Orthodontics-in-Daily Practice PDF

Contributors
R. William McNeill, D.D.S., M.S. H. K. Terry, D.M.D.

Associate Professor of Orthodontics University of Visiting Postgraduate Lecturer
Washington School of Dentistry Seattle, Washington School of Dentistry Washington
University
St. Louis, Missouri
Fujio Miura, D.D.S., M.S.

Professor and Chairman
Department of Orthodontics
Tokyo Medical and Dental University Faustin Neff Weber, D.D.S., M.S.
Tokyo, japan Professor and Chairman
Department of Orthodontics
College of Dentistry
Melvin L. Moss D.D.S., Ph.D. University of Tennessee
Professor of Anatomy Memphis, Tennessee
College of Physicians and Surgeons
Professor of Oral Biology
School of Dental and Oral Surgery
Columbia University
New York, New York Robert A. Wertz, D.D.S., M.S.
Diplomate of the American Board of Orthodontics
Orthodontic Lecturer and Independent Researcher Private
William Marshall Parker, D.D.S. Practitioner in Orthodontics
Instructor in Clinical Dentistry Kunka kee, III in ois
University of Tennessee Memorial Research Center and
Hospital
Knoxville, Tennessee
Raleigh Williams, D.D.S., M.S.D .
Kaare Reitan, D.D.S., M.S.D., Ph.D. Teaching Associate
The Institute of Experimental Research Dental Northwestern University Dental School
Faculty Chicago, lllinois
Uriversity of Oslo
oe Norway
Earl B. Shepard, D.D.S. D. G. Woodside, D.D.S., M.5c.

Director, American Board of Orthodontics Professor and Chairman
Professor of Clinical Orthodontics Chairman, Department of Orthodontics
Department of Orthodontics Washington Faculty of Dentistry
University University of Toronto
St. Louis, Missouri Toronto, Ontario
Copyright 1974 by J. B. Lippincott Company
This book is fully protected by copyright and, with the exception of brief
excerpts for review, no part of it may be reproduced in any form by print,
photoprint, microfilm, or any other means without written permission from the
publisher.
ISBN 0-397-50324-5
Library of Congress Catalog Card Number 73-22136
Printed in the United States of America
134 2
Library of Congress Cataloging in Publication Data

Salzmann, Jacob Amos.
Orthodontics in daily practice. 1.
Orthodontia. I. Title.
[DNLM: 1. Orthodontics. WU400 S186pa 1974)
RK521.S243 617.6' 43 73-22136
ISBN 0-397-50324-5
Preface
This text on orthodontics for everyday dental practice is The newer techniques developed by Dr. Terry are included.
intended for studen ts. practitioners, and teachers. They Dr. Raleigh T. Williams has lectured and conducted
can find here the information best suited to their courses on the Begg technique at many dental schools and
immediate practical needs and can avail themselves of the orthodontic groups. He presents clear-cut illustrations and
wide range of information on the specialty of orthodontics. concise instructions on the construction of the Begg
This volume will be useful for planning and instruction in appliances used in treating different types of malocclusion.
continuing education programs and as a handbook of ready The chapter on the edgewise appliance technique by Dr.
reference in daily practice. R. William McNeill is presented as taught by him at the
Practical instruction is included on occlusal guidance of University of Washington and as practiced in his own
the developing dentition in the young child to obviate office. His explanations and illustrations of appliance
extensive orthodontic intervention later. Stress is laid on construction and case reports are a revelation in their
the construction and use of preventive-interceptive simplicity and perfection.
appliances. Practical cases are discussed and illustrated. Dr. Robert A. Wertz is a pioneer in mid-palatal suture
Orthodontic treatment of adults is now an important separation. His chapter is presented simply and is fully
phase of practice. This subject is presented and illustrated illustrated. He presents illustrated case reports that are of
for the treatment of malocclusion and for the alignment of practical value to the practitioner.
teeth into favorable positions as abutments in restorative A chapter on direct bonding of brackets is contributed by
dentistry. A method is discussed for establishing vertical Professor Fujio Miura. Professor Miura presents the subject
dental height before undertaking restorative dentistry in with an economy of words but with excellent illustrations
occlusal rehabilitation. Techniques are presented in a step- and explanation of the technique.
by-step sequence. The related basic medical and dental Dr. Marshall Parker, a student of Dr. Crozat, has
sciences are explained when they have immediate bearing perfected the technique in the construction and use of the
on diagnosis and treatment. Crozat appliance.
I am proud to be associated with the contributors to this The activator appliance is being used with increasing
text whose names are listed alphabetically and not frequency in the United States for treatment of
necessarily according to the relative importance of their malocclusion and in retention to overcome tongue thrusting.
contributions. The practice of orthodontics now requires Dr. Donald G. Woodside contributes his extensive
the expertise of those who have made special contributions knowledge of activator techniques.
to the specialty. I have included these contributors for this "Tissue Changes in Orthodontic Tooth Movement" is
reason. I am deeply indebted to them. contributed by Professor Kaare Reitan. Professor Reitan is
A detailed account of interceptive-preventive accepted as the leading modern authority on oral tissue
orthodontic therapy is contributed by Dr. Faustin Weber. changes and physiology in orthodontic tooth movement.
He addresses himself to the general practitioner and I wish to. think Dr. A. ]. Mazel, my associate of many
pedodontist as well as to the student and practitioner of years, for his assistance.
orthodontics. Indications and contraindications are given I wish to thank the J. B. Lippincott Company, which has
for treatment with and Without the use of appliances. been publishing my texts for over 30 years, for their high
<The chapter on labioIingual technique is by Dr. standard of professionalism. My thanks go to my secretary,
H. K. Terry, who was long associated with the late Dr. Mrs. Annette Grumman, for her patience and sympathetic
Oren Oliver. Dr. Terry has presented courses as a special attitude, beyond the call of duty, in the typing of the
lecturer in universities and orthodontic groups in Europe manuscript.
and North and South America.
J. A. Salzmann
v
- --r --- -- - - -_.- --_._-- - - ----r J .... .L.LL .... ..L ~J.lbJ. .... J.l--l..;JJ . .I..L'-U\,..l.VJ.l , -
Incidence of the Various Malocclusions .............. . 6

Public Health Aspects ........................................... 1
Essentials of Orthodontic Practice ........................ Prognathism ......................................................... . 5
Psychodynamics of Dentofacial Reverse Occlusion ............................................... . 65
1 6
Malformations .................................................. 3 Bibliography ........................................................ .
General Dental Care .............................................
5
Bibliograph y .......................................................... 7. Skeletal Classification ............................................... . 7
3 47
Facial Skeletal Pattern ......................................... .
2. Growth ~f the Face ............. : ................................... . 4 5
6 Variation of Skeletal and Dental
Definitions of Growth Classification ................................................... . 7
Bone Age Assessment.. ....................................... . 5
and Development ............................................ . 6 57
Bibliography ........................................................ .
Growth of the Skull. ............................................. 6 9
Role of Bone in Orthodontic Therapy .................. 9
8. Stomatognathic Dynamics.................. ... ... 95 9
Origin of the Oral Cavity ...................................... 1 4
Growth of the Mandible ........................................ 0 The Force-Linked Stomatognathic Unit... 95 Facial 7
Growth of the Maxilla .......................................... 1 Balance, Muscle Balance, and
Change in Facial Proportions ................................ 0 Orthodontic Therapy ............................................. 97
Dental Occlusion and Face Growth ...................... 1 The Temporomandibular Articulation...... 99
Dental Occlusion and Facial Profile ..................... 1 Speech and Malocclusion ....................................... 101
Craniofacial Abnormalities ................................... 1 Bibliography .......................................................... -101
Bibliography ......................................................... 2
1 9. Etiologic Factors in Malocclusion ............................. . 10
3. The Functional Matrix 9 3
and Clinical Orthodontics 2 Classification .........................................................
10
Melvin L. Moss, D.D.S., PH.D Genetic Evidence in Malocclusion ........................
................................................. 22 3
Temporomandibular Disturbances ........................
The Functional Matrix Concept. ........................... 52 Midline Deviations ................................................
10
2 6
Mandibular Growth .............................................. 22 Supernumerary Teeth ............................................
References ............................................................ 11
52 Den tofacial Pressure Ha bi ts ...............................
1
27 Mandibular Incisor Crowding ...............................
11
4. Eruption of the Teeth 29 Bibliography .........................................................
.......................................................................................
2 5
. Differences Between Teeth and Bones...... 30 8 11
Order of Tooth Eruption ........................................... 30 10. Dentition Anomalies and Malocclusion .........................126 9
Development of Dentition Numerical Variations of Teeth .................................126 12
from Birth to Age 14 ........... - .. . .............. .. .. . 30 Ectopic Eruption ......................................................126 0
The Third Molars................................. 41 Impactions.......................................... 128 Em ption 12
Bibliography....................................... 42 Anomalies..................... ... .. . . .. 130 Root Resorption 3
and Orthodontic 12
5. Development of Dental Occlusion ................................. 43 3
Therapy .............................................................. 135
Physical Variation and Occlusion ............................. 43 Bibliography ......................................................... 141
Patterns of Dental Occlusion.................. 44 Appositive
Relation of the Deciduous 11. Examination of the Patient........................ 142
Teeth in Normal Terminal Occlusion... 45 Scope ....................................................................... 142
Appositive Relation of the Permanent Oral Examination................................. 143 Suggestions
Teeth in Normal Terminal Occlusion... 46 of Diagnostic Examination
Bibliography....................................... 48 Charts .................................................................. 143
6. Classification of Normal Occlusion 12. Guidance of Occlusal Development .. .. .. ..................... 145

and Malocclusion... .................................................. 50
Scope ....................................................................... 145
Clinical Manifestations of Malocclusion... 52 Types of Orthodontic Treatment ............................. 145
Classification in the Deciduous Reevaluation of Treatment Plans ............................ 145
Den ti tion . . . . . . . . . ... . . . . . . . . . . .. .. . . . . . . . . .. Dentofacial Orthopedics .......................................... 145
.. . 53
vii
viii Contents
The Age Factor in Treatment of 17. Interceptive-Preventive Orthodontics

