolar process, and that the very
344 MALOCCLUSION.
apices of the roots, then so convergent, would ultimately
be moved outward by Nature to their full normal upright
positions. After a number of months of retention it was
still a question as to whether a mistake had not been made
in retaining the full complement of teeth and whether it
FIG. 300.
would not still be better to extract and reduce the sizes of
the arches, but as the teeth were not so prominent as to
interfere with the proper balance of the face, retention was
continued and one day resulted in the gratifying discovery
that very noticeable changes for the better had taken place;
that the jaws and alveolar process were rapidly and nor-
FIG. 301.
mally developing; and that the teeth were assuming normal
angles of inclination, as was shown by comparing the
accurate and truthful models made at the time the retain-
ing devices were adjusted, Fig. 300, with the jaws and teeth
of the patient. Two years later the growth of these tissues
was nearly complete, as shown in Figs. 301 and 302.





TREATMENT OF CASES.–CLASS I. 345
By a comparison through accurate measurements of the
models at the beginning of the period of retention and of
those made two years later some very noticeable and ex-
FIG. 302.
tremely gratifying results, hitherto unnoticed or recorded,
were discovered. For example, the increase in the size
of the vault of the arch, shown transversely just anterior
to the first molars in Fig. 303.
FIG. 303.
V-UZV KN__JT
Measurements were also made of the changes that had
taken place in the positions and angles of inclination of the
teeth and show, Figs. 304 and 305, how pronouncedly the
positions of their apices have been shifted as the result of
growth. The positions of the teeth at retention are in-

346 MALOCCLUSION.
FIG. 304.
FIG. 305.


TREATMENT OF CASEs.--CLAss I. 347
dicated by the solid lines in the engraving, Fig. 306, and
their positions at the time of making the last model, by the
dotted lines. The incisors are represented at A and the
molars at B, the horizontal lines corresponding to the
line of the gum.
FIG. 306.
Who can estimate the advantages thus given, in freedom
to the tongue, in the possibilities for better breathing that
have been established in the nasal region consequent on the
added growth of the jaws and vault of the arch, and also


348 MALOCCLUSION.
in character and beauty given to the face, as a result of
such treatment.
The author greatly regrets that the photographs of the
young lady cannot be shown.
Let the reader in fancy compare these changes with what
would have been the condition of all of these tissues had
four premolars or four first molars been sacrificed. It
FIG. 307.
seemed apparent to the author that the gratifying results
shown in this case would be manifest in all similar cases
if the same plan of treatment were followed, and should
be proof that extraction was no longer necessary. The
truth of this has since been confirmed by the results in the
large number of other cases treated by him, even where
there has been far greater arrest in the development of the
alveolar process than that shown in this case, as we shall
see later.

TREATMENT OF CASES.–CLASS I. 349
The treatment of this case was begun early in 1896 and
|
:
was partially reported in the sixth edition of this work,
and this, so far as the author is aware, was the first time

350 MALOCCLUSI () N.
this important subject received any definite consideration
in dental literature. The possibilities of growth revealed
in this case have been an important factor in revolution-
FIG. 310.
izing the practice of orthodontia and should be taken into
consideration in the treatment of all cases.
The development of the alveolar process as a result of
tooth movement in this case is further discussed in Chap-
ter VII.

TREATMENT OF CASES.–CLASS I. 35]
By a glance at the first molars it will be seen that
the case shown in Figs. 307, 308, 309, and 310, also belongs
to this first great class. It is similar to the one last de-
scribed except that the arches show greater diminution in
size and the malocclusion is correspondingly more exten-
sive. It will be seen how pronounced is the arrest in the
development of the alveolar process, probably being no
more developed in the region of the intermaxillary bones
than at the time of shedding of the deciduous teeth.
The effect, as might be supposed, was very noticeable in
the facial lines of the patient, as shown in Figs. 311 and
FIG. 311. FIG. 312.
312, producing a pinched and flattened appearance about
the mouth.
As so much space would be required for admission of
the upper canines into the line of occlusion, extraction
would at first suggest itself, but recognizing the possibili-
ties in growth of tissues following tooth movement it is
apparent that such a course would be wrong and that the
conservative method should be followed. What was clearly
indicated was the restoration of all the teeth to normal
occlusion by slightly widening both arches, moving all the
incisors labially into line, and elevating, rotating, and
moving slightly lingually the upper canines.
Fig. 313 shows these various movements being accom-
plished simultaneously in both arches by means of ribbed

352 MALOCCLUSION.
expansion arches," D bands, spurred bands, wire liga-
tures, etc.
The anchorage was effected by means of D bands placed
upon the first molars in the lower arch, while in the upper
arch a D band upon the first molar was used on the right
side and an X band on the first premolar on the left side, it
FIG. 313.
* Several of the cuts showing the expansion arch were made before the
invention of the ribbed arch, therefore soldered spurs on the plain arch
to prevent the slipping of the ligatures are shown instead of notches in the
ribbed arch as now used, but referred to in the text as though the notched
ribbed arch had been used.

TREATMENT OF CASES.—CLASS I. 353
being found necessary after a few days of treatment to
transfer the anchorage from the left first molar to this
tooth, as the molar showed displacement distally in resist-
ing the strain incident to the labial movement of the in-
cisors. It is not surprising that the anchorage of the first
molar was insufficient and that the tooth did move distally
in this case, as it may in all cases at this age, for the reason
that the second molar gives it no support, it being still
unerupted and lying in a large open crypt into which the
first molar may quite easily be moved. It is usually well
in such cases to reinforce the molar, which can easily be
done by enlisting the support of one or both of the pre-
molars by means of a wire ligature made to encircle the
three teeth, the wire ligature resting on some portion of
the D band to prevent its sliding beneath the gum.
It will be noticed that there are two ligatures upon the
upper left lateral incisor. One is a plain ligature, as in A,
Fig. 195, for effecting the labial movement; the other, as
in B, encircles the arch and a spur soldered low down upon
the lingual surface of the band upon the lateral. The office
of this ligature was partly to assist in carrying the incisor
forward, but principally to effect its rotation. A notch
in the rib of the expansion arch prevented this ligature
from sliding forward and directed the movement of the
tooth laterally, the arch being so bent that in shape and
spring it bore toward the left and favored this movement,
assisted reciprocally by the band, spur and ligatures upon
the right lateral. The reason for placing the spurs well
toward the gum, important in all such cases, is to resist
the tendency of the arch to slide toward the cutting edges
of the teeth. This tendency is further opposed by crossing
the strands of the ligature near the spur.
The right upper central was also encircled by a ligature
which is prevented from sliding off the tooth by the band.
The form of the expansion arch was occasionally modi-
- 24
354 MALOCCLUSION.
fied by bending to meet the requirements of the moving
teeth and prevent bunching.
Not until the incisors had been moved labially sufficiently
for the full admission of the canines into the line of occlu-
Sion was any effort made toward elevating them in their
sockets. This was also effected by enlisting the spring of
the expansion arch. Wire ligatures were carefully worked
beneath the gum and above the gingival ridges of the ca-
nines and given one full twist on the labial surface, followed
by a final one-half twist with the pliers. One of the strands
was then made to encircle the arch and united with the
other strand by twisting, and the ends clipped down to the
usual length. This period in the treatment is shown in
Fig. 313, made from a study model taken in wax with the
appliances in position.
Tension on the canines by the spring of the expansion
arch was sustained by an occasional twist of the ligatures,
first always pressing upward upon the arch with the finger
in order to relieve the strain upon the ligature while twist-
ing. The author no longer believes in forcing the eruption
of the canines by mechanical means at this age of the pa-
tient. A wider experience has led him to adopt the con-
servative method, namely, to provide space and allow
Nature to effect the erupting in her own way, silmultane-
ously with the development of the previously arrested in-
termaxillary bones. Better results are thus gained.
The movement of rotation being the most difficult, it
was delayed until the teeth were fully erupted to the line
of occlusion, when the spurred band, wire ligature, and
wedges of rubber were applied after the usual manner for
accomplishing the movement, and soon brought about the
desired results.
Owing to the lingual inclination of the crowns of the
lower incisors no bands were necessary, the ligatures
simply encircling the expansion arch and crowns of the
teeth. The lateral pressure from the teeth prevented the
TREATMENT OF CASES.—CLASS I. 355
ligatures from sliding off. It will be noted that a notch
in the ribbed arch directed the movement of the canine
laterally as well as labially.
The slight necessary rotation of the second left premolar
was accomplished by bands, spurs, ligatures, and rubber
wedges, as already described, as soon as the anterior teeth
had been moved into correct position to reduce the crowd-
ing and permit it to turn.
The teeth of the upper arch were retained in their new
positions by a section of wire G soldered to the mesio-
lingual angles of bands on the canines and made to bear
against the lingual surfaces of the intervening incisors, as
in Figs. 233 and 322.
The tendency to rotate of the lower canine and the lin-
gual tendency of the incisors were antagonized by a
similar device, and the canine was retained by a band and
spur, the end of the spur bearing upon the labial surface
of the first premolar, as in Fig. 235.
Fig. 314 shows the upper model of the case at the be-
ginning of the period of retention, and Fig. 315 shows the
occlusion nearly two years later, and it is interesting to
note, by comparing the two engravings, what a marked
change has occurred in the alveolar process in the region
of the incisors. Nature unaided has shifted the roots of
these teeth to closely approximate their ideal positions.
Figs. 316 and 317 represent the face of the patient at this
time, and the improvement in the facial contour is very
noticeable and gratifying.
In the treatment of similar cases belonging to this class
great care should be observed to avoid the displacement
of the molars when used as anchorage, and always to care-
fully maintain their normal mesio-distal relations. Fig.
318 shows the result in a case where this precaution was
not observed. The force necessary in moving the incisors
and premolars of the lower arch into harmony with the
line of occlusion has been so great as to cause a noticeable
356 MALOCCLUSION.
movement of the right first lower molar, and the establish-
ment of mal-relations of all of the teeth in this lateral half
of the arch. Before the advent of the Baker anchorage
FIG. 314.
FIG. 315.
this was a common accident in treatment of cases of this
kind, and one difficult to avoid, but it is now inexcusable,
for by prompt detection and the timely application of
intermaxillary force (see page 255) such unfavorable
movements may be easily prevented.


TREATMENT OF CASES.–CLASS I.
357


358 MALOCCLUSION.
FIG. 318.
FIG. 319.


TREATMENT OF CASES.–CLASS I. 359
In Fig. 319 is shown another case belonging to this class
which is represented from the labial aspect, while Fig. 320
shows the occlusal surfaces of the teeth of both arches.
FIG. 320.
From the positions of the mesio-buccal cusps of the
upper first molars relative to the lower first molars, the
case is readily diagnosed as belonging to the class under
discussion.

360 MALOCCLUSION.
The patient was a lad aged thirteen. The strongly de-
veloped canines are erupting and have forced the lateral
incisors lingually and the centrals into torso-occlusion,
FIG. 321.
while all the lower incisors, though quite even, occupy
positions lingual to normal, and the canines are in torso-
distal occlusion.
Fig. 321 illustrates a study model of the case made with

TREATMENT OF CASES.—CLASS I. 361
the appliances in position. It shows the upper incisors
being moved labially en masse, by means of the expansion
arch, ligatures, and spurred bands, the spur and ligatures
acting upon the right central to effect rotation at the same
time. It will be noted that the deciduous second molar
has been removed and the anchor band X placed upon the
first premolar, not in order to secure greater anchorage
than that which would be derived from the first permanent
molar, but because it was desired to shift the premolar
distally somewhat to assist in gaining much needed space
for the canine. The loosened temporary molar was not
removed, nor change in the anchorage made until sufficient
anchorage from the firm permanent molar with a D band
had been utilized to move the incisors forward to nearly
their correct positions.
The arch was bent to accentuate the labio-buccal move-
ment of the left lateral incisor, the force being reciprocated
from the first premolar on the right through its attachment
by the ligature, as shown.
The disto-torso-occlusal position of the lower canines
here shown is the malposition most often assumed by them,
and as their movement is unquestionably one of the most
difficult to perform they are too often left undisturbed.
But as we now know that there must be complete harmony
in the sizes of the arches in order to insure permanency of
corrected occlusion, and also that the lower arch is the
pattern for controlling the size and form of the upper arch,
how important does it appear that these teeth be moved
forward and turned in their sockets in all cases, that they
may do their part in establishing the full size of the arch.
The canines then, as they should, become as keystones not
only in the lateral halves of their own arch but in a degree
in those of the upper arch, through occlusal influence.
Otherwise we must expect a corresponding diminution in
the size of the upper arch, with a bunching of the teeth
through the influence of the lips.
362 MALOCCLUSION.
It must be remembered that space for their accommo-
dation must always be provided before rotation will be
possible. They must, therefore, be carried forward until
their distal angles shall be free from interference with the
mesial angles of the first premolars. To insure this in this
case notches were made well forward in the ribbed arch to
prevent the ligatures from slipping as the nuts were tight-
ened, as in Fig. 199. In these cases the author has often
used with advantage two wire ligatures, one exercising
force mesially and the other laterally, directed by notches
in the rib of the arch. In this way the most stable attach-
ment is gained and a power exerted equal to the direct
application of a jack-screw. With no other form of liga-
ture would it be possible to exert pressure upon the tooth
in so effective a manner.
After the canines were moved forward sufficiently to be
free from the premolars their rotation was expeditiously
effected by occasional tightening of ligatures in the usual
manner, the spring of the arch being kept constant by
wedges of rubber stretched between it and the tooth bands,
as properly shown in the engraving.
The author believes this to be the most powerful and
practicable means known for performing these oft-needed
movements. If analyzed, it will be seen that the appliance
is only a series of levers, made to act in the most effective
manner. On pure mechanical principles, combining recip-
rocal and simple anchorage, while permitting the most per-
fect control over the direction of movement. .
Fig. 322 shows the teeth after they have been moved
into harmony with the line of occlusion, with the retaining
devices in position.
By studying the original positions of the teeth, together
with their corrected positions in this engraving, it will be
seen that the connection of the upper canines by bands and
a section of wire G, as in Fig. 233, not only resists their
torso-labial tendency, but that their infra-occlusal tendency
TREATMENT OF CASES.—CLASS I. 363
is also resisted by the resting of the wire upon the linguo-
gingival ridges of the laterals, whose lingual tendencies
are in turn resisted by the wire, while their mesial ten-
dencies are resisted by the centrals. At the same time the
FIG. 322.
laterals prevent the rotation of the centrals by contact with
their disto-lingual angles, while the mesial angles of the
centrals are prevented from moving labially by the ten-
sion of the fibers of the peridental membrane, care having

364 MALOCCLUSION.
been exercised to preserve this tension by exerting force
for their proper rotation only on their disto-lingual angles.
Had they been moved labially before rotation, there would
also have been mesial disturbance of the fibers instead of
distal disturbance only, necessitating their retention by
two bands united by spurs. Much advantage is often to be
gained by the intelligent manipulation of the fibers of the
peridental membrane during tooth movement.
The lower right lateral and canine were retained each by
a single band and spur, preventing their torso-distal dis-
placement. Of course the same effect would have resulted
from soldering the bands together, with one spur only from
the band on the canine bearing against the buccal surface
of the first premolar; but as the bands were to be worn
in this case for nearly two years the difficulty of adjusting
both so that one of them would not become loosened and
cause injury to the enamel made the plan objectionable.
There is another decided advantage in the use of spurs
in all such cases, in that the finer adjustment of the teeth
may be easily effected after the application of the retaining
devices by stretching a piece of rubber between the anchor
tooth and spur to create a leverage, and on the subsequent
removal of the rubber wedge, bending back the spur to
hold the tooth in position. This simple and very efficient
method of effecting such slight movements of teeth as are
often necessary on account of slight relapses during re-
tention, must be taken advantage of almost daily by the
orthodontist, thus often obviating the necessity for the
reapplication of the regulating appliances.
Figs. 323 and 324 represent the occlusion and facial
lines of this patient three years after treatment. -
Attention is again called to the development to normal
contour of the alveolar process in the region of the apices
of the roots of the upper incisors Consequent upon the
establishment of normal occlusion and function of the
teeth. It will also be noted that the retention of all of the
TREATMENT OF CASES.–CLASS I. 365
Fig. 323.
FIG. 324.


366 MALOCCLUSION.
teeth has not caused undue prominence of the lips, which
are seen to be in harmony with the other lines of the face,
but that it is a far finer result than could possibly have
followed that most unwarranted practice of sacrificing one
or two teeth from each arch to gain space.

TREATMENT OF CASES.-CLASS I. 367
By comparing the two upper arches shown in Figs. 325
and 326 the great change that has taken place in the form
of the vault of the arch is seen. This marked enlarge-
ment offers many added possibilities to the tongue in
speech and song, and in assisting mastication. It also
greatly benefits the nose, and might, we think, lend much
interest to the rhinologist and offer him food for reflection.
Figs. 327, 328, and 329 show another of the ever varying
forms of malocclusion which the incisors may be forced
FIG. 327.
to assume incident to the difficulties of eruption and lock-
ing. The relations of the jaws and first molars at once
determine the class to which the case belongs and clearly
indicate the required treatment which consists of the
proper enlargement of the arches so as to afford to each
tooth its full normal mesio-distal relation in the arch.
This was easily accomplished by means of expansion
arches (plain arches being used as no lateral deflection of
force was needed), both upper and lower being applied in
the usual way and operated simultaneously.
While the upper incisors were being carried forward and

368 MALOCCLUSION.
|

TREATMENT OF CASES.–CLASS I.
369
:

25
370 MALOCCLUSION.
the first premolars moved buccally, the canines were given
slight lingual movement through the force exerted by the
expansion arch made to bear against their labial surfaces.
The lower incisors were moved forward and laterally, as
well as rotated, by means of bands, spurs and ligatures
adjusted and operated as elsewhere described. Likewise
the canines were rotated. The patient was seen once a
week and increased tension given, first, by renewal or
tightening of the ligatures, giving each as much tension as
it would bear, immediately followed by slightly tightening
the nuts anterior to the sheaths of the anchor bands.
The correctly adjusted teeth are shown from their occlu-
sal aspects in Figs. 330 and 331, and in occlusion in
Fig. 332.
FIG. 332.
The device employed for retaining the lower incisors
is shown in Fig. 331. It consisted of a section of the wire G.
soldered to bands on the left lateral and right canine, with
an additional spur soldered to the lingual surface of the
band on the canine made to bear against the lingual surface
of the first premolar. It will be seen how the teeth are

TREAT'M ENT OF CASES.—CLASS I.
:


|
:
:

TREATMENT OF CASES.–CLASS I. 373
securely and harmoniously held in their new positions by
this device. After it had been adjusted for a few days it was
found that the wire connecting the bands was not quite long
enough to prevent lateral pressure upon the central
and right lateral and that they had consequently been
forced to slightly overlap. This was easily remedied by
two or three pinches of the wire with the regulating pliers.
The retention of the upper anterior teeth was effected
FIG. 337.
with the device shown in Fig. 233, with spurs soldered to
the disto-lingual angles of the bands and made to bear
against the lingual surfaces of the first premolars. This
was found sufficient for the retention of the upper teeth on
account of their favorable relations with the lowers. The
lower retainer was worn for fully a year and a half.
The changes in the facial lines due to treatment are
well shown by comparing Figs. 333 and 334, from photo-
graphs which were taken at the beginning of treatment,
with Figs. 335 and 336, taken a few months after retention.
Fig. 337 illustrates the mal-relations of the teeth in

374 MALOCCLUSION.
another case belonging to this class (the patient aged
twelve), and Figs. 338 and 339 show the teeth from the
occlusal aspect.

TREATMENT OF CASES.—CLASS I. 375
The premature loss of the upper deciduous canines per-
mitted the rapid shortening of this arch until Nature’s
intended space for the permanent canines was greatly
diminished. The principal resistance to the lingual move-
ment of the incisors being gone, they were rapidly tipped
downward and inward through the powerful force exerted
by the lip, and made to exert an unnatural force upon the
lower incisors which caused a bunching of the teeth of the
lower arch and forced the mandible distally somewhat.
That this has resulted is shown by the relations of the first
molars on the right side. The unnatural distribution of
force is rapidly intensifying these conditions which are
augmented by the efforts of the upper canines to erupt.
Had the full space of the deciduous canines, at the time
of their loss, been preserved, the malocclusion would have
been prevented to a large extent. It is easy to see how
effectually Nature has been thwarted in her normal work
of building the alveolar process.
The treatment clearly indicated was to enlarge both
dental arches, carrying the incisors well forward and pla-
cing each malposed tooth in harmony with the line of
occlusion, thus providing ample space for the eruption of
the upper canines, and, by proper retention of the teeth,
wait for Nature to continue the normal development of the
alveolar process and effect the normal eruption of the
canines.
The movements of the teeth were accomplished in the
usual way, as already described in preceding cases, by the
expansion arch, bands, ligatures, etc., the anchor bands
being placed upon all four first molars.
Retention of the upper arch was effected by means of
bands cemented upon the lateral incisors, connected by a
section of the wire G soldered to their mesio-lingual angles
and made to bear against the lingual surfaces of the cen-
trals. The wire was also extended distally in the form
of a goose-neck to engage the sulcus of the first premolars,
376 MALOCCLUSION.
as in Fig. 225, in this way preserving the space required by
the canines. The lower incisors and canines were retained
as shown in Fig. 233. The lower second premolar was
retained by a band and section of wire G soldered to its
buccal surface, the end resting against the buccal surfaces
of the first molar and premolar. The first molars on the
right side were retained in their normal mesio-distal re-
lations, as in Fig. 256.
FIG. 340.
There are certain questions of art as related to the face
in this case which are of unusual interest. As the lips
of the patient were somewhat thicker than is usual, the
degree of the original deformity was partially disguised
in the facial lines, which are shown at the beginning of
treatment at Fig. 340; and at the time of retention the teeth
inclined outward at their cutting edges so much, as a result

TREATMENT OF CASES.–CLASS I. 377
of tooth movement, and their apices were so much farther
lingual than normal on account of arrest in the develop-
ment of the intermaxillary bones, that over-prominence of
the lips was manifest, as shown in Fig. 341, taken at this
time, and indeed criticised by that eminent teacher of art,
Mr. E. H. Wuerpel, who suggested that it probably would
have been better to have resorted to extraction and thus
avoided the necessity for such undue prominence.
FIG. 341.
But the author felt quite certain that conservative treat-
ment, even in this quite exceptional case, was correct; that
the unnatural prominence of the lips would prove to be
but temporary, and that ultimately, as a result of the lips
becoming modified to the new conditions and assuming
their normal functions, together with the complete develop-
ment of the alveolar process and bones of the head, there
would finally be harmony of balance of the mouth and
lips with the rest of the face.

37.8 MLA LOCCLUSION.
How well this belief has been verified is shown by Fig.
342, which represents the facial lines of the young lady
FIG. 342.
FIG. 343.
five years later than the picture last shown. We may also
add that Mr. Wuerpel, upon seeing this picture, expressed


TREATMENT OF CASES.-CLASS I.
379

i
380
MALOCCLUSION.
much surprise and pleasure at the pronounced improve-
ment.
i
:
The growth of the alveolar process and occlusion of the
teeth are shown as they appeared two years after the be-

TREATMENT OF CASES.-CLASS I. 381
ginning of treatment in Fig. 343, and the occlusal aspect
of the teeth at the same time is shown in Figs. 344 and 345.
:
:
Bands are shown upon both upper and lower first molars
in the last three pictures. They were to support the plane

38.2 MALOCCLUSION.
and spur in the retention (Fig. 256) of these two teeth in
their correct relations, as the tendency to return to their
original positions of end to end bite was quite persistent.
The utter absurdity of the doctrine that demands the
reduction of the typical number of teeth in order to prevent
too great prominence of the lips is illustrated in the results
shown in the next case, which was treated by the author
FIG. 350.
some years ago when he was still dominated by that per-
nicious teaching.
Figs. 346 and 347 show the occlusion from the right and
left sides before treatment, and Figs. 348 and 349, after
treatment.
By carefully studying the facial lines of the patient
before and after treatment, shown in Figs. 350 and 351, it
will readily be seen what a blunder was committed in
the sacrifice of the first upper and lower premolars on the
right side, as is plainly shown in the lack of the proper

TREATMENT () F. CASES.–CLASS 1. 383
fulness of the upper lip and the consequent most unpleas-
ing angle between the nose and lip. The left side of the
mouth in the region of the canine is far more pleasing than
the right side, and this is easily understood by reference
to the occlusion, for on the left side the occlusion is normal,
Fig. 351.
º
while on the right side it is abnormal. The upper and
lower right canines have been moved distally into the
spaces made vacant by the loss of the first premolars,
thereby shortening the right lateral half of both arches
and placing the canines at an abnormal angle and relation
with the lips, thus robbing the face of its typal contour and
proper balance.
Fig. 352 shows the models of the teeth in occlusion, and

384 MALOCCLUSION.
Fig. 353 shows the occlusal view of the upper model, in
the case of another girl, aged twelve, which is similar to
that shown in Fig. 337 except that the constriction of the
FIG. 352.
upper arch is considerably greater. This case is especially
interesting by reason of the complete arrest in the develop-
ment of the alveolar process in the region of the intermax-
illary bones, and is another glaring example of the unfor-
FIG. 353.
tunate result following the premature extraction of the
upper deciduous canines.
As the type of this patient is entirely different from that
of the one illustrated in Fig. 340, the lips being thin and
the profile line almost straight, the effect of the malocclu-


TREATMENT OF CASES.-CLASS I. 385
sion is more noticeable, and the deficiency in the con-
FIG. 354.
FIG. 355.
tour of the mouth very apparent, especially manifest by the
obtuse angle formed between the nose and the upper


26
386 MALOCCLUSION.
lip, as shown in Fig. 354. A front view is shown in Fig.
355.
Who cannot see that this remarkable diminution of the
dental arches from their normal size has produced a cor-
responding diminution from the normal in the contour
of the face, and that the logical treatment demands that
the arch shall be enlarged to its full normal size and the
teeth retained until Nature shall have caught up, as it were,
in her work of developing the alveolar process which has
been so long arrested? Although this plan of treatment is
so clearly demanded in the interests of occlusion and facial
balance, its performance occasioned many misgivings, for
never before had the author seen a case with the intermax-
illary bones and alveolar process so deficient in develop-
ment, and on account of the extreme lingual positions of
the apices of the roots of the teeth, it became apparent that
if their crowns were moved labially into harmony with the
line of occlusion the angles of protrusion would be so great
as to leave the teeth almost procumbent in the process,
this, as well as causing marked “open bite.” It also
seemed doubtful whether Nature could or would supply the
large amount of bone required for the normal positions
of the teeth. Yet in fancy the author could see the most
unfortunate result that must follow the extraction of four
premolars, which would have been necessary in order to
harmonize the sizes of the two arches. He could see the
already reduced arches further reduced and the unnatural
angles at which the canines would have to stand as they
were moved distally to take the place of the first pre-
molars; and the consequent restriction of the tongue and
nasal passages coincident with the lack of development of
the intermaxillary bones and vault of the arch, and more.
As the rest of the bones of the face and head progressed
in development, the author could realize how marked would
be the ultimate deformity as the lack of proper contour of
the mouth thus became gradually intensified. So he deter-
TREATMENT OF CASES.–CLASS I. 387
mined to pursue the conservative plan, having faith that
if Nature were properly assisted the result, though pos-
FIG. 356.
sibly not ideal, would be far more desirable than if the
invariable, time-honored custom of mutilation in such cases
were resorted to.
FIG. 357.
It was decided to move the incisors forward only a part
of the distance necessary to make space for the canines
during the first period of treatment. There they were re-


388 MALOCCLUSION.
tained in the positions shown in Fig. 356 and the young
lady dismissed for one year in order to allow the process
to develop. The facial lines of the patient at this time are
FIG. 358.
shown in Fig. 357. Upon her return gratifying changes in
the growth of the process and in the positions of the apices
of the roots of the teeth were noted, yet it was still doubt-
FIG. 359.
ful as to whether the full normal amount of bone would
ever be deposited. However, the incisors were then car-
ried forward to correspond with their correct relations
with the line of occlusion and the arch slightly widened, the


TREATMENT OF CASES.–CLASS I. 389
teeth retained, and the patient dismissed for another year.
Upon her next return the results shown were indeed grati-
fying. The growth of the bone and process had been ex-
tensive, the teeth had moved downward so that the “open
bite” had disappeared, and the apices of the roots of the
incisors had been carried forward until the teeth had at-
fained their approximately normal angle of inclination.
FIG. 360. FIG. 361.
The occlusal positions of the teeth at this time are shown
in Fig. 358 and the occlusion in Fig. 359, and the result
upon the facial lines in Figs. 360 and 361. Although the
face is still somewhat lacking in normal contour, it will
doubtless continue to improve, as the author does not
doubt that the growth of the intermaxillary bones and
alveolar process will continue for some considerable time.
When we consider how promptly Nature has responded,
and how generously the missing bone has been supplied
in this quite remarkable case, and when we further consider

390 MALOCCLUSION.
the results attained in occlusion and in art, and what would
have been the results had mutilation been resorted to, it
would seem that its practice in any such case should here-
after be regarded as but little less than criminal.
Let us contrast the results in the treatment of this case
with those shown in Fig. 362." The case originally must
FIG. 362.
have been very similar to that shown in Fig. 352, but in
order to harmonize the “large teeth with the small jaws”
six beautiful premolars and one first molar were sacrificed
resulting in complete chaos in the occlusion, or a far worse
condition than could possibly have been present before
treatment was begun, and with both speech and facial lines
greatly and permanently impaired. The case, as here
shown, is one of many similar cases in like condition, the
models of which have been sent to the author for consulta-
tion.
Fig. 363 shows the occlusion of another case similar to
that shown in Fig. 352, with nearly as pronounced arrest
* “The Orthodontia of the Old School,” Hopkins. Transactions American
Society of Orthodontists, 1904.

TREATMENT OF CASES.—CLASS 1. 391
in the development of the intermaxillary bones, and Fig.
364 shows the face of the patient at the time of beginning
FIG. 363.
the treatment, and how greatly its natural beauty is
marred by the malarrangement of the teeth.
FIG. 364.
Fig. 365 shows the occlusion after one and one-half
years of retention, during which time marked growth in


392 MALOCCLUSION.
the development of the alveolar process had taken place, al.
though by no means yet complete.
FIG. 365.
FIG. 36(5.
Fig. 366 shows the improvement in the facial lines after
the lapse of another year and a half, or three years after


TREATMENT OF CASES.-CLASS I. 393
the beginning of retention. The teeth at this time were in
fine occlusion, with normal development of the alveolar
process. It would be hard to describe the pronounced im-
provement in the appearance of the patient following the
correction of the malocclusion and the changes in the tis-
sues incident thereto.
Figs. 367, 368, and 369, represent the occlusal relations
of the teeth of a boy thirteen years of age, and Figs. 370
FIG. 367.
and 371 show the teeth from the occlusal aspect, and from
the relations of the first molars the case is readily diag-
nosed as belonging to this class. The arrest in the develop-
ment of the alveolar process is greater than in the case last
described, almost the limit of possibility in the malocclu-
sion seeming to have been reached.
The effect of this malocclusion on the facial lines of the
patient, though very great, most unfortunately cannot be
here shown, as through oversight his photograph was not
taken at the time of beginning the treatment, and the

394
MALOCCLUSION.
mistake was not discovered until treatment had progressed
so far as not to permit of showing the original condition of
|
the facial lines. The author would here emphasize the im-
portance of vigilance on the part of the orthodontist on
this point in order to avoid like serious losses.

TREATMENT OF CASES.-CLASS I.
395
*I 18 *BIJI
*018 （ĐIJI

"8:18 （01）.1"Z18 （ĐIJI

TREATMENT OF CASES.-CLASS I.
397
ºg 18 ºſºl）]
'# 18 º DI, H.

398 - MALOCCLUSION.
The case had a simple beginning, like those early de-
scribed in this chapter, and shows how rapid and progres-
sive has been the development of the malocclusion.
Again the demands of facial art and occlusion clearly in-
dicate that in treatment all of the teeth must be retained,
the arches enlarged to their normal sizes, and at the same
time each tooth moved into its correct relation with the
line of occlusion. Several periods of rest and activity were
necessary in this case to allow for growth in the alveolar
process and intermaxillary bones.
The changes in the positions of the teeth, as well as
the greatly enlarged dental arches are shown in Figs. 372
and 373 and the occluded relations of the teeth of the two
arches are shown in Figs. 374 and 375.
We would again call attention, by a comparison of the
original with the present conditions, to the great increase
in growth of the alveolar process and intermaxillary bones,
and the greater freedom given to the tongue. -
Another point of interest is worthy of note. It will be
seen how large is the pattern of the incisors and, indeed,
of all the teeth, and how apparently out of proportion they
originally were with the sizes of the jaws—a most typical
case in which to point out the absurdity of the theory, so
long maintained, of attributing this apparent inharmony
of size to inheritance of large teeth and Small jaws.
Although at the time of beginning treatment this boy
was rather delicate and undersized, the size and pattern of
his teeth clearly indicated that he would ultimately be
large in stature, which is indeed, now being abundantly
verified. - . -
Figs. 376 and 377 show the boy's face at the time of mak-
ing the last models.
The movements of the teeth were brought about by
means of the ribbed expansion arches, bands and ligatures,
in the main as heretofore described. To attempt to de-
scribe in finer detail the treatment of this or of any com-
TREATMENT OF CASES.–CLASS I. 399
plex case of malocclusion would be tedious and probably
unfruitful. It seems to the author that the only possible
way for any student to become familiar with the details

400 MALOCCLUSION.
is through experience, following the main principles al-
ready laid down. Unfortunate as it may be, the artist
cannot describe all of the details of his pictures. He can
Only lay down certain general principles as to the use of
brush and colors, which should inspire and direct the
student of art in reaching similar or better results by
patient, intelligent effort.
It will be seen by referring to Fig. 370 that there is un-
usual displacement of all of the lower incisors and of the
left canine, and that the displacement of the lateral incis-
ors is complete, that is, that the very apices of the roots are
far lingual to their normal positions, and as the crowns
were moved both labially and laterally the teeth rapidly
assumed a dangerously procumbent position. In order to
effect the movement of their apices, as well as of their
crowns, a device was used which was as efficient as it was
simple, and the method so far as the author knows is de-
scribed here for the first time.
The retaining device, as shown at Fig. 233, was adjusted.
It consisted of bands cemented to the canines, connected
by a section of wire G made to bear against the lingual
surfaces of all the lower incisors, the crowns of which
were not yet in perfect alignment, though approximately
so. Before cementing the bands in position two of the
longer of the delicate tubes R were soldered to their mesio-
labial angles on a line parallel with the long axes of the
teeth. Similar tubes were attached in like manner to the
labial surfaces of bands cemented upon the lateral incis-
ors. Two delicate staples were now bent from the medium-
sized lever L, and one of them placed in position, one of the
legs of the staple being inserted into the tube attached to
the canine band and the other into the tube on the lateral
incisor. Having demonstrated its correct dimensions and
adaptation it was removed and given a twist so that the leg
intended for the lateral incisor would incline forward much
farther than the line of axis of the procumbent tooth. It
TREATMENT OF CASES.—CLASS I. 401
was now sprung into position, and thus a constant, but
gentle force was given to this lateral incisor, the result
being to support the crown of the tooth and move its apex
slowly labially, this force being resisted by the stronger
and more firmly attached anchor tooth—the canine—with
the tendency of forcing the apex of its root in the direction
opposite to that of the lateral incisor.
In like manner the other staple was made to operate,
and although the anchor teeth were slightly disturbed, the
apices of the roots of the two laterals were slowly moved
into their normal positions. The time occupied in moving
the left lateral was about three months. It was of course
necessary to occasionally remove and modify the form of
the staple in order to maintain the necessary force.
The section of wire G connecting the anchor bands upon
the lower canines, before mentioned, not only served as
temporary retention for the incisors, but rendered the ca-
nines, as anchor teeth, more secure.
The same method as employed in their moving was used
in effecting the retention of these teeth, the staple, though
without spring, being allowed to rest in position.
In studying the forms of the dental arches in this case
at this stage of the treatment, Figs. 372 and 373, it will be
Observed that they are narrower and longer than normal
and might suggest to those who follow the Bonwill law in
its application to orthodontia, the advisability of widening
and shortening them. This is not necessary. We must re-
member that the jaws and alveolar process are yet far
from their full development, but since we have placed the
teeth in their normal relations we have given Nature an op-
portunity to complete the development, which she must do,
normally, and in accordance with the typal demands of the
individual, through the now normal workings of the forces
which govern occlusion—forces which must ultimately es-
tablish and control the normal form of all dental arches
where the teeth are in normal relations.
27
402 MALOCCLUSION.
The device for the final mechanical retention of the lower
teeth in this case is shown in Fig. 245, and in position on
the teeth in B, Fig. 244; and for the upper teeth in B,
Fig. 241. -
FIG. 378.
ITIG. 379. FIG. 380.
Figs. 378, 379, and 380 show a case where there is very
pronounced mal-relations of the incisors and canines, and
if diagnosed superficially it would appear to belong to the
second division of the second class of malocclusion, for the


TREATMENT OF CASES.–CLASS I. 403
retrusion of the upper centrals and protrusion of the lat-
erals give it the typical appearance of these cases. Yet
by an examination of the relations of the first molars it
will be seen that it clearly belongs to the first great class
and that when the incisors are brought in harmony with

404 MALOCCLUSION.
the line of occlusion there will be ample space for the
Second lower premolars to erupt, when they will assist
individually in supporting not only the weight of the jaws
in occlusion, but, of still more importance, the first molars,
and directly and indirectly the teeth anterior to the pre-
molars.
Figs. 381 and 382 show the result of carrying out this
plan of treatment, or the establishing of the normal in
Occlusion, by lengthening the lateral halves of the lower
arch after the manner described in connection with the
cases shown in Figs. 207, 419, 421 and 422, and correcting
the positions of the teeth of the upper arch by means of
the expansion arch, spurred bands, ligatures, etc., as
already frequently indicated. Although there is not yet
perfect harmony between the occlusal planes of the pre-
molars on the left side, their full normal relations must fol-
low as time progresses.
By examination of the facial lines at the time treatment
was begun, Figs. 383 and 384, it will be noted how much
the normal lines demanded by this type of face have been
thrown out of balance by the malocclusion, and Figs. 385
and 386 show the degree to which they have already been
restored through the restoration of normal occlusion.
Fig. 387 shows the occlusion of the teeth of a girl eleven
years of age, and the case is typical of a very common form
of malocclusion. The malocclusion is chiefly confined to
one side of the dental apparatus and is commonly the result
of the premature loss of the deciduous canine, which
permits the rapid diminution in the size of the arch, forcing
the permanent canine in its effort to erupt into over-prom-
inence, which in turn is reacted upon the lateral, causing its
partial or complete lingual displacement, with usually some
disturbance of the positions of the centrals.
The disturbance in the balance of the facial lines, as in
all cases, is in direct proportion to the degree of the mal.
occlusion. Obviously no greater blunder could be com.
TREATMENT OF CASES.
–CIASS I. 405
*#88: “ĐIJI
"888

"ĐIJI
406 MALOCCLUSION.
mitted than the resort to extraction, for as the first molars
are in normal relations the full complement of teeth in both
:
:
upper and lower dental arches is essential to the establish-
ment of harmony in the sizes of the arches, an invariable
requirement in all cases. What is clearly indicated is the


TREATMENT OF CASES.—CLASS I. 407
enlarging of the dental arch (one or both as needed,
though the teeth of the lower arch in cases of this type
are often in excellent alignment), and compelling each
tooth to occupy its correct relation with the line of occlu-
sion. And yet this often requires considerable time, skill,
and patience, as very often both central incisors, as well
Fig. 387.
as the lateral nearest to the prominent canine, have not
only been carried lingually but shifted laterally, changing
their relations with the median line and necessitating not
only their labial and often torsal movement, but their
lateral movement, in order to restore their harmonious re-
lations with the median line. The movement of the lateral
and canine of the opposite side of the arch may also be
necessary in order to provide room.
All of these movements can best be effected by means
of the ribbed expansion arch made to bear against the
prominent canine, with force reciprocated from the pre-
molars, laterals and centrals, at the same time giving it
a form which will exert spring laterally upon the anterior

408 MALOCCLUSION.
teeth. In order to exert this spring the arch should bow
out from the teeth on the comparatively normal side, the
result of which, if notches be made in the arch at suitable
places and wire ligatures be used, is to deflect the centrals
and laterals in the desired direction. This is intensified by
the occasional renewal of the ligatures and tightening of
the nut in front of the sheath of the anchor band on the side
of the greatest malocclusion. In rare instances it may
also be necessary to enlist the assistance of intermaxillary
anchorage, as in Fig. 211. The form of the expansion arch
must of course occasionally be modified as the teeth are
moved in order to best conserve the energy of the ap-
pliance.
The movement of the prominent canine may often be
hastened by a piece of rubber stretched between it and the
expansion arch. -
We have mentioned elsewhere that the canine, from its
location and time of taking its position in the arch, may be
regarded as the keystone in its lateral half of the dental
arch. Now, as in the case last described, the arch having
been enlarged for the reception of the keystone, as it were,
the chief problem in retention will be to maintain this
important part of the structure in position, when it must
follow, as in masonry, that all the other portions of the
arch will be harmonious as to relation and support. The
retention of the canine in such position will resist the
movement of all the other teeth in the direction of their
tendencies. This is effectually accomplished by the device
shown in Fig. 232, consisting of a band cemented to the
lateral incisor, to which has been soldered at its disto-labial
angle a section of the wire G that is passed transversely
across the labial surface of the canine and first and second
premolars, its end being securely held by means of a wire
ligature surrounding it and the latter tooth. In many in-
stances the device shown in Fig. 233 will be found very
efficient. Of course if the laterals have been moved from
treatMeNºt of cases.—class 1.
409
I'ig. 388.
FIG. 389. FIG. 390.


410 MALOCCLUSION.
FIG. 391. FIG. 392.
-
FIG. 393.


TREATMENT OF CASES.–CLASS I. 411
torso-occlusion they must be retained in the usual way
by bands, spurs, etc.
FIG. 394.
FIG. 395.
Fig. 388 shows the result of such treatment in this case,
Figs. 389 and 390 show the face of the patient at the be


412 MALOCCLUSION.
ginning of treatment, and Figs. 391 and 392 show it at the
time the last model was made.
Figs. 393 and 394 show similar cases treated in like
manner to the one just described, with the results in occlu-
sion shown in Figs. 395 and 396.
FIG. 396.
So far we have considered cases belonging to this class
in which the malocclusion has been principally confined
to the incisors and canines. We will now consider a type
not infrequently met with in which the malocclusion is
made more complex by reason of the molars and premolars
being also more or less involved. The malocclusion may
include one or all of the buccal teeth on one or both sides
of both arches, the involved upper teeth being in lingual
occlusion.
The author would here call special attention to the very
pronounced and unfortunate results which must follow the
force thus wrongly distributed. Normally, as in Fig. 3, the
great force upon the teeth incident to mastication is per-

TREATMENT OF CASES.–CLASS I. 413
fectly distributed in the direction of the long axes of the
teeth, the force tending to maintain the normal width of
both arches and the teeth at their proper angles of in-
clination, while in the form of malocclusion now to be
considered, the forces being wrongly distributed tend to
diminish the width of the upper arch, especially in the
region of the apices of the roots of the teeth, and to abnor-
FIG. 397.
mally widen the lower arch in this region. The effect of
this abnormal distribution of force is graphically shown
in Fig. 397, which represents the posterior view of the
malocclusion in a very pronounced case.
It is easy to understand how the vault of the arch and
bones of the nose gradually became involved until normal
breathing became impossible, and as the space for the
tongue was so greatly restricted, it was with much difficulty

414 - MALOCCLUSION.
that the man could enunciate his words sufficiently to be un-
derstood.
Fig. 398 shows the malocclusion in a case where all of
the teeth are involved, and it will be seen that the upper
molars are in lingual occlusion and the lower molars in
buccal occlusion, although all are in normal mesio-distal
relations, thus clearly placing the case in the first great
class of malocclusion.
It is interesting to study the beginnings, progress and
disastrous effects of such malocclusion upon the develop-
FIG. 398.
..
a
º Tºº-º-º: t
*
º ºzº.”
2.
-:
º
ment of the jaws and dental apparatus as a whole, and it
should give emphasis to the importance of early treatment,
for even this very complicated case had a very simple
beginning, dating from the eruption of the first permanent
molars. Doubtless at this time the positions of the molars
were very nearly normal, but as they came into near rela-
tion they failed to lock normally. Probably the points of
the cusps upon first coming into contact hesitated, as it
were, for a time, but through slight adverse causes were
unable to assume their normal relations, hence their in-
clined planes being once started in wrong directions so
continued as their eruption progressed. r

















TREATMENT OF CASES.—-CLASS I. 415
The result of such mal-locking is the perversion or wrong
distribution of the great force incident to mastication, the
effect in the upper arch being, as we have said, to exert
a marked mal-influence by preventing the normal widening
through growth of the alveolar process and jaw in the
region of the first molars. As a result of receiving the
force upon the lingual instead of the buccal cusps of the
lower first molars these teeth were gradually carried bodily
(apices of the roots as well as crowns) buccally to their
normal relations with the line of occlusion, the effect being
a gradual narrowing, or prevention of growth, of the en-
tire upper arch, with a proportionate abnormal widening
of the lower arch, and probably, to some extent, of the en-
tire mandible. The similar mal-locking of each tooth an-
terior and posterior upon its subsequent eruption and lock-
ing was thus made easy, each in taking its position in the
arches exercising a corresponding harmful effect on the
development of the alveolar process and jaws. y
By such perversion of force great inharmony was
established, not only as to the forms of the dental arches
and the jaws, but, to a very noticeable degree, in the facial
lines, giving an unnaturally wide, baggy appearance to the
lower part of the face, with abnormal narrowness in the
region of the maxilla.
The requirements in treatment of this case ought, it
would seem, to be clearly indicated to any thoughtful mind.
As the forces through malocclusion have caused the perver-
sion of growth and development, so the correction of the
malocclusion must cause these forces to act as stimulants
toward the normal in growth and development.
The plan of treatment, then, was to widen the upper
arch by moving buccally the molars, premolars and canines,
the moving of the lateral incisors labially and out of torsal
occlusion, and the rotation of the centrals.
These movements are being effected, as shown from the
occlusal aspect of the teeth of the upper arch with the
416 MALOCCLUSION.
appliances in position in Fig. 399, the description of which
is given in the chapter on Adjustment and Operation of
Appliances.
The narrowing of the lower arch was accomplished by
means of a device manufactured for the occasion, and is
the only instance where an appliance differing from the
author’s standard forms has been required in the treatment
of cases described throughout this book, and even this
has been discarded since the addition of the ribbed ex-
FIG. 399.
pansion arch which has been found quite as efficient, and is
always ready at hand.
The device used, however, consisted of a piece of Stubb's
steel wire slightly less than one-eighth of an inch in diam-
eter, bent to closely conform to the shape of the arch, the
temper being so soft as to make this easy of accomplish-
ment. The extreme ends were bent sharply at right angles
and filed to sharp, delicate hook-like points, which were
made to engage the buccal pits on the first molars, as in
Fig. 400. If the points are bent at the proper angle and
made extremely sharp, drilling of even delicate pits in the
enamel is rarely necessary, as they will readily remain in

TREATMENT OF CASES.—CLASS I. 417
position when grasping these teeth at any point, especially
just beneath the gingival ridge.
After the device had been tested and found to be of
exactly the size necessary, its ends were sprung closer
together, in order to conform it to the pattern to which
the dental arch was to be molded. It was then tempered
to extreme hardness, after which it was polished and given
a spring temper by being held in contact with a sheet
of thin metal over a flame until its color had changed to
a light blue. It was then sprung into position and exerted
FIG. 400.
considerable force in a lingual direction upon all the molars
and premolars, but the force being so evenly distributed,
little inconvenience was experienced by the patient and the
dental arch was soon molded into correct shape by the
bending of the alveolar process. After its spring had been
expended it was allowed to remain as a retaining device for
several weeks, held in position by one or two wire ligatures.
Fig. 401 shows the upper arch completed and the retain-
ing devices in position, while Fig. 402 shows both arches
completed and the teeth in occlusion. The lingual tendency
of the upper incisors and the torso- and infra-occlusal ten-
dencies of the upper canines, as well as the lingual tendency

28
418 MALOCCLUSION.
of the molars and premolars, were resisted by double bands
connected by a section of the wire G, and a vulcanite plate,
as illustrated. The bands upon the canines are also shown
in this engraving.
FIG. 401.
$ ill & j #!
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º
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It should be unnecessary to mention that different
periods of activity and rest were also necessary for the
movement of the teeth of the upper arch in this case.
,
Often in less complicated cases we will find a similar
locking of one of the upper molars, and through the ab-


































TREATMENT OF CASES.–CLASS I. 419
normal distribution of the force the perversion of the
normal growth of the alveolar process is always rapid and
pronounced, hence the malocclusion should be promptly
corrected.
Fig. 403.
Fig. 403 shows a case where but one of the lateral halves
of the upper arch was thrown into lingual occlusion by the
lingual locking of the right upper first permanent molar.
FIG. 404.
The patient was a child eight years of age. The deciduous
molars and canines are still in position.
The plan of treatment clearly indicated was the widening
of the upper arch by moving buccally the teeth of the af-
fected side only, with labial movement of the centrals and


420 MALOCCLUSION.
torso-labial movement of the laterals. Fig. 404 shows a
view of this arch from the occlusal aspect, with the appli-
ances for accomplishing these movements in position.
It will be seen that all of the teeth on the left side are
used as anchorage and their combined resistance concen-
trated upon the right first permanent molar through the
force distributed by the external and internal arches. But
a few days were necessary to move this tooth into correct
position. A wire ligature was then made to encircle the
second deciduous, molar and the expansion arch on the
right side, thus practically transferring the force to this
tooth. Later the right deciduous first molar was moved
out in the same way. The object of moving the teeth one
at a time on the right side was to avoid overtaxing the
anchorage derived from the opposite side of the arch. Had
the effort been made to move them all at the same time
it is probable that on account of the increased resistance
offered by the inlocking of the inclined planes of the cusps
of the molars on the abnormal side the displacement of the
teeth on the normal side would have been more rapid than
the correction of the positions of the teeth on the abnormal
side.
While the appliance was acting upon the lateral half of
the dental arch, the lateral incisors were carried forward
and rotated by bands, spurs, and ligatures, with notches in
the expansion arch to prevent the slipping of the latter,
and these movements were further assisted by the occa-
sional tightening of the nuts on the expansion arch.
The teeth were retained by a vault plate which main-
tained the proper width of the arch, and by bands upon
the laterals connected lingually by a section of the wire G.
which effectually prevented the disto-torso-lingual move-
ments of the incisors.
It has been found that the reinforcement of the expan-
sion arch by means of the reinforcement wire, shown on
the inside of the dental arch in Fig. 404, is unnecessary
TREATMENT OF CASES.—CLASS I. 421
in the case of young patients, especially since the intro-
duction of the ribbed expansion arch, the rib greatly in-
creasing its power. Further experience has also shown
that it is usually unnecessary to move out of lingual occlu-
sion similarly inlocked deciduous teeth. Their cusps, how-
ever, should be shortened by grinding so that they may not
interfere with the normal widening of the arch through
growth which is greatly accelerated by the placing in nor-
FIG. 405.
mal occlusion of the first permanent molars. These teeth
and the incisors being normally placed and supported, the
premolars should erupt and lock normally.
No movements of the lower teeth having been necessary
in this case, they of course required no retention.
Fig. 405 shows the occlusion of the teeth eight years after
treatment. The facial lines were practically faultless. We
regret not being permitted to reproduce them here. They
are especially gratifying when we consider the probable
result of allowing the malocclusion to develop, which usu-

422 MALOCCLUSION.
ally produces that unsightly deformity characterized by a
twisted appearance so noticeable in the face of the pa-
FIG. 406. FIG. 407.
FIG. 408.
tient shown in Figs. 406 and 407, caused by the lingual
locking of the right upper molar, which in turn caused the


TREATMENT OF CASES.–CLASS I. 423
shifting of the mandible from left to right, as shown in
the malocclusion of the teeth, Fig. 408.
Fig. 409 shows the occlusion of the teeth six years later,
and Figs. 410 and 411 show the comparatively good balance
in facial lines which has resulted from the restoration of
the teeth to normal relations.
As the lingual locking of the upper molars is a char-
acteristic which we have said may accompany any of the
FIG. 409.
classes, divisions or subdivisions of malocclusion it will be
further discussed in considering the treatment of the vari-
ous cases of other classes in which it occurs.
There is also another form of malocclusion, which, al-
though it may appear in any of the classes, is more often
found in the first great class. It is commonly termed
“open bite,” characterized by more or less space between
the upper and lower teeth anterior to the first or second
molars, although usually involving only the upper and
lower incisors and canines.
The causes of some of the forms of open bite are very

424
MALOCCLUSION.
"[[# ‘91）H
°0IŤ （0IJI

TREATMENT OF CASES.-CLASS I. 425
Fig. 412.
Fig. 413.
Ed T H S M M T. H.
No v /4 ºc 3


426 MALOCCLUSION.
obscure. The condition is generally, however, due to the
habit of holding the tongue between the cutting edges of
the incisors, or frequently protruding it, the form and ex-
tent of the space according with the greatly varying habits
of the tongue. Fig. 412 shows a quite typical case. The
extent of the separation of the incisors is also shown from
a posterior view in Fig. 413.
The restoration of the teeth to normal occlusion by move-
ment of the upper centrals and laterals downward and in-
ward is usually not difficult, these being, as before noted,
the easiest tooth movements to perform, especially if the
eruptive movement be the first accomplished. But this, in
most of these cases, is only a minor part of the difficulties
encountered by the orthodontist before success in the op-
eration is assured. The real difficulty is in breaking the
vicious habits of the tongue which must rest largely with
the patient, and the author is convinced that few patients
have the strength of will to ever master this habit. His
experience in a large percentage of these cases has been
most discouraging, and has often occasioned doubt as to
the advisability of undertaking cases where the habit and
its results are well-established. Very often after the com-
plete restoration of the teeth to normal occlusion and many
months of efficient retention he will find, upon the removal
of the retaining device, that the habit is still in force and
will result in rapidly forcing the teeth into their original
mal-relations.
Fig. 414* shows the method of correcting infra-occlusion
of the incisors by means of the expansion arch. The mid-
dle of each side of the arch was made to bear against a
spur soldered to a band on the canine, which acted as a ful-
crum, the center of the arch being sprung over hook-like
spurs projecting from the labial surfaces of bands on the
central incisors, its spring thus exerting a downward force
*Angle. Fourth edition, 1894.
TREATMENT OF CASES.—CLASS I. 427
upon them. The use of ligatures instead of spurred bands
for the incisors is now preferred. Either of the arches E
or the arch B may be used.
This is an excellent method of correcting infra-occlusion
of teeth, and yet it must not be forgotten that the force
also tends to elevate the anchor teeth and that they must
not be overtaxed by the attempt to move too many teeth at
once. Not more than one or two should be moved at a time.
If pronounced vertical movement of the anchor teeth
should occur the bands should be shifted to other molars.
FIG. 414.
In correcting infra-occlusion of the teeth by this method,
first shown in the fourth edition of this work, it has since
been found that the spurs acting as fulcra are rarely
necessary, the spring of the arch gained through the
pry of the sheaths of the anchor bands usually being
ample. It is well, however, to reinforce this anchorage
with intermaxillary force; that is, stretching a delicate
rubber ligature from the hook attached to the upper ex.
pansion arch to one upon the lower expansion arch, or to
attachments on the lower canines, as in Fig. 185.
The best means of retaining teeth so elevated is to allow
the device employed for their movement to remain in posi-
tion the requisite time, or to employ methods described in
the chapter on Retention.

428 MALOCCLUSION.
Fig. 415" shows another case of pronounced infra-occlu-
sion principally of the incisors, canines, and premolars, of
the upper arch. This condition was augmented by slight
supra-occlusion of the second molars, which were the only
teeth coming in contact when the jaws were closed.
The plan of treatment that seemed most advisable was
the shortening of the second molars and the lengthening
of all the incisors, canines and premolars. This was accom-
plished by means of the spring of the expansion arches,
reinforced by intermaxillary anchorage, exactly as de-
scribed in the last case.
FIG. 415.
All of the lower incisors and the canines were banded
with delicate, neatly fitting bands made from the thinnest
band material (C). These bands were to prevent the
ligatures from slipping off the teeth. The upper lateral
incisors and canines were banded in like manner for the
same purpose. Bands were unnecessary on the upper cen-
* Angle, Chapter on Orthodontia, “The American Text-book of Operative
Dentistry,” January, 1905.

TREATMENT OF CASES.—CLASS I. 429
trals, as the ligatures were twisted above the gingiva on
these teeth, thereby preventing their slipping off. The
finest of the three sizes of wire ligatures were used in
ligating the teeth to the expansion arches, after the latter
had been bent to give the greatest downward Spring to the
upper and upward spring to the lower. The force from this
spring was intensified by two of the delicate rubber liga-
tures which were stretched from one arch to the other and
made to engage hooks which had been soft-soldered
to the expansion arches opposite the canine teeth. The
effect of these ligatures was not only that of assisting in
elevating the incisors and canines in their sockets, but also
in depressing the second molars, which was probably
effected to slight extent. Later these teeth were further
slightly shortened by grinding. -
It will be noted that the left lower first molar is in buccal
occlusion, and that its antagonist is in lingual occlusion.
The expansion arches, before insertion, were bent to give
spring for the correction of these positions.
After the movement of the teeth had been continued
for about six months a period of rest was given the patient
to await the growth of the alveolar process, during which
time retention of the teeth was effected simply by allowing
the arches and ligatures to remain passively in position.
The case was of course occasionally inspected to make sure
that all bands and ligatures were in order, and at the end
of the period of rest the development of the tissues was
noticeable and gratifying. The arches were removed and
after bending them to give the necessary spring, they were
reinserted and tension again given to the teeth through
the adjustment of ligatures, as previously. After contin-
uing the movement very slowly for three months more
an impression was taken of the labial and buccal surfaces
of the teeth while in océlusion, as illustrated in Fig. 416,
which truthfully indicates the relations of the teeth at this
time. w
430 MALOCCLUSION.
Further movement of the teeth seemed to the author
unnecessary. The patient was again dismissed with in-
structions to return for occasional inspection of her teeth,
which were retained as formerly by means of the arch
and ligatures. These were worn for about a year and then
removed. No unfavorable movements of the teeth re-
curred.
Great caution should be observed in all such extensive
operations for elevating the teeth not to excite inflamma-
Fig. 416.
tion or to move the teeth too rapidly. The movement should
be very slow, but continuous, otherwise there will be great
danger of destroying the pulps. This should be apparent
when we remember how extensive must be the changes in
the peridental membrane and alveolar process, and what
a severe strain is put upon these tissues incident to effect-
ing such great changes in the positions of the teeth.
Such cases present many points of interest. One that
impresses the author is the readiness and completeness
with which the gum tissues, and probably to some extent
the alveolar tissues, follow the teeth in these extensive

TREATMENT OF CASES.-CLASS I. 431
movements... It is doubtful whether the treatment of these
cases should ever be undertaken after maturity, although
we have as yet nothing but theory to suggest fear of alveo-
lar disintegration as a result later in life.
Fig. 417 shows another very marked example of this
type of cases which is further complicated by diminution
in the sizes of the arches and crowding of the anterior
teeth, especially the upper, together with lingual relations
FIG. 417.
of the upper first molars with the lowers, with the usual
result of modifying the growth of the alveolar process, as
already pointed out in connection with the cases described
on pages 414 and 419.
In the treatment of this case, begun in April, 1903, it will
be observed how extensive must be the elevation in order to
bring all the teeth into harmony with the line of occlusion,
and how great must be the force necessary to accomplish
these movements, and yet by analyzing the true conditions
and pursuing a course of treatment in accordance with the

432 - MALOCCLUSION.
requirements the entire operation may be greatly simpli-
fied, with the saving of considerable force.
The first step in treatment to suggest itself would
probably be the downward movement of the upper incisors,
canines, and premolars, with the elevation of the lower
canines and premolars. In the logical plan of treatment,
however, this would not be the correct procedure. For
the time being the problem of the “open bite” should be
ignored, and the case treated as if not complicated there-
with. The arches should be enlarged and the teeth moved
into alignment. By this time the open bite would be in-
creased instead of diminished, which, of course, should
occasion no anxiety, for it would be but the natural result.
What we may consider the second stage of the operation
—the movements of elevation—may then be begun, and
accomplished as already described in the two cases im-
mediately preceding. As all of the teeth were loosened in
the first operation their elevation will require far less force
than if this operation had been the first performed, besides
taxing the fibers of the peridental membrane and the
nervous and vascular systems much less. In fact very
little force was needed in this case, but great caution was
necessarily exercised in order to avoid inflammation, long
periods of rest being allowed for the building of normal
bone, etc., the necessity for which has already been pointed
out. -
The result of following this plan of treatment is shown
in Fig. 418, the impressions being taken with the teeth in
occlusion two years after the beginning of treatment.
The incisors and canines of the upper arch were retained
in the same manner as in the case last described, the upper
expansion arch also being allowed to remain in position
with the incisors attached thereto by ligatures, and with
a button attached to the buccal surface of a band on the
lower canine which a very delicate rubber ligature engaged,
it also engaging a button on the expansion arch in the
TREATMENT OF CASES.-CLASS I. 433
region of the upper canine. Another delicate rubber liga-
ture was also made to operate in like manner on the oppo-
site side of the dental arches. After a time these rubber
ligatures were worn only during the sleeping hours, and
later only on each alternate night, their wearing being thus
gradually discontinued as the teeth became established in
their corrected positions.
The holding in correct relations of all four of the first
molars was made far more difficult by a very needless
FIG. 418.
blunder committed by a dentist who had attempted the
correction of the malocclusion some two years previously.
In his effort to reduce the “open bite” he had removed
all of the cusps of all of these molars by grinding, thus
depriving the teeth of their power for maintaining their
normal relations. This necessitated further grinding of
these teeth in the effort to establish other cusps for their
mutual support, which at best can never be anything but
a travesty on Nature’s beautiful normal patterns. No

29
434 MLA LOCCLUSION.
practitioner should ever change the occlusal surface of a
tooth until he fully realizes what this change will ultimately
mean, not only to the tooth itself but to all the other teeth,
and if he be intelligent, even though but beginning to com-
prehend the great principles of occlusion, he will long
hesitate before resorting to mutilation be it ever so slight.
We now come to the consideration of mutilated cases, or
cases that have been caused or aggravated by the ex-
traction of one or more teeth.
FIG. 419.
Fig. 419 shows the left sides of two models of a case,
before and after treatment. The occlusion on the right
side was normal. On the left (upper model) the lateral
halves of both arches were shortened, the upper permanent
lateral incisor being in contact with the first premolar.
The mouth had a shrunken appearance and the incisors
were shifted from the median line. This condition was the
result of the unfortunate and unnecessary premature loss
of the deciduous upper canine and the first and second de-
ciduous lower molars.