Malocclusion ................................................. 146 Faustin N. Weber, D.D.S., M.S. .. ................................................ 211
Differences in Response to Treatment.. ............ 146
Scope ...................................................................211
Space Maintainers ............................................. 148
Prevention of Dental Arch Collapse ................. 149 Clinical Techniques ............................................211
Treatment of Labial Frenums ............................ 150 Crossbites ............................................................215
Dental Arch and Jaw Discrepancies ................. 154 Elimination and Control of Harmful
Abnormal Overbite ............................................ 155 Oral Habi ts ..................................................... 227
Su pernu merary Teeth........................... 230
Abnormal Overjet .............................................. 157
Serial Extraction .......... . .. . ... . . . . . .. . . . . .....235
Open bi te ......... ; . . . . . . . . . .. .. . . . . . . . . . . . .. ..
The Lingual Holding Appliance ........................ 237
. . . . . .. 157
Surgical Exposure of Teeth ................................ 238
Tongue Thrusting .............................................. 159 Extraction of Overretained Primary
The Split-Plate Appliance ................................. 161 Teeth ............ ............................................ ..... 239
The Hawley Retainer ......................................... 162 Summary ......... . ......................................... . .... 244
The Higley Stabilizing Plate ............................. 163 Bibliography .... ............................................ ..... 245
The Chincap ....................................................... 164
Construction of Acrylic Retainers .................... 164
Repairing Retainers ........................................... 164 18. Extraction in Orthodontic Therapy............ 246
Bibliography ...................................................... 165 Criteria .................................................................246
13. Radiography in Orthodontics ................................. 167 The Tweed Diagnostic Triangle . . . .. . . . . . .. 248
Radiation Control. ..............................................167 Effect of Extraction on the Facial Profile ..........249
Intraoral Radiography ........................................167 The Choice of Teeth for Extraction ....................250
Extraction Without Orthodontic
Extraoral Radiography .......................................169
Therapy ..........................................................257
Bibliography .......................................................175
Bibliography ......................................................260
14. Cephalometric Radiography ............. .....................176
19. Serial Extraction ......................................................262
Use of Cephalograms .... .............. .....................176
The Cephalometer ........... .. .. ..... .. ..................176 Indications for Serial Extraction .. . . . . . . . .......262
Techniques ..................... .............. .....................176 Contraindications to Serial Extraction ...............262
Tracing Cephalograms .. .............. .....................179 Nance's Method of Serial Extraction .................263
Bibliography .................. .............. .................... 181 Treatment Without Extraction-
Case Histories ................................................. 264
Tweed's Orthodontic Guidance .......................... 270
15. Radiographic Cephalometries in Diagnosis
The Tweed Diagnostic Facial Triangle .............. 270
and Treatment .....................................................183
Tweed's Facial Types .........................................271
Clinical Value .....................................................183 Bibliography ....................................................... 272
Standardization of Cephalometric
Technique .......................................................183 20. Biomechanics in Orthodontic Therapy ...................274
Cephalometric Landmarks, Lines,
Planes and Angles ..........................................183 Nomenclature ......................................................274
Limitations of Radiographic Anchorage ...........................................................275
Cephalometries... .. . .. . . .. ......... . . . . . .. .....190 Passive and Active Appliances ..........................277
Radiographic Cephalometric Reference Steel Wire Force .................... ............................ 277
Lines .. . . . . . .. ......... . . . . ......... . . . . . ....... 191 Differential Force .. , .............'" .........................279
Components of Cephalometric Analysis ...........192 Orthodontic Appliance Force and
Evaluation of Growth and Orthodontic Therapy Resistance ....................................................... 279
Changes.............................. 195 Torque ................................................................. 279
Bibliography .......................................................196 Coil Spring Force................................. 280
Archwire Loops ..................................................281
l6. Cephalometric Analysis........................... 197 Elastic Force ....................................................... 283
Bibliography ....................................................... 285
The Downs Analysis .......................................... 197
Ricketts' Analysis................................. 202 The
21. Appliance Construction and Use ............................ 288
Margolis Maxillofacial Triangle......... 203
Bjork's Facial Analysis .. ................. .. .. .. .......204 Basic Requirements of Orthodontic
Crowding of the Teeth ..................... .. .. . .. .....206 Appliances ...................................................... 288
Sassouni's Radiographic Cephalometric Lingual Appliances ............................................ 288
Anal ysis .........................................................206 Methods of Separating Teeth
The Moorrees Mesh Diagram ............................ 20; for Banding ..................................................... 292
Bibliography ..................................................... 210 Stainless Steel Appliances ................................. 292
Contents . ix
Soldering Precious Metals ................................... 293 Treatment in Severe Microglossia and
The Hawley Retainer ........................................... 294 Mandibular Dental Arch Collapse ................... 333
The Removable Stabilizing Plate ........................ 296 Bibliography ......................................................... 334
Acrylic Retainers ................................................. 298
The Extraoral Appliance ...................................... 300
Jumping the Bite .................................................. 304 24. Diagnosis and Treatment in the Permanent
Sliding Jigs ........................................................... 305 Dentition ...........................................................335
Teeth Protectors ................................................... 305 Malocclusions .......................................................335
Bibliography ........................................................ 306 Incomplete Dentition ............................................335
Ectopy and Impaction ...........................................335
Case Reports .........................................................344
22. Diagnosis and Treatment in the Deciduous Extreme Maxillary Protrusion . .. . .. ....................344
Dentition .. . . . . . . . . .. ................ . . . . . . . . .. . .. Bimaxillary Prognathism ......................................350
307 Orthodontics in Mandibular Resection .................364
Types of Normal Occlusion in the Surgical Orthodontics........................... 365
Deciduous Dentition .........................................307 Interception of Malocclusion in
Deciduous Dentition as an Indicator Scoliosis Patients ...............................................367
of a Normal Permanent Dentition ....................308 Teeth Protectors .................................................... 368
Indications for Treatment in the Bibliography ......................................................... 372
Decid uous Dentition .. .. .. .. .. . .. .. .. .. .. ... 309
Contraindications to Treatment in the 25. Orthodontic Treatment of Adults ...............................373
Deciduous Dentition .........................................310
Timing of Occlusal Guidance ...............................310 Psychodynamics of the Adult Patient ...................373
Estimates of Dental Age in the Tissue Tolerance in Adult Therapy .......................373
Deciduous Dentition ........................................ 310 Scope of Orthodontics for Adults 376
Early Treatment in Class III Case Report ...........................................................377
Malocclusion .................................................... 310 Treatment of Abnormal Overbite ......................... 379
The Chincap ......................................................... 310 Bruxism ................................................................ 381
Indications for Deciduous Tooth Orthodontics in Occlusal Rehabilitation .............. 381
Extraction ......................................................... 312 Bibliography ......................................................... 386
Premature Loss of Decid uous Teeth .................. 314
Effect of Sequence of Tooth Eruption 26. Orthodontics in Cleft P ala te Therapy......... 387
on the Deciduous Dentition ............................. 315
Diastemas in the Deciduous Dentition ................ 316 Etiologic Factors ................................................... 387
Spacing of Teeth .................................................. 316 Types of Cleft Lip and Palate ............................... 387
Crossbite ............................................................... 316 Dental Abnormalities ............................................ 387
Thumb and Finger Sucking .................................. 318 Orthodontic Intervention ......................................389
Nailbi ting ............................................................. 318 Cleft Palate Orthopedics .......................................396
Bibliography ......................................................... 319 Cleft Palate Speech ...............................................403
Bibliography ..........................................................406
23. Diagnosis and Treatment in the Mixed Dentition . . . . .
. . . . . .. .. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 321 27. The Edgewise Appliance
Scope of Treatment ..............................................321 R. William McNeill, D.D.S., M.S ................................ 408
Indications for Treatment .....................................321 Development .........................................................408
Anteroposterior Occlusal Changes ......................321 Appliance Components .........................................410
Genetic Influence on Dentofacial Band Fitting and Bracket Placement ....................412
Changes in Monovular Twins ..........................322 Archwire Formation ..............................................414
Orthodontic Treatment and Favorable Reciprocal Tooth Movement and
Growth Changes ...............................................324 Achorage ...........................................................419
Orthodontic Treatment and Unfavorable Case Reports ........................................................ 421
Growth Changes ......................................... :.. 327 References .............................................................433
Influence of Treatment Timing on
Dentofacial Changes ........................................330
28. Direct Bracket Attachment to Enamel
Two-Stage Treatment in the Mixed
Without Banding Teeth
Den tition .............. . . . . . . . . .. ....... . . . . . . .. . ..
330 Fujio Miura, D.D.S., PH.D. .. .................. 434
Changes in the Two-Stage Therapy Bonding Technique .............................................. 434
wi th Favorable Growth ....................................330 Removal of Bracket .............................................. 435
Prognostic Factors in Treatment Clinical Use of Brackets ....................................... 435
in the Mixed Dentition .....................................331
x . Contents
29. The Begg Technique Skeletal-Dental Reaction ............................. : .... 552

Raleigh Williams, D.D.S., M.S.D .................................... 438 Results ........................................................... .....552
References ..................................................... ..... 554
Three Fundamental Concepts .............................438
Stages of Begg Treatment ..................................438
Effectiveness of Begg Treatmen t ......................... 438
34. The Activator
Appliances .......................................................... 440
Donald G_ Woodside, D. D.S ................................ : ............. 556
Diagnosis in Begg Treatment ............................ 442 t
Illustrative Case Histories .................................. 442 Possibilities and Limitations ...............................558

Reten tion . . . . . . .. . . . . . . . . . . . . . . . . . . . . .. .. . . .. Functional Occlusal Plane Changes in
459 Class II Treatment ...........................................568
References ..................... .................................... 459 Bi te Registration and Theories of Action ..........570
Construction of the Activator .............................578
30. The Twinwire Appliance: Construction and Further Considerations in Appliance
Use in Treatment Construction and Manipulation for
Earl E. Shepard, D.D.S .................................................... 460 Class II Correction ..........................................586
The Labial Arch ................................................. 460 The Use of the Activator in the
Molar Appliance ................................................ 461 Management of Class III
Anterior Bands ................................................... 461 Maloccl usions . .. .. .. .. .. .. .. .. . .. .. .. ........... 588
Headgear Attachment ........................................ 462 Advantages and Disadvantages of
Coil Springs ....................................................... 462 Activator Therapy ........................................... 590
Cases Involving Extraction ............................... 462 Indications and Contraindications ...................... 591
Bibliography .......................................................477
31. Labiolingual Technique 35. Tissue Changes in Orthodontic Tooth

H. K. Terry, D.M.D ............................................................... 480 Movement
Kaare Reitan, D.D.S ............................................................592
Band Technique ................................................. 480
Construction of the Precious Metal Physiologic Tooth Movement ............................ 592
Lingual Archwire ........................................... 482 Tissue Changes as Related to the
Construction of the Stainless Steel Anatomical Environment ................................592
Lingual Archwire ........................................... 484 Continuous Forces ...............................................593
Construction of the Maxillary Lingual Methods of Tooth Movement............... 602
Appliance ....................................................... 486 Intermittent Forces, Removable
Construction of the Maxillary Labial Appliances .. .............................. .. .... .. .. .. ....605
Appliance ....................................................... 495 Tooth Movability ............................ ......... .........607
Case Reports ...................................................... 501 Pulp Changes ................................... ......... .........611
References .......................................................... 512 Root Resorption .............................. ......... .........612
References ....................................... ......... .........613
32. The Crozat Appliance in Theory and
Practice
W. Marshall Parker, D.D.S ........................................... 513 36. Retention and Relapse in Orthodontic
Therapy ...............................................................616
Construction of the Appliance .......................... 514
Insertion of the Appliances ................................ 521 Causes of Relapse ...............................................616
Adjustment ........................................................ 522 Prevention of Relapse .........................................616
Case Histories .....................................................527 Advantages of Early Treatment ..........................617
Results of Orthodontic Therapy ..........................618
Muscle Reactions to Orthodontic Force .............618
33. Midpalatal Suture Opening Variation Between Centric Relation and
Robert A. Wertz, D.D.S Centric Occlusion.............................. 618
542
History ................................................................542 Retainers ............................................................. 618
Indications ..........................................................542 Recrowding of Mandibular Incisors 619
Contraindications ...............................................546 Occlusal Mannerisms ......................................... 620
Records ...............................................................546 Relapse After Incisor Extraction ........................ 620
Appliance Construction and Third Molar Eruption and Incisor
Manipulation .................................................. 546 Recrowding ..................................................... 620
Stabilization ........................................................ 549 Related Factors in Retention and
Retention ............................................................ 550 Relapse ............................................................ 620
Forces ................................................................. 550 Occlusal Equilibration ........................................ 623
asal Area Changes ..........................................551 Bibliography ....................................................... 626
Contents . xi
37. Orthodontics in Public Health and Defining Handicapping Malocclusion .................629