TREATMENT OF CASES.—CLASS I. 435
It needs but slight reflection to realize what must further
follow this unfortunate loss. The permanent upper canine
on erupting must be forced into pronounced labial occlu-
sion, with marked disturbance of the left lateral and cen-
tral, while in the lower jaw marked malocclusion must fol-
low the eruption of the premolars.
The treatment clearly indicated was the lengthening of
the left lateral halves of both arches and moving the cen-
trals forward and shifting their positions into harmony
with the median line. *
This was accomplished in both arches simultaneously
by means of expansion arches, bands, and ligatures. No
bands on the teeth to be moved were necessary. The
incisors were laced to the arch with plain ligatures, as
in A, Fig. 195. The notches in the ribbed arches for
preventing the ligatures on the upper lateral incisor and
lower canine from slipping were placed about opposite
the middle of the centrals, so that force produced by tight-
ening the nuts in front of the sheaths of the anchor bands
on the first molars exerted a direct mesio-labial movement
of these teeth, and as the nuts were tightened only on the
affected side the lateral shifting of the incisors, as the
arches were lengthened, was natural and easy. See Figs.
207, 321, and 399. -
The result of treatment is shown in the lower model,
the sides of the arches having been sufficiently lengthened
to admit of the eruption of the upper canine and lower
premolars.
Retention was effected by means of a section of wire G
which engaged tubes R., one of which was soldered at its
end to the mesial surface of a No. 2 band on the molar,
and the other similarly attached to the distal surface of
a band on the canine. A few pinches from the regulating
pliers slightly lengthened the wire, giving a firm resistance
to the distal tendency of the canine, as in Fig. 224. A
similar device, Fig. 225, was placed upon the upper lateral
436 MALOCCLUSION.
and first premolar. These were worn until the eruption of
other teeth made their use no longer necessary.
In the model on the right of the engraving, Fig. 420, is
shown a case from which several valuable lessons may be
learned. The case was that of a young lady sixteen years
old. Two years previous to the making of this model the
occlusion of her teeth was practically faultless, and with
the exception of the left lower first molar the teeth were
of excellent structure and color. At this time this molar
was lost through neglect of caries; then followed the tip-
FIG. 420.
ping forward of the second molar—the inevitable result.
Its inclined planes being locked in occlusion, as the tipping
progressed the mandible was forced to recede, at the same
time causing slight forward movement of the left molars,
premolars, and canine of the upper arch, resulting in the
gradual shifting to nearly complete distal occlusion of the
teeth in this lateral half of the lower arch anterior to the
space. Pressure from the upper lip gradually molded the
upper arch to the diminishing size of the lower, as shown
by the bunching of the incisors, while pressure from the
lower lip assisted in moving distally the teeth anterior to
the space, all of which might have been avoided by the
timely insertion of an artificial substitute.

TREATMENT OF CASES.—CLASS I. 437
The treatment clearly indicated" was the lengthening of
the lateral half of the lower arch, the tipping to an upright
position of the second molar, and the correction of the
positions of the teeth in the upper arch, or the restoration
of all the occlusal planes of the teeth to their original
positions.
The truing of the positions of the upper teeth was accom-
plished by means of the expansion arch, bands, and liga-
tures, while the lengthening of the lateral half of the lower
arch was effected in the same manner as in the case last
described. -
The molar was tipped to an upright position by force
exerted upon the nut in front of the sheath of the anchor
band, and also by bending the expansion arch at the point
where it entered the sheath so as to give a spring or pry
upward on the mesial end of the sheath and a downward
pry on the distal end. The result is shown in the model
on the left in the engraving. -
The patient was then referred to her dentist for an
artificial substitute for the lost molar, which being provided
in the form of a bridge served the double purpose of reten-
tion and mastication. The requirements of orthodontia
and bridging are such as should induce a closer study of
their relations, and if, before making bridges for their
patients, dentists would refer them to competent orthodon-
tists better results would very often follow. The placing
of bridges on leaning piers is unmechanical, and, as ap-
plied to the mouth, both unmechanical and unphysiological.
A point we would emphasize in relation to this case is
that the changes taking place in this previously faultless
arch, as a result of the loss of this first molar, are such
as must and do always follow the loss of this tooth. Ex-
amine a thousand similar cases and as many similar results
will be found.
* Angle. Sixth edition, 1900.
438 MALOCCLUSION.
It will be noticed in the model on the right that none
of the teeth on this side occlude, but that they merely touch
:
at irregular intervals, and are practically worthless for
mastication. What we would especially emphasize in this

TREATIMENT OF CASES.—CLASS I. 439
connection is that the odontocide is not relieved of his
responsibilities by the extraction. He must immediately
replace the lost tooth by some form of artificial substitute
or be certain that he has established conditions that will
lead to the serious impairment of the occlusion on the side
of the arch from which he has extracted the tooth.
Figs. 421 and 422 show a most unfortunate result from
both right and left sides, following the extraction of the
four first permanent molars, which, though perfectly sound,
were removed at the age of nine years with the idea of
making space to prevent malocclusion of the other
teeth, and how successful was the effort is readily seen.
The result is but natural. Not only have the remaining
teeth been rendered almost useless for mastication, but
in recent years there has been chronic pericementitis, re-
sulting from the wrongly directed force upon the molars
in their tipped and abnormal positions. The facial lines
were also greatly marred by the arrest in the development
of the alveolar process, as shown in Fig. 424, for without
the wedging influence of those most important teeth—the
first molars—the teeth anterior could not be pushed for-
ward by the eruption of the second and third molars, which
is necessary for the proper contouring of the face.
Gold-capping of the leaning molars, resorted to by the
patient’s dentist in this case to improve the occlusion, only
aggravated the condition, for the gold crowns only gave a
longer leverage thereby increasing the force through occlu-
sion for tipping the teeth.
There was but one logical and rational plan of treatment,
namely, to regain the lost spaces of the four molars and
replace the teeth by artificial substitutes.
To accomplish the movements of the teeth the same
general plan of treatment was followed as in gaining the
space for the missing first molar in the case last described.
All four second molars were encircled by D bands, but
before placing the lower bands in position the sheaths were
440 MALOCCLUSION.
resoldered to align properly. The ribbed expansion arches
were inserted, in which hook-like notches were made just
anterior to the four canines. The heavy wire ligatures
were looped over the second premolars, brought forward
to engage these notches, and firmly twisted, thereby at Once
exerting a strong tension in a mesial direction on all the
second premolars, which in turn was transmitted to the
first premolars, canines, and laterals, as in Figs. 207 and
419. This force was of course reciprocated to the second
molars to move them distally and in turn transmitted to
the third molars.
This appliance having been most carefully and firmly
adjusted, it will be seen that the occasional tightening of
the nuts in front of the sheaths must result in gradually
carrying forward all the teeth anterior to the spaces, and
at the same time in moving all the molars distally. The
most difficult problem apprehended was to gradually effect
at the same time the tipping to an upright position of the
greatly leaning lower second molars. Yet by taking ad-
vantage of the possibilities of the upward pry of the ex-
pansion arch, this was readily effected.
As the movements of the teeth progressed, the spring of
the arch from the upward pry gradually became insuffi-
cient, necessitating the removal of the lower D bands and
the re-soldering of their sheaths in order to again intensify
it. - -
As it was desired to carry all of the teeth anterior to
the spaces well forward, the force necessary was so great
that before its completion the molars had been moved dis-
tally and to upright positions. Their further movement
was then arrested by changing the anchorage from simple
to stationary, easily effected by bending the arches so as
to prevent further upward spring.
Notwithstanding the advanced age of the patient (thirty-
eight years) supposedly unfavorable for the treatment of
malocclusion, it being the most advanced age recorded for
TREATMENT OF CASES.–CLASS I. 441
such an extensive operation, the author was agreeably
surprised to find that the teeth were moved quite as easily
and fully as rapidly as is usual in the case of a miss of
eighteen, and with no unfavorable symptoms following the
movement of any of the teeth.
The result in occlusion is shown in Fig. 423. It will be
seen that all the teeth anterior to the space have been
Fig. 423.
carried well forward, and that the molars have been moved
distally and into correct relations.
Retention was effected by a vulcanite plate both above
and below which bore against the lingual surfaces of the
anterior teeth and filled the spaces of the missing molars,
and the case was finally referred back to the patient’s den-
tist, who, after some months, skilfully inserted some very
perfect bridges.
The remarkable changes in the sizes of the arches and

442 MALOCCLUSION.
the relations and inclinations of the teeth are naturally
reflected in the lines of the mouth as related to the other
:
:
features, as will be noted by comparing the face before and
after treatment, as shown in Figs. 424 and 425.
Great as are the changes in the facial lines, the close

TREATMENT OF CASES.–CLASS I. 443
FIG. 426.
FIG. 427.


444 MALOCCLUSION.
FIG. 428.
FIG. 429.


TREATIMENT OF CASES.—CLASS I. 445
student will observe that there is still not complete normal
contour of the mouth, which, as we perceive, is but natural
when we remember how the arches were robbed in youth of
that normal wedging influence of the first molars, so neces-
sary to effect the normal development of the bones of the
face and its consequent normal contour.
Figs. 426 and 427 show unfortunate mal-relations of
teeth which are directly traceable to the extraction of the
first lower molar on the right side, and a filling in the first
lower molar on the left which in size and form, though
similar to those commonly seen, is in direct violation of
Nature’s tooth pattern and requirements, not only in the
function of mastication but in the maintenance of the nor-
mal relations of all the other teeth. The result, from the
loss of the molar, and from such a filling, is what must
always follow—diminution in the size of the arch; and as
the loss of the molar occurred some time before the erup-
tion of the canines, the lingual movement of the upper in-
cisors naturally resulted from the pressure of the lips and
the lack of resistance through occlusion of the lower teeth,
with the usual added complications of the shifting of the
upper incisors to the left and out of harmony with the
median line, while the opposite was the result with the
lower incisors. The bite, also, has naturally been greatly
shortened through lack of normal support from the first
molars and the downward and inward movement of the
upper incisors. -
It must be apparent that without interference the mal-
occlusion will be progressive. It is clear in the treatment
of this case, that further extraction would only augment
the existing conditions, and that the only logical plan was
to enlarge the lower arch, regain the full mesio-distal di-
ameter of the space made vacant by the loss of the molar,
enlarge the upper arch, and place all of the teeth in their
normal positions, which was accomplished by means of
the expansion arch operated after the manner already
446 MALOCCLUSION.
:
:
described for performing the various movements here re-
quired. The result of such treatment is shown in Figs. 428
and 429. The upper deciduous canine having been lost, its
successor is about to erupt, as also shown.

TREATIMIENT OF CASES.–CILASS I. 447
The retention of the lower arch was effected by the
proper form of bridge for the missing molar. On the left
side it will be seen that there is inharmony between the
relations of the canines and premolars which can never be
corrected until the diminished crown of the lower molar has
been restored to its full mesio-distal diameter and contour.
The profile of the patient before and after treatment is
shown in Figs. 430 and 431.
It has been deemed necessary to show but very few
simple cases belonging to this class for the reason that all
their peculiarities are embraced in the more complex, a
thorough understanding of which renders easy the man-
agement of the former.
CHA PTE R XVII.
TREATMENT OF CASES.—CLASS II, DIVISION 1.
IT will be remembered that the distinguishing character-
istics of cases belonging to this division of this Class are
distal occlusion of both lateral halves of the lower arch,
more or less undeveloped mandible, narrowed upper arch,
lengthened and protruding upper incisors, and lengthened
lower incisors. It will also be remembered that those
afflicted with this type of malocclusion are in almost every
instance affected with some form of nasal obstruction ne-
cessitating mouth-breathing which usually begins at an
early age, causing the mouth to be held open almost con-
stantly and the lips and buccal muscles to act abnormally.
In the effort to breathe, the upper lip is drawn upward and
fails to develop in size and function, exercising little
restraint upon the labial movement of the incisors. Their
protrusion, therefore, becomes more and more pronounced,
partially as a result of pressure from the tongue and
narrowing of the arch through malocclusion and the action
of the buccal muscles, but principally because the lower
lip is so frequently forced against their lingual surfaces
in Swallowing and in the effort to moisten the mucous
membrane of the mouth. Both upper and lower incisors
become lengthened, probably from lack of function, so that
the Occlusal edges of the lower are in many cases in contact
with the mucous membrane of the hard palate.
It is a common mistake to suppose that this form of
malocclusion is the result of over-development of the upper
jaw. The author has never seen a case where this con-
dition existed, neither are the teeth of the upper jaw
“inherited too far forward,” as we have pointed out in the
chapter on Occlusion.
448
TREATMENT OF CASES.—CLASS II. 449
The narrowed upper arch and lengthened upper teeth,
the lower jaw diminished in size and distal in relation, the
arrest in the development of the nasal apparatus, the mod-
ification in form and function of the nose and muscles, and
the marred facial lines are but the natural results of the
failure of the first permanent molars to lock normally at
the time of their eruption, accompanied and probably pre-
ceded by pathological conditions of the nose or throat that
established the habit of mouth-breathing. It is interesting
to note the gradual and progressive development of cases
belonging to this class, after once started, through the
perverted functions of respiration and occlusion. It seems
reasonable to believe that the mandible is arrested in de-
velopment by being held distally through malocclusion and
the abnormal action of the muscles. And there is yet
another reason which seems hitherto to have been un-
noticed, namely, the abnormal distribution of force on the
lower teeth through the malocclusion. Normally the force
is distributed on the line of the long axes of the teeth, but
when the lower molars lock in distal occlusion the force is
received principally upon the anterior half of their crowns,
as shown in Fig. 432, the tendency being to drive their
apices distally, or at least to prevent their normal move-
ment forward, which would also prevent the normal
growth and lengthening of the jaw. This seems most prob-
able when we consider how pronounced is the interference
with the normal growth of the mandible, maxilla, and alveo-
lar process, by the abnormal distribution of force in those
cases where the upper teeth on erupting lock in lingual oc-
clusion, as has already been pointed out in the considera-
tion of the cases illustrated in Figs. 397 and 398.
Cases belonging to this division usually begin with the
mal-locking of the first permanent molars at the time of
their eruption, although we now know that they may be
established much earlier, or during the development of the
deciduous denture, and this is not remarkable since nasal
30
450 MALOCCLUSION.
obstructions from adenoid growths are often well-defined
at two and three years of age. They may be so slight at
first as to occasion mouth-breathing only at intervals and
later disappear entirely, but if sufficient at the time of the
eruption of the first permanent molars to deflect the nor-
mal relations of these teeth into abnormal (distal) rela-
tions—and but a few days would be necessary to accom-
plish this—the nucleus of conditions would be established
FIG. 432.
which must progress until all of the conditions of a typical
case of either the first or second divisions of this class
have developed. Once established it is remarkable what
similarity exists between the cases of each division es-
pecially those of the first, the differences being chiefly in
degree which is usually in proportion to the age of the
patient. And as we have already noted in the chapter
on Facial Art, the disturbance in the balance of the facial
lines is very noticeable and in direct proportion to the
degree of the malocclusion.

TREATMENT OF CASES.–CLASS II. 451
The logical plan of treatment of cases belonging to this
division is to divert from abnormal to normal action the
forces which are operative in producing the deformity,
or, first remove the cause by proper treatment of the nose,
Fig. 433.
making normal breathing not only possible, but actual, and
then establish the normal occlusion of the teeth and the re-
tention of the same until all of the tissues and muscles in-
volved shall have become normal in growth and harmon-
FIG. 434.
ious in function through their mutual co-operation. Nat-
urally, the earlier the treatment, the more perfect must be
the ultimate result.
Figs. 433 and 434 show the occlusion of the teeth in a
well-defined case belonging to this division of a child less


452 MALOCCLUSION.
than four years of age. It will be seen that all the lower
teeth are in distal occlusion and all of the forces wrongly
FIG, .435.
directed, and that the development must be continuously
retrogressive so long as these conditions are permitted to
exist.
FIG. 436.
Notwithstanding the complexity of the malocclusion and
the extreme youth of the patient the treatment was easily
and successfully performed, and Figs. 435 and 436 show the
splendid results in the establishment of normal occlusion.


TREATMENT OF CASES.–CIASS II.
453
:
:
º


454 MALOCCLUSION.
By comparing Fig. 437 with Fig. 438 it will also be noted
how marvelous are the changes in the facial lines of this
child as a result of this treatment.”
As the result of intelligent treatment Nature is now
permitted to progress normally in her work of building the
denture, and the prospects of the ideally normal result,
as compared with the possible result in cases that have
been allowed to progress until “all of the teeth (perma-
ment) have erupted,” ought strongly to impress all
thoughtful persons with the gravity of the error of delay.
FIG. 439. FIG. 440.
Figs. 439 and 440 show the occlusion of the teeth of a boy
aged nine years. The cusps of the deciduous teeth being
worn nearly smoothit was very easy for the first permanent
molars to begin abnormal relations in locking as their erup-
tion proceeded, thus effectually preventing the normal
locking of the teeth Subsequently to erupt.
* This patient was treated by Dr. Guilhermena P. Mendell, of Minneapolis.
It is the youngest case on record where anything like such extensive mal-
occlusion of the deciduous teeth has been corrected. The case was reported
at the meeting of the American Society of Orthodontists, September, 1905.

TREATMENT OF CASES.—CLASS II. 455
The plan of treatment followed in this case is the most
natural, logical, and practicable. It consisted in establish-
ing normal occlusion between the first permanent molars
and maintaining them in these relations, and at the same
time insisting on the proper treatment of the nose and
throat and on the patient’s forming the habit of breathing
normally.
All four of the first permanent molars were fitted with D
bands and the expansion arches slipped into position after
first bending them so as to make them lie in close proximity
to the dental arches they were to encircle. As there was the
proper width of the dental arches between the first molars,
no lateral spring was given to the expansion arches, and
as no lateral movement of the incisors was necessary the
ribbed arches were not needed, the plain arches only being
used. -
The sheaths of the anchor bands were aligned so that
the upper expansion arch rested just below the gingival
margins of the incisors, while the lower rested at a point
about one-half the distance between the cutting edges of
the incisors and the gingival line. No ligatures or plain
bands were necessary. Sheath-hooks were soldered to the
upper expansion arch at points opposite the lateral incisors
and the arch adjusted. The patient was then dismissed
for several days until he should become thoroughly ac-
customed to wearing the appliances and all soreness had
subsided. One of the most delicate of the intermaxillary
elastics was then adjusted by first hooking it over the
sheath of the lower D band, bringing it forward, and slip-
ping it over the sheath-hook on that side, as shown in
Fig. 190. The patient was impressed with the necessity
of keeping the lips and jaws closed in order that the force
of the intermaxillary elastic might be expended in the de-
sired direction and the normal function of the lips estab-
lished. But only after many weeks of patient persistence
was he enabled to overcome the habit of holding the mouth
456 MALOCCLUSION.
in the half-open manner characteristic of those suffering
from this deformity, even after the successful treatment
of the nasal passages.
After wearing the single elastic for a few days another
was added in like manner on the other side and the nuts of
the upper expansion arch adjusted until all the force of the
elastics was expended upon them, and transmitted to the
upper molars, the arch not being permitted to bear on the
prominent incisors. In this way the force from the inter-
maxillary elastics was directly reciprocated from one op-
posing molar to the other, and the mesial movement of the
lowers and the distal movement of the uppers thus begun.
After about two weeks the patient had become so
thoroughly accustomed to the appliances and the force
from the ligatures as to be hardly conscious of their pres-
ence. Another elastic was then added on each side which
was inspected once each week.
As the upper molars were moved distally the nuts were
occasionally tightened in order to prevent any force being
exerted upon the central incisors, and as the lower molars
were moved forward, carrying with them the teeth anterior
to them, the anterior part of the lower expansion arch
naturally was deflected downward below the gingival mar-
gin of the incisors. To remedy this it was removed and
carefully bent upward just anterior to the nuts. After
a short time the molars had been moved into their normal
mesio-distal relations, but the movement was carried some-
what beyond the normal to allow for the adjustment and
settling of the retaining devices.
The appliance was then allowed to remain passive for
two or three weeks, only the weakest of elastics being used,
after which it was removed and the teeth carefully cleansed.
The sheaths on the anchor bands were removed by un-
soldering, and after the attachment of planes and spurs
to the bands by Solder at the proper angles they were re-
placed and firmly cemented, as shown in Fig. 256. The
TREATMENT OF CASES.–CLASS II. 457
treatment thenceforth consisted in the occasional inspec-
tion of the intermaxillary retainers, and insisting on the
patient's breathing normally and exercising the normal
function of his lips.
Normal conditions now being established, the growth
of the denture progressed normally, and as each deciduous
tooth was lost its successor erupted and locked in normal
occlusion, thus assisting in maintaining the proper rela-
tions of the jaws and dental arches.
FIG. 441. FIG. 442.
Figs. 441 and 442 show the occlusion of the teeth of the
boy three years later.
Fig. 443 shows his profile at the time of beginning treat-
ment, and Fig. 444 at the time of making the last model
of his teeth.
It will be seen how the unpleasing facial lines have been
changed to those of proper balance, and continuous change
for the better (or toward the normal) must follow as
growth and development progress.
The use of intermaxillary force, as in the treatment
of this case, might raise the question as to whether the
anchor bands alone would not be sufficient without the

458 MALOCCLUSION.
lower expansion arch. Without it the molars would be
partially rotated and deflected buccally incident to the
FIG. 443.
great strain upon them necessary to carry all of the lower
teeth forward.
FIG. 444. -
Figs. 445 and 446 show the mal-relations of the jaws and
teeth from both right and left sides of a miss twelve years


TREATMENT OF CASES.–CLASS II. 459
of age. On the right side there is complete distal occlusion,
but on the left the teeth are not yet in full distal occlusion,
yet as probably all of the inclined planes favor this relation
it is only a question of a short time when, if allowed to
continue, it must be fully established.
The upper arch is gradually becoming narrowed through
the influence of the muscles, and the upper incisors forced
labially through the action of the lower lip.
FIG. 445. FIG. 446.
The same general plan of treatment was followed as in
the last case, but as the malocclusion had become more com-
plicated through the eruption of more of the permanent
teeth, with greater labial prominence of the upper incisors,
the difficulties in treatment became greater, necessitating
that the upper arch be shortened in front, and widened
in the region of the premolars and canines, and that the
crowns of all the upper teeth be tipped distally and those of
the lower tipped mesially sufficiently to establish normal
occlusion.
As the malocclusion began with the distal locking of
the first permanent molars, and the protrusion of the in-

460 MALOCCLUSION.
cisors (only a symptom) is the result of the same, the
logical plan of treatment is again to begin with the first
molars and not with the symptoms, or prominent incisors,
as in the older plans of treatment so long followed, leaving
the movement of the incisors until the last.”
Plain expansion arches were adjusted in precisely the
same manner as in the case last described, D bands having
been placed on all four first molars, and sheath-hooks
attached to the upper expansion arch between the lateral
incisors and canines. After the patient had become accus-
tomed to wearing the appliances the movement of the teeth
was begun through the application of the intermaxillary
elastics. - -
In the treatment of the last case simple-intermaxillary
anchorage was employed, that is, the upper and lower
molars were pitted against each other, the force being
reciprocal, the crowns of the opposing teeth being tipped in
opposite directions. In cases similar to the one under
consideration, however, it is usually necessary to employ
stationary-intermaxillary anchorage, that is, securing such
attachments to the lower molars as will prevent their tip-
ping forward, and necessitating that if moved at all they
be moved at the apices of their roots as well as at their
crowns (see stationary anchorage). In this way the
resistance of the lower teeth to the great strain necessary
in compelling the distal movements of all of the upper
teeth is enormously increased. This was accomplished
by exercising unusual care in clamping and burnishing the
bands upon the lower molars to fine adaptation and bend-
ing the lower expansion arch just anterior to the nuts so
that when inserted it would, at its anterior part, rest
about one-eighth of an inch below the gingival line and
thus exert a spring upward and backward on the crowns
* See paper read by the author before the New York Institute of Stoma-
tology, October 7, 1902. Published in the International Dental Journal,
October, 1903. -
TREATMENT OF CASES.—CLASS II. 461
of the molars and prevent their tipping forward. It was
then raised upward to about midway of the crowns of the
incisors and securely held in this position by means of wire
ligatures made to encircle it and each incisor, thus prevent-
ing its downward movement, as permitted in the last case.
As no anterior attachments were made to the upper expan-
sion arch, it being left free, the force exerted by the inter-
maxillary elastics upon the upper molars permitted their
tipping, which was assisted by the leverage of the expan-
sion arch and sheath-hooks, especially when the mouth was
open. Delicate intermaxillary elastics were first employed
and after a couple of weeks their number was doubled.
The first and second upper molars were moved distally
quite rapidly. This was continued rather beyond the re-
quired distance. Indirectly, through the attachment of the
dental ligament the second premolars had also been drawn
distally to a noticeable extent. The movement mesially of
all of the lower teeth was also noticeable, though slight.
The bands were now removed from the upper first molars
and X bands were placed upon the right upper first and left
upper Second premolars, the nuts on the arch moved for-
ward, the arch replaced in position, and the elastics again
applied, the nuts being turned to points on the arch that
would allow the delivery of all of the force to the premolars
and none to the incisors. In order to effect the distal
movement of the left upper first premolar both upper pre-
molars on the left side were encircled by a wire ligature
which was made to rest gingivally to the sheath and occlu-
Sally to the screw on the lingual surface. The premolars
were soon carried distally the requisite distance, and the
canines, also, somewhat, through their fibrous attachments.
The force was now transferred to the incisors by releas-
ing the nuts of the expansion arches from the sheaths of the
X bands; and the wire ligatures were removed from the
lower incisors, thus allowing all the lower teeth to tip for-
ward. The upper incisors and canines were soon moved
462 MLALOCCLUSION.
the desired distance linguo-distally, thus establishing
normal mesio-distal contact between all of the teeth of the
upper arch, and normal occlusion of the denture.
These movements were effected in about two months.
The normal mesio-distal relations of the teeth were main-
tained by bands upon the lower canines. These bands were
made from the band material H and very carefully fitted
and cemented. Upon their labial surfaces were soldered
flattened spurs of metal which engaged the mesial inclines
of the upper canines, as in Fig. 260. The case at this stage
is shown in Fig. 447. The spurs were frequently inspected
and occasionally modified by bending, in order to increase
FIG. 447.
or diminish the bearing as needed. Later it was found that
the molars on the right side were not maintaining their full
normal mesio-distal relations. They were promptly en-
circled by plain clamp bands No. 2 which had been fitted
with spur and plane, Fig. 256, and carefully cemented in
position. By occasionally bending the spur to give heavier
bearing, their full normal relations were soon re-estab-
lished.
The labial movement of the upper incisors was antago-
nized by a section of wire G made to bear against their
labial surfaces, the ends being soldered to carefully fitted
bands upon the canines. The patient was frequently ad-
monished of the importance of establishing the habit of

TREATMENT OF CASES.—CLASS II.
463
'6ff; * 9IJI
'8ff; ’’DIJI

464 MALOCCLUSION.
normally closing the lips and holding the teeth in correct
position. As the nose had been successfully treated during
the early stages of the orthodontic operation, normal
breathing and normal lip function were gradually estab-
lished and the patient dismissed after two years. The
occlusion at this time is shown in Figs. 448 and 449.
FIG. 450. FIG, .451.
Figs. 450 and 451 show the front and profile views of the
patient’s face before treatment, Fig. 452 shows the profile
at the time of retention of the teeth, and Figs. 453 and 454
show front and profile views at the time the models shown
in Figs. 448 and 449 were made.
It is gratifying to note how progressive has been the
growth towards the normal in balance resulting from
Nature’s being permitted to continue it in a normal man-
I101". -
In the treatment of all such cases the degree to which the
upper teeth should be moved distally and the lower teeth

TREATMENT OF CASES.–CLASS II. 465
FIG. 452.
FIG. 453.


466 MALOCCLUSION.
forward must be determined by the operator, and accom-
plished by the careful and intelligent manipulation of the
anchorage and application of force, both of which should
be under his complete control.
FIG. 454.
As we have seen elsewhere, Nature exercises the greatest
care in correctly placing the upper molars mesio-distally;
hence the question may here be appropriately asked, why,
if this be true, it is necessary to move the upper molars
distally in these cases, as follows in this plan of treatment.
This is easy of explanation. The mandible, being under-
sized through the perversion of forces, the movement of
the teeth, if limited to the lower, would compel them to

TREATMENT OF CASES.–CLASS II. 467
Fig. 455.
FIG. 456.


468
MALOCCLUSION.
FIG. 457.
FIG. 458.



TREATMENT OF CASES.–CLASS II. 469
lean forward at too great an angle, while by dividing the
movements between the teeth of the opposite arches this
is prevented, and Nature, being assisted and stimulated
through the correct distribution of force upon the teeth
and normal functions of the muscles, is enabled to normally
develop the mandible and all other tissues involved.
Through the stimulus thus given it is quite probable that
FIG. 459. - - FIG. 460.
in time the teeth of the upper arch will regain their normal
relations with the skull. -
Figs. 455 and 456 show the occlusion from the right and
left sides of another typical case, with the usual character-
istics, and Figs. 457 and 458 show the occlusion after the
case has been treated exactly as described in the last case.
The resultant changes in occlusion are clearly manifest
in the better balance of the facial lines, as will be seen by
a comparison of Fig. 459, which shows the face before
treatment, with Fig. 460, which shows it after treatment,
or at the time of making the models shown in Figs. 457

470 MALOCCLUSION.
Fig. 461.
FIG. 462. Fig. 463.


TREATMENT OF CASES.-CLASS II. 471
and 458. Fig. 461 shows the still greater improvement in
the face incident to the growth of the mandible two years
later than in the last picture.
Figs. 462 and 463 show the occlusion from the right and
left sides of another most pronounced case belonging to
this division.
The treatment was identical with that employed in the
last two cases, that is, beginning with the first permanent
molars and moving them into their proper mesio-distal re-
FIG. 464.
lations, continuing with the premolars, and finally adjust-
ing the canines and incisors.
Fig. 464 shows the period in treatment immediately after
the premolars had been tipped distally into contact with
the previously moved first molars. The X bands which in
this case had been employed on the first premolars are
dimly shown in this study model.
After the canines and incisors had been retracted the
molars and premolars were secured by the usual intermax-
illary retention. Fig. 465 shows the case at this stage of
the operation, and Figs. 466 and 467 illustrate it by better
models made six months later, or at the time of removal of

472 MALOCCLUSION.
all retaining devices. The change in the facial lines due to
treatment are shown in the chapter on Facial Art, Figs.
61, 62, 63, 64, and 65.
Fig. 465.
Figs. 468 and 469 show the face of a boy aged thir-
teen, and from the receding chin and disturbance of bal-
FIG. 466.
ance in the lines about the mouth it is not difficult to
diagnose the cause as malocclusion of the type belonging
to this division. By referring to the malocclusion, Figs.