Prepayment Programs ......................................... 628 Trea tmen t Desirabili ty .. ......... .. .. .. ...... .........638
Organization of Public Health Bibliography .................................. ......... ............643
Orthodontic Programs ..................................... 628
Principles in Administration of Public Index .............................................................................. 645
Health Orthodontic Programs ......................... 628
Dedication
"I hold it for courtesy and ample proof of an honorable
modesty to acknowledge by whom one has profited." The
Elder Pliny (23 A.D.) "Natural History"
This book is accordingly dedicated to those responsible
for the development and progress of orthodontics.
1
Principles of Orthodontic Therapy
Definition: Orthodontics is a branch of the science and of "straight teeth" by the patient and his or her immediate
art of dentistry that deals with the developmental family. This is influenced by the age and sex of the patient
pathologic and positional aberrations of the teeth, the as well as by the general valuation accorded "straight
jaws and the orofacial soft tissues. teeth" by the ethnic group and the cultural environment.
Scope of Orthodontics: Orthodontics encompasses, Malocclusions hazardous to dental health and function
directly and indirectly, physical anthropology, biometrics or detrimental to facial appearance are not always so rated
biomechanics, gnathostatics, endocrinology, genetics, by the patient or the immediate family. Conversely,
pediatrics, dietetics, and most of the health sciences. malocclusions of minor importance have been known to
Orthodontic principles underlie every phase of dental act as a deterrent to a person's social and environmental
practice. Orthodontics is an important factor in the adjustment and achievement.
maintenance of dental, oral, and general health, It is important to take into consideration the patient's
masticatory function, and personality adjustment when attitude toward the malocclusion and the desire to correct
facial esthetics are involved. it. The patient's attitude is an important factor in the
achievement of a successful treatment result.
The techniques followed in treatment must be
PUBLIC HEALTH ASPECTS acceptable to the patient and suitable for the correction of
With the growth of public and private prepayment the malocclusion. The operator should be expert in the
dental care programs the latent potential need for dental manipulation of the appliance used. However, he should
care, including orthodontic treatment has been translated be familiar also with the advantages and disadvantages of
into an active demand. various appliances employed in orthodontics and choose
The change in dentist-patient relations brought about those appliances that will enable him to obtain the best
by the active participation of the "third party," those results.
responsible for the funding and conduct of public health
and private prepayment dental care programs, has
affected not only the extent but also the very nature of
dental practice.
Whether the severity of a malocclusion is such as to
ESSENTIALS OF ORTHODONTIC PRACTICE
require the services of a specialist in orthodontics or
whether it can be treated by the generaLpractitioner must An understanding of normal and abnormal dentofacial
be determined on an individual basis. In the final analysis growth and development are basic requirements if the
the decision depends on the orthodontic education, patient is to benefit from the treatment. There are many
treatment ability, and experience of the dentist. phases of orthodontics that should be performed by the
family dentist even if he does not practice orthodontics in
general. In any event, the family dentist should be
.- prepared to discuss and counsel parents on the orthodontic
Patient Motivation
needs of their children.
Motivation of patients to seek orthodontic treatment - Malocclusions express themselves clinically in
and this applies also to dental service in craniofacial abnormalities and poor relation of the dental
_ general-does not depend as much as is generally believed arches; tooth crowding, spacing, and rotation; proximal
on socioeconomic status, level of education, or even contact alterations and changes following premature
elimination of the financial block through prepayment shedding or prolonged retention of deciduous teeth;
programs. The determining factor in the demand for supernumerary teeth; agenesis of tooth
orthodontic care is the appreciation
1
2 . Principles of Orthodontic Therapy
germs; and postnatal loss of teeth. Spacing of teeth, THE CHILD AS AN ORTHODONTIC PATIENT
crossbite, and openbite predominate in the deciduous
Orthodontic treatment can extend over months or years.
dentition, while crowding and rotations and dental arch
If the proper dentist-patient relationship is not established
malrelation are more frequently found in the permanent
at the beginning, even before mechanotherapy is
dentition.
instituted, successful results will be found unobtainable.
Orthodontic therapy primarily requires an under-
Most children will accept orthodontic treatment if the
standing of the dynamics of growth and development and
reasons for it are explained in terms they can understand.
of the general health status of the patient, in addition to a
Information should be given the child without hesitation
broad knowledge of the dentofacial complex. While
and in an authoritative manner. The child is a captive
abnormal jaw relation can be easily recognized in the
patient; usually forced by the parents to accept treatment,
young child, positional anomalies of individual teeth in
he is apt to be uncooperative. If he is to cooperate, the
children with mixed dentition cannot always be diagnosed
child should be induced by mutual understanding to accept
as requiring treatment on the basis of a single dental
the treatment on his own volition. Repeated broken
examination.
appointments and broken appliances are evidence of non-
The frame of reference in the treatment of maloc-
acceptance of treatment by the patient. Time taken to
clusion, and of general dental practice, cannot be confined
explain the treatment and to establish mutual
to mechanics alone. Every dental examination should take
understanding will dispel the patient's fears. Treatment
into consideration the state of the occlusion, the method of
time and waiting time per visit should be as short as
swallowing, over retained or prematurely lost deciduous
possible. Time intervals seem longer to young children
teeth, shifting and loss of permanent teeth, supernumerary
than to adults.
teeth, and other conditions that can interfere with the
Children whose mothers have a high anxiety level
developing occlusion of the child's teeth and eventually
exhibit more negative or uncooperative behavior than
with the dental health of the adult.
others. The mother's anxiety, her prediction of her child's
untoward reaction to the treatment, and her rating of the
child's level of anxiety, especially when made in the
presence of the child, .are significantly related to the
Scope
child's cooperation: Bhnd obedience should not be
expected of the patient. It may at times be beneficial to
Orthodontic practice deals directly or indirectly with the postpone orthodontic treatment until the child can
following: understand and appreciate its value.
1. Guidance of occlusal development. The effectiveness of the orthodontist is diminished
when his attitude to the child becomes intolerant and
2.Elimination of impairment of masticatory function
resentful. Impatience places the child on the defensive and
caused by dental malocclusion.
diminishes confidence in himself and in the orthodontist.
3. Reducation of susceptibility to dental caries caused
Patient listening and straightforward replies to the child's
by dental irregularities.
questions make treatment easier for the patient to accept
4. Correction of dentofacial abnormalities of genetic,
and for the orthodontist to accomplish.
congenital, and environmental origin.
All patients do not have the same threshold for pain and
5. Improvement of dentofacial esthetics.
discomfort. What appears to be undue complaining by the
6.Elimination of periodontal disease and other
patient may be the real response brought about by mental
conditions of the oral tissues resulting from malocclusion.
as well as physical discomfort, although the same
7. Correction of shifted teeth prior to the construction
operation may not be quite as objectionable to other
of bridges and partial dentures.
patients.
8. Elimination of harmful dentofacial habits.
The child who requests a hand mirror to see "what is
9.Correction of temporomandibular abnormalities
going on," should be given a mirror if it is apparent that
caused by malocclusion.
denial of the request will lessen cooperation. It will soon
~mportant requirements in the orthodontic treatment of be found that the child tires of the mirror and forgets to use
young children are (1) knowledge of the development of it.
normal occlusion and the time sequence in the The parents should be told in simple language the
development of the dentition, and (2) the ability to importance of their continued interest and coopera-
recognize the rate of a child's general physical maturation
in relation to the development of the dental growth
pattern.
General Dental Care . 3
bon in the treatment to be undertaken for the child. It is sion or facial defects, the patient may evidence certain
better to foster a kindly parent-child relationship than to unusual traits and personality changes. The orthodontist
ask parents to "police" the treatment, which can result in should alert parents to this possibility.
undue parent-child tensions.
GENERAL DENTAL CARE
The Adolescent Patient
Oral Hygiene
The orthodontic appliance is a symbol of childhood to
the adolescent. Adolescents resent the implication of Patients should be instructed in tooth brushing before
abnormality in any part of their body. This seems to apply and after appliances are inserted in the mouth. While
especially to the teeth. The adolescent may deny that the orthodontic appliances do not cause dental caries, they
teeth require "straightening," especially if they are not provide increased possibilities for the retention of food
grossly disfiguring. When the condition is disfiguring, the debris. The patient must observe proper home care in
adolescent is tom between wanting the teeth straight and keeping the teeth and appliances clean in order to avoid
reluctance to wearing orthodontic appliances. It is better plaque formation and enamel etching. Parents should be
for orthodontist-patient relations if the adolescent patient notified in writing if the patient does not brush the teeth as
comes for treatment alone or with a friend and is nbt instructed, and when general dental treatment is necessary.
escorted by the mother. Orthodontic bands and other appliances should not be
placed on carious teeth. Children with malocclusion tend to
have more caries than those with good occlusion.
PSYCHODYNAMICS
OF DENTOFACIAL MALFORMATIONS
The psychic effect of a dentofacial defect can be of