TREATMENT OF CASES.—CLASS II. 473
470 and 471, it will be observed that all of the typical char-
acteristics are present.
It will also be noted that the first premolar on the left
side is in torsal occlusion. The treatment of the case was
proceeded with exactly as in the case shown in Figs. 445
and 446, no effort being made to correct the torsal position
of the premolar until after the teeth of both arches had been
moved into their normal mesio-distal relations. It having
FIG. 467.
then been loosened, its rotation was more easily accom-
plished. This was done by means of the traction screw,
as in Fig. 635, its angle engaging a staple on the mesio-
lingual angle of a band that had been cemented on the pre-
molar, the long sheath of the traction screw being soldered
to the lingual surface of a No. 2 band upon the first molar,
the screw of which was placed on the buccal surface and in
this case pointed distally. This band was also utilized for
the usual intermaxillary retention, the plane of metal being
soldered to the flat portion of the screw, bearing against
which was the spur soldered to a carefully fitted and ce-

474
MALOCCLUSION.
|
i

TREATMENT OF CASES.–CLASS II.
475
'I1'ſ 'BIJI
*0.1† "ĐIJI

476 MALOCCLUSION.
mented band upon the lower first molar. Force was ex-
erted upon the tooth to be rotated by occasional tightening
of the nut, and as its lingual cusp was drawn distally the
force was reciprocated to its buccal cusp and in the oppo-
site direction by the intervening second premolar.
In a short time the tooth had been rotated a little more
than the requisite amount, and, the traction screw occasion-
ing no annoyance, it was allowed to remain as a retainer
FIG. 472.
... as long as intermaxillary retention was employed, or about
One year.
Both molar and canine intermaxillary retention was em-
ployed on the opposite side through bands, planes and
spurs, as in Figs. 256 and 260.
The corrected occlusion is shown in Fig. 472, and the
improvement in the facial lines in Figs. 473 and 474.
In many of the pronounced, well-established cases be-
longing to this class the narrowing of the arch in the region
of the canines and premolars is often very noticeable,

TREATMENT OF CASES.–CLASS II. 477
necessitating its widening by the buccal movements of these
teeth. This is easily accomplished by giving much lateral
i
:
spring to the expansion arch which exerts force laterally
upon these teeth through ligatures and which is further


478 MALOCCLUSION.
assisted by the wedging force of the incisors as they are
made to move distally by the pressure of the arch on their
labial surfaces.
Another favorite plan of the author for widening the
arch in these cases is to delay this operation until the pre-
molars are carried distally, then remove the expansion
arch and substitute for it one of the threadless arches B
with much lateral spring. This arch readily glides through
the sheaths of the anchor bands and in its efforts to
FIG. 475.
straighten itself bears with much force against the prom-
inent incisors independently of the intermaxillary elastics,
which force is reciprocated to the premolars and canines
through their wire ligatures, favoring their buccal move-
ment. Very often in simple cases this force is ample with-
out the additional force from the intermaxillary elastics,
yet more often their use also is advisable. See Fig. 206.
In some well-defined cases belonging to this class the
upper canines are found to incline mesially after all the
other teeth have been moved into their full normal mesio-
distal relations. In cases where it is seen that this will
occur, as the movements of the other teeth progress it is

TREATMENT OF CASES.—CLASS II. 479
the author's favorite plan to encircle the canines with
strong, carefully fitted bands, soldering a piece of wire G.
to each band parallel with the long axis of the tooth and
bending the lower end of the wire forward in the form of
a hook about one-fourth of an inch below the point of
the cusp. These hooks engage extra intermaxillary elas-
tics which are stretched back to also engage the sheaths
of the D bands on the lower first molars, as in Fig. 475.
This is an efficient method for accomplishing the movement
of these very firmly rooted teeth, and may be employed
FIG. 476. FIG. 477.
simultaneously with the expansion arches. It may also
be used to re-establish the correct positions of these teeth
in case of their relapse, thus avoiding the replacing of
both expansion arches and the upper D bands.
Figs. 476 and 477 show the occlusion of the teeth in an-
other case belonging to this class—that of a girl ten years
of age. The deciduous molars have not yet all been lost.
The incisors are unusually protruded for a child of this
age, but this is easily accounted for by examining the pic-
tures of the face, Figs. 478 and 479, and noticing how thick


480
MALOCCLUSION.
and firm the lips are and with what firmness the lower is
drawn upward and bears against their lingual surfaces.
It will also be noticed that there is a space between the


TREATMENT OF CASES.--CLASS II. 481
premolar and canine on the right side, necessitating more
than the usual distal movement.
The case was treated after the plan already carefully
described, the distal movement of the canine being effected
simultaneously by the method just outlined, and in connec-
tion with the usual other appliances. The result in occlu-
sion is shown in Fig. 480.
FIG. 480.
The improvement in the facial lines at the time of reten-
tion is shown in Figs. 481 and 482, and two years after the
completion of retention in Figs. 483 and 484.
By far the greatest difficulty in the treatment of this
case was to induce the child to discontinue the habit of
forcing the lower lip against the lingual surfaces of the
incisors, and for this purpose the device shown in Fig. 262
was adjusted at various times for various periods.
In all cases belonging to this division where there has
been extraction, with the usual shortening of one or both
of the lateral halves of one or both of the dental arches,
the malocclusion is necessarily more complex, with in-
creased protrusion of the upper incisors, etc., especially

32
482 MALOCCLUSION.
if the teeth have been extracted from the lower dental arch.
The difficulties of treatment in such cases are of course
increased, yet we should very rarely depart from the ideal
conservative plan, even in these cases. The leaning teeth
should be tipped to their normal upright positions, the lost
space regained, and the missing teeth, if permanent, sub-
FIG. 48l. FIG. 482.
stituted by the best possible bridge-work in which the full
normal contour of crown and cusps of the missing teeth is
restored. If the lost tooth be deciduous the space must be
maintained, allowing its successor full opportunity for
eruption.
Figs. 485 and 486 illustrate a case of this description
where the first permanent molars had erupted and locked


484 MALOCCLUSION.
in distal occlusion. Both right upper premolars have
erupted, with the canine just emerging from the gum, while
the lower first premolar on this side has fully erupted and
the canine partially. The second lower deciduous molar
has just been lost, with its successor about to erupt. On
the left side the upper deciduous canine has recently been
lost, with nearly full eruption of the first premolar and
partial eruption of the second. In the lower jaw on this
FIG. 485. FIG. 486.
side the canine and first premolar have fully erupted, the
latter being nearly in contact with the first molar. This
was occasioned by the unnecessary sacrifice of the second
deciduous molar three years previously which had allowed
the usual forward tipping of the first permanent molar,
and the shifting distally of the mandible and the teeth
anterior to the space—the inevitable result.
The X ray revealed a second premolar of normal form
and position prevented from erupting by the crowding of
its approximal associates. As a result of this extreme

TREATMENT OF CASES.–CLASS II. 485
shortening the mesial inclined plane of the lower canine
occludes with the distal inclined plane of the upper first
FIG. 487.
FIG. 488.
premolar, or nearly the width of two premolars distal to
its normal position.



486
MALOCCLUSION.
:
:

TREATMENT OF CASES.–CLASS II.
487
:
:

488 MALOCCLUSION.
In treatment practically two operations are necessary,
first, the lengthening of this lateral half of the lower
arch, with regaining of the lost space of the missing tooth
and tipping of the first molar to its upright position, etc.;
and second, the movement mesially of all the lower teeth
and distally all the upper teeth into normal mesio-distal
relations. These two operations were performed simul-
taneously. The ribbed expansion arch was employed on
the lower arch, and while the intermaxillary elastics were
effecting the reciprocal movement of the upper and lower
molars, the lower left molar was being tipped to upright
position, and the first premolar, canine, and incisors on this
side were being carried forward by means of a ligature
thrown around both canine and premolar and made to
engage a notch in the rib of the expansion arch at a point
between the lateral incisor and canine, the arch also being
bent to exert a pry upward and backward upon the molar,
precisely as described for lengthening one or both of the
lateral halves of the arches in Class I, and shown in Fig.
207. -
Figs. 487 and 488 show the corrected occlusion, and by
comparing Figs. 489 and 490, which show the face before
treatment, with Figs. 491 and 492, which show it after
treatment, it will be seen what fine balance has been estab-
lished in the facial lines.
Figs. 493 and 494 show the occlusion of another case
belonging to this division in which all of the various pe-
culiarities of these cases are well illustrated. These are
rapidly being intensified by reason of the premature loss
of deciduous teeth. Granting for the moment that their
removal may have been necessary, we insist that it became
necessary immediately thereafter to maintain the full
mesio-distal diameters of the sacrificed teeth by suitable
retaining devices in order to prevent the inevitable diminu-
tion in the size of the arch and the grave consequences
incident thereto. We again insist that no dentist is re-
TREATMENT OF CASES.–CLASS II. 489
lieved of responsibilities following his extraction of per-
manent teeth unless he takes prompt measures to prevent
the malocclusion which otherwise will surely follow.
i
:
By reference to Figs. 495 and 496 it will be observed
how greatly the facial lines of this bright, intelligent boy

490 MALOCCLUSION.
have been thrown out of balance. We know that the teeth
when in correct occlusion are a striking mark of beauty,
:
:
but how unsightly they become when so unfortunately
placed as in this case!


TREATMENT OF CASES.—CLASS II. 491
There is a shortening of the bite, due to the abnormal
distribution of force upon the first molars and the loss of
so many deciduous teeth. After requisite enlargement
of the lower arch and the establishment of the normal
mesio-distal relations of the teeth, the reduction of the
prominent incisors, etc., and all had been maintained by
proper retaining devices, after methods already described,
it was found, as is occasionally the result in these as well
as in cases belonging to other classes, that the bite was
still too short, and its proper lengthening becomes very
necessary in order that the incisors may have their proper
relations. Various methods have been resorted to for ac-
complishing this, but the only one that has proven Satis-
factory to the author is one that has long been in use,
namely, to separate the bite by a vulcanite plate thickened
in front and covering the vault of the arch, with depres-
sions in the plate for the reception of the lower incisors
so that the full thrust of the jaw may be received upon
these teeth instead of upon the molars. The plate is
prevented from becoming forced upward in front, and
from being loosened in the rear by hooks firmly im-
bedded in the plate and made to engage the cutting edges of
the upper incisors. When properly adjusted this plate
should relieve all strain from the first molars which are
separated at least three thirty-seconds of an inch. If con-
stantly worn for from two to six months the molars will
have become lengthened and the proper length of bite es-
tablished. The result of this method of treatment is shown
in the fine balance that has been given to the facial lines,
Figs. 497 and 498, and in the improvement in the occlusion,
shown in Figs. 499 and 500.
Figs. 501 and 502 show the occlusion in another most
pronounced case of this class. All of the various constant
peculiarities following the distal locking of the first molars,
due to mouth-breathing, are here present, and these con-
ditions have been intensified by bad dental operations.
86ſ ^{21,H
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*ĐIJI


TREATMENT OF CASES.—CLASS II.
493
:
:

494
MALOCCLUSION.
"ĐINH
*IOg "ĐINH

TREATMENT OF CASES.–CLASS II.
495

496 - MALOCCLUSION.
Very unscientific but familiar forms of fillings have been
placed in the lower first molars, causing shortening of both
lateral halves of this dental arch and the lengthening of
the upper first permanent molar on the left. The effect
of such marked malocclusion is strikingly reflected in the
facial lines, shown in Figs. 503 and 504.
The treatment consisted in lengthening both lateral
halves of the lower dental arch sufficiently to allow the
placing of crowns of normal size and contour of cusps upon
the lower first molar roots; the shifting distally of all the
upper teeth; the reduction of the prominence of the upper
incisors to their proper angle of inclination, and the shift-
ing mesially of all the lower teeth into harmony of occlu-
sion with them, and the retention of the same for nearly
two years, after plans already described in connection with
the treatment of other cases belonging to this class. The
corrected occlusion is shown in Figs. 505 and 506.
The improvement in the balance of the facial lines is
shown in Figs. 507 and 508, and although still imperfect,
it is confidently expected that as time goes on still finer
balance will be worked out by Nature in her efforts to
establish the normal. - -
As might be expected the abnormal functionating of the
lips in the effort to disguise the deformity has increased
their thickness and muscular strength. The difficulty of
overcoming this habit was great. It was only mastered by
a strong will and determination persistently exercised by
day, and the lips held in their proper relations during
sleep by strips of surgeon’s adhesive plaster extending
from the base of the nose to the chin. These were regularly
applied and gave no special inconvenience to the patient,
with such results as leads the author to believe it a plan
often to be followed with advantage in similar cases.
Another point of much interest in connection with this
case was the very noticeable increase in self-respect and
dignity which gradually developed in this sensitive boy
TREATMENT OF CASES.—CLASS II.
497
:


498 MALOCCLUSION.
as the deformity formerly causing him such real anguish
diminished. The author has repeatedly noticed this with
:
other patients, and it adds much interest and pleasure to
the work of the orthodontist.

TREATMENT OF CASES.—CLASS II. 499
The former plan of treating cases belonging to this
division, and still followed by many, was to restore har-
mony in the sizes of the dental arches by sacrificing two
teeth from the upper dental arch, usually the first pre-
molars, and retracting the canines and incisors. The
method for retracting the canines and effecting these
changes is shown in the Appendix, but the plan is so ob-
viously defective that it is now regarded as obsolete by all
Orthodontists of the new school. Therefore nothing further
need be here added other than to say that by such treatment
Nature’s intended balance of the facial lines according
to the type of the individual was always greatly and per-
manently disturbed. The upper arch being greatly dimin-
ished from its normal size gave a corresponding abnormal
restriction to the tongue, with consequent impairment of
speech; and the mal-relations of the inclined occlusal
planes, thus permanently established, greatly impaired the
efficiency of the teeth in the mastication of food, etc., etc.
Another plan of treatment to be considered is that intro-
duced by Dr. Norman W. Kingsley, orthodontia’s greatest
genius. It has many advantages in its favor, and is decid-
edly preferable to the plan demanding mutilation which we
have just mentioned. The Kingsley method consists in
having the patient voluntarily move the lower jaw forward
the requisite distance to establish normal mesio-distal re-
lations of the teeth of the opposing jaws, or “jumping the
bite,” as he termed it, and then retaining the teeth in this
position. Of course before the teeth of the lower jaw can
be made to harmonize with those of the upper the upper
arch must be widened in the region of the canines, pre-
molars, and molars, and the prominent upper incisors re-
duced. For this latter purpose Dr. Kingsley first utilized
occipital anchorage. -
The greatest difficulty to overcome in following this plan
of treatment is to keep the lower jaw forward and the teeth
functionating in their normal relations long enough for the
500 MALOCCLUSION.
change in all of the tissues involved to become permanent.
For this purpose various forms of plates were resorted to,
and as most of them were under the control of the patient
FIG. 509.
;
;
ſº
!|
and annoying to him, he frequently temporarily omitted to
wear them, and this often brought discouragement and
caused a large percentage of failures. In fact the diffi-
FIG. 510.
::::. .
:: * * ,
culties to be overcome in retention were so great that even
the possibilities of success by this method were doubted
by many, as strenuous controversies in the literature bear









TREATMENT OF CASES.–CLASS II. 501
witness. Yet that it could be and was accomplished there
is no longer any doubt. The author succeeded in the treat-
ment of several cases, after this method, but only after
Fig. 511.
devising the plan of retention shown in Fig. 512, and then
only after the persistent use of the device for usually about
two years.
FIG. 512.
The history of one of these cases, here described, is of
unusual interest. The occlusion at the beginning of treat-
ment is shown in Figs. 509 and 510, and additional interest
attaches to the case in the fact that the deciduous incisors
were protruding, as is shown in Fig. 511, made from a



502 MALOCCLUSION .
photograph taken when the child was two years old, though
whether or not the deciduous lower molars were in distal
occlusion it is now of course impossible to determine.
The corrected occlusion two years after the beginning of
treatment is shown in Figs. 512 and 513. The improve-
FIG. 513.
ment in the facial lines of the patient is well shown by a
comparison of Fig. 514, taken before treatment was be-
gun, with Fig. 515, taken at this time. The author Was
greatly gratified with his success in this case and believed
it to be a most desirable plan of treatment, as with it the
full complement of teeth could be preserved and normal OC-
clusion established, and it seemed the normal facial lines
could also be established.
About three years after the discontinuance of retention,
on examining the facial lines and the teeth of the patient,
an important discovery was made, namely, that although
the normal relations had been maintained between the
teeth, the mandible had slowly drifted back to probably
very nearly its former relations with the skull, but in so
doing the crowns of the teeth of the upper arch had been
dragged distally to a noticeable degree, while the crowns

TREATMENT OF CASES.—CLASS II.
503

i
504
MALOCCLUSION.
FIG. 516.
FIG. 517.


TREATMENT OB' CASES.—CLASS II. 505
of the teeth of the lower arch had been tipped forward.
In other words there had been accomplished by the muscles
of mastication and persistent, difficult retention, what we
now aim to accomplish and do accomplish with the Baker
anchorage, often in so short a time as three weeks in
patients of this age.
Fig. 516 shows a model of the case taken at the age of
fourteen years which clearly shows the changes incident
to the recurrent movement of the jaw, and Fig. 517 shows
the profile of the face of the young man at this time. The
position of the chin in its relation to the rest of the face
also confirms the fact that the mandible has slipped back.
This discovery in this case led to the examination of
other cases similarly treated, with the same results, so it
Seems probable that the plan of treatment first described
should be regarded as the one most practicable and desir-
able for this class of cases.
TREATMENT OF CASES.—CLASS II, DIVISION 1, SUBDIVISION.
As already noted in the classification of malocclusion the
first Division of the Class just considered, has a Subdi-
vision in which the distal occlusion is unilateral only, the
other characteristics being in most cases practically the
same as in the full division. It is interesting to note,
however, that in many instances the protrusion of the in-
cisors in this subdivision is quite as great as in the division,
and this fact has often led to the unfortunate sacrifice of
a premolar on both the normal and abnormal sides of the
upper dental arch when treatment has been conducted after
the older methods regardless of the real requirements of
occlusion.
The correct plan of treatment is to establish harmony
in the sizes and relations of the arches and normal occlu-
sion, by the movement of the malposed teeth of the lower
arch mesially and those of the upper arch distally, at the
same time reducing the protrusion of the upper incisors,
506
MALOCCLUSION.
and any other malpositions of individual teeth that may
exist.
i
:
The disturbance in the balance of the facial lines is often
very pronounced, and is always just in proportion to the
extent of the malocclusion.

TREATMENT OF CASES.–CLASS II. 507
Figs. 518 and 519 show the occlusion in a typical case
belonging to this subdivision—that of a boy eight years of
age—and Fig. 520 shows the extent of the disturbance in
the balance of the face.
In the treatment the same plan was carried out as that
already described in the treatment of cases belonging to the
FIG. 520.
division, the only difference being that the intermaxillary
elastics were made to operate only on the affected side.
As the first permanent molars had not yet fully erupted
the placing of the anchor bands upon them would have
occasioned unnecessary pain, therefore the smaller bands
D were placed upon the second deciduous molars. Wire
ligatures were not needed in connection with the lower
expansion arch, as stationary anchorage was not required.
Force upon the upper incisors from the intermaxillary

508 MIALOCCLUSION.
elastics was prevented by the proper adjustment of the
nut of the expansion arch on the sheath of the anchor band
FIG. 521.
on the abnormal side, as already described in connection
with other cases. The nut on the opposite side of the arch,
FIG. 522.
as well as those on the lower arch, not being required, were
removed. Gradually the upper molar was shifted distally


TREATMENT OF CASES.—CLASS II. 509
and the lower teeth mesially the requisite distance, then
the force was distributed to the prominent incisors after
loosening the nut so as to give the full bearing of the ex-
pansion arch upon them.

510 MALOCCLUSION.
At this point, to prevent the shifting of the expansion
arch laterally, a single elastic was also made to engage the
sheath-hook and the sheath of the lower anchor band on
the normal side. All of the teeth were soon brought into
normal relations, as shown in Fig. 521.
FIG. 525. FIG. 526.
Retention was effected by means of the plane and spur
made to operate on the second deciduous molars on the
right side. The upper incisors were retained by spurs
soldered to bands which were cemented upon the lower
central incisors, the spurs projecting outward and upward
to engage their labial surfaces, as shown on one tooth in
the engraving. This device also served the double purpose
of assisting in breaking the habit of biting the lower lip.
The facial lines of the patient at the time of retention
of the teeth are shown in Fig. 522.
Figs. 523 and 524 show another clearly defined case be-
longing to this subdivision, of a young lady thirteen years
of age. The incisors are less prominent than is usual with
such cases, probably due to the pathological conditions of

TREATMENT OF CASES.–CLASS II. 511
the nose being less pronounced, permitting more nearly
normal breathing and lip function.
Fig. 525 shows the profile of the face, and it will be seen
what a coarse expression is given to the mouth as a result
of the malocclusion.

512 - MALOCCLUSION.
The teeth were restored to normal occlusion in the man-
ner last described, it being necessary, however, to enlist
stationary anchorage in the lower arch to effect the requi-
site distal movement of the upper teeth.
Retention was effected by means of the bands with plane
and spur, operated on the right first premolars, as shown
in Fig. 259.
Figs. 527 and 528 show the corrected occlusion, and Fig.
526 shows how greatly the balance of the mouth has been
improved as a result of this treatment. -
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So similar are these cases in occlusion, habits of patients,
and in necessities of treatment that it seems unnecessary
to report others. -
Cases that are complicated by the loss of teeth should
be treated as already described for cases of this sort be-
longing to the main division.
Before the introduction of the Baker anchorage the only
practical plan of treating these cases was the establishment
of harmony in the sizes of the arches by sacrificing the
first upper premolar on the abnormal side and retracting
the incisors and canine to close the space, in the same
manner as shown in Fig. 529, in which a combination of the
traction screw, arch B, headgear and elastics is employed,
º















TREATMENT OF CASES.—CLASS II. 513
as described in the appendix. The result of such treatment
is only improved occlusion instead of normal occlusion.
It is thought by many that treatment by this plan is .
quicker and easier than by the one just described. This,
however, is a mistake, as treatment by the former plan is
accomplished more rapidly and easily, besides giving far
finer balance to the face, normal freedom to the tongue,
and consequently better power of speech, with decidedly
more efficient occlusion of the teeth.
34
C H A P T E R XV III.
TREATMENT OF CASES.—CLASS II, DIVISION 2.
IT will be remembered that in cases of malocclusion
belonging to this Division, as in those of Division 1 of
this class, the teeth of the lower arch are in distal occlusion
in both its lateral halves. The upper arch, unlike that in
cases of Division 1 in which it is abnormally long and nar-
row, is shortened, with incisors bunched and overlapping,
to approximately harmonize in size with the anterior part
of the lower arch.
Figs. 530 and 531 show the simple case belonging to this
division, of a boy twelve years of age. Unlike the con-
ditions of the other division, the incisors are less elevated
in their sockets, owing, probably, to their being better able
to functionate, but the result of distal occlusion and re-
cession of the jaw and chin greatly mars the facial lines.
Although these cases are often apparently more com-
plicated than those of the first division, in reality, when we
consider all of the various conditions, they are seen to be
less so and more easily treated, for being free from path-
ological conditions of the nose, and with normal func-
tions of the lips, they are under our better control. Al-
though the teeth in many instances are found to be greatly
crowded, and all of them in mal-position, yet with the plan
of treatment now at our command we can so perfectly con-
trol the distribution of force for their movement, both
individually and collectively, as to make the operation of
establishing normal occlusion not difficult, especially if
undertaken in youth. We can also be assured of complete
success and with much certainty predict the time in which
the operation of tooth movement may be accomplished.
And as the patients are normal breathers, naturally hold-
514
TREATMENT OF CASES.–CLASS II. 515
FIG. 530.
FIG. 531.


516 MALOCCLUSION.
ing their jaws closed the requisite amount of time, after
proper treatment the cusps of their teeth are locked for
their mutual support, thus assisting the retaining devices
and obviating the necessity for their being worn so long
as is usually required in cases belonging to the first division
of this class.
The plan of treatment formerly employed, and still
strongly insisted upon by a few writers, necessitated the
sacrifice of one or more teeth in the upper arch, usually the
first premolars, and the establishment of harmony in the
sizes of the arches by the retraction of the teeth anterior
to the spaces. The most efficient method of treatment
under this plan is shown in Fig. 649. Those still advoca-
ting this plan claim that it simplfies the operation and
shortens the time of treatment, and that a “sufficiently
good occlusion,” or “serviceable occlusion” of the remain-
ing teeth, with good balance of the face, are gained.
Although the only practicable plan prior to the acqui-
sition of the intermaxillary anchorage, for reasons already
given in considering like treatment in the first division of
this class it should be abandoned, for in reality the oper-
ation is not made simpler or easier, but on the contrary a
longer time is required and more difficulties are encoun-
tered than in maintaining the full complement of teeth and
placing them all in normal occlusion—the only logical plan.
This plan we will now consider.
Briefly, it consists in moving distally all the molars, pre-
molars and canines of the upper arch about one-half the
width of a premolar tooth, with a simultaneous and equal
mesial movement of all the teeth of the lower arch, thus
establishing the normal relations and functions of all their
inclined occlusal planes—normal occlusion—and the best
possible balance of the facial lines.
As the lower molars in this case had locked in distal oc-
clusion, with normal distribution of force from the lips
upon the incisors, it is obvious that the malocclusion thus
TREATMENT OF CASES.–CILASS II. 517
begun would be progressive, each succeeding tooth upon its
eruption being compelled to lock abnormally, until finally
there would be complete malocclusion of all the teeth, with
the mandible effectually locked distally to normal, and with
consequent inharmony of balance of the mouth and lower
part of the face.
For the treatment of this case, as well as for all other
cases belonging to this division, no appliance could be more
ideal than the expansion arches, either plain or ribbed, the
various movements of the incisors being accomplished by
means of bands, Spurs, and ligatures, as already thoroughly
described for accomplishing these movements in cases be-
longing to Class I, and also in chapter XIII; while at the
same time the mesial movement of all the lower, and the
distal movement of all the upper teeth is accomplished,
also by means of the expansion arches, with intermaxillary
elastics made to engage the distal ends of the sheaths of
the anchor bands on the lower molars, and the sheath-hooks
attached to the upper expansion arch at points opposite
the lateral incisors, exactly as described for the treatment
of cases belonging to the first division of this class, and in
the chapter above referred to.
The force necessary to move outward the central incisors
by means of ligatures was reciprocated to the laterals
through the ligatures made to engage Spurs on their disto-
lingual angles close to the margin of the gum, and the
combined force of all assisted somewhat in the distal move-
ment of the upper molars. As the tipping of the molars
only was needed in this case, simple-intermaxillary anchor-
age was employed, the same as used in the case shown in
Figs. 439 and 440. Figs. 532 and 533 show the result of
such treatment in the case above illustrated.
Figs. 534 and 535 show the right and left sides of the
dental arches with the teeth in occlusion of a very compli-
cated case belonging to this division, the patient being a
young man twenty-two years of age, with strong, well-
518 MALOCCLUSION.
developed teeth and jaws all of the teeth being in malocclu-
sion as a natural result of the mal-locking of the first per-
manent molars upon their eruption, yet following the above
plan of treatment the teeth, even at this age, were all read-

TIREATMENT OF CASES.–CLASS II. 519
ily moved into normal occlusion. Of course, the golden
time for the treatment of this case was at, or soon after,
the time of eruption of the first permanent molars, the dif-
ficulties having gradually increased with the advance of
years. It is quite probable that at that time it would only
have been necessary to direct the first molars into normal
relations.
FIG. 534. FIG. 535.
In the treatment of this case anchor bands were placed
upon the lower second molars and first upper molars, and,
as very little widening of the arches was necessary, the
expansion arches were bent to conform approximately to
the general forms of the dental arches as they appeared
at the time of beginning treatment. As the upper incisors
were required to be moved forward and rotated they were
fitted with bands carefully cemented into position, with
spurs placed at appropriate points on their linguo-gingival
margins. After slipping the expansion arches into posi-
tion, ligatures were made to engage the spurs and arches,
and firmly tightened, thus exerting mesial and torsional
force. The upper expansion arch, having been provided
with sheath-hooks (in this case opposite the canines), the
intermaxillary elastics were applied with gentle pressure

520 MALOCCLUSION.
at first, which was gradually increased until three were
worn on each side. -
The appliances were carefully inspected twice each week,
the wire ligatures renewed, or tightened by a one-half turn,
and the nuts upon the expansion arch anterior to the
sheaths tightened until there was an added snug feeling
upon the molars. Gradually and far more rapidly than
anticipated the firmly imbedded molars of the upper arch
were moved distally, while those of the lower arch were
carried mesially into full normal mesio-distal relations.
The amount of force necessary being about equal in both
arches, so far only simple-intermaxillary anchorage was
employed. -
The molar bands on the upper dental arch were now dis-
continued and X bands placed upon the second premolars.
The nuts on the upper expansion arch were turned forward
and after modifying its form to that of an ideal dental arch
it was again slipped into position and force again applied
to the centrals and laterals by means of fresh wire liga-
tures. In order to carry the canines distally a wire ligature
on each side was made to embrace the three teeth and
twisted at a convenient point on the buccal side. To pre-
vent these ligatures from sliding beneath the gum they
were made to rest above the sheaths of the anchor bands
on the buccal side and beneath the screws on the lingual
side.
By renewing the intermaxillary ligatures and continuing
to tighten the nuts in front of the sheaths of the anchor
bands at intervals, the premolars and canines were grad-
ually made to travel distally into their normal mesio-distal
relations with the lower teeth.
But one elastic on each side, exerting only sufficient force
for retention, was now applied. The finer adjustment of
the incisors being perfected they were held passively by
the ligatures for several weeks, or until all soreness of the
teeth had subsided. All appliances were then removed
TREATMENT OF CASES.–CLASS II. 521
and the teeth carefully cleansed, and both molar and canine
retention, as in Figs. 256 and 260 was applied on both sides,
while the incisors were retained as in Fig. 233. In about
four months the device for the retention of the molars was
removed, while the canine and incisor retention was con-
tinued for over a year. Recurrent movement of the inci-
sors began to be manifest two or three weeks after the
removal of the retaining devices and they were promptly
replaced and their correct relations established the second
time by means of rubber wedges, followed by bending the
spurs, as discussed in the chapter on Retention.
FIG. 536. FIG. 537.
The improvement in the occlusion of the teeth is shown
in Figs. 536 and 537.
Fig. 538 shows the facial lines of the patient before
treatment and Fig. 539 shows the result of the establish-
ment of normal occlusion.
Figs. 540 and 541 show the malocclusion of the teeth of
a girl, aged eleven years, clearly belonging to this division,
and if we were to rest our examination on the models alone
it would seem that the teeth of the lower jaw were in
normal mesio-distal relations with the skull while those of
the upper, especially the molars of the right side, had, by
some force, been moved mesially from their normal rela-

522 MALOCCLUSION.
tions with the skull. Yet this is not the fact, as is easily
proven by a study of the facial lines in Fig. 542. If we
were to resort to the extraction of but a single premolar in
the upper arch the possibility of establishing the correct
balance of the facial lines would be forever lost. What is
clearly indicated in treatment is the shifting mesially of
the teeth of the lower arch and distally those of the upper
into normal occlusion, and reduction of the prominence
of the right upper canine permitting its normal movement
downward into the line of occlusion, and the correction of
FIG. 538. FIG. 539.
the positions of the incisors; and as the upper first molar
on the left side in locking assumed lingual relations with
the lower, it must be moved buccally while the lower must
be moved lingually.
All of these various necessary movements were accom-
plished by means of the expansion arches and intermaxil-
lary elastics, with wire ligatures made to exert force upon
the lateral incisors, all in the usual way, and as already
described. The prominent canine was reduced by the ex-
pansion arch made to bear against its labial surface, with
an intervening wedge of rubber. The buccal movement of

TREATMENT OF CASES.—CLASS II. 523
the left upper first molar was effected also by the expansion
arch bent so as to exert an outward force upon it, while the
:
opposing molar was moved lingually by bending the ribbed
arch so that it would exert an inward force.

524 MALOCCLUSION.
The teeth were carefully retained by molar and incisor
retention, as in Figs. 256 and 233, the various tooth move-
ments having required about four months’ time. An addi-
tional spur was soldered to the band which bore the plane.
of metal upon the first upper molar on the left. This spur
FIG. 542.
projected downward and bore against the buccal surface
of the lower first molar between its disto-buccal and fifth
cusps, thus compelling the normal buccal relations of these
teeth, as in B Fig. 257. It was thought advisable to allow
six months for the settling of the molars and growth of the
alveolar process before perfecting the adjustment of the
incisors.

TREATMENT OF CASES.—CLASS II. 525
The occlusion at this stage of the operation is shown in
i
:
Figs. 543 and 544, and the improvement in the facial lines
in Fig. 545.

526 MALOCCLUSION.
As the molars become settled in their sockets and de-
velopment of the alveolar process progresses, better occlu-
sion between the incisors will follow.
Occasional inspection of this case will yet be necessary
for at least a year.
FIG. 545.
Figs. 546 and 547 show another well-defined case belong-
ing to this division, of a girl twelve years of age. All of the
usual characteristics are present, namely, complete distal
occlusion of the lower molars and premolars, retrusion and
bunching of the upper incisors, normal lip function, normal
breathing, etc. The deciduous canines have recently been

TREATMENT OF CASES.–CLASS II. 527
lost and their permanent successors are just beginning to
erupt. An added complication—the abnormally short bite
FIG. 546.
—is here present. The molars have failed to erupt their
normal length, allowing the lower incisors to come in con-
FIG. 547.
tact with the vault of the arch, while the cutting edges of
the upper incisors pass beyond the gingival margins of the


52S MALOCCLUSION.
lower. Of course this abnormal telescoping of the incisors
is due in no small degree to the tipping downward and in-
ward of the upper incisors from their normal angle, and
the tipping lingually of the lower incisors, and although
such a condition is more or less present in all cases be:
longing to this division, yet it is here present to an unusual
degree, the principal reason being that the molars have
not fully erupted.
FIG. 548.
Placing the teeth in their normal relations will greatly
improve the bite, as shown in Fig. 548, where it has been
accomplished. -
How greatly the face is shortened and thrown out of
balance is shown in Figs. 549 and 550, which again empha-
sizes the truth of the law that the variation from the nor-
mal balance of facial lines is in proportion to the degree
of malocclusion.
The plan of treatment for restoring the normal mesio-
distal relations of the teeth and positions of the incisors
was the same as in cases already described. X bands, how-
ever, were placed upon the second upper premolars and the
second and first premolars were at first ligated together,
while the ribbed expansion arch was made to line slightly
above the gingival margin of the upper incisors. As with

TREATMENT OF CASES.–CLASS II. 529
the centrals and laterals attached by means of the wire
FIG. 549. FIG. 550.
T T
FIG. 551. FIG. 552.
ligatures in the usual way the expansion arch would nat-
urally spring down. The tendency of the spring thus given


35
530 MALOCCLUSION.
was to lengthen the premolars and shorten the upper in-
cisors while they were moved labially by tightening the
nuts in front of the sheaths of the anchor bands, renewal
of ligatures, etc. This upward spring also prevented the
ligatures from sliding downward on the crowns of the in-
cisors. As the result of the force from the intermaxillary
elastics and the spring of the arch, very excellent mesio-
distal relations of the teeth were established, as shown in
FIG. 553.
Fig. 548. Figs. 551 and 552 show the facial lines at this
time. But the bite is still far too short, and, as Dr. Kirk
has well said, “It is of quite as much importance that
the proper length of bite be established as it is that any
other phase of malocclusion be corrected,” and for this
purpose the bite plate, as described on page 491, was made
use of. It was worn for one year, completely relieving the
molars of occlusal contact. As a result they became
lengthened to a noticeable degree, and the incisors were
possibly shortened to some slight extent.
Two years after the discontinuance of all treatment a

TREATMENT OF CASES.–CLASS II. 531
model of the teeth was made which shows the present con-
dition of the occlusion, Fig. 553; and Figs. 554 and 555
show the facial lines of the patient at the time of making
this model. While numerous simpler cases belonging to
this division might be reported here, this seems unneces-
sary as the stories they might tell in occlusion and art and
in the methods of accomplishing the various tooth move-
FIG. 554. FIG. 555.
ments are embraced in the cases already reported, and if
these be understood the treatment of simple cases should
offer no difficult problems.
TREATMENT OF CASES.–CLASS II, DIVISION 2, SUBDIVISION.
Cases that are easily classified as belonging to this sub-
division differ from those of the main division only in de-
gree, the teeth of one of the lateral halves of the arches
being normal as to mesio-distal relations, while those of the
opposite side are locked in distal occlusion. This is accom-

532 MALOCCLUSION.
panied by the bunching and overlapping of the incisors
which may be limited to those of the upper arch, or, as
frequently happens, may also involve those of the lower
arch. Of course inharmony in the balance of the facial
lines exists in a corresponding degree.
Cases of this type are frequently met with and often
present complications in treatment quite as difficult to
overcome as are found in cases belonging to the main di-
vision, yet as the patients are normal breathers, if no
FIG. 556. FIG. 557.
vicious habits of the lips exist and the cases are intelli-
gently managed, success may be assured, although the
period of retention may often be protracted.”
Figs. 556 and 557 illustrate a typical case belonging to
this subdivision—that of a boy ten years of age.
It will be noted that the first permanent molars, decid-
uous molars, and canines on the left side are in normal
* Even in these cases vicious habits of the lips, especially the lower, are
not infrequent. They should receive close attention.

TREATMENT OF CASES.–CLASS II. 533
-- ~~
relations, while those on the right side are locked in com-
|
|
plete distal occlusion, with retruding upper central in-
cisors, and that all of the lower incisors, are more or less

534 MALOCCLUSION.
lingual to the line of occlusion, with one of them pro-
nouncedly so. The result of this retrusion of the incisors
is to produce the usual abnormal overbite.
As a result of the malocclusion the lines of the face are
naturally thrown out of harmony of balance, as is shown in
Figs. 558 and 559.
The object to be accomplished in the treatment of this,
as in all cases, is normal occlusal relations between
all of the teeth. This necessitates the labial movement of
all the lower incisors and the upper centrals, the torso-
lingual movement of the upper laterals, and the slight
widening of the upper arch in the region of the canines
and first premolars, with the mesial movement of all the
lower molars and the canine on the right side, and the
slight distal movement of the opposing upper teeth.
For the accomplishment of these various movements in
this as well as in all other cases belonging to this subdi-
vision, the expansion arches, with intermaxillary elastics
on the abnormal side, give us the most complete control,
and in efficiency and simplicity far outrank any other
device.
In this case the anchor bands were placed upon the upper
second deciduous molars, and in the lower arch on the
right first permanent molar and the left second deciduous
molar. The intermaxillary elastics were of course em-
ployed only on the affected side, very lightly at first and
finally increased to two fairly strong elastics, and as the
lower molars (permanent and deciduous) were gradually
moved forward and their opponents moved distally, the
wire ligatures were used efficiently in correcting the var-
ious mal-positions of the incisors, all as frequently de-
scribed.
Intermaxillary retention for maintaining the proper
mesio-distal relations of the teeth and dental arches was
employed upon the first permanent molars on the right
side, as in Fig. 560. The retention of the lower incisors
TREATMENT OF CASES.–CLASS II. 535
was secured as in Fig. 233, and of those of the upper arch
by bands on the upper lateral incisors, connected by a sec-
tion of wire G soldered to their mesio-lingual angles, which
rested against the lingual surfaces of the centrals.
There remained a strong tendency toward the slight
bunching of the upper incisors, which continued until all
of the permanent teeth, with the exception of the third
molars, had become fully erupted and thoroughly estab-
FIG. 560.
lished. Figs. 561 and 562 show the occlusion of the teeth
toward the close of the period of retention.
Figs. 563 and 564 show the excellent balance of the
young man’s face resulting from the treatment.
Fig. 565 shows another case belonging to this subdivi-
sion, of a boy twelve years old. Although the teeth on the
right side have not yet locked in full distal occlusion the re-
lations of the inclined planes are such that this must soon
result. The teeth of the left side are in nearly ideal occlu-
sion and their forms and relations are nearly faultless,
yet if the teeth of the right side were allowed to remain in
their present positions derangement of the lower incisors
would be almost certain to follow from the disturbance of

536
MALOCCLUSION.
the upper lateral which must be carried mesially and lin-
gually as the canine forces its way in eruption.
:
For effecting the distal movement of the right upper
molars and premolars, as well as the labial movement of

THEATMENT OF CASES.
CLASS
II.
537
*†9.g. "ĐINH
"899 "BIJI

538
MALOCCLUSICN.
"999 "BIJI
ºg 99 "ĐIJI

TREATMENT OF CASES.—CLASS II. 539
the right upper lateral incisor, and the mesial movement
of the opposing teeth, the expansion arches, intermaxillary
elastics, etc., were adjusted and operated in the usual
way. - w
Fig. 566 shows the corrected occlusion and the manner
of retention, which may be used with advantage in similar
Ca,SéS. -
The mesial movement of the upper premolars and molars
was combatted by a spur made from nickel-silver wire and
soldered to a clamp band cemented upon the first lower
premolar, which passed upward and lingually to bear
against the mesial surface of the crown of its antagonist.
In this way ample space was maintained for the erupting
canine. The retention of the lateral was secured by a band
cemented upon its crown and carrying a spur which ex-
tended upward and bore against the mesio-labial surface
of the canine. The force so exerted directed the latter
tooth distally as it slowly erupted into the space provided
for it. When it had erupted far enough to be interfered
with by the spur on the lower premolar the spur was gradu-
ally reduced by grinding and finally dispensed with alto-
gether.
In similar cases when the canine shall have taken its full
normal position the finer adjustment of the lateral may be-
come necessary, which may be easily accomplished by an-
other spur soldered to its band and made to bear upon the
disto-labial surface of the central, with an intervening
wedge of rubber that should be removed after the lateral
has been correctly adjusted and the spur bent to bear
directly against the central for its retention.
Eigs. 567 and 568 show another typical case belonging to
this subdivision—that of a young man eighteen years of
age. It will be seen that all the usual characteristics of
cases belonging to this subdivision are present. The left
lateral halves of the two arches are abnormal, the lower
teeth being in distal occlusion, with bunching of the in-
540 MALOCCLUSION.
cisors, and with torso-lingual relations of the upper in-
cisors.
FIG. 567.
FIG. 568.
The case was treated according to the plan already in-
dicated, and Figs. 569 and 570 show the corrected occlu-


TREATMENT OF CASES.—CLASS II. 541
sion which has given normal balance and strength to the
Fig. 569.
FIG. 570.
face. This is easily verified by comparing the profile of
the young man, Fig. 572, taken after treatment, with that


542 - MALOCCLUSION.
shown in Fig. 571, taken just before the beginning of the
operation.
Figs. 573 and 574 show the right and left sides of a case
of a boy, aged thirteen, belonging to this subdivision.
The malocclusion is far more complex than is usual in
cases belonging to this subdivision, due to the lingual lock-
ing of the upper premolars and the first permanent molar
on the left, in addition to the distal locking of the lower
molars, premolars and canine on this side. This is further
FIG. 571. FIG. 572.
complicated by the great shortening of the upper arch, due
to the pronounced lingual positions of the incisors and ar-
rest in the growth of the alveolar process following the pre-
mature loss of the upper deciduous canines through ab-
sorption of their roots. The further eruption of the upper
canines is rapidly carrying the laterals and first premolars
still further into lingual occlusion.
The occlusal aspect of the upper dental arch at this time
is shown in Fig. 575 and of the lower in Fig. 577.
The marked diminution from the normal in the sizes of
the arches so interfered with the normal functions of the

TREATMENT OF CASES.–CLASS II. 543
tongue as to noticeably impair the speech, and also, as
might be expected, to greatly impair the balance of the
facial lines. That such has been the result is clearly shown
in the front and profile views of the face, Figs. 579 and 580.

544 MALOCCLUSION.
Notwithstanding there is almost complete arrest in the
growth and development of the alveolar process, and the
apparent impossibility of providing room in so small a
jaw for the full number of teeth of such large patterns,
FIG. 575. FIG. 576.
FIG. 577. FIG. 578.
yet to have extracted a single tooth would have been an
irreparable blunder and would have rendered it impossible
to ever secure the normal functions of the teeth, tongue,
and nose, or to establish Nature’s intended contour and
balance of the face.
The correct plan of treatment, which ought even in this


TREATMENT OF CASES.–CLASS II. 545
remarkable case to be clear and apparent to the reader
who has followed us thus far, is to enlarge the upper arch,
widening it in the region of the premolars, carrying the
:
:
incisors labially, moving buccally the upper first molar and
lingually the lower first molar on the left side, during
periods of activity followed by periods of rest, all pre-

36
546 MALOCCLUSION.
cisely as described in the treatment of cases with similar
characteristics belonging to the first class, and at the same
time carrying the upper molars and premolars on the left
side distally and the lowers mesially.
In carrying out this plan of treatment all four first
molars were banded, much buccal spring being given to the
upper expansion arch and lingual spring to the lower,
ribbed arches being used. The distal movement of the
upper teeth and the mesial movement of the lower on the
left side was begun immediately with two strong inter-
maxillary elastics. Gradually the upper arch was widened
and lengthened until normal mesio-distal, as well as linguo-
buccal, relations of the molars and premolars were secured.
The incisors had been moved forward probably half the
requisite distance, affording partial room for the eruption
of the canines.
At this period the teeth were retained and the patient
dismissed for six months to permit the growth of the bone.
As a result of tipping the upper incisors forward and es-
tablishing the normal relations between the molars, the
upper and lower incisors were greatly separated. This
occasioned no anxiety, as the author felt assured that the
normal settling of the molars, and the normal growth of the
alveolar process in the region of the incisors would in time
establish their proper relations as to length of bite. At the
end of six months this had occurred to a noticeable degree
and the canines had meantime also proceeded most favor-
ably in their movement downward toward their correct
positions.
The incisors were then carried forward sufficiently to
permit the normal location of the canines, and the arch
was widened slightly more than required for occlusion in
order to better stimulate the growth of the bone.
The teeth were again retained and the patient dismissed
for another six months. Upon his return the positions and
relations of the teeth were as shown in Figs. 581 and 582,
TREATMENT OF CASES.–CLASS II. 547
which represent models made at this time. Better rela-
|
tions of the inclined occlusal planes between the teeth on
the left side will undoubtedly follow the still greater de-

548
MALOCCLUSION.
:
:

TREATMENT OF CASES.—CLASS II. 549
velopment of the alveolar process. The teeth will be
inspected occasionally for several months to come.
The occlusal aspect of the teeth after their correction
is shown on the right in Figs. 576 and 578, and the gratify-
ing improvement in the contour and balance of the face
is shown in Figs. 583 and 584.
It is not difficult to imagine what the facial lines of this
young man would have been if, as usual, two or three pre-
molars had been sacrificed pursuant to the unfortunate
teachings so long followed in the treatment of similar
Ca,SéS. -
The devices for retention used during the last period
consisted of plain bands, cemented on the lateral incisors,
connected on their lingual surfaces by a section of the
wire G made to bear against the gingival ridge of the
central incisors. Two sections of wire G were also sol-
dered to the labial surface of the bands on the lateral
incisors, which extended distally to the first molars and
bore heavily upon the canines, as in Fig. 232. Wire liga-
tures were made to encircle each of the premolars and
the section of wire G which was given lateral spring in
order to exercise greater force in their retention. The
normal relations of the first molars on the left were main-
tained by plane and spur, as in Fig. 256, with an additional
spur soldered to the band on the upper molar which bore
heavily upon the disto-buccal angle of the lower molar, as
shown in B Fig. 257.
CHAPTE R x Ix.
TREATMENT OF CASEs.-CLAss III, DIVISION 1.
DEFORMITIES under this class begin at about the age of
the eruption of the first permanent molars, or even much
earlier, and are always associated at this age with enlarged
tonsils and the habit of protruding the mandible, the latter
probably affording relief in breathing. It is the author’s
belief that these are potent factors in causing the mesial
locking of the permanent teeth as they erupt. When once
the mesio-buccal cusp of the upper first molar begins to
engage the distal, incline of the disto-buccal cusp of the
lower first molar, the effect is to mechanically force the
mandible forward on each closure of the jaws. This in
time forces the deciduous teeth, as well as each succeeding
permanent tooth as it erupts, into malocclusion, thereby
gradually causing all the other inclined planes to act out
of harmony with Nature’s intended plan, and accelerating
the forward movement of the mandible. Not only this, but
the muscles are thus made to exert force on the mandible
abnormally and thereby to stimulate it to abnormal growth
and malformation. The wrong distribution of the force on
the crowns of the teeth through occlusion clearly shows
this, also, to be a factor in the development of these de-
formities. See also page 449. -
So, inharmony being once established, it usually pro-
gresses rapidly, only a few years being necessary to de-
velop by far the worst type of deformities the orthodontist
is called upon to treat, and when they have progressed until
the age of sixteen or eighteen, or after the jaws have be-
come developed in accordance with the malpositions of the
teeth, the case has usually passed beyond the boundaries of
malocclusion only, and into the realm of bone deformities,
550
TREATMENT OF CASES.–CLASS III. 551
for which, with our present knowledge, there is little possi-
bility of affording relief through orthodontic operations.
It is the author’s belief that if the throat could be prop-
erly treated, and the first molars at the time of their erup-
Fig. 585.
tion mechanically assisted into normal occlusion and there
compelled to remain by delicate yet efficient retention for a
few months, these unsightly deformities would rarely, if
ever, develop.
FIG. 586.
There may be, and doubtless are, other factors that enter
into their production which are as yet but imperfectly
understood, but we are convinced that they are of minor


552
MALOCCLUSION.
FIG. 587.
ITIG. 588.



TREATMENT OF CASES.—CLASS III. 553
importance when compared with those we have mentioned.
The time-honored custom of attributing these conditions
to heredity and degeneracy, still made prominent in the
latest books on orthodontia, has, in the author’s opinion,
no substantial Support. -
Figs. 585 and 586 show the malocclusion in the case of
a child six years of age, who for some time had been a
sufferer from greatly enlarged tonsils. The first molars
are erupting and the lowers in taking their positions would
soon become locked in mesial occlusion. This is a fair ex-
ample of these cases at this age.
The deciduous teeth are rapidly conforming to the ab-
normal occlusion, the lower incisors now closing in front
of the upper. The tendency to greater complexity is thus
clearly indicated. The effects on the facial lines are shown
in Figs. 587 and 588.
The condition has developed rapidly, the contour of the
baby face being thus changed in but a few months. The
case was promptly referred to a rhinologist who was suc-
cessful in removing the tonsils, as well as in the subsequent
necessary treatment.
The treatment for the malocclusion was simple and easy.
Small D bands were placed upon all four deciduous second
molars and the Small plain expansion arches were adjusted,
as per combination shown in Fig. 210, and force was ex-
erted by means of the intermaxillary elastics made to en-
gage the sheath-hooks on the lower expansion arch, which
were placed well forward or opposite the lateral incisors
and stretched back over the distal ends of the sheaths of the
upper anchor bands. As a result the teeth were shifted
into normal relations in a very short time.
They were retained by means of two delicate spurs sol-
dered to the lingual surfaces of accurately fitted bands
on the upper deciduous central incisors, the Spurs extend-
ing downward and somewhat forward in front of the lower
centrals and compelling the normal closure of the man-
554 MIALOCCLUSION.
dible. Figs. 589 and 590 show the occlusion at this stage,
the lower deciduous laterals meantime having been lost.
The pronounced change in the facial lines resulting from
FIG. 589.
the corrected occlusion is shown at this stage in Figs. 591
and 592.
The perversion of the forces of the muscles, inclined
planes, etc., having been arrested and the normal functions
FIG. 590.
of the muscles and inclined planes established, it is gratify.
ing to know that although two years have since elapsed the
molars still retain their full normal relations, with a con-


TREATMENT OF CASES.–CLASS III. 555
tinuation of the normal growth of the denture, and develop-
ment of the facial lines toward the normal, as shown in
Figs. 593 and 594, notwithstanding that retention was dis-
continued after the loss of the deciduous upper central in-
cisors through absorption of their roots, which occurred
only a few weeks after the retaining devices above de-
scribed had been placed upon them.
FIG. 591. FIG. 592.
º
Figs. 595 and 596 show the rapidly developing malocclu-
sion of another case belonging to this class. This case is
very similar to the one last described, the patient being but
little older. The mandible is being forced forward and the
first permanent molars, in their eruption, are assuming
mesial relations. The upper central incisors had been but
recently lost. The disturbance in the facial balance is well
shown in Figs. 597 and 598.
The treatment was identical with that last described and
the result in the occlusion of the teeth one year later is
shown in Fig. 599, made from an impression in plaster
with the jaws closed.
This child had suffered frequent attacks of acute inflam-
mation of the throat and had chronic enlargement of the

556
MALOCCLUSION.
ºf (jſ）
º I, I,
"869 · 91, H.

TREATMENT OF CASES.-CLASS III. 557
tonsils. They were removed by the rhinologist and the
throat was greatly benefited by further treatment. Up
to the time of the death of the child one year ago the
normal relations of the teeth continued, with continued
development of the facial lines toward the normal, and
every indication of a normal completion of the denture and
normal contour of the face.
FIG. 595. - FIG. 596.
Figs. 600 and 601 show the malocclusion in another case
of a patient somewhat older, in which the natural progress
of the deformity is clearly indicated, for following the ab-
normal locking of the first permanent molars, all of the
teeth anterior thereto have, as they erupted, been forced
into mesial occlusion. The resultant inharmony in the
facial lines is shown in Fig. 602.
The treatment clearly indicated was to establish har-
mony in the sizes of the arches and normal relations of the
inclined planes of the teeth. Without the intermaxillary
anchorage this would have been very difficult or impossible,
but by its use the desired changes were effected, and that,
too, quite speedily.


558 MALOCCLUSION.
The same combination of appliances as that described
for the case shown in Figs. 585 and 586 was also used in
this case. Anchor bands D were placed upon the upper
É
5
first molars, with X bands upon the lower second premo-
lars. The upper incisors were moved forward at the same
time by their attachment with ligatures to the expansion

TREATMENT OF CASES.–CLASS III. 559
arch, the force being reciprocated from the upper first
molars at first directly upon the lower premolars and first
permanent molars. Gradually they were moved into their
normal mesio-distal relations, when the nuts on the lower
FIG. 599.
FIG. 600. FIG. 601.
expansion arch were turned forward to allow the force to
be received by the incisors and canines.
Somewhat to the author's surprise in the short space
of three weeks the teeth were moved into their normal
mesio-distal relations, as shown in Figs. 603 and 604. It
is quite probable that the mandible was also moved distally


560 MALOCCLUSION.
somewhat. In fact this is shown in the facial lines after
FIG. 602.
FIG. 603. FIG. 604.
treatment, Fig. 605, but the principal change was in the po-
sitions of the crowns of the teeth.


TREATMENT OF CASES.—CLASS III. 561
No effort was made to establish better relations between
the premolars, the author knowing full well that as these
teeth continued their eruption they would necessarily be
forced into their correct relations through the influence of
their inclined occlusal planes.
The retention was effected by means of the device shown
in Fig. 512, and already described in connection with molar
FIG. 605.
retention in the first Division of Class II, the difference in
its use being that the action of the spur was reversed by
causing it to close behind the metal plane in this case,
instead of in front of it, as in the other Class.
By the introduction of the intermaxillary anchorage the
possibilities of success in the treatment of cases belonging
to this class have been greatly increased, but after much
experience the author is convinced that in well-defined
cases where the jaws have become considerably out of

37
562 MALOCCLUSION.
harmony as to size and relations their successful treatment
is practically hopeless, for though we may ofttimes improve
the occlusion temporarily, if we do not gain the influence
and full support of the inclined occlusal planes, failure
in most instances must ultimately result. They are good
cases for the orthodontist to avoid. There are limits in
Fig. 606.
general surgery and we should wisely recognize that there
are also limits in orthodontia and intelligently expend our
energies upon cases in the treatment of which success is
at least probable.
Figs. 606 and 607 show the occlusion of the teeth in one
of the most pronounced cases of this type the author has
seen uncomplicated by extraction, and how greatly, yet
proportionately, the facial lines are marred by the mal-
occlusion is shown in Figs. 608 and 609. It is our belief
that the upper jaw and dental arch are normal and in

TREATMENT OF CASES.–CLASS III. 563
normal relation to the skull, and that the deformity results
wholly from the abnormal form, size, and position of the
mandible, which probably might have been successfully
corrected if taken at an early age and treated as were the
other cases belonging to this class already discussed. The
only possible chance for improvement of this and of all
FIG. 607.
similarly advanced cases is the operation suggested by the
author some fifteen years ago, which consists in shortening
the body of the mandible by the removal of a section of
bone from each of its lateral halves, placing the remaining
segments in apposition and firmly securing them and gain-
ing union as usual in double or multiple fractures of the
jaw as described in the chapter on Operative Surgery.
Naturally at first thought the operation would seem very
formidable and attended by very great risks, but we know
that the recuperative powers of the mandible are great and

564 MALOCCLUSION.
that even the severest double comminuted fracture nearly
always unites readily, even with the most primitive
:
:
methods of fixation still so commonly employed by phy-
sicians, and that, too, frequently in defiance of septic con-


TREATMENT OF CASES.—CLASS III. 565
ditions. So it would seem that if the operation be per-
formed skilfully under the most favorable, aseptic con-
ditions, and according to scientific methods of fixation, the
risk should not be great and the recovery prompt, with
occlusion and facial lines vastly improved. Yet the author
would strongly impress the caution that the operation is
not one for the reckless experimenter to undertake, but at
best it should be performed only as a last resort and then
only in rare and favorable cases and under the most favor-
able environment. º
TREATMENT OF CASES.—CLASS III, DIVISION, SUBDIVISION.
As cases belonging to the subdivision of Class III are
in unilateral mesial occlusion, the treatment clearly in-
dicated, especially in young patients, is after the same plan
we have already described for the full division, exerting
force, however, only on the side that is in mesial occlusion.
These cases are very rare.
C H A P T E R X. X.
OPERATIVE SURGERY.
WHILE all of tooth movement is essentially surgical, that
by the use of appliances may be properly called Conserva-
tive Surgery. To distinguish, the operations involving the
use of cutting instruments may be designated as Operative
Surgery. While such operations should probably be em-
ployed only as auxiliary to the conservative method, they
are possibly destined to play a more important part in the
practice of the future, and will be briefly considered.
Immediate Movement.—As the changes in the tissues in-
cident to tooth movement are as a rule necessarily slow,
requiring the operation to be more or less protracted, dif-
ferent writers” from time to time, among whom may be
mentioned Tomes, Stellwagen, and Bryan, have advocated
the use of forceps to effect the immediate movement of
teeth into correct positions.
Dr. Bryan, of Basle, Switzerland, was first to improve
on the operation by Surgically removing a portion of bone
in advance of the moving tooth.f
The immediate movement of teeth has usually been re-
sorted to only where one, or at most two, were to be rotated
*J. Lefoulon, who wrote a work in 1841 (French) which was translated
and published in the American Library of Dental Science, says on pages
132 and 133, “Almost all of the writers who have treated on this subject,
i. e., regulating, have spoken of artificial luxation. This is a means which we
have already condemned, and which we cannot too frequently disapprove
The ancients, and some of the moderns, yet imitate them, employing the
‘pelican’ for this purpose: a violent maneuver, which exposed them to the
risk of breaking the tooth at the neck, and thus to replace a deformity by a
mutilation a hundred times worse. Besides it is a cruel operation, which
should be rejected the instant mild means can be employed which, at least,
are equally efficacious.”
+ Described in a paper read before the American Dental Society of Europe
in August, 1892.
566
OPERATIVE SURGERY. 567
or moved from inlock. The operation has never met with
much favor, for it is a practice as inexcusable and imprac-
ticable as it is barbarous.
First, it is so formidable that naturally but few care to
submit to it.
Second, the risk to the tooth and pulp, as well as to the
other tissues involved, is so great that it is wholly un-
warrantable.
And last, it is wholly unnecessary, for in cases that
would seem most favorable for this operation a suitable
appliance will in a very short time effect by the conserva-
tive method the desired result, without risk and with but
little more than inconvenience to the patient.
Alveolar Sections,—The removal of bone in advance of the
moving tooth may, we think, be desirable in some cases as
auxiliary to the conservative method. While it is probably
never necessary in the movement of teeth of young chil-
dren, in patients of more advanced age, where the bone is
dense and of considerable thickness, and absorption slow,
it may be resorted to with possible advantage, especially
in the reduction of labial protrusion of incisors, as in Fig.
653. Yet in practice it does not seem to lessen the amount
of force required, nor hasten the movement of teeth to
nearly the extent we might expect. Doubtless if the only
obstacle to tooth movement were the resistance of the bone
the operation would be greatly hastened by its removal,
but when we remember the firm resistance offered by the
fibers of the peridental membrane by their attachment to
the plate of bone in the rear of the moving teeth, as well
as on all sides, this is readily understood.
In the removal of bone it is highly important that only
sharp, clean fissure-burs of medium diameter, with end
cut, and which have been thoroughly sterilized, be em-
ployed, and that the peridental membrane be not injured
in the operation. To insure this a thin Septum of bone
should be allowed to remain between the membrane and the
568 MALOCCLUSION.
cavity formed. The cavity should be crescent-shaped, of
somewhat greater length than the diameter of the tooth,
when practicable, and in depth about two-thirds the length
of the root.
Resection of Peridental Fibers.-After a careful study of the
fibers of the peridental membrane, the direction in which
they extend, their distribution and attachment, and know-
ing the strong resistance offered by them to tooth move-
ment and that they must often be forcibly severed or
slowly absorbed at their points of attachment in order
to permit of tooth movement, it occurred to the author that
it would be but reasonable and wholly in keeping with good
practice to surgically sever them.” He would earnestly
caution conservatism, however, advising the severance of
only such fibers as would most probably be absorbed.
At first thought it might seem to be a painful operation.
In reality it is very simple and nearly painless, provided
it is properly performed with suitable instruments. The
form of instrument is of much importance, and those most
suitable are the iris needle and cataract knife. These seem
to be most perfectly adapted also for operations on the
peridental membrane. They are illustrated in Fig. 610.
In their use, if we wish to sever the principal obstructing
fibers of a tooth, as for example those which resist rotation,
Fig. 611, we have but to pass them down along the angle
of the root. It has been found better to first adjust the
regulating appliances and allow them to exert tension for
two or three days, that the fibers may be well tightened
by stretching. This facilitates insertion of the delicate
blade and makes the severing of the fibers more complete.
In retraction of the canine the severing of the fibers in the
rear of the tooth to the depth of one-third the length of the
root seems to be sufficient to greatly expedite the movement.
In some cases the duration and difficulty of the movement
* Dental Cosmos, November, 1899.
OPERATIVE SURGERY. 569
may possibly be lessened by the intelligent combination of
methods,--the surgical severing of fibers and removal of
FIG. 610. FIG. 611.
| || || |
º
bone, in connection with the use of the regulating appli-
a.IlCéS. -
Section of Frenum Labium.—A form of malocclusion charac-
terized by a space between the upper central incisors (and