Fluoridation Treatment
greater importance to the patient than the actual handicap
warrants. What may appear to the orthodontist as a minor A study by Salzmann andAst of children in a fluoridated
deformity can be magnified in the mind of the patient until community in the State of New York showed that the
it becomes a dominant factor in personality adjustment. decrease in malocclusion was not caused directly by the
The possibility of psychic damage to the child through effect of the fluoride but by the dramatic reduction in the
tooth extraction, especially without permission, should be number of teeth lost through decay, and especially the
given consideration. Procedures that can have traumatic preservation of the permanent first molars. Topical fluoride
effects such as brute force, broken promises, and surprise treatment should be given before appliances are inserted. A
attacks should be avoided. Children who show personality marked reduction in caries and enamel etching has been
disturbances should receive special attention. found in teeth treated with stannous fluoride.
The orthodontist should not extract .rr push loose
deciduous teeth out of the mouth without permission of the
patient. If permission to extract is refused the extraction
should be postponed or the child should be referred to his Water Jets
own dentist. Extraction is looked upon by some children as Water pulsating devices can prove destructive to the soft
an aggression and may lead to continuing poor cooperation tissues of children if too strong a jet is used. Gingival
if performed against the will of the patient. tissues may show damage since the oral tissues in children
Malformations which are obvious to the onlooker, such are not fully keratinized and are less resistant to high water
as severe malocclusion, jaw malformations, cf~ft lip, and pressures than those of adults. Transient bacteremia related
cleft palate, frequently are attended by p~ychosomatic to bacterial endocarditis has been found in patients with
complications that may require counselling to assure papillary gingivitis following the use of strong pulsating
acceptance by the patient of his improved appearance. water irrigation devices. These devices, while beneficial
Patients should be reassured from time to time that their when properly employed, should not be used on inflamed
abnormal dental condition is being corrected. Some adults soft tissues.
with malocclusion have been known to become obsessed
with their dentofacial deformity. After the correction of
severe malocclu-
Preliminary Dental Treatment
Completion of dental operations such as fillings,
extractions, prophylaxis, and other services should precede
orthodontic procedures. Interproximal fill-
4 . Principles of Orthodontic Therapy
ings should be completed the same day started in order to ---: Nutrition research of dental significance: 19601962. J, A.
avoid gingival packing of temporary stopping and shifting D. A 66:607,1963.
of teeth. Teeth should be cleansed of tartar and debris. The Faubion, B.' H.: Treatment analysis and diagnosis: A review
of the literature. Am. J. Orthodontics, 52:103, 1966.
lysozyme in the saliva may act as a caries-inhibiting agent
Fisk, R. 0.: Physiological and sociopsychological significance
on clean teeth.
of malocclusion. J. Canad. D. A 29:635, 1963.
Teeth have a variable resistance to caries attack.
Fullmer, H. M., Martin, G. R, and Burns, J. J.: Role of
Enamel etching of teeth is not necessarily an indication of
ascorbic acid in the formation and maintenance of dental
caries. Such teeth can remain caries-free, and in some cases
structures. Ann. New York Acad. Sci., 129;286-294, 1962,
the etching may disappear. Etching may occur in teeth of
Fulton, J. T,: Suggested principles for public orthodontic
children with a high caries incidence. Copalite mixed with a
small amount of chlorobutanol can be used as a coating to programs for children. Am. J. Orthodontics, 34:777, 1948.
---: Orthodontics as a health service. Am. J. Orthodontics,
protect teeth under orthodontic bands .
36:336, 1950.
. Orthodontic bands should be adequately cemented, and
Galanter, D, R., and Minami, R. T.: The periodontal status of
appliances kept clean. Bands should not impinge on gingival autografted teeth: A pilot study of thirty-one cases. Oral
tissues around the teeth. At each visit the orthodontist Surg., Oral Med. & Oral Path., 26:145, 1968.
should ascertain that all bands are well cemented and should Haas, A J.: Palatal expansion: Just the beginning of
regularly examine the teeth for possible caries. dentofacial orthopedics. Am. J. Orthodontics, 57:219,
1970.
Harrington, R, and Breinholt, V.: The relation of oral
mechanism malfunction to dental and speech develop-
ment. Am. J. Orthodontics. 49:84, 1963,
BIBLIOGRAPHY
Hawes, R. R: Report of three patients experiencing
juvenile periodontosis and early loss of teeth. J. Dent.
Ando, Y. J.: Psychological responses of patients in ortho- Child., 27:169, 1960.
dontic treatment. J. Nihon Univ. School Dent. 3:134, Hellgren, A.: On the relationship between some occlusal
1961. characteristics and periodontal disease, Report of 30th
Ast, D. B.: The Newburgh-Kingston caries fluorine study. Congress, European Orthodont. Soc., The Hague, Holland,
VII. Correlation of ingested water fluorides to dentofacial 1954, p. 221.
development. Am. J. Orthodontics, 41 :45, 1955. Ingervall, B.: The influence of orthodontic appliances on
Autissier, J.: Preventive orthodontics in relation to perio- caries frequency. Odont. Revy., 13:175, 1962.
dontal disease. Internat. D. J. 13 :386, 1963. James, G. A, and Beagrie, G. S.: The care of the periodontal
Bach, E. N.: Incidence of caries during orthodontic treat- tissues during orthodontic treatment. Dent. Practitioner
ment. Am. J. Orthodontics, 39:756, 1953. 13:268,1963.
Ballard, C. F.: Discussion of the mouth breather, Proc. Jamison, H. C;; Prevalence of periodontal disease in the
Roy. Soc. Med., 51:279, 1957. deciduous teeth. J. A. D. A 66:207, 1963.
Berendt, H. c., and Brand, A: Somatische an psychologische Klein, E. T.: The thumb-sucking habit: Meaningful or empty.
aspecten van vingerzuigen. (Somatic and psychologic Am. J. Orthodontics, 59:283, 1971.
aspects of finger sucking), Tijdschrift V. Tandh., 65:11, Kramer, 1. R H.: Alveolar bone in health and disease with
1958. special reference to local practice, Dent. Practioner,
Berger, H.: Integral diagnosis: A pragramatic approach to 12:327, 1962.
case analysis and treatment planning in orthodontics. Krogman, W. M.: Introduction, Am. J. Orthodontics,
Israel J. D. Med., 21:1,1972. 61:219,1972.
Bhaskar, S. ., et al.: Water jet devices in dental practice. Maj, G., Squarzoni Grilli, A T. and Belletti, M. F.: Psy-
J, Periodont., 42:658, 1951. chologic appraisal of children facing orthodontic treat-
ment. Am. J. Orthodontics, 53:849, 1967.
Bien, Saul, M.: The mechanism of tooth movement: An
Markus, M. B.: The reaction of the pulp to pressure, Am. J.
investigative approach. J. Dent., 36:191, 1966.
Orthodontics & Oral Surg., 32:682,1946.
Burket, 1. W,: The effects of orthodontic treatment on the
Mieler, I. and Reimann, H.: The frequency of periodontal
soft periodontal tissues. Am. J. Orthodontics, 49:660, " diseases in children and youth aged 3 to 18 years.
1963. Paradontologie, 2:101, 1968.
j;lurton, R c.: The problem of facial pain. J.AD.A., 79:93, ~ Miller, J., and Hobson, P.: The relationship between
1969. malocclusion, oral cleanliness, gingival conditions and
Carman, J. L.: Arrested root absorption during orthodontic dental caries in school children. Brit. D. J., 114:33, 1961.
treatment. Int. J. Orthodontia, 23:35, 1937. Parfitt, G. J.: A five year longitudinal study of the gingival
Derichsweiler, H.: Beeinfliissung der apikalen Basis durch condition of a group of children in England. J. Periodont.,
kieferorthopadische Massnahmen. Fortschr. 28:26, 1957.
Kieferorthopadie. 24:46, 1963.
Dreizen, S,: Diet and dental decay. lllinois D. J., 32:20,
1963.
'--/
Bibliography . 5
Posselt, U., and Emslie, R D.: Occlusal disharmonies and their ---: An answer to "How much orthodontics shall the pedodontist
effect on periodontal disease. Internat. D. J., 9:367, 1959. do?" Am. J. Orthodontics, 44:630,1958. ---: Biology,
Poulton, D. R: Electric pulp testing in orthodontic patients. orthodontics and the modification of man. Am. J. Orthodontics,
J. Dent. Child., 28:308, 1961. 47:924,1961.
---: Evaluation of space-closing techniques with the aid of ---: You and your patient. New York Univ. J. Dent. 21:109,1963.
laminagraphic cephalometries. Am. J. Orthodontics, 54:899,
---: Prevention of malocclusion and the practice of general
1968.
dentistry. Am. [. Orthodontics, 51 :706, 1965. ---: Role of
Ratcliff, P. A.: Relationship of periodontists and orthodontists
kiriesthetics and oral motor function in orthodontic therapy. Am.
with special reference to the periodontal problems created and
]. Orthodontics, 59:89, 1971. ---: Reliability of prediction in
helped by orthodontists, p. 11, Bull. Pacific Coast Soc.
orthodontics. Am. J.
Orthodorit., July, 1961.
Orthodontics, 61 :518, 1971.
Reitan, K.: To what extent can orthodontics be a contributing
---: An Appraisal of Surgical Orthodontics. Am. J.
factor in the treatment of periodontal cases? - orske Tan. Tid.
70:476-481, 1960; 70:527-533, 1960.
Savara, B. S.: The role of computers in dentofacial research and
Ricketts, R. M., Bench, R W., Hilgers, J. J., and Schulhof, R:
the development of diagnostic aids. Am. J. Orthodontics, 61
An overview of computerized cephalometries. Am. J.
:231, 1972.
Shapiro, M.: Orthodontic procedures in the care of the
Rowe, M. H.: Hemifacial hypertrophy: Review of the literature
periodontal patient. J. Periodont., 27:7, 1956.
and addition of four cases. Oral Surg., Oral Med. & Oral
Spence, W. J.: A clinical and histological study of pathology of
Path., 50:572, 1962.
gingivae during orthodontic tooth movement. Brit. D. J.,
Salzmann, J. A.: Diagnosis in orthodontics: Theory and practice.
100:358, 1956.
Am. J. Orthodontics, 28:414, 1942.
Stuteville, O. H.: Injuries to the teeth and supporting structures
---: Orthodontic therapy as limited by ontogenetic growth and
caused by various orthodontic appliances and methods of
the basal arches. Am. J. Orthodontics, 34:297, 1948.
preventing these injuries. J. A. Dent. Ass. & Dental
---: Discussion. A review of orthodontic research, 1946-1950.
CosmOS,24:1494, 1937.
Internat. D. J., 3:356, 1952.
Use of computers in orthodontic analysis and diagnosis:
---: Facial asymmetry in the newborn. Am. [. Orthodontics,
A symposium. Am. ). Orthodontics, 61:219, 1972.
39:954, 1953.
York, T. A. and Dunkin, R. T.: Control of periodontal problems
Salzmann, J. A., and Ast, D. B.: The Newburgh-Kingston
in orthodontics by use of water irrigation. Am. ].
fluorine study. IX. Dentofacial growth and development-
Orthodontics, 53:639, 1967.
cephalometric study. Am. J. Orthodontics, 41:674,1955.
Zachrisson, B. U., and Sigrun Zachrisson, S.: Caries incidence
and oral hygiene during orthodontic treatment. Scand. J. Dent.
Res., 79:394, 1971.
f-
2
Growth of the Face
DEFINITIONS OF GROWTH AND during the first 2 years after birth. The cranial base does not
DEVELOPMENT reach 90 per cent of adult size until about the 13th year.
Dental abnormalities of occlusion can exist in the presence
Growth is the physicochemical process by which an of a normal cranial base.
organism becomes larger. Development is the sequence of Bones of the face and cranium are polygenic in origin.
changes from fertilization to maturity. Development mayor Each of the facial bones is developed according to its
may not show itself as an increase in size. It consists of specific genes. Thus, they have independent developmental
histologic, morphologic, functional, and maturative and growth vectors. Van der Klaauw considers the skull to
changes. Normal growth in a child cannot be assessed be composed of more than 30 relatively independent
against statistical averages; rather a range of growth functional units, each governed by its own functional
measures accepted as normal according to genetic, ethnic, growth center. Scott divides the craniofacial skeleton into
internal and external environmental factors and in keeping eight different regions, each having its own growth pattern.
with the child's own rate of growth and development However, the bones can be grouped also by specific
should be the standard of comparison. functional muscle attachments and nerve supply, what
Moss calls functional matrixes. Disturbances in a functional
matrix can show themselves in modification of the
GROWTH OF THE SKULL morphology of the jaws and malposition of the teeth.
The growing skull does not balloon out at an equal rate

in all directions; all growth centers are not active at one
time. This can be seen in the size and outline of the bones
of an infant's skull compared with those of an adult. The
Cranial and Visceral Areas 01 the Head
greatest increase in size of the skull is in anteroposterior
depth, relatively less in height, and least in breadth. The head can be divided into cranial and visceral
Circumference of the cranium increases from 65 to 90 per portions. The visceral portion of the skull includes the face
cent of adult size below the orbits, the cephalic end of the
Figure 2-1. The body proportions change