570 MALOCCLUSION.
rarely between the lower centrals) is quite frequently en-
countered.
The closing of this space by drawing together the in-
cisors is a comparatively simple operation, requiring only
a few hours, or days at most. But notwithstanding the
ease with which these spaces may be closed they are yet
well known to be unsatisfactory and annoying cases to
treat, on account of the difficulties of permanently estab-
lishing the teeth in their corrected positions. For it is
usually found, even after months of the most perfect Sup-
port by the retaining device, that following its removal
the teeth will rapidly assume their former positions. By
a more careful study of these cases the reason for this be-
comes obvious, the cause has not been removed, which,
as we have shown in the chapter on Etiology, is usually an
abnormal development and attachment of the frenum la-
bium, Fig. 612.
It is evident that the portion of the ligament passing
between the teeth must be removed, or so modified that it
will no longer act mechanically upon them. *9
The author has derived partial success by the mere sever-
ing of the ligament with a pair of delicate scissors, union
of the ends while healing being prevented by occasional
manipulation. But the plan now followed by him,” and
which gives the best results, is to take advantage of the
contraction of tissue resulting from actual cautery, as rhi-
nologists do in operations on the nose for deflected septum.
With a suitable lancet or bistoury a deep incision is made
between the teeth, splitting the ligament, after which an
electro-cautery knife, Fig. 613, at red heat, is passed
through the incision.
No pain will be occasioned if, preliminary to the opera-
tion, the tissue be locally anesthetized. Great care should
be exercised in the use of the cautery instrument, which
* Dental Cosmos, November, 1899.
OPERATIVE SURGERY. 571
FIG. 612. FIG. 613.
FIG. 614.
º::$rs
º:
•º *
• *Vº
*
& "º ſº. Tº
º
\\\



572 MALOCCLUSION.
should come in contact only with the abnormal tissue, the
wounding of the peridental membrane being rigidly
avoided, and for this reason the clean incision is first made
to simplify the operation. t.
The teeth should be drawn together and mechanically
supported for several weeks or months. The author’s
favorite method of closing the space is by the exertion of
pressure by means of a wire ligature occasionally tightened
by twisting or renewal, it being made to encircle two short
spurs or buttons soldered to the mesio-labial angles of ac-
curately fitting bands cemented upon the teeth to be moved,
Fig. 614. The bands should be in position before the oper-
ation is performed.
This same device is very satisfactory for retention, or
the bands may be removed and replaced by similar bands
joined by solder.
Although the contraction due to the cicatricial tissue is
considerable, yet when we remember the character and
structure of the peridental membrane and the immense
number of normal fibers acting to combat this tendency,
and that they are practically double in these cases, for two
teeth are involved, the necessity for support for a consider-
able length of time (a year and a half in some cases) should
occasion no surprise.
Double Resection of the Mandible.*—Several years ago the
author became convinced that no operation depending upon
tooth movement alone could establish proper relations of
the teeth or materially improve the facial lines in certain
cases of pronounced over-development of the mandible.
It seemed to him, however, that suðh cases might be suc-
cessfully treated by the removal of a section of bone from
each of its lateral halves, the segments brought into apposi-
tion and Securely held, the same as in treatment for double
* See Dental Cosmos, July and August, 1898, and April, 1903; also Inter-
national Dental Journal, October, 1898, February, May, and August, 1899.
OPERATIVE SURGERY. 573
FIG. 615.
FIG. 616.
ºl. -



574 MALOCCLUSION.
fracture of the mandible, and with even greater promise
of repair, although the operation was not contemplated
except as a remedy for the most aggravated conditions as
illustrated in Figs. 615 and 616. -
The removal of a single complete section of the mandible
had been reported in numerous operations for the relief of
ankylosis, tumors, gunshot wounds, etc., but a search of the
literature failed to reveal at that time any instance of the
removal of complete sections from each of the lateral
halves.
The author’s proposition was discussed with surgeons
and dentists. A few of the former believed it to be practi-
cable; the latter almost invariably predicted certain failure.
Since first proposed the operation has been performed
twice—once successfully at the Baptist Hospital in St.
Louis and although the method of fixation employed was
crude, the union was excellent and the result without injury
to the pulps of the teeth; and once in New Orleans, when
it nearly cost the patient his life, with total loss of the
mandible through necrosis. In the latter case, however,
failure was not surprising, as the sections were removed
at the angles instead of from the body of the jaw, and prac-
tically no support was given to the segments of bone, the
Barton bandage and wiring the bones being depended upon
for fixation, one crude wire ligature being employed on
each side. One of these wire ligatures became loosened
and dropped out on the third day following the operation,
and it was not replaced, the surgeon having become fright-
ened and abandoning the patient.
The plan which the author would suggest for securing
fixation, and one which reduces the operation to great sim-
plicity and accuracy, is as follows. As occlusion is the
governing principle in determining the extent of reduction
of the mandible, accurate models should be made of the
teeth of the patient from impressions most accurately
taken in plaster. These models should then be placed in
OPERATIVE SURGERY. 575
a metal articulator and sections corresponding in extent
and location to those it is desired to remove from the man-
FIG. 617.
dible should be removed from the plaster model. The
plaster mandible should be reduced until the best attainable
FIG. 6] S.
occlusion between the teeth of its segments and those of the
upper model have been gained, and the segments united


576 MALOCCLUSION.
with thinly mixed plaster of Paris applied into the spaces
from the lingual side with a fine camel's-hair brush.
Fig. 617 shows an exact duplicate of the model shown
in Fig. 618 which has been so treated. The further per-
fection of the occlusion should be gained by grinding, or
left for future orthodontic operations.
FIG. 619.
The lower model should then be duplicated in suitable
metal, and over this, with counter dies a metal plate should
be swaged, preferably of silver, as shown in Fig. 619. The
plate should be allowed to extend downward a short dis-
FIG. 620.
tance over the gum, but not impinge upon it. It should then
be removed and sawed through where the anterior cut of
the section is to be made, as indicated by the dotted lines
in Fig. 619. The ends of the segments should then be stiff-
ened with half-round wire, and small metal buttons soldered
to the plate near the stiffened ends as low down and as high


OPERATIVE SURGERY. 577
up as possible both buccally and lingually, as shown in Fig.
620. Numerous holes, suitably located, for the escape of
FIG. 621.
IFIG. 622.
the surplus cement should be made in various parts of the
plate, the patient’s teeth thoroughly cleansed, and all three


38
578 MALOCCLUSION.
segments carefully cemented upon the teeth, as shown in
Fig. 621. Then at any convenient time the sections may
be removed from the mandible, the ends of the plate offer-
ing excellent guides for the blade of the saw. After this
has been done the segments of bone should be brought into
correct apposition and firmly held by wire ligatures
wrapped about the metal buttons, as in Fig. 622.
This would give the firmest support to the segments and
offer the best opportunities for prompt and healthy union
of the bone.
A PPE N DIX.
THE following illustrations and their descriptions show
a few of the many possible ways in which the jack-screw,
traction screw, and levers, the description and history of
which has been previously given, may be employed in ef-
fecting tooth movement. These combinations are given a
separate place in this work in order to avoid confusion to
the reader when studying the methods of treatment now
regarded as more nearly in accord with the latest advance-
ment in the practice of orthodontia which have been pre-
viously considered. Yet some of these are still favorites
with the author for minor operations, several new com-
binations being here shown for the first time.
Jack-screw.—In employing the jack-screw for exerting
force upon the teeth to be moved the base of the sheath
may be secured in various ways, as shown in Fig. 623."
First, by means of a small dowel, made by soft-soldering
a piece of the wire G into the end of the sheath, which is
made to rest in a pit in the anchor tooth, as in A.
Second, by means of a spur made from the wire G sol-
dered to the anchor band, over which the end of the sheath
of the jack-screw may be slipped, as in B.
Third, also by means of a dowel made to engage a
tube R soldered to the anchor band, as in C. In this way
the length of the sheath may also be increased in the rare
instances where a longer sheath may be required.
Fourth, by pointing the end of the sheath with a file
and letting the point rest in a tube on the anchor band, as
in D.
* Fourth edition, 1894. Angle. 579
580 MALOCCLUSION.
Fifth, by soldering the sheath directly to the anchor
band, as in E and F. - -
Sixth, by notching the end of the sheath, and resting it
against a wire, as in G.
FIG. 623.
Seventh, by soldering the end of the sheath directly to
another sheath, as in H. *
Eighth, by means of a spur made from the wire G sol-
dered to the sheath and engaged with a tube R soldered to
the anchor band, as in I. -
Ninth, by slipping the end of the sheath over the screw
of an anchor band, as in J.



APPENDIX. : 581
Of these various ways of attaching the sheath, those
shown in B, E, F, and J, are preferable.
The point of the jack-screw is held firmly in position in
six principal ways, as shown in Fig. 624.”
First, by engaging a notch in its end with a similar notch
in the united ends of the band, as in A, the notches to be
made with a separating file.
Second, by pointing the end of the screw and engaging
it with small tubes R soldered to the band, as in B.
FIG. 624.
Third, by a mortise in the band to engage the point of
the screw, as in C. -
Fourth, by an elliptical ring soldered to the band, as
in D, and engaging the notched point of the screw.
Fifth, by means of a staple soldered to the band, as in
E, and engaging with it the notched point of the screw.
Sixth, by resting the screw, suitably pointed, in a pit
formed in the enamel, or in a filling, as in F.
Of these various ways those shown in D and E are pre-
ferred.
* Fourth edition, 1894. Angle.

582 MALOCCLUSION.
Fig. 625 shows the jack-screw effecting the labial move-
ment of the upper canine teeth, which are provided with
plain bands cemented upon their crowns.
FIG. 625.
To the mesio-
lingual angle of one is soldered a spur which engages the
base of the sheath of the jack-screw (as in B, Fig. 623),
while the notched point of the Screw engages a staple sol-
dered to the mesio-lingual angle of the other canine.
FIG. 626.
º
|\{\º
ſºilsº
ºll||ºš G
wº {". º: * I
§
º
|
º º
º
º
! ſ ! | |
: ſ | : º
º º |
?
-
º
M',\! º \\\\
| f º º º º º º N
By
tightening the nut the teeth are moved in opposite direc-
tions. The tubes R, in anticipation of reinforcing anchor-
age, are also shown, one upon the side of the sheath of
the screw, the other upon the lingual surface of a band
encircling the first premolar.
As the right canine will




































APPENDIX. 583
probably be moved into position first, its further progress
will be arrested, as well as its anchorage reinforced, by a
ligature inclosing the reinforcement tubes, drawn tight and
the ends twisted.
Tubes R soldered to the labial surfaces of the bands upon
the moving teeth are also shown. These are in anticipation
of retention by means of a section of the wire G to be
slipped through them, its ends to bear against the labial
Surfaces of the adjoining teeth.
Fig. 626* shows a combination in which the jack-screw
is made to exert force in moving labially an inlocked ca-
nine. The point of the screw engages a pit in the enamel,
the base of the sheath having been previously slipped over
a spur (B, Fig. 623) soldered to the mesio-lingual surface
of the anchor band No. 1 clamped upon the first premolar.
Reinforcement of the anchorage was gained by means of a
Section of the wire G, the ends of which were hooked into
tubes, one being soldered near the base of the jack-screw,
the other upon the mesio-lingual angle of a band encircling
the lateral incisor. Later experience has proved that an
easier and better way of attaching the reinforcement wire
is to omit the tube from the band, soldering the straight
end of the wire directly to the band. The other end of the
wire, before bending, is passed straight through the tube
in the direction of the base of the screw, then bent, and the
surplus wire cut off. The bending of the wire should be
the last part of the operation, or after the cementing of the
band upon the lateral and the complete adjustment of the
SCrew.
A modification of a similar combination of the jack-screw
is shown in Fig. 627, f in the labial movement of an inlocked
lateral, the point of the screw engaging a staple on the
lingual surface of a band on the malposed tooth. The base
* Third edition, 1892. Angle.
# Sixth edition, 1900. Angle.
584 MALOCCLUSION.
of the screw engages a spur on the anchor band. Reinforce-
ment of the anchorage was gained by a loop made from the
wire G which engaged a tube R soldered at right angles to
the sheath of the screw on its palatine surface. The ends of
the wire, bent in the form of hooks, engage wire ligatures
encircling canine and central incisor. This combination
is quickly and easily made, and the reinforcement through
Fig. 628.
the ligatures is quite as efficient as if bands were used,
which, besides requiring more time and trouble in adjust-
ing, would occupy valuable space. Of course such ligature
reinforcement would be useless with fibrous ligatures, as
slipping and stretching would render them inoperative.


APPENDIX. 585
Fig. 628" shows a combination of the jack-screw where
reciprocal anchorage was used to accomplish the lingual
movement of the lateral and labial movement of the canine,
the sheath of the jack-screw being cut short to allow it to
travel forward over the spur as the nut was turned, until
its base finally rested against the anchor band, when the
lateral was drawn into place and reinforced the anchor
tooth in resisting the moving canine.
The extra tube on the sheath of the jack-screw was in
anticipation of further reinforcement of anchorage, if it
\
|
|
|
:|
|
i-
s
|
|
|
5.H.A.
FIG. 629.
AJº º º,
/º/, * \\º
º
*W* º | º i tº-
should be found necessary, by hooking another piece of the
wire G into the tube after soldering the other end to a
band upon the first premolar. It was not found necessary
in this instance, but it is always well to anticipate the pos-
sible need of spurs, tubes, etc., in order to avoid the trouble
of removal and re-adjustment of appliances, the evil effects
of relinquishment of pressure, etc.
Fig. 629* represents a combination of two jack-screws
for moving labially out of inlock two central incisors (one
also being in torso-occlusion), the patient being a child
eight years of age. The incisors were encircled by plain
bands, the union of the bands being made at their disto-
* Fourth edition, 1894. Angle.














586 MA LOCCLUSION.
lingual angles and notched (as in A, Fig. 624) to hold a
straight section of the wire G against which rested the
notched points of the jack-screws. The bases of the sheaths
were slipped over the ends of the screws of the anchor
clamp bands (as in J, Fig. 623) and the force was exerted
by tightening the nuts of the jack-screws. Rotation of the
central was accomplished at the same time by Occasionally
tightening the wire ligature (A, Fig. 195) encircling the
tooth, its looped ends engaging the wire and union of the
band. Retention was effected principally by the occlusion
with the lower teeth, the bands, however, having been re-
moved and soldered at points of contact and recemented
in position.
In using the jack-screw it is always best to employ as
long a sheath as possible, turning the nut close up to the
chisel end, in order that there may be ample length of the
Screw to effect the necessary movement. -
Two sheaths are provided for the jack-screw, to afford
ample length for all cases. They should, of course, be
cut shorter if the case demand. The author has occasion-
ally found it necessary to use this screw and sheath com-
bined only one-fourth of an inch in length, as might be
found necessary in restoring to an upright position a molar
which had inclined into the space made vacant by the loss
of another tooth.
Other combinations in which the jack-screw plays an
important part will be described and illustrated under Mis-
cellaneous Combinations.
Traction Screw.-Although there are many possible com-
binations with the traction screw, in reality its uses should
be limited to two, or possibly three. Its most important
use is that of retraction of that most obstinate tooth, the
canine, as shown in Fig. 630." This it accomplishes so
easily and perfectly, when properly adjusted and managed,
* First edition, 1887. Angle.
APPENDIX. 587
that it easily takes rank, we believe, over all other appli-
ances for this purpose. We shall illustrate the use of this
appliance, singly or in combination with other appliances
somewhat later, and will here only describe its correct ad-
justment. -
The canine and anchor teeth are carefully banded after
the manner previously described for adjustment of the
plain and anchor clamp bands. The traction screw is then
held in position, and the short and long sheaths made to
FIG. 630.
touch the bands at the exact points they are to occupy when
Soldered. With a suitable instrument the anchor band is
Scratched parallel with the long tube to indicate its align-
ment, and the exact point of contact of the edge of the short
sheath with the band on the canine is located and indicated
by a suitable mark. Lest this be obliterated upon heating
the band may be perforated at this point with a small drill.
Having noted as accurately as possible the angle at which
this tube shall stand to properly line with the right angle
of the shaft, minute notches are made in the edge of the
band mesially and distally, to line with the end of the tube,
Fig. 631. The bands are now removed from the teeth and
the right angle of the screw from the short sheath,
and a minute piece of solder partially fused upon the edge
of the short sheath at the point intended for attachment to
the band. The sheath is then held with the solder-placing
pliers (Fig. 157) in the left hand, the band being held by
its untrimmed ends in the right hand, the end of the tube

588 MALOCCLUSION.
lining with the notches A and B, Fig. 631, and the solder
fused by contact with the flame at the proper point.
A little experience will enable the operator to make this
—the most difficult of all the attachments in this system—
easily and quickly, yet it is highly essential that the tubes
be attached at the right point and at the proper angle, or
the angle of the screw will not fit. Probably the beginner,
therefore, may better temporarily wax the tube in position
FIG. 631.
and invest and solder as he would in attachments to be
made in bridge- or crown-work.
Be it remembered that the tube attached to the canine
band must always stand at right angles to the long axis of
the tooth, that a free, hinge-like movement of the tooth
in retraction may be gained; not parallel with the long
axis, as persisted in by some, with resultant binding and
prevention of free movement.
The surplus ends of the bands are now trimmed off and
smoothed, and the band deoxidized and cemented in posi-
tion. While the cement is hardening the long sheath is
soldered, according to alignment, to the No. 2 band, using
plenty of solder, a piece one-fourth of an inch square and
of the usual sheet thickness. It is then cleansed and

APPENDIX. 589
slipped upon the screw and the nut adjusted, the angle is
hooked into the tube upon the canine band, and the clamp
band slipped over the crown of the molar and gently tight-
ened. It is allowed to remain a day or two before cement-
ing, in order that this operation, so important to
perform thoroughly, may be accomplished without interfer-
ence by pressure from the approximal teeth and so that
both the canine and the anchor tooth may move slightly and
become more perfectly adjusted to their relations with the
two bands.
The proper length of the screw having been determined,
the Superfluous portion is cut off behind the nut. Never
shorten the screw and then attempt to place the nut upon
it. Heat must in no instance come in contact with any por-
tion of the shaft of the screw.
Before finally cementing the band in position, it should
be removed, cleansed and dried. The crown of the molar
should also be thoroughly cleansed and dried, the final
cleansing being done with a pledget of cotton moistened
with alcohol or ether. The crown being properly protected
from moisture, cement is quickly mixed to the proper con-
sistence and the interior of the band nearly filled. The
angle of the traction screw is then inserted into the short
tube and the anchor band and cement carried down over
the crown of the molar with the thumb and finger, forcing
the cement well down about the crown. The band is quickly
worked into the desired position, and its nut tightened
until firmly clamped. The superfluous cement is then
wiped off and the patient dismissed until the next sitting
before tightening the nut of the traction screw, in order
that the cement shall become thoroughly set and the most
rigid attachment possible be gained.
If the operation so far has been carefully performed, the
nearest approach to stationary anchorage will have been
gained, so that the canine may be moved distally without
changing the relation of the occlusal planes of the anchor
590 MALOCCLUSION.
tooth with those of the opposite jaw. It is very important,
however, not to strain the attachment by overtightening
the nut of the traction screw at any time. One-half a revo-
lution of the nut each day, or just enough to exert a slight
snug feeling upon the canine is all the force necessary.
Very often patients may be provided with wrenches and
trusted to tighten the nut regularly each day themselves.
This movement, of all, however, should be conducted with
the greatest regularity, and unless the patient can
FIG. 632.
y : º || || ‘.
§ º . º Mºyº
§§ sº º § º # e. -
- ºft § ºl" | || . . ºčilº
tº "ºº" ſº
º º i º ill ºw º º
j." "" | wº \
"...m.,.\,\º
| im'º, ºn \
'', |" * 1: W.W \
| ſ. ...iſ |...}. W W º, | *
,' ' lſ \\ wº #
º º - \\ º
t º: "Any
ſ:
ºſt |'' ſ | Wºº &
'' | | | | | W
thoroughly comprehend and carry out instructions he
should not be depended upon.
It is nearly always best to operate the screw on the
outside of the arch, by placing the tube engaging the angle
of the screw in the region of the mesio-labial angle of the
tooth, or in the same manner as shown on the right in
Fig. 632.* -
It is very important that the angle of the screw be passed
into the tube its full length, otherwise it will be broken
when force is exerted.
If it is desired to rotate the canine as it is moved distally,
this may be accomplished by using a staple instead of a
* Third edition, 1892. Angle.










APPENDIX. 591
tube for engaging the angle of the traction screw, as shown
on the left of Fig. 632. In this instance the angle of the
screw is parallel with the long axis of the tooth, instead
of at right angles to it, as when the tube is used. In this
manner force is exerted on one side of the band only, and
rotation, as well as retraction, takes place.
In some instances it may be desirable to operate the
screw on the lingual side of the arch, as in Fig. 633. The
shifting of the canine lingually or labially in its distal
movement may be accomplished by bending the screw
FIG. 633. FIG. 634.
º)
º º ſ º
Fº
|{\ º | º : º
y
ſ º º |%
||||||||||}|\, \! || ||:.
|ºilº
|||| º
| Wº
º
>
W
where it enters the sheath, as in Fig. 634. As the nut is
tightened the screw is gradually straightened as it is drawn
into the sheath, thus arranging the teeth in proper align-
ment. - -
A method of reinforcing the anchorage is also shown in
this engraving, by enlisting the resistance of the lateral
incisor. The tooth is banded and provided with one of the
tubes R soldered at its disto-lingual angle, which engages
a straight section of the wire G, the other end resting in
another tube R soldered at an obtuse angle near the end
of the sheath. The fine adjustment of this wire may be.
effected by means of the regulating pliers.






















592 MALOCCLUSION.
Fig. 635* shows the use of a traction screw in effecting
rotation of a premolar, in combination with the clamp
bands Nos. 1 and 2. The angle of the screw engages a
staple made of the wire G soldered to the mesio-lingual
angle of the band encircling the premolar. By tightening
the nut at A traction force is exerted on one side only,
while resistance in the opposite direction is offered by the
intervening premolar.
FIG. 635. FIG. 636.
Tt is well known that rotation of these teeth by ordinary
methods is difficult. This method is very efficient and most
desirable in many such cases.
In Fig. 636f is shown another use of the traction screw,
in effecting the labial movement of a lateral and at the
same time providing space for its movement. A strip of
band material F is looped around the lateral, the ends rest-
ing on the labial surfaces of the adjoining teeth. To one
end is soldered vertically one of the short tubes D, while on
the other end is a similar tube attached horizontally. Into
these tubes the traction screw is placed, being bent to
conform to the proper curve of the arch, and as the nut
* Sixth edition, 1900. Angle.
# First edition, 1887. Angle.

APPENDIX. 593
is tightened the ends of the band material are pushed
farther apart.
Although efficient it is troublesome on account of its
liability to work loose and so requires frequent tightening.
It is now rarely used by the author except in the quick
readjustment of teeth that have partially relapsed toward
their original malpositions through accident during the
period of retention.
This device with a straight screw, as in Fig. 637, will be
found to be the most simple and efficient for moving into
occlusion a single badly lingually leaning premolar—a
tooth that would yield reluctantly to the ligatures and ex-
pansion arch.
IFIG. 637. FIG. 638.
Lever.-In the movement of rotation of a single lateral
incisor by means of the lever L, shown in Fig. 638,” the
plain band, with a tube on its mesio-labial angle, was
cemented upon the lateral. One end of the lever engaged
the tube; the other end was sprung around and made to
engage a hook on the buccal surface of an anchor band
on the second premolar, which was reinforced by a section
of the wire G passed through the tube R on its lingual
* Angle. Transactions Ninth International Medical Congress, 1887.

39
594 MALOCCLUSION.
surface, the ends of the reinforcement wire being made to
bear against the lingual surfaces of the first molar and
first premolar. -
Additional reinforcement may often be gained by lig-
atures made to encircle lever and teeth intervening between
the moving tooth and the main anchor tooth. The lever
should be occasionally removed and straightened to in-
tensify the force. The various sizes of the levers furnish
ample range for the needs of larger teeth, but as the force
exerted by the lever is so great the smallest sizes are
usually preferable. -
FIG. 639.
Fig. 639* shows a combination of the lever for rotating
a central and lateral incisor and moving labially the other
lateral incisor. The resistance end of the lever is passed
through a tube R soldered to the disto-labial angle of a
band on the right lateral. The power end, bent in the form
of a hook, is secured by a wire ligature engaging the nut
on the anchor band on the first molar. This is the author’s
favorite method of securing this end of the lever, as the
strongest anchorage and greatest control are thus secured.
Additional force is applied to the rotating lateral by
allowing the end of the lever to bear against the labial
*—
* Sixth edition, 1900. Angle.

APPENDIX. 595
surface of the canine, and it is further intensified by an
intervening wedge of rubber. At the same time the left
lateral is being moved from lingual occlusion and the
central rotated by means of wire ligatures, band, and spur,
as would be similarly employed if the expansion arch were
used instead of the lever.
FIG. 640.
sº" *::::::..
* - º º,
W]|}|| ||
§ . .", |*|W
|
ſ
, "'º
A. º º h
§ ſ º | º º) \ \º
ſº º A.
Fig. 640 shows a combination where two levers Were
used in rotating two upper canines, the ends of the levers
engaging tubes R soldered to bands upon the moving teeth.
The power ends of the levers engaged hooks soldered to an
anchor band upon the first molar, the anchorage being
reciprocal.
- FIG. 641.
tutiº - - • $ºsts, -
.it it?” TSN & 2, Nºrt,
N”“ss,
% N
%
& “
º C • * * ~ * º * ſº
,::::::::
Fig. 641* shows two central incisors being rotated in
opposite directions at the same time by means of the lever.
Upon the incisors have been cemented plain bands with
tubes R soldered at their disto-labial angles. One end of
* Archives of Dentistry, 1888. Angle.


























596 MALOCCLUSION.
a section of the smallest size of lever wire was inserted into
one tube and then into the other by springing and sliding,
as a door-bolt is slid into position.
Fig. 642 shows a view from the labial aspect of the ap-
pliance in position. The spring of the wire exerts pressure
lingually on the mesial angles, while the ends of the lever
operate in the opposite direction on the distal angles of the
teeth. As the teeth are turned it may be necessary to occa-
sionally remove the lever and straighten it in order to
maintain the pressure. Should one tooth be rotated suffi-
ciently before the movement of the other is complete, its
further movement should be arrested by a spur soldered
to the disto-lingual angle of its band and made to bear
against the lateral incisor. If the teeth show a tendency to
separate as they rotate this should be prevented by a wire
ligature which should inclose the ends of the lever on the
labial surface and drawn tight.
Although this is a simple and efficient method of per-
forming double rotation of the incisors, it must be remem-
bered that in most instances these positions of the teeth
are only a symptom, or the result of lateral pressure from
narrowing of the arch, which must first be widened to pro-
vide room for their occupancy. In such cases the expan-
sion arch is better Suited for accomplishing the movement
of double rotation of the incisors while widening the arch
at the same time, yet where there is sufficient room for the
incisors it would be difficult to find a more ideal method
than the use of the lever, as above described. This would
be peculiarly true in cases where the teeth, after regulating
by enlargement of the arch, have, from neglect or en-

APPENDIX. 597
forced absence of patients, partially relapsed into their
former malpositions during the period of retention.
Fig. 643 shows a modification of this principle. The
central incisors are banded and spurs of the wire G., pre-
viously soldered to their disto-lingual angles, are made to
bear against the lateral incisors. Ligatures engage these
FIG. 643.
spurs, passing between the teeth and being firmly twisted
to the ends of the lever, binding it down closely in contact
with the surfaces of the teeth, the spring of the lever giving
labial movement to the lateral incisors and torsal move-
ment to the centrals. The device, being so simple and
easily and quickly applied, is a favorite with the author,
being often used, either in this form or in some of its many
possible modifications for the readjustment of incisors that
have partially relapsed from their corrected positions.
FIG. 644.
When opposite movements of incisors in double rotation
shall be found necessary it may be accomplished by means
of the lever L, made to rest in notches in a section of the
wire G soldered to the disto-labial angles of the bands,
while a wire ligature encircling spurs soldered to the mesio-
lingual angles passes between the teeth to inclose the center


598 MALOCCLUSION.
of the lever, as in Fig. 644.” The ligature should occa-
sionally be tightened by twisting. After the teeth have
been sufficiently rotated temporary retention may be ef-
fected by means of a ligature inclosing the spurs only.
Miscellaneous Combination.—Fig. 645; represents one of the
author’s early combinations of appliances for rotating
central incisors and widening the dental arch, the rotation
of the incisors to be accomplished through reciprocal force
by means of a short section of piano wire, as in Fig. 641,
with force exerted against the lateral halves of the arch by
FIG. 645.
...tº:::::::::::: *Sºº:::::::::
€: 1:...“…: § | S. “ss:::::y
§Ø j Nº ge
ºWººl; ºff.
\ §j. |
/W sº y!!Nº. ſº
means of the spring from another section of piano wire.
The ends of this section of wire were bent sharply at right
angles and engaged in tubes R which were soldered at right
angles to other tubes R slipped onto sections of the wire
}, the latter being held in place against the lingual surfaces
of the canines and premolars and made secure by resting
in tubes R attached to clamp bands on the molars and plain
bands on the canines. A ligature engages both sections of
the piano wire which serves, through its reciprocal force,
to assist the rotation of the centrals and hold in correct
position the anterior part of the vault spring. !
* Sixth edition, 1900. Angle.
# Third edition, 1892. Angle.