radically with development. The skeleton (A)
and musculature (B) of a newborn are compared
with those of an adult. (Boyd, E.: Outline of
Physical Growth and Development
Minneapolis, Burgess, 1941)
6
4.
3.
Growth of the Skull . 7
Fig. 2-2. (A) The skull of a newborn registered at porion and superimposed along the
Frankfort horizontal on the skull of an adult. (B) The decided increase in absolute facial size
and in proportion to the entire skull proceeds from birth to completion of skeletal growth. The
skulls shown here are registered on the Frankfort horizontal. (C) (Top) skulls, registered on the
nasion, demonstrate differences in proportion and in overall size. The cranium occupies a
larger proportion of the child's skull. The adult's face is not only larger but also occupies a
larger proportion of the skull than the child's. (Bottom) the lateral views of the child of 3 years
and the adult - registered on the Frankfort horizontal-are compared.
&rth & Adult A
3yrs. Adult
Anterior lateral
fontanel
Fig. 2-3. The face, like the skull as a whole, is never truly
symmetrical. (A) Note the comparatively large orbits and the
narrow maxilla and mandible in this anterior view of a newborn's
skull. The occipital bone is not fused. The lower border of the
nasal opening extend only slightly below the orbital opening.
The greatest width of the skull equals or exceeds the combined
height of the cranium and face. In the adult, width is only three-
quarters of this dimension. Face width at birth is as 10 to 4. It is
as 9 to 8 in the adult. The right orbit is usually higher. The right
maxillary and malar bones may be more prominent than the left.
(8) Lateral aspect of the skull at birth. The face con ists
essentially of the jaws.
8 . Growth of the Face 5.
Fig. 2-4. Structural details

of a long bone. (a) Longitu-
dinal section; union of epiph-
yses with diaphysis at line of
Nerve epiphyseal fusion is evident.
(1, 2, and 3) Enlargements
Lamellae ~."
come from areas indicated by
Haversian canal t squares and arrows. (1)
Periosteum @. Periosteum and compact

bone, longitudinal section;
shows structures entering
haversian canal. (2) Portion
Endosteum Muscle of muscle attachment, en-
attachment -Compact bone larged; fusion of tendon
b Medullary fibers with periosteal fibers.
cavity (3) Microscopic section of
bone marrow. (Red bone
marrow shown; not from
Diaphysis
correct location, for con-
venience of illustration.) (b)
Artery
Cross section through di-
aphysis. (4) Periosteum and
compact bone, cross section
Medullary cavity
enlarged from area indicated
in (b); shows contents of
haversian canal.
Reticular
(Greishemer. E. and
tissue - Bone marrow Wiedeman, M.: Physiology
and Anatomy. ed. 9.
Philadelphia, J. 5. Lippincott,
""' ................................................... . 1972)
Eosinophil
E rythrob lasts
a
alimentary tract, the oral cavity, the respiratory organs, the traumatic ongm. It may be caused by a malformed
maxilla, the mandible, and the teeth. The close condyle, by neurogenic activity, and by habits.
interrelation of the visceral structures of the head is The inherent growth pattern of the face is influenced in
evident from the very beginning of their development. its developmental course by function, growth of the
here is a wide divergence between cranial and visceral sinuses, development, form, and position of the teeth, the
growth. Postnatal changes in the visceral part of the face facial musculature, the tongue, and countless general,
are much greater than in the cranial. The greatest changes physical, and environmental factors. Growth of the face,
are those in the dentofacial region, especially in the jaws. especially of the mandible, extends over a longer period of
At the age of 6 years, the braincase is almost of adult size, time than growth of the other parts of the head. The face is
but the jaws and the face are still characteristically therefore longer under the influence of environmental
infantile. factors, and its growth consequently is more irregular and
Facial asymmetry may be caused by genetic influence. unpredictable. An annual record of the growth rate in face
It may be congenital, or of pre- or postnatal height can be of practical value in deterrnin-
6.
7. Role of the Bone in Orthodontic Therapy . 9
ing the stage of development and the timing and plan of

orthodontic treatment.
ROLE OF BONE IN ORTHODONTIC THERAPY

Bone structure changes in overall outline in response to
pressure, tension, vascular, endocrine, nutritional, and
other influences. Bone responds directly or indirectly to
the stresses exerted on it by the muscles, by mechanical
appliances, and by the disturbance of the equilibrium of
the periodontal ligament by orthodontic appliance force
and other pressure and tension causes. It is on the lability
of bone that orthodontic tooth movement is based.
Fully formed bone shows a structural arrangement
intended to withstand the maximum amount of pressure
and tension to which it is normally exposed. Changes in
bone function bring about changes in external form and
internal architecture. However, the architecture of the jaws
of the newborn shows the arrangement of the trabeculae Fig. 2-5. Lateral aspect of facial bones of a fetus. The
and bone architecture to be in line with functional stress trabeculae of the cancellous bone in the maxilla molar, and
even in the. prefunctional state (Fig. 5). mandible run in the direction of functional stress although
the bones are still in their prefunctional state. (Courtesy of
Spencer R. Atkinson)
Types of Bone Formation

Lability of Bone
Intramembranous bone forms through the activation of
Because bone is hard and rigid, its lability is not osteoblasts, specialized bone forming cells, in one of the
immediately apparent. As the child grows bone is further layers of fetal connective tissue. The bones of the cranium,
sha ped to the requirements of the body. the face, and the clavicles are
Fig. 2-6. (a) The diameter of the nar-

row condylar neck is progressively re-
duced from the wider dimensions of the
posterior-moving condyle. Inward
growth of the buccal and lingual cor-
tices (cJ is accomplished by a com-
bination process of periosteal resorption
(-) and endosteal deposition (+). This is
an example of the V principle (b).
(Enlow, Am. J Orthod.)
c
intramembranous in origin. All other bones in the body later it is divided into an oral and a nasal portion.
are formed from cartilage. When the mandibular processes of the first branchial
arch are fused, and the frontal and maxillary processes
The Mandibular Condyle complete their fusion, the mouth appears as a slit covered
with membrane. The nasal cavity and the mouth are not
There is no interstitial growth of bone in the human separated until some time during the third fetal month,
body with the exception of the mandibular condyle. when horizontal oral ingrowths - known later as the
Certain parts of the mandibular condyle are of lateral palatine processes - and the extension from the
membranous origin and others are of carti1aginous fron tonasal process unite to form the palate. The lateral
origin. The growth of the condyle can be influenced by wall of the medial nasal process and the medial wall of
mechanical stimulation, especially in young children the lateral nasal process must come into contact for fusion
during active growth. to occur. Underdevelopment of one or the other process
prevents this contact, in which event fusion does not
occur and clefts result. The genetic factor in cleft lip and
ORIGI OF THE ORAL CAVITY
palate frequently is misunderstood because a recessive
The embryonic stomodeal depression, the anlage of gene is involved and there may be many cases of children
the oral cavity, is bounded by the overhanging with clefts born into a family with a negative history of
frontonasal process, the paired lateral nasal processes cleft palate and vice versa (Fig. 2-7).
above, the paired maxillary processes laterally, and the
mandibular arch below. In early embryonic life the
stomodeum consists of a single chamber;
GROWTH OF THE MANDIBLE
Fronto-nasal "-
process
........ Enlow pointed out that the mandible becomes
Lateral nasal process displaced forward and downward while it grows
predominantly upward and backward. Actual growth -in
Primitive
oral cavity the forward area at the chin itself is
Fig. 2-7. (Top) Head of human embryo of about 33 days,

showing boundaries of primitive oral cavity. (Drawn from model
of His. X 7.) The mandibular processes have joined, giving rise to
the mandibular jaw and other tissues and forming, with the aid of
the second visceral arch, the inferior boundary of the primary
oral cavity and the floor of the mouth. The frontoriasal process
has differentiated into the lateral and mesial nasal processes.
Toward the close of the 6th week, the maxillary processes of the
first branchial arch approach the midline where they unite with
the lateral margins of the respective mesial nasal processes of the
frontonasal process and with the lateral nasal process on each
side, thus beginning the separation of the nasal pits -from the oral
cavity. With the completion of the palatal septum, the isolation of
the nasal fossae from the mouth is effected. From the conjoined
mesial nasal processes are developed the nasal septum, the bridge
of the nose, the middle portion of the upper lip and the
intermaxillary segment of the upper jaw; the rest of the upper jaw
being developed from the maxillary processes of the first
branchial arches. Arrested development and imperfect union
between the maxillary processes and the frontoriasal process
result in cleft lip and cleft palate. Piersol-]. B. Lippincott (Center)
Head of a fetus of 42.5 mrn., seen en face and in profile (X 2.5).
The mandible is now in prognathous relationship to the maxilla.
(After Retzius) so stated by Keibel and Mall (Bottom) Head of a
fetus of 117 mrn., in profile. Natural size. Note the mandible is
again in distal position. (After Retzius. From Keibel and Mall; J.
B. Lippincott Co.)
- 9.
Growth of the Maxilla . 11
slight. The marked lengthening process takes place at the Fig. 2-8. (A) Nasal sep-
posterior ends. This represents the dominant mode of tum (NS), Frontal process NS
enlargement. IT
(F.P.), palatal process pp
Underdevelopment of the mandible, and overgrowth of (P.P.), tongue (T), and
the mandible, are mainly independent of the growth of the Meckel's cartilage with
maxilla and vice versa. Forward translation of both jaws mandibular bone to the
A
increases during growth, the mandible increasing relatively right and left. (B) Frontal
more than the maxilla. The increase in jaw length is greater section of the face of a
than the forward growth of the cranial base. When this human embryo. The oral
occurs it gives the lower face a more advanced position in cavity (D. C.) has not yet
D
relation to the base of the skull as the child grows older. LT
separated from the nasal
Increase in ramus height contributes to the forward rotation cavity; dental lamina B
of the mandible. (D.L.) is present; the
The mandible in the newborn infant shows trabecular tongue is now below the
arrangements in line with functional force even before palatal processes. (C)
function asserts itself. 1 ~1e jaws will grow in the presence Frontal section through the
of anodontia if muscle function is not impaired. head of a human embryo D
Mandibular growth is retarded when the mandible is l
at about 8 weeks shows T
ankylosed and the vector of growth is disturbed. the anlage of the maxilla
Bjork describes three types of forward rotation of the (Max.), the dental lamina
mandible. and the oral cavity is
(D.L.), the tongue (T), and
Type I. Forward rotation with the centers of rotation at separated from the nasal
the beginning of the
the temporomandibular articulations. This results in deep cavity.
mandible (Man.). The
overbite with underdevelopment of anterior face height. GROWTH OF
palatal processes have now THE MAXILLA
Type II. Forward rotation with the center of rotation joined,
Growth in the maxilla, as in the mandible, occurs mostly
located at the incisal edges of the mandibular incisors. This in a posterior and superior direction with displacement in
is caused by marked development of posterior face height an inferior and anterior direction. The many parts and areas
and normal increase in anterior height. of the whole maxillary bone, grow in a complex variety of
Type III. In cases with abnormal maxillary or regional directions, and the entire bone is involved in these
mandibular overjet the center of rotation is displaced multidirectional growth movements.
backward to the premolars. Anterior face height is The appositional growth on the oral surface of the hard
underdeveloped as posterior face height increases and a palate, with resorption on the nasal surface, tend to lower
deep bite develops. the palate and reduce the size of the oral cavity. The
downward and forward rotation of the mandible more than
compensates for this reduction. In addition, growth of the
maxilla - including the maxillary alveolar process - also
tends to in-
Fig. 2-9. Growth additions

in the mandible make re-
modelling necessary in order
to adapt the dimensions and
re~ional shaping of the in-
creases. The dark stippling
indicates the areas that
undergo progressive bone re-
moval. Surfaces that are de-
pository are indicated by
light stippling. As bone is
added, all parts undergo
shifts in relative position.
(Enlow, D. H.: The Human
Face, ew York, Harper, Row,
1970)
12 . Growth of the Face
Fig. 2-10. The distribution of re-

gional depository (light stippling) and
resorptive (dark stippling) areas. The
letter t indicates areas where variation
normally occurs in the location of the
reversal line between resorptive and
depository surfaces. As the maxilla
becomes displaced anteriorly new bone
deposits are progressively added onto
the periosteal surfaces of the maxillary
tuberosity which faces posteriorly.
Continued bone deposition results in
posterior growth, increasing the
anteriorposterior dimensions of the
maxilla. (Enlow, D. H.: The Human
Face, New York, Harper & Row, 1970)
Growth of the Palate