APPENDIX. 599
This device was formerly in high favor with the author
and has many imitations, but since the perfection of the
expansion arch and the introduction of wire ligatures it
has been entirely superseded in the author’s practice.
Fig. 646* shows a combination for widening and length-
ening the arch. The notched ends of the jack-screws en-
gage a section of one of the levers L held in position by
notches formed in the united ends of bands upon the lateral
FIG. 646.
incisors. The sheaths of the screws were secured to anchor
clamp bands No. 2 upon the first molars, as in F, Fig. 623.
The incisors were moved forward by turning the nuts of
the jack-screws, while the arch was widened by the spring
of the lever L, the ends bent sharply at right angles and
made to engage delicate holes bored in the sides of the
Sheaths of the jack-screws, all as clearly shown in the en-
graving.
A modification of this plan is to exert pressure laterally
by means of a third jack-screw in place of the spring, this
screw being notched at each end and made to rest in con-
tact with the other screws, anterior to their nuts.
Another combination is shown in Fig. 647, † in which the
torso-labial movement of the laterals was effected by means
of two jack-screws and two levers. The points of the jack-
* Fourth edition, 1894. Angle.
† Third edition, 1892. Angle.

600 - MALOCCLUSION.
screws engaged mortises in bands on the disto-lingual
angles of the laterals, their bases resting over spurred
bands on the anchor teeth. As the teeth were moved la-
bially by tightening the nuts of the screws, they were also
FIG.
rotated by the two levers L which were crossed in front.
The resistance ends of the levers were inserted in tubes
soldered to the labial portions of the bands. One of the
power ends was secured by being latched into a hook sol-
dered to the buccal surface of one of the anchor bands, the
other being bent sharply at right angles and engaging
FIG. 648.
º § \\ -- º, -
* w Wi º . % ſ * \
º - z º.º. 2 Aº
| \"
º
| | |
W
º
ſ
|
| º
ºffº | l
º º º º
º
º
º º º
º
§ſiº |
º
|| ". º º
ſº º
#/. º d
º W W
ºr
º
% ſº W
ſºft||||}|, #||
| | : -
*: § | | | | |W Wi
º º
% º
a tube soldered at right angles to the tube on the band on
the opposite lateral, thus exerting a certain amount of
reciprocal force. . .
Another combination for effecting the lengthening of the
arch by moving forward all of the incisors by means of two
|
l W
\
| -
::::::::


































APPENDIX. 601
jack-screws, the points of which engage staples soldered to
the disto-lingual angles of bands on the lateral incisors,
is shown in Fig. 648.* The necessary rotation of the in-
cisors was accomplished at the same time by means of a
section of one of the levers L, sprung into tubes upon the
disto-labial angles of the bands upon the laterals. The
central incisors were laced to the lever by means of floss-
silk ligatures. As the nuts of the jack-screws were tight-
ened all of the incisors were carried forward. At the
same time they were rotated by the elasticity of the lever.
Fº
º
º º
º,
:=º:E:
===
:-->
".
Fig. 649; shows a very important combination of the
traction screw and expansion arch for shortening one of
the lateral halves of the arch and at the same time correct-
ing malpositions of the teeth.
The traction screw should be first adjusted as already
described, and as shown in Fig. 630. In addition it should
be provided with one of the tubes D soldered to the side of
the sheath Y near its mesial end. This is for the reception
and support of one end of the expansion arch in place of the
usual D or X band. The nut of the expansion arch is to
bear against this tube, and when so used should be re-
versed, the friction sleeve being turned mesially. The
|
*-
-
ºº w* --
;
s
--:
Sºº
1 --
2.º
~~*
.>
.3
*
H. A * |||||||
|
* Third edition, 1892. Angle.
t Sixth edition, 1900. Angle. Also Dental Cosmos, September, 1899.


























602 MALOCCLUSION.
other end of the expansion arch is supported in the usual
way, as in Fig. 199. As the canine is retracted into the
space made vacant by the loss of the first premolar the
malposed incisors are rotated by means of the ligatures,
bands, and spurs, as is well shown in this engraving, and
also in Fig. 199.
FIG. 650.
à
º%
: ".% .%
º
º 2\º
Wº:
g
! §\º
sº º §sº
j E. º
|
:
ºWº§
Gi
|;
tººs-ºº
i--w
:s
§
: | A.M. \\
| º º
º
º
*
\
{:}; |
ſº
à
& ºt
|#
#||
#;
ğg §
§:
łºt |
|É
The general position of the incisors is controlled by
tightening or loosening the nuts of the expansion arch, as
in Fig. 649, in accomplishing the movements of the incisors.
A similar combination may be used on the opposite side
of the arch when it is desirable to shorten both of the lat-
eral halves.
Similar combinations of the traction screw with the B
arch may be used, as in Fig. 650. For the support of the
front of the arch it may be allowed to rest in notches
formed in the united ends of the bands on the incisors, as
in C, Fig. 651,” or in notches filed in pieces of the wire G
(B, Fig. 651) soldered across the labial surfaces of the
bands, as shown in Fig. 652, or against short spurs of the
* Sixth edition, 1900. Angle.

























APPENDIX. 603
wire G soldered to the labial surface of the band near its
upper edge and at right angles to the long axis of the
tooth, as in A, Fig. 651. The latter is the author's favorite
method, as it presents a neater appearance and effectually
FIG. 651.
prevents the arch from sliding against the gum—the only
direction, in reality toward which it tends. The illustra-
tion, Fig. 650, shows a combination of the traction screws
used as auxiliaries to the headgear, traction bar, and B
FIG. 652.
arch in order to more speedily effect the retraction of the
incisors and canines in a typical case belonging to the first
division of the second class. The usual extreme care is
necessary in applying the traction screws according to
directions already given for their proper adjustment.


604 MALOCCLUSION.
In the engraving one screw is shown as being operated
on the lingual side of the arch. It is more effective when
used on the outside, as correctly shown on the left. The
spring arch B is adjusted in the usual way, except that the
ends of the arch are supported by telescoping short tubes
soldered to the sheaths of the traction screws.
Formerly, when extraction in these cases was deemed
necessary, this combination was a favorite with the author,
especially in cases after maturity of the patient. By its
use retraction of the canines could be effected in about
one-half the time necessary by any other known method.
The surgical removal of bone anterior to the moving teeth,
as elsewhere described, still further expedited this move-
ment. .
FIG. 653.
|
º
Fig. 653 shows another combination for shortening and
widening the arch by means of the headgear and arch B,
as already described, the canines being moved laterally by
a section of wire G lengthened by pinching with the regu-
lating pliers, as elsewhere described. *
Sections of bone lingual to the central incisors have been
surgically removed to expedite their lingual movement.







APPENDIX. 605
Fig. 654” shows a combination for retraction of the ca-
nine and labial movement of the lateral incisors. While
the traction screw was accomplishing the distal movement
of the canine it was assisted by the loop and traction screw
FIG. 654.
2. sº | | S. ". §
gº r *N iſ - | º, ºw. º º
#, ºf jºº |
h | º '', Sº, º
º Nºxº
Ž
- º º ſ
º/ | |, ||
|||ſin, "|| || “...lº ſº.
|, f | º
ſ/ º i. , ſ º # | | i. º . F. -- i º
ſ
". *|| ".
iſºlº", -
º | º l"tº i:
ºº,
|
:
º
§
|
|
|
device, as in Fig. 636, operating upon the incisor, while the
other incisor was being moved labially by means of a jack-
Screw, the base of which rested over a spur soldered to the
sheath of the traction screw operating upon the canine.
FIG. 655. FIG. 656.
Figs. 655, 656,ºf and 657, f show simple and convenient
methods of moving single teeth that are lingually or la-
* Third edition, 1892. Angle.
f Fourth edition, 1894. Angle.























606 MALOCCLUSION.
bially displaced. . In Fig. 655 anchorage is gained for the
wire ligature by slipping the short sheath of one of the
jack-screws over the end of the screw of the No. 2 band
upon the first molar. -
In Fig. 656 the screw of the clamp band was lengthened
by soldering to its end an additional piece of metal.
In Fig. 657 a piece of the wire G, or a section of the lever
L, was bent sharply at right angles and made to engage
a tube R soldered to a clamp band No. 2 upon the first
molar.
Fig. 658 shows a method of making a long clamp band
which is sometimes useful in closing spaces between teeth.
FIG. 658.
º
To the ends of a section of band material of suitable
length are soldered tubes D, one horizontally and one per-
pendicularly, which engage the angle and screw ends of
the traction screw. By tightening the nut the size of the
band is diminished and force exerted.
FIG. 659. FIG. 660.
ºr *tº:
Figs. 659° and 660° show efficient devices for widening
the arch in the region of the premolars. Force is exerted
by a lever L of suitable length, its ends being secured by
* Fourth edition, 1894. Angle.


APE*ENDIX. 607
tubes R which have been soldered at right angles to sec-
tions of wire G soldered to the lingual surfaces of the
anchor bands, as in Fig. 659, or in a closed-end tube at-
tached directly to the anchor band, as in the left of Fig.
660, or the tube may be soldered to a side of the nut of the
clamp band, as on the right. This form of device is often
useful in widening the dental arches of children to release
lateral pressure upon the centrals, to be followed by a deli-
cate vulcanite plate covering the vault of the arch, for re.
tention, as in Fig. 252.
Fig. 661 shows a simple and efficient way of making the
attachments of the lever directly to the screw ends of the
FIG. 661.
anchor bands by first bending the ends of the lever in the
form of a hook, then bending the hook at right angles to
the lever. It was suggested by Dr. Edmonds. This in-
genious attachment would also be found efficient in adjust-
ing the reinforcement wire, as in Figs. 215 and 404.
Another combination of appliances for effecting double
rotation of the central incisors is shown in Fig. 662.” It
consists of bands having spurs or tubes soldered at their
mesio-labial angles to engage a tightly drawn and twisted
* Sixth edition, 1900. Angle.

608 MALOCCLUSION.
wire ligature. Between the bands is stretched a strip of
rubber. By the occasional renewal of the ligature a power-
ful force is exerted that will turn the teeth readily. Tem-
porary retention is effected by the application of a fresh
wire ligature and dispensing with the rubber.
Fig. 663 shows the application of this same principle in
the rotation of two lower premolars, which may often be
made use of alone, or it may be used as an auxiliary in
assisting the ligatures which have been employed in the
usual way for rotating these teeth in connection with the
FIG. 663. - FIG. 664.
expansion arch; or, it may be employed independently Of
the expansion arch, though used at the same time.
Still another modification is shown in Fig. 664, where
two premolars require rotation in the same direction. The
teeth are fitted with plain bands. Short spurs project from
the buccal surfaces of these bands and a strand of the Wire
ligature is looped over the spur on the second premolar,
both ends being carried between molar and premolar, then
carried back between the premolars to engage a strip of
rubber. One strand of the ligature is then made to engage
the spur on the first premolar, drawn and twisted firmly
with the other strand just posterior to another strip of the
rubber which is made to bear against the buccal surface of
the first premolar. This produces a constant and powerful

APPENDIX. 609
force for the rotation of these teeth. It also is a favorite
device with the author and may be used with success with-
out the rubber wedges. :
Fig. 665* represents a very meat and convenient method
of forcing the eruption of a canine which had become
FIG. 665.
impacted by the too long retention of the deciduous canine.
The first upper premolar was encircled by a No. 1 band;
to its labial surface, parallel with the long axis of the tooth,
FIG. 666.
was soldered a tube R which engaged a section of the wire
G bent sharply at right angles, the other end being flattened
* Dental cosmos, 1891. Angle.


40
610 MALOCCLUSION.
and bent to engage the occlusal edge of the lateral. A short
section of a common pin was set in the enamel of the im-
pacted tooth. One had also been soldered to the anchor
wire. A ligature was then made to connect both pins, which
exerted constant pressure.
While this simple and delicate device is perhaps the
nearest to the ideal for simple cases, where the forcing of
the eruption of a tooth not greatly deflected from its
normal incline is desired, yet in such pronounced cases of
deflection, as indicated by Fig. 665, in which the tooth is
thoroughly imbedded in a strong encasement of bone, the
anchorage is not sufficient to overcome the resistance, and
the expansion arch, as in Fig. 666, is better, and in some
cases even the combining of all the anchorage attainable
in this manner, with that gained from intermaxillary an-
chorage, as in Figs. 186 and 187, is necessary, as we have
found in a number of cases.
APPENDIX. 611
FINAL SUGGESTIONS.
I. As normal occlusion of the teeth is the basis not only
of all orthodontic operations, but of all other dental oper-
ations, it is one of the prime wishes of the author in writing
this book to awaken a keener interest in and closer study
of occlusion, not only by orthodontists, but by dentists,
rhinologists, and all students interested in the artistic
proportions of the human face.
Failure to appreciate the requirements of art in the
practice of orthodontia is as readily recognizable as its
effect is lasting. All who hope to attain true success in
practice should cultivate studious observation of normal
and abnormal facial lines in their relations to, and depend-
ence upon, occlusion.
II. In studying a case of malocclusion give no thought
to methods of treatment or appliances until the case
shall have been classified and all peculiarities and varia-
tions from the normal in type, occlusion, and facial lines
have been thoroughly comprehended. Then the require-
ments and proper plan of treatment become apparent.
III. In moving a tooth the best result is obtainable by
applying only that degree of force necessary to bring about
physiological changes in the tissues. The practice of
applying great force at irregular intervals serves only to
defeat the desired object, for it induces pathological in-
stead of physiological changes in the tissues, exciting in-
flammation, and causing unnecessary pain. In no instance
should the pressure be greater than to cause a snug feeling,
which is perhaps the best indication of the proper degree of
force.
612 MALOCCLUSION.
IV. The wise and skilful orthodontist may and will avoid
causing pain, as well as unnecessarily prolonging ortho-
dontic operations, and in so doing will contribute much
toward overcoming in the mind of the laity the great prej-
udice against those operations that has been caused
thereby in the past. -
V. The normal denture, so beautiful in part and in
whole, and contributing so greatly to the beauty, happi-
ness, health, and longevity of the possessor, must, as it is
studied and comprehended, impress all thoughtful persons
with the great importance of and wonderful future for the
Specialty of Orthodontia. Yet to expect all to succeed in the
practice of Orthodontia would be as unreasonable as to ex-
pect all students of the violin to become artists in its use.
Only those who have an aptitude and fondness for the work
and who will study the subject broadly, deeply, and
thoroughly in all its relations should attempt its specializa-
tion. Any incompetent, Superficial temporizing in its prac-
tice must inevitably react, and ofttimes with telling effect,
on the operator. -
VI. Success in orthodontic operations does not consist
in simply placing the teeth in normal relations, as this is
only a stage in treatment, but in the final, the ultimate
results, gaged by the functions of mastication, speech, and
respiration, as well as by the beauty and balance of the
face.
VII. We are just beginning to realize how common and
varied are vicious habits of the lips and tongue, how power-
ful and persistent they are in causing and maintaining
malocclusion, how difficult they are to overcome, and how
hopeless is success in treatment unless they are overcome.
VIII. The period of the retention of the teeth, after they
have been moved into normal occlusion, is one of the most
important in treatment, and so complicated and persistent
are the delicate forces that tend to derangement of the
established occlusion as to necessitate the most thoughtful
APPENDIX. 613
consideration of the problems involved, and a degree of
skill in overcoming them which much experience alone can
develop, even among those with talent for the work.
IX. This book is intended for careful study and analysis,
preface and all. Its thoughts are necessarily so inter-
woven that no man can comprehend it or profit much by
reading only parts of it, or the whole superficially. To
its readers we commend the advice of Sir Andrew Clark to
readers of any book deemed worthy of attention, to “read
it at least three times; first, to see what it is all about;
secondly, to see what it says; and thirdly, in an attitude of
friendly hostility.”
IN DE X.
A.
ADENOIDS, 115, 309, 450
Adhesive plaster, 496
Age, correct for treatment, 30, 309, 310,
313, 440, 452, .519
Alveolar process, absorption of, 132, 133
arrest in development of, 145, 312,
340, 342, 348, 351, 376, 377, 384,
386, 393, 415, 419, 449, 542, 544
bending of, 132, 417
changes in, incident to tooth move-
ment, 132, 315, 393, 430, 469
changes in, subsequent to tooth move-
ment, 140-143, 319, 336, 343, 344,
350, 355, 364, 546 w
development of, 30, 312, 375, 377, 380,
388, 389, 392, 393, 398, 401, 429,
524, 526, 548
disintegration of, 430
general consideration of, 118-132
modified growth of, 431
section of, 567
Anchorage, change made in, 361, 440
Baker form of, 193, 232, 235, 254, 257,
262, 356, 505, 512, 553
defective, 228
devices for reinforcing, 582, 583, 584,
585, 591, 593
devices for securing, 224, 225
for buccal movement of teeth, 420
for retention, 266, 432
intermaxillary, 194, 202, 224, 233, 256,
260, 356, 408, 428, 432, 455, 456,
479, 488, 507, 516, 530, 557, 561,
610
manipulation of, 466
occipital, 172, 189, 191, 194, 202, 224,
234, 235, 266, 499
reciprocal, 224, 229, 247, 256, 266, 582,
;
585 -
reinforced, 226, 230, 427, 583, 584,
585, 591
simple, 224, 225, 226, 247, 440
simple-intermaxillary, 460, 517, 520
simple-reciprocal, 362
stationary, 224, 227, 229, 247, 256,
258, 440, 507, 589
stationary-intermaxillary, 460, 512
sources of, 224
Appliances. (See Regulating Appliances)
Art. (See Facial Art)
Artificial luxation, 566
Artificial substitutes for teeth, 96, 168,
265, 307, 308, 437, 439, 482
B
BAKER anchorage. (See Anchorage)
Banding, canines, 217, 302, 428, 479,
587, 588
crowded teeth, 238, 240
sore teeth, 267
Band driver, 208, 240
Band material, author’s C, 202, 203,
329, 334, 428
F, 189, 202, 203, 329
H, 189, 202, 203, 462
Bands, anchor clamp, adjustment Of,
236-240, 245, 252, 587 -
adjustment of for stationary anchor-
age, 227, 256, 587, 591, 592
attachments to, 226, 227
author's improvements of, 198
cemented, 227, 289
description of author’s, 202
early history of, 169, 170, 171
for intermaxillary movements of teeth,
257-259, 455, 457, 460, 461, 471,
479, 519, 520, 528, 534, 546, 558
for intermaxillary retention, 299-303,
381-382, 473, 476, 510, 512, 539,
549, 561 • -
general uses of, 193, 246, 329, 361,
427, 582, 583, 585, 598, 599, 609
long, 228, 606
resoldering sheaths of, 239, 439, 456
Value of, 178
Bands, plain, adjustment of, 240, 245,
572, 587
and planes for intermaxillary reten-
tion, 302-304, 510, 553
and spurs for retention. (See Reten-
tion)
and Spurs for rotation, 245, 254, 361,
420, 519, 595-597, 600, 607
attachments, 211, 212, 219–221, 230
author’s method of making, 215-219,
220, 221
deoxidizing, 221, 588
615
616 INDEX.
Bands plain, early history of, 169, 170
erroneous methods of making, 213, 216
first cemented, 170, 171
for canines, 217, 260, 302, 428, 479,
598 - -
for intermaxillary movement of teeth,
260
for retention, 267, 268
for treatment, 329, 335, 361, 370, 398,
426, 572, 583, 585
importance of perfect, 240
injuries to teeth from wearing, 267,
281, 282 -
inspection of retaining, 280
Magill’s, 171, 215
materials for making, 170, 171, 179,
181, 214, 216
notched, 190, 221, 602, 603
to prevent slipping of ligatures, 249,
325, 353, 428
united for retention, 279, 280, 364, 586
value of, 187
Bite, end-to-end, 32
improved, 528
jumping the, 499
necessity for lengthening, 491
open, 386, 389, 423, 431-433
plate for shortening, 491, 530
proper length of, 546
shortened, 445, 491, 527, 530, 534
Bridging as related to orthodontia, 437,
441, 445, 482
Blowpipe, 208, 210, 217, 222
Bone, arrest in development of intermax-
illary, 114, 354, 384, 386, 390,
391, 476, 477
bending of, 132, 133, 417 -
changes in incident to tooth move-
ment, 133
deformities of, 550
growth of, 389, 398, 432, 442, 546
redeposited, 132, 312, 388 -
surgical removal of, 566, 567, 604
Brass wire ligatures. (See Ligatures)
C
CANINE teeth, abnormal inclination of,
383
as anchor teeth, 401
banding, 217, 302, 428, 479, 587, 588
buccal movement of, 137, 330, 476–478
device for intermaxillary movement of,
260, 479, 481
distal locking of lower, 49, 542
distal movement of, 132, 383, 534
displacement of, 400
Canine teeth, elevation of, 231, 245, 351,
429, 609, 610
extraction of. (See Loss of Teeth)
extreme distal position of lower, 485
imbedded, 161
impaction of, 36, 98
importance of correcting malpositions
of, 361
infra-occlusion of, 423, 427
intermaxillary retention of, 301, 302,
462, 476, 521
keystone of the arch, 361, 408
labial movement of, 226, 355, 362, 488,
534, 582, 583
lateral movement of, 355
lingual movement of, 258, 351, 370
most common malposition of, 361
non-development of, 161
occlusion of, 10
over-prominence of, 37, 404
premature loss of deciduous. (See De-
ciduous Teeth)
providing space for, 336, 354, 362,
375, 376, 387, 408, 435
readjustment of, 277, 479
reciprocal movement of, 230, 320
reduction of prominence of, 522
result of mal-eruption of, 360
retention of, 275-279, 282, 284, 285,
295, 341, 355, 362, 364, 370, 376,
408, 417, 418, 432, 549
retraction of, 227, 229, 260, 383, 471,
512, 587-591, 603, 605
rotation of, 351, 354, 362, 370, '590,
591, 595
simultaneous movement of first pre-
molar and, 488
Causes of malocclusion, abnormal frenum
labium, 103, 104
cleft palate, 32
degeneracy, 552, 553
disuse, 102
enlarged tongue, 33
enlarged tonsils, 550, 555, 557
extraction. (See Loss of Teeth)
habits, 32, 33, 104-111
heredity, 398, 552, 553
imperfect fillings, crowns, etc., 97,
445, 496
mechanical, 89
nasal obstructions. (See also Mouth-
breathing), 46, 111-117, 448, 450
non-development of teeth. (See Loss
of Teeth) - ... •
prolonged retention of deciduous teeth,
98
Supernumerary teeth, 99
tardy eruption of permanent teeth, 98
INDEX.
617
Causes of transposed teeth, 100
Cemented bands, (See Bands, clamp and
plain) -
Chin, heavy, 86
lack of development of, 74
normally developed, 64, 72, 76, 84
receding, 81, 83, 47.2
relation of to the rest of the face,
505
type of, 83, 84
weak, 85
Chin retractor, 194
Classification of malocclusion, 35, 55, 57
. Class I, beginnings of, 29, 98, 320, 323,
398
dissimilar cases of, 37, 40, 42, 43
distinguishing characteristics of, 36,
319, 325, 340, 351, 359, 403
general consideration of, 31, 36, 75–78,
319, 325, 328, 332, 335-336, 340,
342, 343, 351, 360, 367, 373, 384,
390, 393, 402, 414, 423, 431, 434
intermaxillary retention in, 382
malocclusion chiefly on one side, 404,
419
marring of facial lines in.
Lines)
mouth-breathing in, 117
protrusion of incisors in, 106
result of extraction in treatment of
cases in, 383, 390
retention of cases in, 331, 334,
: 341, 344, 355, 364, 370, 373,
382, 391, 400, 402, 411, 417,
427, 432
retention of mutilated cases in,
441, 445
treatment of cases in, 320, 322,
328, 334, 335, 336, 340, 351,
361, 367, 375, 383, 387, 388,
404, 407, 412, 415, 419, 426,
431, 445
treatment of mutilated cases in,
436, 439, 445
use of intermaxillary anchorage in,
408 .
Class II, advantages of early treatment
in, 312, 313 -
beginnings of, 116 *
developing cases of, 55, 92
use of Baker anchorage in, 232, 257
use of occipital anchorage in, 234, 235
Class II, Division 1, beginnings of, 116,
449, 459
cases in, complicated by extraction,
481, 484, 488
distinguishing characteristics of, 44,
448, 473, 491
(See Facial
337,
375,
420,
435,
325,
356,
398,
428,
435,
Class II, Division 1, general considera-
tion of, 32, 44, 81, 448, 451, 454,
458, 476, 479, 483, 488, 491
habits accompanying, 108, 109
“jumping the bite” in, 499, 501
marring of facial lines in. (See Facial
Lines)
old plan of treatment of, 499, 603, 604
“protrusion cases,” 57, 189
results following reduction of protrud-
ing incisors, 137
retention of cases of, 456, 462, 473,
500, 501
similarity between cases of, 35, 450
treatment of cases of, 451, 452, 455,
459, 469, 471, 473, 481, 488, 491
use of Stationary-interinaxillary an-
chorage in, 460
use of simple-intermaxillary anchor-
age in, 460
Class II, Division 1, Subdivision, distin-
guishing characteristics of, 49,
505
general consideration of, 49, 50, 505,
507, 510
habits accompanying, 108, 109
intermaxillary retention in, 298, 303
marring of facial lines in. (See Fa-
cial Lines) -
old plan of treatment of, 512
retention of cases of, 510, 512
treatment of cases of, 505, 507, 512
Class II, Division 2, beginnings of, 116,
117, 516
distinguishing characteristics of, 50,
514
general consideration of, 51, 84, 517,
521, 526
marring of facial lines in.
cial Lines) -
old plan of treatment of, 516
retention of cases of, 521, 524
treatment of cases of, 516, 517, 518,
519, 522, 528
Class II, Division 2, Subdivision, begin-
nings of, 117
(See Fa-
distinguishing characteristics of, 51,
531, 539
general consideration of, 85, 532, 535,
539, 542
marring of facial lines in.
cial Lines)
retention of cases of, 534, 539, 546,
549
treatment of cases of, 534, 536, 540,
544, 546
Class III, Division, advantages of early
treatment in, 312, 313
(See Fa-
618
INDEX.
Class III, Division, appliances for reduc-
tion of cases of, 194, 258
association of cases of with enlarged
tonsils, 550, 553, 555, 556
author’s operation for reduction of,
563, 572, 578
beginnings of, 550
developing cases of, 55, 550
distinguishing characteristics of, 52,
550, 555
general consideration of, 52, 53, 86,
550, 555, 561, 562 - --
marring of facial lines in. (See Fa-
cial Lines)
retention of cases of, 551, 553, 561
treatment of cases of, 553, 555, 557
use of Baker anchorage in, 232, 235,
258, 557, 561
use of intermaxillary retention in, 303
use of occipital anchorage in, 234,
235
Class III, Subdivision, distinguishing
characteristics of, 54
general consideration of, 565
Cribs, 225
ID
DECIDUOUS teeth, buccal occlusion of
lower, 40 -
distal occlusion of lower, 309, 311,
452, 453
disuse of, 103
effects of extraction of. (See Loss of
Teeth)
functions of, 90
grinding of, 421
importance of, 17, 92, 93
importance of maintaining space of,
482, 488
intermaxillary retention of, 510, 553
malocclusion of, 89, 90, 311, 452, 550,
553
mechanical influence of, 92, 93
mesial occlusion of lower, 553
movement of by lengthening wire, 320-
323 -
movement of molars, 91, 420
normal development of, 89
pitted for spurs, 226, 320
premature loss of, 92, 375, 384, 404
434, 484, 488
prolonged retention of, 98
protruding incisors, 501
retention of, 93
shortening cusps of, 421
treatment or, 320, 322, 323
unnecessary movement of, 421
Deciduous teeth, used as anchor teeth,
226, 323, 507, 534, 553
Wearing of, 116, 454
Dental apparatus, abnormal development
of, 88, 311
Component parts of, 89
development of after correction of
malocclusion, 140, 307
disturbance in development of, 81, 111,
114, 115, 305, 306
effect on of lingual locking of molars,
414
evil effects of extraction upon, 94, 96
malocclusion chiefly on one side in
Class I, 404 -
normal development of, 8, 12, 73, 88,
91, 305, 454
normal growth of, 457, 555
types of, 14, 15 ;
Dental arches, abnormal development of,
91, 92
advantages of enlargement of, 367
asymmetrical development of, 91, 93,
320, 435, 539
changes in sizes and relations of,
441 w
constriction of upper, 384
devices for contraction of, 416
diminished in size, 29, 75, 335, 351,
386, 404, 431, 436, 542
distal occlusion of both lateral halves
of lower, 80, 448
distal occlusion of one lateral half
of lower, 84 -
effect on of force wrongly distributed,
32, 33, 35, 413
effect on of lingual locking of upper
first permanent molars, 413, 415,
419
enlargement of, 335, 340, 375, 407,
432, 491, 545
expanding and shortening lateral
halves of upper, 251, 401, 459,
478
expansion of upper, 21, 245, 247, 334
forces maintaining normal width of,
413
harmonious as to size, 335
harmonizing sizes of through extrac-
tion, 419, 512, 516
harmony of sizes of dependent on full
complement of teeth, 63, 406
influence of lower on upper, 29, 31,
338, 361, 413
interdependence of, 26-28, 361
lengthening of lateral halves of, 247,
254, 404, 435, 436, 488, 600
mutual support of, 25, 27, 335
INDEX. 619
Dental arches, narrowed and lengthened
upper, 47, 81, 108, 401, 448, 449,
,459
narrowed in region of canines and
premolars, 459, 476
narrowing, 247, 416
normal development of, 26, 88, 91
normal form and relations of, 9, 63
relations of in Class I, 36, 37, 319,
328, 335, 336, 367
relations of in Class II, Division. 1,
46, 448, 459
relations of in Class II, Division 1,
Subdivision, 49, 84, 505
relations of in Class II, Division 2,
50, 514
relations of in Class II, Division 2,
Subdivision, 51, 531
relations of in Class III, Division,
52, 86, 550
relations of in Class III, Subdivision,
54, 565 $
retention of, 290, 341, 417, 420, 445
shortened by extraction, 92, 434, 481,
484
shortened, due to malocclusion, 496,
542
shortening of, 247, 250, 459
shortening of after extraction, 383,
602
widening of, 341, 351, 388, 415, 519,
534, 545, 546, 606
widening of, in region of deciduous
teeth, 330
widening of, in region of premolars
and canines, 251, 341, 534, 545
widening one lateral half of, 247, 420
Dental ligament, 132 .
Denture. (See Dental Apparatus) &
Diagnosis, 20, 35, 43, 54, 56, 75, 359,
402, 472
E.
ETIOLOGY of malocclusion. (See Causes)
Expansion arch. (See also Regulating
Appliances)
adjustment of B, 251
adjustment of E, 236, 240, 241, 245,
248, 252, 256
adjustment of for intermaxillary move-
- ment of teeth, 254, 257-260
attachments, 222
author's improvements of, 167, 198,
256
B used in combination with traction
screw, 602-604
bending for fine adjustment of, 241,
248, 252, 324, 354. 429, 455
Expansion arch, child's size of, 200, 553
description of B, 190
description of E plain, 199
description of E ribbed, 200, 421
early forms of, 168, 196, 197
efficiency of, 246, 247, 252, 254, 534
E used in combination with traction
screw, 601
incorrect use of, 262
introduction of, 168, 195, 196
notching E ribbed, 246, 249, 330, 355,
362, 435
reinforcement of, 261, 262, 420
to gain buccal spring from, 251, 252,
341, 429, 523, 546
to gain lingual spring from, 523, 546
uses of B, 251, 478, 512, 603
F'
FACE. (See also Facial Lines), art of,
61, 376
beauty of, 348
correct views of in photographs for
orthodontists, 159
deformity of, 95, 422
harmony of proportion of, 74, 328,
344, 377
inharmony of balance of, 517 -
lack of proper contour of, 386, 389,
439, 442, 544 #
law of balance of, 62, 63, 65, 73, 76,
79, 85, 86
proper contouring of, 93, 142
relation of chin to, 505
types of, 61, 66, 72, 74, 81, 83, 84
Facial lines, harmony of, 60, 61, 62,
64, 66, 72, 81, 93, 366
improved from treatment of malocclu-
sion, 76, 79, 81, 85, 86, 328, 331,
335, 340, 356, 364, 373, 376, 378,
382, 388, 389, 392, 398, 404, 412,
423, 441, 447, 454, 457, 464, 469,
471, 472, 476, 481, 488, 491, 496,
502, 505, 510, 512, 521, 525, 530,
531, 535, 541, 549, 554, 555, 560
inharmony of from malocclusion, 44,
60, 74, 79, 87, 311, 449, 489, 543
law governing inharmony of, 44, 47,
50, 81, 404, 450, 506, 528
law governing balance of, 6.2, 63, 65,
73, 76, 79, 85, 86, 319, 464
marring of from loss of teeth, 71, 74,
83, 87, 95, 308, 382, 439, 441,
447, 522
marring of from malocclusion, Class
I, 44, 75, 76, 80, 328, 332, 336,
351, 373-376, 382, 386, 391, 404,
411, 422, 441, 447
620
INDEX.
Facial lines, marring of from malocclu-
Sion. Class II, Division 1, 47, 79,
81, 454, 457, 464. 469, 472, 479,
488, 489, 496, 502
marring of from malocclusion, Class
II, Division 1, Subdivision, 50,
84, 507, 511
marring of from malocclusion, Class
II, Division 2, 51, 84, 521, 522,
528
marring of from
II, Division 2,
85, 534, 542, 543
marring of from malocclusion, Class
III, 53, 86, 553, 555, 557, 562
permanently marred, 390
relation of to normal occlusion,
65, 66, 71
Fillings, imperfect, 97, 445, 496
Final suggestions, 610-612
Force, application of for tooth move-
ment, 224
danger of displacing anchor teeth from
too great, 193, 356, 427, 431
employed in banding teeth, 215
exerted from lengthening wire, 208,
225, 226, 320, 323, 373, 435, 604
exerted from lip pressure, 375
for movement of apex of root, 40l
for rotation, 363, 364, 476, 591
from arch B, 478
from arches E, 324, 370, 420, 435,
437, 523
from inclined plane, 270, 271
from mastication, 412, 415
from occipital anchorage,
234
from rubber wedges, 322
from wire ligatures, 322, 324, 420
intermaxillary, 257, 262, 356, 427,
457, 460, 461, 488, 553
intermaxillary for movement of in-
cisors, 461, 509
irresistible, 247
perversion of, 415, 449, 466, 554
proper direction of, 225, 256
proper distribution of, 174, 193, 256,
412, 413, 417, 449, 514, 516
pulling, 183, 185, 195
pushing, 183, 185, 195 -
reciprocal, 230, 231, 246, 247, 251,
269, 299, 407, 440, 456, 460, 476,
478, 488, 559, 598, 599
rotary, 183, 186, 187, 195
wedging, of incisors, 478
wrongly directed, 178, 439
Forces governing malocclusion, 25, 28,
29, 30, 550, 554, 557
malocclusion, Class
Subdivision, 52,
63,
Forces governing malocclusion, establish-
ment of, 457 .
influence of, 328, 449, 451, 459
Forces governing normal occlusion, 24,
27, 35, 36, 266, 401, 439, 451, 555
Frenum labium, abnormal, 103, 104
as related to maxillary suture, 104
normal, 104
section of, 570
G
GAG, 197, 326
German silver. (See Regulating Appli-
ances)
H
HEADGEAR, author’s, 191
introduction of, 189
practical uses of, 191-193, 194, 234,
512, 603, 605
Heredity, 398, 552, 553
I
191, 192,
IMPRESSIONS, author's method of taking,
145-148
made with teeth in occlusion, 432
materials for taking, 144, 145
proper trays for, 145
uniting, 150
warnishing, 151 -
Incisors, abnormal inclination of, 528
abnormal overbite of, 51, 78, 528, 534
combination of movements of, 245,
249, 323, 370
depression of, 530
difference in positions of in Divisions
1 and 2, Class II, 44
effect on of abnormal lip function, 31,
32
elevation of, 47, 429
eruption of into malpositions, 29
extraction of laterals, 95
inclination of, 53, 343, 354
infra-occlusion of, 43, 108, 423, 426,
427 .
inharmony of with median line, 445
intermaxillary retention of, 303, 432,
510, 553
labial movement of, 225, 325, 336, 340,
351, 353, 354, 361, 367, 888, 407,
420, 488, 505, 517, 534, 545, 558,
585, 592
lateral movement of, 370, 407
lengthened from lack of function, 448,
449
lingual displacement of lower,
322, 400, 404
106,
INDEX.
621
Impressions, lingual movement of, 137,
258, 471, 496, 505, 534
making space for with traction Screw,
592
malformed, 100, 162
non-development of lateral, 162
non-eruption of, 71
occlusion of, 10 .
patterns of, 398
pronounced malocclusion of, 40, 402
protrusion of, 44-46, 81, 107, 108, 250,
403, 448, 459, 479, 505
protrusion of increased by extraction,
95, 481 *
reciprocal rotation of centrals, 230
recurrent movement of, 521
recurrent tendencies of, 337
retention of, 273-278, 284, 295,
341, 355, 362, 364, 370, 376,
401, 417, 418, 420, 427, 432,
521, 524, 535, 549
retraction of, 336, 471, 512
retrusion of, 46, 50, 51, 403, 533
rotation of, 247, 330, 334, 353,
400, 407, 420, 534, 593, 594,
597, 600, 601, 607
separation of upper and lower, 546
temporary retention of, 268
to shorten upper, 530
wedging force of, 478 -
Instruments, 203, 208, 216, 217, 226,
240, 320, 373, 435, 591, 604
Intermaxillary anchorage. (See Anchor-
age)
Intermaxillary elastics, 201, 231, 257,
259, 427, 428, 429, 432, 455, 456,
461, 479, 488, 507, 510, 517, 530,
534, 546, 553
Intermaxillary retention. (See Incisors ;
Canines, Molars, Premolars)
Interproximal spurs, 282-295
332,
388,
462,
370,
595-
J
JACK-SCREW, adjustment of, 579–581
author's improvements of, 184
auxiliaries to, 187, 188
combined with traction screw, 605
combined with levers, 599, 600
description of Dwinelle's, 183
invention of, 171
power derived from, 362
supersedence of, 168
uses of, 226, 230, 582, 583, 585, 586,
599, 600, 605
Jaws, author's operation for double re-
section of lower, 563, 572-578
Jaws, effect on of lingual locking of up-
per molars, 414, 415
establishment of normal relations of,
457
growth of, 343
inharmony as to size and relations of,
562
lack of development of, 44
“large teeth and small jaws,” 342, 398
lower distal to normal, 449
normal mesio-distal relations of,
42, 43
overdevelopment of, 563
recurrent movement of lower, 505
relations of in malocclusion, 367
retrusion of lower, 44
Jumping the bite, 499, 501, 502
40,
L
LENGTHENING wire for tooth movement,
208, 225, 226, 320, 323, 373, 435,
604
I lever, author’s, 187
auxiliaries to, 187, 188
combined with jack-screw, 599, 600
device for movement of apices of roots,
400
early use of, 186
for buccal movement of premolars, 605
for double rotation, 595, 597, 59S, 607,
60S
for readjustment of teeth, 597
for reinforcement of expansion arch,
261, 262, 420, 606, 607
for single rotation, 593, 594, 595, 600
for widening dental arch, 598, 599,
606, 607
introduction of piano wire for, 172
reinforcement of, 594
Ligatures, brass wire,
242, 245, 330
description of author's, 203
for elevation of teeth Without bands,
354, 426, 427
readjustment of teeth, 269, 597
reinforcing anchorage, 584, 594
temporary retention, 26S, 269, 331
separating teeth, 238
simultaneous labial movement of
canines and premolars, 253, 488
simultaneous labial movement of
first and second premolars, 439,
461, 528
general uses of in treatment, 246, 248,
251, 258, 322, 325, 353, 437, 478,
517, 599, 601
introduction of, 198, 241
adjustment of,
for
fol"
for
for
for
for
622
INDEX.
Ligatures, renewal of, 253, 520
soldered to wire G, 244
to prevent sliding beneath gums, 353
to prevent slipping of, 249, 260, 353,
435
to tighten, 243
used to gain stationary anchorage with
arch, 461
used in double resection of mandible,
578
used for rotating, with bands and
tubes, 230, 607, 608
used for spurs on arch, 223
used in retention, 275, 279, 290, 291,
408
Ligatures, fibrous, 241, 242, 584
rubber. (See Intermaxillary Elastics)
Line of occlusion, definition of, 22
description of, 21
elevation of teeth into, 431
teeth placed in harmony with, 330,
334, 335, 340, 375, 388, 406
Lips, abnormal angle between nose and
upper, 383-386
abnormal functions of, 31, 32, 46, 448,
459, 480, 496
abnormalities of, 376, 377
closed with strips of adhesive plaster,
496
influence of pressure of, 321, 328, 343,
361, 375, 436, 445
necessity of establishing normal func-
tions of, 455, 462, 464
necessity of overcoming pernicious
habits of, 111, 481
normal functions of, 5, 16, 31, 51, 78,
321, 328
pernicious habits of, 107, 108, 481
retaining devices to prevent biting of,
303, 304, 510
Loss of Teeth, complications in treat-
ment due to, 512
effect of extraction on facial lines, 74,
83, 87, 95, 308, 382, 439
extraction, 3, 55, 63, 74, 87, 93-96,
481, 482
extraction of canines, 95
extraction of first permanent molars,
94, 265, 390, 436, 437, 439, 445
extraction of lateral incisors, 95
extraction of premolars, 229, 382, 390,
499, 505, 512
inadvisability of extraction, 93, 342,
344, 348, 351, 386, 390, 406, 544
maintaining space after, 271-273, 441,
488
non-development, 71, 161, 162
non-eruption, 161
Loss of Teeth, premature, of deciduous
canines, 37, 375, 384, 404, 434
premature, of deciduous molars, 90-92,
434, 484, 488
regaining space after, 308, 437, 439,
445, 482
MI
MALOCCLUSION, advantages of early cor-
rection of, 419
beginnings of, 37, 115, 320, 398, 414,
449, 459
causes of. (See Causes)
classification of, 35
chiefly confined to incisors and ca-
nines, 412
complicated by extraction, 95, 96, 481,
488
complicated by pernicious habits, 107,
108, 111, 307, 426, 455
definition of, 7
development of, 29, 115, 140, 375, 398,
414, 449, 450, 517, 555
diagnosis of. (See Diagnosis)
forces governing. (See Forces Govern-
ing Malocclusion)
forms of common to all classes, 41,
43, 423
including buccal teeth, 412
of deciduous teeth, 89, 90, 311, 452,
550, 553
prevention of, 375, 436
proper age for correction of, 30, 309,
313, 519
relation of to disturbed facial lines.
(See Facial Lines)
seven positions of, 23
tabulated classification of, 58
time required for treatment, 313, 317
Mandible. (See also Jaws), abnormal
form of, 563
abnormal position of, 563
author's operation for reduction of
prominent, 563, 572-578
diminished in size, 47
distal movement ol, 559
distal position of, 46, 80, 84
lateral displacement of, 40, 555
normal development of, 469
shifting of, 502
Maxilla. (See Jaws)
Median line, 407, 434, 435, 445
Models of cases of malocclusion, cabinet
for, 157
from impressions of teeth in occlusion,
432
plane for trimming, 156
pouring, 152
INDEX. 623
Models of cases of malocclusion, repair-
ing, 152
separating, 152
“study,” 158, 325, 354, 360
tripaming, 152, 153
uses of, 344
value of, 158
Molars, advantages of early adjustment
of, 30
artificial substitutes for, 265, 436, 437,
439
as anchor teeth, 325, 329, 352, 356,
361, 375, 427, 439, 455, 460, 519,
534, 546, 558
asymmetrical locking of, 116
buccal movement of upper, 137, 246,
415, 522, 523, 545
buccal occlusion of lower, 40, 42, 429
constancy as to correct location of
first, 17, 19, 20, 466
displacement of, 228, 353, 356
distal locking of lower first, 116, 309,
449, 454, 459, 516
distal movement of in Class I, 436,
440
distal movement of upper, 257, 258,
303, 456, 461, 488, 508, 517, 520,
536, 546
distal occlusion of lower, 44, 46, 47,
49, 51, 433, 449, 482, 484, 491,
516, 533, 542
effects of extraction of first. (See
Loss of Teeth)
effect of imperfect fillings in, 97, 445,
446
first as basis of diagnosis, 20, 55
first as key to occlusion, 19, 20, 55
grinding of, 429, 433
importance of first, 17, 19, 21, 94
intermaxillary movement of, 456, 460
intermaxillary retention of, 290, 298-
301, 303, 376, 456, 462, 471, 473,
476, 501, 521, 524, 534, 539, 549,
561
lengthened through use of bite plate,
491, 530
lingual movement of upper, 137, 523,
545
lingual occlusion of upper, 412, 414,
419, 422, 429, 431, 522
mal-locking of, 154, 414, 518
mesial movement of lower, 257, 303,
456, 488, 509, 520, 534, 546
mesial occlusion of lower, 52, 553,
555, 557
necessity for moving uppers distally
explained, 466-469
normal occlusion of, 10, 36
Molars, normal mesio-distal relations of,
42, 43, 49, 328, 335, 336, 350,
359, 367, 403, 471, 473
reciprocal movement of upper and
lower, 488
regaining space for lost, 437, 439, 441,
445, 488
reinforcement of, 353
result of movement of anchor teeth,
356, 427
retaining regained space of, 272, 277,
298, 445
retention of, 269, 277, 282, 298
rotation of, 244
supra-occlusion of, 428
tipping to upright position, 436, 437,
440, 482, 488
wedging influence of, 91, 93, 95, 439,
442
Mouth, effect on of extraction, 94
effect on of mouth-breathing, 113, 456
harmony of balance of, 377
inharmony of with other features, 80,
81, 84, 472, 517
lack of normal contour of, 75, 351,
383, 385, 434
weakness of, 85
Mouth-breathing, causes of, 113, 449 -
effects of, 46, 81, 111, 115, 448, 450,
491
Movements of teeth, after death of pulp,
139
age limit for, 143
antagonizing, 266, 274, 278, 284, 285
before full formation of root, 139
buccal, 135, 137, 246, 248, 251
by lengthening wire. (See Lengthen-
ing Wire)
collectively, 254, 415, 416
combinations of, 245, 253, 323, 337,
351, 370, 375, 398, 407, 437,
439
depression, 134, 228
distal, 135, 138, 254, 257, 303
elevation, 134, 354, 427, 429, 431
immediate, 566, 567
intermaxillary, 254, 257, 455, 456, 460,
486, 505, 509
labial, 133, 135, 245, 252, 253, 325
lingual, 135, 137, 251
mesial, 135, 138, 254, 303
one at a time, 420
pain incident to. (See Pain in Tooth
Movement)
physiological laws governing, 134
reciprocal, 230, 456
rotation, 134, 245, 354
singly, 226, 227
624 INDEX.
Muscular pressure, influence of ab- P
normal, 29, 31, 82, 46, 51, 328, PAIN incident to tooth movement, 177,
554 256, 267, 268, 310
influence of normal, 25, 26, 32, "35,
330, 451, 505
N
NASAL obstructions. (See Mouth-breath-
ing)
Nomenclature, 24
Nose, abnormal angle of with upper lip,
383, 385, 386
effect on of mouth-breathing, 112-114
effect on of treatment of malocclusion,
142, 367, 464
freedom from pathological conditions
of, 514
necessity for treatment of, 451, 455
normally developed, 76
pathological conditions of, 265, 449,
510, 511
treatment of, 464
undeveloped, 81, 306
O
OCCLUSION, after treatment illustrated,
364, 370, 380, 382, 389, 391, 398,
404, 411, 412, 421, 423, 429, 432,
435, 440, 445, 452, 457, 464, 469,
476, 481, 488, 491, 496, 502, 510,
512, 517, 521, 525, 531, 535, 539,
540, 543, 546, 554, 555, 559
as related to facial art, 63, 64, 65, 79,
81
definition of, 7
details of, 9-11, 343
development of, 72, 91
effect of establishment of, 364
establishment of normal, 338, 341, 455
forces governing. (See Forces Govern-
ing Normal Occlusion)
general consideration of, 7, 8, 12-16
improved, 513
key to, 16, 17, 55, 319
maintenance of, 27, 93
of deciduous teeth, 17, 89
“Sorviceable,” 516
Open bite, 386, 423, 432, 433
Orthodontia, as a specialty, 4, 5
as related to facial art, 60, 62
breadth of, 2, 8
co-related sciences, 2, 8
definition of, 7
soldering required in, 210
teaching of, 3, 8
Overbite, 534
Peridental Membrane, blood supply to
130
cells of, 122
fibers of, 123-130, 135, 363, 432
functions of, 122
intelligent manipulation of, 364
pathological condition of, 265
resection of fibers of, 568, 569
structure of, 122
Periods of activity and rest in tooth
movement, 315, 316, 387, 398,
418, 429, 432, 471, 545, 546
Photographs, 158, 393
Piano wire. (See Lever)
Plaster Plane, 156
Plates, bite, 491, 530
for retention, 278, 296, 297, 418, 420,
441
for retention after “jumping the bite,”
500
for securing anchorage, 225, 278, 296,
297
introduction of vulcanite, 173
Ringsley’s modification of, 278
old forms of, 177, 225
Pliers, author's band-forming, 208, 216
author’s regulating, 208, 226, 320,
373, 435, 591, 604
author's soldering, 217
How's, 208
Premolars, as anchor teeth, 352, 361,
439, 461, 471, 520, 528, 558
buccal movement of, 137, 246, 248,
251, 370, 476-478
deflection of, 92
displacement of, 228
distal locking of lower, 49, 51, 542
distal movement of, 257, 461, 478,
520, 536, 546
establishment of full normal relations
of, 404
for stationary anchorage, 228
infra-occlusion of, 423, 427
intermaxillary retention of, 301-303,
471, 512, 539
lengthening, 530
lingual occlusion of, 412, 542
mesial movement of, 439, 440, 488,
546
non-development of, 161
occlusion of, 10
providing space for, 404
retention of, 269, 275-277, 282, 298,
301, 370, 373, 376, 417, 418, 476,
549
INDEX.
625
| Regulating appliances, early history of,
| 168, 182, 183
first complete system of, 173
fol:
contraction of lower arch, 416,
417
for forcible eruption of canines, 609
for intermaxillary movement of teeth,
f Class I, 254, 257, 260, 408
for making space for movement of in-
Cisors, 592
movement of teeth en mass C, 415,
416
moving teeth of only one lateral
half of arch, 420
for
for
for reciprocal movement of teeth of
opposite arches, 455
for retraction of canine. (See Ca-
nine Teeth)
for rotation of premolars, 473, 476,
592
for shortening arches after extraction,
603
for shortening bite, 491
for tipping molars to upright position,
437, 488
for treatment of abnormal frenum la-
bium, 572
general consideration of, 163-167, 182
inspection of, 456, 520
lever combination for double rotation,
596, 507, 607, 608
lever combination for single rotation,
593, 594, 595, 600
materials for construction of,
179, 184
miscellaneous combinations of, 598,
599, 600, 603, 605, 606
necessary qualifications of, 174-178
obsolete forms of, 175, 176, 326
to regain space of lost teeth, 439, 445,
482, 488
uses of pinched wire.
ened Wire)
used as retaining devices,
4.17, 429, 456, 520
Regulating pliors. (See Pliers)
| Retaining devices, adjustment of, 240,
267, 270, 331, 332
bands and spurs, 268, 282, 297,
323, 331, 341, 355, 362, 364, 370,
373, 375, 400, 408, 418, 435, 456,
462, 510, 535, 539, 549, 553
bands united, 279, 280, 364, 586
base wire and interproximal spurs,
2S3-295, 296
base Wire and T-bar,
bridges, 445, 482
for holding lips closed, 496
173
Premolars, revealed by the X-ray, 484
rotation of, 244, 254, 355, 473, 592,
608
sacrifice of, 382, 383, 505, 512, 601
simultaneous movement of first and
canine, 253, 488
simultaneous movement of first and
second, 439, 461, 528
torsal occlusion of, 473
used to reinforce anchor teeth, 353
Pressure, abnormal, 29, 46, 328
deficient muscular, 32
from expansion arch, 247
from regulating appliances, 163
from rubber wedges, 253
normal muscular, 25, 26
of lips, 31, 51
of tongue, 32, 35
Pulps of teeth, 131, 138
R
REGULATING appliances, accustoming pa-
tients to the wearing of, 455
combination for movement of anterior
teeth only, 320, 322
combinations of for treatment, Class I,
323, 325, 329, 330, 334, 335, 340,
351, 355, 361, 362, 367, 370, 375,
398, 407, 408, 416, 420, 426, 428,
435, 437, 439, 445
combinations of for treatment, Class
II, Division 1, 455, 456, 457, 458,
460, 462, 471, 473, 478, 488, 603-
605
combinations of for treatment, Class
II, Division 1, Subdivision, 507,
510, 512
combinations of for treatment, Class
II, Division 2, 517, 510, 520, 522,
523, 528, 530
combinations of for treatmont, Class
II, Division 2, Subdivision, 534,
539, 546
combinations of for treatment, Class
I I I, jj;3, jS
combination for rotation only, 607,
608
combination for forcing eruption, 609,
610
Combinations of for treatment of muti-
lated cases, 435, 437, 439, 445,
488, 512
complex, 174, 175
device for movement of apices of
roots, 400, 401
device for intermaxillary movement of
upper caminos, 260, 479, 4S1
(See Length-
323, 325,
290, 291
41
626
INDEX.
Retaining devices, for final mechanical
retention, 270, 402
for maintaining space of missing teeth,
271, 272, 277, 298, 375, 437, 441,
445
for maintaining teeth after elevation,
295, 296, 427, 429, 432
for protracted retention, 271
“gooseneck” device, 272, 375
inspection of, 280, 429, 457
lengthened section of wire G, 435
materials for construction of, 267
materials for construction . of inter-
proximal, 294
materials for making plane and Spur,
299
necessary qualifications of, 266, 267
planes and spurs for intermaxillary,
290, 299-302, 304, 376, 456, 462,
473, 501, 510, 512, 524, 534, 539,
549, 553, 561
plates, 278, 296, 297, 298, 341, 420,
441
regulating appliances used as, 323,
4.17, 429, 432, 456, 520
skeleton forms of, 298
spurs in pius in enamel, 271
to overcome habits, 426, 481, 510
use of wire ligatures as, 268, 269, 275,
279, 290
Respiration, effect of perverted function
of, 449
necessity of establishing normal, 455
normal, 514, 532
Retention, after elevation, 295, 296, 427,
429, 432
after “jumping the bite,” 499-501
after section of frenum labium, 572
author's latest method of, 283, 295
chief problem in, 408
discontinuance of, 432, 433, 555
forms of anchorage in, 266
general consideration of, 263-266
importance of occlusion in, 264-266,
586
intermaxillary, of deciduous teeth, 510
of canines. (See Canines)
of Class I, II and III. (See Classes)
of dental arches, 290, 291, 375, 420
of incisors. (See Incisors)
of lower teeth, 285, 287, 402, 440,
445
of molars. (See Molars)
of premolars. (See Premolars)
of upper teeth, 290, 402, 417, 440
permanent mechanical, 270, 332, 402
principles of, 263
readjustment of teeth after, 373, 521
Retention, reciprocal, 303
temporary, 267-269, 331
time necessary for, 264, 265, 873
Rhinology, as related to orthodontia,
367, 553
Roots of teeth, adjustment of, 143, 355
changes in position of, 137, 142
development of alveolar process over,
364
displacement of apex of, 23, 138, 400,
413, 449
lingual position of apex of, 386, 400
movement of apex of, 136, 137, 142,
143, 344, 345, 376, 377, 385
Rubber, use of in Orthodontia, as inter-
maxillary ligatures. (See Inter-
maxillary Elastics)
elastics used with headgear, 189, 191,
193, 234, 512
- for buccal movement of teeth, 249,
251, 253, 362
for elevation, 277
for labial movement of teeth, 322
for lingual movement of teeth, 203,
246, 408, 522
for rotation, 203, 230, 269, 354, 355
in retention, 282, 364, 521, 539
introduction of, 172
|
S
|
SCISSORS, 208
Skiagraphs,
illustrations of, 99, 105, 161, 162
use of, 100, 484
value of, 160
Shoath hooks, 198, 202, 257, 4.55, 460,
510, 517, 519, 553
Soft-soldering, 222, 429
Solder, 212
Soldered attachments, to arches, 202,
222
to clamp bands, 226, 227
to plain bands, 211, 212, 219, 220, 230
Soldering, author's pliers for, 207
author's method of, 211, 217, 220
lamp for, 208, 210, 217, 222
spurs, 220, 222
tubes, 220
Speech, impairment of from malocclu-
sion, 1, 308, 390, 414
Study models. (See Models)
Supernumerary teeth, 99
Surgery, alveolar section, 567
double resection of mandible, 563, 572,
574-578
operative for tooth movement, 566,
567, 604
INDEX,
627
Surgery. removal of bone, 566, 567, 604
resection of peridental fibers, 568
Section of frenum labium, 569
T
TABULATED classification of malocclusion,
57, 58
Technique work, 220
Teeth, permanent, abnormal inclination
of, 343, 376
all on one side used as anchorage, 420
apparent disproportion of to sizes of
jaws, 398, 544
appliances for correcting malposed.
(See Regulating Appliances)
artificial substitutes for, 96, 168, 265,
307, 308, 437, 439, 482
buccal occlusion of lower, 40, 42, 414,
429
depression of, 248
development of into malocclusion, 29,
30, 40
displacement of anchor, 225, 227, 228
248, 427
displacement of retained, 270
distal locking of lowers, 46, 50, 85,
539
disuse of, 102
elevation of, 232, 248
extraction of. (See Loss of Teeth)
function of, 7, 93
grinding of, 14, 323, 421, 429, 433
immedia to movement of, 566
impaction of, 36, 98
importance of early correction of, 30
importance of full complement of, 63,
307, 406, 516
injuries to from bands, 280-282
interdependence of, 12, 13, 24, 25, 27,
31, 93, 96
lack of full complement of, 307
lingual occlusion of upper, 42, 412,
431, 542
malocclusion of. (See Malocclusion)
models of. (See Models)
movements of. Movements of
Teeth)
mutual support of, 11, 12, 13, 265
non-development of, 161, 162
normal angle of inclination of, 389
normal development of, 26, 72
normal occlusion of, 9-11, 60
patterns of individual, 14, 75
providing space between for banding,
23S
pulps of, 138, 139
(See
Teeth, reciprocal movement of in oppo-
site arches, 230, 257, 456, 488
regaining space for missing, 308, 439,
445, 482
readjustment of after treatment, 194,
269, 277, 282, 364, 373, 479
reciprocal movement of in same arch,
244
relation of alveolar process to, 118
relation of in normal occlusion to
facial lines, 63, 64, 74, 86
relation of to line of occlusion, 23
retention of. (See Retention)
self-adjustment of after movement to
correct relations, 141, 561
seven malpositions of, 23, 24, 35
space between upper and lower ante-
rior, 423, 546
supernumerary, 99, 100
“third dentitions,” 99
transposed, 100, 101
types of, 14, 75
Throat, inflammation of, 555
pathological conditions of, 265, 465,
550, 551, 557
treatment of, 4.55
Thumb-sucking, 106
Tissue changes incident to tooth move-
ment, 132, 315, 393, 430, 469
i Tissue changes subsequent to tooth
movement, 140-143, 319, 336, 343,
344, 350, 355, 364, 546
Tongue, abnormalities of, 33
normal influence of, 32, 33
perrlicious habits of, 108, 426
restricted space for, 306, 413, 542
Tonsils, enlarged, effects of, 309, 550,
553, 555
removal of, 553
Tooth movement.
Teeth)
Traction Bar A, adjustment of, 191
description of, 191
uses of, 191, 193, 512
Traction screw, adjustment of, 227, 587.
590
author's, 172, 185, 186
auxiliaries to, 187, 18S
combined with arch B, 602-604
combined with arch E, 601
combined with jack-screw, 605
for movement of lateral incisor, 592
for retraction of canines, 227, 512,
590, 591, 601-605
for retention, 278, 476
for rotation, 473, 590, 591, 592
Trays. (See Impressions)
Treatment, advanced age for, 440
(See Movements of
628 INDEX.
Treatment, advantages of eatly, 30, 311, V
312 WARNISHES for impressions, 151
conservative, 377 Vault of arch, changes in resulting from
demands in, 351, 386, 398, 415 treatment, 367
different periods of, 282, 315, 316 lower incisors in contact with, 527
difficulties of, 459 measurements of, 345
difficulties of increased by extraction, narrowed, 413
482, 512
general consideration of, 305-309, 319 W
general effects of, 347 WIRE, iridio-platinum, 294
ideals in, 308 gold, 294
Wire cutters, 208, 220
Wire G, description of, 187-189
device for intermaxillary anchorage,
479
indication of required, 367, 375, 406,
419, 428, 431, 432, 435, 436, 439.
445, 455, 488, 496, 505, 516, 522
logical plan of, 451, 455, 460
objects to be accomplished in, 307, 534
old plan for Class II, Division 1
cases, 499, 512, 516, 603, 604
periods of activity and rest in, 315,
316, 387, 398, 418, 429, 432, 471,
545, 546
proper age for, 30, 309, 310, 313, 440,
452, 519
gaining space for missing teeth, 308.
439, 445, 482
time required for, 178, 310, 313, 315
Tubes, author’s, 187, 400
for rotation, 594, 595
for general tooth movements, 598, 600,
607, 609
introduction of, 173, 184
soldering to screws, 287
to reinforce anchorage, 582, 583, 591
to solder, 220
two united, 212, 261, 606
for “gooseneck” device, 271, 375
for reinforcing anchorage, 303,
584, 585, 591, 593
for securing base of jack-screw,
580, 586
lengthened by pinching,
320, 323, 373, 435,
soft-soldered to ligature wire, 244
spurs for retention, 269, 272, 274, 276,
332, 341, 355, 362, 370, 375, 401,
408, 420, 462, 535, 549
Spurs of for tooth movement,
329, 597, 598, 606, 609
spurs of set in fillings. 271, 300
staples of, 219, 400, 592
to solder, 22()
to support expansion arch, 603
used as base wire, 294
used in retention, 272, 27.3, 435
used with retaining plate, 298
583,
579,
20S, 225,
604
226,
219,
united to bands, 211, 271, 273, 279, Wire ligatures. (See Ligatures)
435, 583 Wire, piano. (See Lever)
used in retention, 270, 271, 273, 279, Wrenches, 189, 208
435, 583
Types of faces, 61 X
of teeth, 14, 75 X-RAY. (See Skiagraphs)
THE END.
JAN 22 1920
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