Width of the palate occurs mostly in the region of the first
molars and is attained by increases on each side of the
median suture. Five-sixths of the mature width of the palatal
arch is attained, on an average, by 4 years of age, and
maximum width is reached at about 19 years. Overall
increases in palatal width occur by apposition on the outer
surface of the bone during the first postnatal year. Alveolar
growth while the permanent teeth are erupting adds to palatal
length and width. The palatine process of the maxillary bone
grows downward by resorption from the internal cortex,
while the periosteal side of the lingual cortex shows deposits
of new bone.
The temporomandibular articulation shows a shallow
outline at birth. With the eruption of the teeth and the
establishment of the occlusion, the temporomandibular
articulation assumes a more definite form. It has a wide
range of accommodation and can usually adjust to changes
in the occlusion of the teeth. No correlation has been
demonstrated between the shape of the mandibular condyle
and the type of dental occlusion. Large variations in the
temporomandibular articulation are to be found in
Fig. 2-11. Lateral view of the skull, showing the main individuals with the same type of normal occlusion or
sites of growth in the maxilla and mandible. The coronoid malocclusion.
process of the mandible and part of the zygomatic bone have
been removed to show the pterygomaxillary junction. (1)
Growth at the maxillary tuberosity, mostly backward and
lateral to the ptervgornaxillarv junction. (2) Growth at the
alveolar process. (3) Growth to the zygomaticomaxillary
suture. (4) Growth of the maxillary process in the floor of CHANGE IN FACIAL PROPORTIONS
the orbit. (5) Growth of the mandibular condyle. (8'1,
Growth at the posterior border of the ramus. (7) Growth at Increase in facial proportions manifests itself as follows:
the alveolar process. 1. General facial growth from infancy to adolescence and
increase in size of the dental arches
2. Increase in size of the muscles of mastication and
crease the size of the oral cavity. The nasal cavity grows in expression
both anterior and posterior directions by apposition and 3. Growth of the alveolar processes of the maxilla and
enlarges also by resorption on the intranasal surfaces, with mandible with the development and eruption of the
attendant bone apposition on the oral, superior nasal, and deciduous and permanent dentition
intracranial surfaces.
10. Change in Facial Proportions . 13
Fig. 2-12. Outlines of skulls showing

progressive increase in relative and
absolute amounts of growth of the face
compared with the cranium at each
succeeding dental stage. There is also
an indication of the forward, downward
and outward growth translation of the
jaws in relation to the cranium. (A)
Skull at early infancy, before the
completion of the deciduous dentition.
(B) Skull at late infancy; the deciduous
dentition is complete. (C) Skull at
completion of eruption of all
permanent first molars and all
permanent incisors. (0) Deciduous teeth
being replaced by permanent
successors. (E) Skull at early adulthood;
eruption of third molars is complete.
(Coutresy of Milo Hellman).
Fig. 2-13. (A) Front view of skull

outline showing dimensions of face
width: (l) bizygomatic, (2) bicondylar,
(3) bigonial, and(4) nasal width. (8)
Lateral view of skull outline showing
dimensions of face height: (1) total
face, (2) upper face, (3) lower face, (4)
dental, (5) nasal, (6) ramus. (Courtesy
Milo Hillman)
...-
-
fig. 2-14. The sites of the maxillary sutures

(ddtk lines) in the photograph of the maxilla of a
Fr()lll~)~
16-year-old boy in the diagrammatic outline of a maxllJary ..
skull. Note the arrangement of the "uturi:
frontornaxillary-, zygomaticomaxillary-, zy-
%Y l-;onU.ll'kuu-
gomaticotemporal- and pterygopalatine sutures in rn lJ'Jral .-
Iutur-"
the same inclination from above, downward, and
~)''''jHllatl('(t-
backward. (Weinmann, JP., and Sicher, H.: Bone ."axil
la.ry
and Bones. ed. 2. St. Louis C. V. Mosby, 1955) xut ur
T'l"ry/l'()-
pala trn
suturr-
TABLE 2-1. FACIAL EXPRESSION
Muscle Origin Insertion Innervation and Action
1. Muscles of the Lips, Muscles of the Face, Mastication, the Tongue, Pharynx and Soft Palate
Orbicularis oris Various muscles running Fibers surround oral open- Facial nerve. Draws lips together.
into lip ing, forming a sphincter
Levator labii Root of nose and maxilla Alar cartilage; upper lip Facial nerve. The whole muscle raises the
superioris upper lip. The levator labii superioris
alae que nasi alaeque nasi also lifts the wings of the nose.
Raises upper lip.
Levator labii Maxilla below orbit Upper lip
superioris
Zygomaticus Zygomatic bone Upper Lip Raises upper lip.
minor
Depressor labii
inferioris Mandible below canine and Lower lip Facial nerve. Draws lower lip downward.
Incisivus labii premolar teeth
(inferior and Maxilla and mandible, near Orbicularis oris muscle Facial nerve. Draws corners of lips medially.
superior) canine and lateral incisor These are part of orbicularis oris.
Zygomaticus teeth Facial nerve. Raises corner of mouth and
major Levator Zygomatic bone Orbicularis oris muscle draws it laterally.
anguli oris
Risorius Facial nerve. Raises corner of mouth and
Canine fossa of maxilla Orbicularis oris muscle draws it medially.
Facial nerve. Draws comer of mouth laterally.
Subcutaneous tissue over Skin and mucous membrane at Facial nerve. Draws corner of mouth
parotid gland corner of mouth Orbicularis downward.
Depressor Mandible below canine, pre- oris muscle
anguli oris molar, and first molar teeth
Maxilla, mandible, and
Buccinator pterygomandibular raphe Orbicularis oris muscle and Facial nerve. Draws corner of mouth laterally;
skin of lips pulls lips and cheeks against teeth.
Facial nerve. Draws up skin of chin.
Mentalis Mandible, below lower lateral Skin of chin
incisor
2. Muscles of Mastication
Masseter Zygomatic arch Lateral surface of ramus of Masticator or motor root of trigeminal nerve.
mandible Raises mandible and draws it forward.
Masticator or motor root of trigeminal nerve.
Temporal Temporal fossa of temporal Coronoid process of mandible Raises mandible.
bone Neck of condyloid process of Masticator or motor root of trigeminal nerve.
Lateral Lateral pterygoid plate and mandible Draws mandible forward and sideward; aids
pterygoid sphenoid in opening mouth.
Masticator or motor root of trigeminal nerve.
Medial Maxilla, palatine and sphe- Medial surface of ramus of Draws mandible upward and sideward.
pterygoid noid bones mandible
3. Muscles of the Tongue, the Pharynx, and the Soft Palate

Genioglossus Superior mental spine of Fascia of tongue; hyoid Hypoglossal nerve. Anterior fibers retract
mandible, near midline bone tongue; remainder draws it forward and
depresses its tip. Draws hyoid bone upward
and forward.
Hyoglossus Body and great cornu of hyoid Fascia of tongue Hypoglossal nerve. Depresses side of tongue
bone and retracts it.
Styloglossus Styloid process of temporal Side of tongue Hypoglossal nerve. Draws tongue backward.
bone Pharyngeal plexus (vagus nerve). Draws side
Palatoglossus Aponeurosis of soft palate Side, dorsum, and under- of tongue upward and soft palate downward.
surface of tongue Constricts faucial isthmus.
Change in Facial Proportions' 15
TABLE 2-1.-Continued
Muscle Origin Insertion Innervation and Action
Inferior con- Lateral surfaces of thyroi and Dorsal part of pharynx Pharyngeal plexus. Constricts pharynx; aids
strictor of cricoid cartilages in swallowing.
pharynx
Middle con- Greater and lesser cornua of Dorsal part of pharynx Pharyngeal plexus. Constricts pharynx; aids
strictor of hyoid bone; stylohyoid in swallowing.
pharynx ligament
Superior con- Pterygoid process, ptery- Dorsal part of pharynx; Pharyngeal plexus. Constricts pharynx; aids
strictor of gomandibular raphe, and occipital bone in swallowing.
pharynx mylohyoid ridge of man-
dible
Stylopharyngeus Styloid process of temporal Thyroid cartilage and lateral Glossopharyngeal nerve. Lifts pharynx in act
bone wall of pharynx of swallowing.
Palatopharyngeus Aponeurosis of soft palate Thyroid cartilage and lateral Pharyngeal plexus (vagus nerve). Closes
wall of pharynx opening between nasal and oral pharynx;
depresses soft palate and raises pharynx.
Levator veli Undersurface of temporal Aponeurosis of soft palate Pharyngeal plexus (vagus nerve). Raises soft
palatini bone and cartilage of palate; narrows pharyngeal opening of
auditory tube auditory tube.
Tensor veli Scaphoid fossa of sphenoid Palate bone and aponeurosis Masticator or motor root of trigeminal nerve.
palatini bone and cartilage of auditory of soft palate Tightens soft palate; opens auditory tube.
tube Aponeurosis of soft Pharyngeal plexus (vagus nerve). Draws up
Uvulae palate and palatine bones Uvula the uvula.
From Greisheimer E. and Wiedeman, M.: Physiology and Anatomy. Ed. 9. Philadelphia, J. B. Lippincott, 1972.
4. Enlargement of the maxilla and the growth of the veolar processes to accommodate the developing molars. The
maxillary sinuses face shows a tendency to become unusually longer in height
5. Enlargement of the mandible and shorter in depth in those children who begin to manifest
6.Increase in size of the nasal area and paranasal sinuses abnormal occlusion.
7. Enlargement of the orbits Growth in depth occurs at a greater ratio in the mandible
8. Expansion of the ethmoid and sphenoid bones than in relation to the maxilla, resulting in a more forward
relationship of the jaw in the adult than in the child. Active
growth in width and depth of the face precedes tooth eruption.
With the eruption of the deciduous second molars and the
permanent first, second, and third molars, there occurs a
Method of Face Growth forward translation of the entire face that makes the face
The face is projected downward and forward in relation to longer and deeper.
the anterior portion of the cranial base, although the vector of Growth in Face Height (vertical growth) occurs after
facial growth varies among individuals. Growth of the face eruption of the first molars. Stability of the permanent first
proceeds at the anterior surfaces of the parietal and at the molar in its anteroposterior position is influenced by the size
sphenoid bones, the anterior surfaces of the pterygoid pro- and position of the teeth and the muscles.
cesses of the sphenoid, and at the zygomatic process of the Height (vertical growth) of the face is related to growth of
temporal bone. the maxillary sinuses and tooth development and eruption.
Depth. The highest percentage of anteroposterior growth Vertical growth is not always synchronous with forward
occurs after the deciduous dentition has been completed but translation. It is accomplished by increase in the palatoalveolar
before the permanent first molars are erupted. Forward area and in the upper part of the face. Some vertical growth
growth of the face is extremely active immediately preceding occurs with nasal development in the first 6 months after birth
and during the early stages of eruption of each of the and continues with the eruption of the deciduous dentition and
permanent molars. As the braincase expands forward the face with development and
is translated forward and at the same time growth produces
the backward expansion of the palate and the al-
Fig. 2-15. Expansion of the brain (arrow) causes expansion of the neurocranial
capsule, within which the calvariae are embedded. This motion passively carries
the cranial bones outward. Osteogenesis at the sutural borders (black areas) is
secondarily compensatory to this process and is not the primary cause of growth
of the neurocranium. (Courtesy of M. L. Moss)
11.
growth of the alveolar process itself. Face height is greater fluence dental occlusion. Growth projection of the
in children with abnormal occlusion, except in Class II, mandible may be forward without increasing vertical
Division 2 malocclusion. (See Chapter 6). height of the face, or it may be downward without
Face height increases rapidly to about 10 months and increasing depth of the lower part of the face.
then shows a marked drop in rate which continues to 3 Discrepancies in size between the maxilla and the
years of age. There is continued but slow growth in height mandible can thus increase in proportion and in overall
which shows some acceleration at 3 to 4 years, 7 to 11
dimensions.
years, and 16 to 19 years. Growth in height after the first 3
Growth in face width occurs on the free surfaces of
years is slow. It is more vigorous during the second 10
the bones by apposition. The lateral walls of the palate and
years, lasts longer and is more extensive in males than in
zygomatic arches go through a lateral proliferation that
females.
widens the face. Face width is smaller in children with a
Height of the lower third of the face depends on the tendency to abnormal occlusion.
direction of the rotation of the mandible. During growth Arch length is stable from age 4 years to 6. It increases
the projection of the lower face may change, but this does after age 6 as a result of permanent molar eruption and the
not necessarily always in- increased labial inclination of the
Fig. 2-16. (A) The skull is an ovoid

structure. The frontal bone forms the
Corona.l .sul u re
vault of the skull and the rim of each
orbit. The nasal bones form the roof of
Porie<o.l bone the nasal cavity. The fused maxillae form
the upper jaw, which articulates with the
cranium by way of the frontal and
Great wing of'
SpheMid. ethmoid bones. The mandible is sus-
Frcnlc! Temporo.l bone
Smo.U wing of spheno<d
pended by means of the temporoman-
Grea< winq of sphenoid 1 .' dibular ligaments from the glenoid
fossae of the temporal bones.
Z;'J'l0ma.hc o rbiculucis oculi
Perpend'cula.r
El.brnoid [nrra.- plo"e of ethmoid
orbil,,1 fommon
-NClsat 5eph.lm
Mo s sel e r
- Zygomat.i.c boM
Vomer Buccin.al-
ot'
Mo."UIa.
Masseter
Pla.hj5ma A
12.
Change in Facial Proportions . 17
(B) The lateral view of the skull shows some of SquamouoS JouhJTE:
the cranial and facial bones and sutures and
sites of some muscle attachments. (C) The base
of the skull shows the foramen magnum in the
occipital bone, the posterior nares anterior to
which lies the bony palate, and the roof of the
mouth, which separates it from the nasal
cavity. The bony palate consists of the palatine
processes of the maxilla and the horizontal
parts of the palatine bones. The palato-
Tempcrolls
maxillary- (medial palatal), the sphenoccipital-
, and the temporozygomatic sutures are
shown. (Greisheimer, E., and Wiedeman; M.: GreoJ wlnq
Physiology and Anatomy. ed. 9. Philadelphia, of 'phenold
J. 5. Lippincott, 1972)
No.5,,1
Zy~omo.hc
bone
Anr.na.al
~Fine
Mo-xilla
Mandibt.
Menbc l
Fora m en.
B
Pa.lO-t'ne process of moxi ll o.
Posterior n"5al ~Plne G-reQrer pCllohne f"romen 7 -

ygornatic proces5 of m.,,,,Lito.
HorLumta[ plare
of palClte bone
Pterygoid
hamulus
Z~qomCllic
ptoce~s. o~
l-e m poro.l
c
Carotid co.no l
FotL1.Xl'len spi.nosum
MClndibu1.G.t'
Fos sc.
Pel:roty"'-panic
fi~~ure
Mc sce id.
Occip'la.L
process cond,:!l e
Occipil-a.L
bone
c
permanent incisors. As the permanent central and lateral life. As the face matures, the bony profile becomes less
incisors emerge, intercanine width increases on an convex, and the anterior teeth appear less protrusive.
average approximately 3 mrn. Variation in facial growth increases in range between the
Later Changes. Total face height in males, nose ages of 6 and 12 and continues to increase thereafter.
height, and bizygomatic width show significant increase Some dimensional changes in the human head and
up to and including the third decade of
14.
Fig. 2-17. Section of head showing nasal

cavity, roof of mouth, and lower jaw, pos-
terior view. The external pterygoid and ;\rl-icular disc.,
internal pterygoid muscles are shown passing
from their origin to their insertion.
Mo.ndLbtllo["
(Greisheimer, E., and Wiedeman, M.:
Physiology and Anatomy. ed. 9. Philadelphia,
]. B. Lippincott, 1972) ___ Levator- vaH polefini
IJh."N.jCj,oLd f"Ossa---_. i-
Sphll.llOm.OMibulu["
li.qam~nl-(cu~) - -- - - ~
r ' . Humulus or p'er'J'l.0id ."

p.ro.S$ of- ~phl!nold
~~p.r~ryqo[d4W~ tnh ... nm
G"l'nioglossus/I .
CrofZ.n.iohyoldo/Cu," /
Diqo.tl"'ic", (entql"'iOl"' IodI'I)
Fig. 2-18. Sagittal section of the

head of young adult. The oral
relationship is shown with the
mouth in repose. The lips barely
touch, while the "physiologic
space" is present between the
maxillary and mandibular incisors.
The tongue follows the general
curvature of the palate but is not
directly against it. (Courtesy of
Piersol Anatomy, ]. B. Lippincott
Co.) (Piersol, G. A.: Human
Anatomy. Philadelphia, ]. B.
Lippincott, 1931)
Orbicularis oris
Genio-glossus
Dental Occlusion and Face Growth' 19
Fig. 2-19. (Top left) Transverse section of the

jaws at the molar region showing the relationship
of the jaws, teeth, cheeks, and tongue in a
normally developed head. (Top right) Sagittal
section showing relationship of lips, incisors, and
tongue in normal development. (Bottom left>
Transverse section in molar region of a constricted
arch showing lingual inclination of the teeth and
the comparatively lower position of the tongue in
relation to the body of the mandible. (Bottom right>
Relation of the lips, teeth, and tongue in a lip biter
with labioversion of the maxillary incisors. The
latter two usually are accepted to represent the
relation of the dentofacial structures in a mouth
breather. (Modified after B. E. Lischer)
face and profile continue to occur throughout life and into In children with malocclusion, the line of occlusion may be
senility. Attempts to produce lasting changes in the facial irregular or have too great a pitch to allow free jaw
profile by changing the angular relationship and position movements without separating the dental arches to avoid
of the incisor teeth when growth is continuing are subject cuspal interference.
to vicissitudes which can influence the final result for
better or for worse. Muscle Function and Jaw Growth
Muscle function is a factor in shaping the dental arches
DENTAL OCCLUSION A 0 FACE GROWTH and is important in maintaining the stability of the teeth
following orthodontic treatment. Muscle pressure is
Dentofacial anomalies can show themselves in the particularly influential before and during tooth eruption in
predentition stage, and during the deciduous, mixed, and
maintaining effective and normal occlusal relations of the
permanent dentition periods. Normal occlusion depends
jaws and teeth in the growing child. Strong muscle force
on normal face growth, among other factors. There is no
correlation between caries incidence and jaw growth. Jaw and a strong musculature are associated with well-
growth is not directly under the influence of caries developed jaws, but not necessarily with perfect alignment
susceptibility. Malocclusion can occur in children whose of the teeth.
teeth are free from caries.
After eruption of the permanent teeth is completed,
there is little if any anteroposterior growth of the face,
although considerable vertical growth and some Muscles and the Soft Tissue Profile
transverse growth still occur. Apparently impacted third
molars may find room in the dental arch during late Soft tissue changes incidental to orthodontic treatment
adolescence. Contrarily, some normally erupting third center primarily around the lips. However, lip posture is
molars may later show impaction. This can be caused by not always closely correlated with the dental arches. The
insufficient growth or an ectopic eruption path of these profile can, nevertheless, be changed in most people by
teeth. orthodontic therapy which changes the position of the
incisor teeth.
Since the functional forces exerted by the tongue, the
circumoral musculature, the buccinators, and the muscles
Line of Occlusion of mastication are not equal in amount, we can conclude
that there are other factors in addition to muscle balance
When viewed in their vertical aspect, the teeth in the responsible for the stability of the dentition and the
maxillary and the mandibular arches show a curve or line occlusion of the teeth. Among these factors are the axial
of occlusion. The line of occlusion should be positions and interarch relation of the teeth; the habitual
differentiated from the curve of Spee, which is an resting posture of the tongue, the kinesthetics of the denti-
imaginary curve passing through the condyles and the tion that are developed by the proprioceptors, and
cusps of the teeth and ending at the incisal edges of the
mandibular central incisors.
Fig. 2-20. In the left column are

pretreatment views of a girl with
extreme overjet, overbite, and a
lip-biting habit. The photos in the
right column were made 8 years
later. Favorable growth occurred in
this patient.
the quantity and quality of the functional forces exerted Between 7 and 12 years the deciduous dentition is shed
during the excursive movements of the mandible. and all of the permanent dentition except the third molars
Age Changes in Face Growth and Dental erupt. Growth in width, height, and depth of the face
Development occurs.
Between birth and 7 years the deciduous dentition is From 12 to 20 years the eruption of the permanent
completed and the permanent first molars erupt. The most dentition is completed; the third molars erupt. Some
intensive anteroposterior growth (depth) of the face residual vertical growth still is to be seen in females, but
occurs. more intensive vertical growth occurs in males.
Total face height, nose height, and bizygomatic
Dental Occlusion and Face Growth 21
Fig. 2-21. This boy's growth was un-

favorable, but the treated malocclusion did
not relapse. Prerreatrnent views are in the
left-hand column; on the right are photos
taken 5 years out of retention.
width show significant size increases during the third can augment dentofacial development and influence the
decade of life. Head length, head breadth, and head entire dentofacial complex. The vector of growth can
circumference do not significantly change with age. The change while the patient is undergoing orthodontic
size of the nose is also an important factor in the treatment and after treatment is completed. A retrognathic
appearance of the facial profile. face may in early adulthood become an orthognathic or
Growth Changes and Orthodontic Therapy. even a prognathic face. It is possible for the skeletal type to
Orthodontic therapy is not limited to changes in teeth change while the dental occlusion is maintained as it was
arrangement and the alveolar process alone. It corrected.
DENTAL OCCLUSION AND THE FACIAL CRANIOFACIAL ABNORMALITIES

PROFILE
A short basion-sella-nasion angle, when associated with a
The facial profile is shown before and after rhinoplasty maxilla of short depth, may show mandibular prognathism
(See Fig. 18-11). The occlusion and jaw relationship were not even if the mandible is of normal length. An obtuse cranial
changed by orthodontic therapy. It can be seen that the facial base requires a deeper maxilla and may show mandibular
profile in its entirety was changed by rhinoplasty alone. The retrusion even when the mandibular body is of normal length
straightening of the profile following rhinoplasty was caused and position. A relatively horizontal anterior cranial base from
wholly by cutaneous and muscle changes. The dental sella to nasion (S-N) in relation to the Frankfort horizontal
malocclusion present was not treated, and the relationship of indicates that the posterior parts of the face occupy a relatively
the jaws, was not changed by surgical or orthodontic means. higher position in the skull. This can produce an abnormally
Facial appearance is influenced only in part by the steep mandibular plane with mandibular retrusion. Steep
relationship of the jaws and the teeth. The amount and inclination of the anterior cranial base leads the posterior part
tonicity of the muscles, the skin of the face, the size of the of the face to assume a low level in the skull with a horizontal
nose and of the soft tissues in general play an important part mandibular plane in most cases.
in the establishment of facial contours and appearance.
BIBLIOGRAPHY Baume, L. J. and Holz, J.: Ontogenesis of the human

temporomandibular joint. II. Development of the temporal
Applebaum, E.: Integration of anatomic and cephalometric components. J. D. Res., 49:864, 1970.
studies of growth of the head. Am. J. Orthodontics, 39:612, Bayer, L. M., and Bayley, N.: Growth pattern shifts in healthy
1953. children: spontaneous and induced. J. Pediat., 62:631, 1963.
Asling, C. W.: Recent developments in biologic studies on the Bien, S. M.: Factors in muscle activity. Tr. European
osseous system. Am. J. Orthodontics, 47:830, 1961. Orthodont. Soc., p. 266, 1961.
Atkinson, S. R.: Balance-the magic word. Am. J. Ortho- Biourge, A.: Macroglossie et microglossie. Orthod. Franc.,
dontics, 50:189,1964, 37:345, 1966.
Avery, J. K, and Devine, R. K: Development of ossification Bjork, A.: The face in profile. Svensk Tandlak, Tidskr. 40: No.
centers in the face and palate of normal and cleft palate 5B Suppl., 1947, Lund, Berlingska Boktryckeriet. ---: A
human embryos. Cleft Palate Bull., 9:25, 1959. discussion of the significance of growth changes in facial
Avis, V.: The relation of the temporal muscle to the form of pattern and their relationship to changes in occlusion. D.
the coronoid process. Am. J. Phys. Anthropol., 17:99, 1959. Record, 4:5, 1954.
Baer, M. J.: Dimensional changes in the human head and face ---: Facial growth in man, studied with the aid of metallic
in the third decade of life. Am, J. Phys. Anthropol., 14:557, implants. Acta odont. scandinav., 13:9, 1955. ---: Cranial base
1956. development. Am. J. Orthodontics, 41 :198, 1955,
--: Some observations on variations of tongue posture as seen ---: Facial growth in man studied with the aid of metallic
in lateral skull radiographs and their significance, Trans. implants. Am. J. Orthodontics, 42:62,1956. ---: Variations in the
European Orthodont. Soc., p. 69, 1959. growth pattern of the human . mandible: Longitudinal
Bambha, J. K., and Van Natta, P.: Longitudinal study of facial radiographic study by the implant method. J. D. Res., 42:400,
growth in relation to skeletal maturation during adolescence, 1963.
Am. J. Orthodont. 49:481-493, 1962. ---: Sutural growth of the upper face studied by the implant
Basmajian, J. V.: News views on muscular tonus and re- method. Acta odont. scandinav., 24:109,1966. ___ : Bone
laxation. Canad. M.A.J., 77:203, 1957. growth as revealed by in vivo markers.
Bassett, C. A. L.: Current concepts of bone formation. Am. J. Phys. Anthropol., 29:155, 1968.
J. Bone Joint Surg., 44A:1217, 1962. Bjork, A., and Palling, M.: Adolescent age changes in sagittal
Baume, L. J.: Experimentelle, Erforschung der Skelett- jaw relation, Alveolar Prognathy and Incisal Inclination.
Morphogenese mit spezieller Beriicksichtigung der Acta odonto. scandinav. 12:201, 1955.
Schiidel-Entwicklung. SMfZ., 67:673, 1957. Bosma, J. F.: Maturation of function of the oral and pharyngeal
---: Principles of cephalofacial development revealed by region. Am. J. Orthodontics, 49:94, 1963.
experimental biology. Am. J. Orthodontics, 47:881, 1961.
Bourne, G. H., (ed.): The Biochemistry and Physiology of
---: Die entwicklungsmechanik des Mittelgesichtes in
Bone. New York, Academic Press, 1956.
embryogenetischer Sicht. Deutsche Zahn-, Mund-, u.
Broadbent, B. H.: The orthodontic value of studies in facial
Kieferh., 38:1, 1962.
growth. Cleveland, Proc, Conf. on Adolescence, 1930.
Bibliography . 23
--: The face of the normal child: Bolton standards and technique. der Kieferorthopadie, Heft 3 and 4: Band 24, 367-372, 1963.
Angle Orthodontist, 7:183, 1937. Hellman, M.: An introduction to growth of the human face from
--: Ontogenetic development of occlusion, development of occlusion. infancy to adulthood. Int. J. Orthodontia, 18:777, 1932.
Philadelphia, University of Pennsylvania, 1941. ---: The face in its developmental career. Dental Cosmos, 77:685,
Bronstein, 1. P., Abelson, S. M., Jaffe, R. H., and von Bonin, G.: 1935.
Macroglossia in children; review of literature, report of case of Hovell, J. H.: The relationship of the orofacial musculature to
true muscular hypertrophy and suggested classification. Am. J. occlusion: Current British thought. In Kraus, B.S., and Riedel, K
Dis. Child., 54:1328, 1937. A.: Vistas in Orthodontics. Philadelphia, Lea & Febiger, 1962.
Burstone, C. J.: Process of maturation and growth prediction. Am. J. Hunter, W. 5., Balbach, D. K and Lamphier, D. E.: The Heritability of
Orthodontics, 49:907, 1963. Attained Growth in the Human Face. Am. J. Orthodontics,
Coben, S. E.: Growth concepts. Angle Orthodontist. 31:194,1961. 58:128,1970.
Davenport, C. B.: The development of the head. Am. J. Koch, J. C. The laws of bone architecture. Am. J. Anat. 21 :177, 1917.
Orthodontics, 29:541, 1943. Kraus, B.S.: Prenatal growth and morphology of the human bony
Diamond, M.: Posterior growth of the maxilla. Am. J. palate. J. D. Res., 39:1177, 1960.
Orthodontics & Oral Surg., 32:359,1946. Kraus, B.S., and Decker, J. D.: The prenatal interrelationships of the
Dockrell, R. B.: Regression lines for facial growth rates from 4Y2 to maxilla and premaxilla in the facial development of man. Acta.
151/2 years. Tr. European Orthodont. Soc., 105:133, 1960. Anat., 40:278, 1960.
Du Bru!, E. L., and Sicher, H.: The Adaptive Chin. Springfield, III., Krogman, W. M.: The reliability of serial measurements taken on
Charles C Thomas, 1954. children of different body build. Am. J. Phys. Anthrop., 11 :259,
Enlow, D. H.: A morphogenetic analysis of facial growth. 1953. (Abstract.)
Am. J. Orthodontics, 52:283,1966. ---: The study of child development. Science, 117:3, 1953.
--: Wolff's law and the factor of architectonic circumference. Am. J. ---: The growth of bone: some concepts of import to dental medicine.
Orthodontics, 54:803, 1968. J. D. Med., 10:8, 1955.
--: The Human Face. New York, Hoeber Medical Division, Harper & ---: The integrity of optimum growth and development, Merrill-Palmer
Row, 1970. Quart. 2:80-83,1956.
Enlow, D. H., and Harris, D. B.: A study of the postnatal growth of ---: The physical growth of children: an appraisal of studies 1950-
the human mandible. Am. J. Orthodontics, 50:25, 1964. 1955. Monog., Soc. Res. Child Dev. 20:
I Enlow, D. H., and Hunter, W. 5.: A differential analysis of sutural

and remodeling growth in the human face. Am. J. Orthodontics,
52:823, 1966.
Serial #60, No.1, 1955. 1-91, 1956.
---: A guide outline for the study of physical growth in children,
Philadelphia, Philadelphia Center for Research in Child Growth,
Eschler, J.: Bruxism and function of the masticatory muscles. 1958.
Parodont. Zurich., 50:109, 1961. ---: The meaningful interpretation of growth and growth data by the
Ford, E. H. K: The growth of the foetal skull. Brit. J. Anat., 90:63, clinician, Am. J. Orthodontics, 44:411-432,1958.
1956. Kolas, 5., et al: The occurrence of torus palatinus and torus
--: Growth of the human cranial base, Am. J. Orthodontics, 44:498, mandibularis in 2,478 dental patients. Oral Surg., 6:1134, 1953.
1958. Koski, K.: Cranial growth centers: Facts or fallacies? Am.
Gerlach, H. G.: Asymmetrien im Kiefer-Gesichtsbereich. J. Orthodontics, 54:566, 1968.
Fortschr. Kieferorthop., 29:3, 1968. Lebret, L.: Growth changes of the palate. J. D. Res., 41 :1391, 1962.
Glass, D. F.: Bone deformation caused by external pressure. Lasker, G.: The palatine torus; its relationship to age, sex, race, diet,
European Orthodont. Soc., p. 302, 1961. degeneracy, systemic disease, dental conditions, and hyperostosis
Gottlieb, B.: Die Appositions-und Resorptionsvorgange an Knochen of the jaws. J. D. Res., 26:459, 1947.
und Zahne, Zeitschr. Stomat., 23:375, 1925. Marshall, D.: Dimensional growth. Am. Journal Orthodontics, 44:99,
Creep, R. O. and Sobel, A. E., Chairmen: Recent advances in the 1958.
study of the structure, composition, and growth of mineralized Medawar, P. B.: The shape of the human being as a function of time.
tissues. Ann. N. Y. Acad. Sci., 1960. Proe. Roy. Soc., (B) 132:133, 1944.
Gresham, H.: Changes in facial profile. D. Practitioner, 9:80, 1958. Melsen, B.: Time of closure of spheno-occipital synchondrosis
Gwynne-Evans, E.: II. The upper respiratory musculature and determined on dry skull: Radiographic craniometric study. Acta
orthodontics. D. Record, 68:5, 1948. odont. scandinav., 27:73, 1969.
Hamilton, W. J., Boyd, J. D., and Mossman, H. W.: Menezes, D. M. and Foster, T. D.: Comparisons of craniofacial
Human Embryology-Prenatal Development of Form and Function. features in monozygous and dizygous triplets. D. Practitioner, 21
Cambridge, Heffer & Sons, 1959. :103, 1970.
Hauenstein, P.: Beitrag zum Studium der transversalen Cesichts- und
Oberkieferentwicklung, Fortschritte
Meredith, H. V.: Growth in head width during the first twelve years ---: The calcification process. ], A. D. A, 62:516, 1961. Subtelny,
of life, Pediatrics, 12:411, 1953. J. D,: A longitudinal study of soft tissue facial structures and their
---: Changes in form of the head and face during childhood. profile characteristics, defined in relation to underlying skeletal
Growth, 24:215, 1960. structures. Am. [, Orthodontics, 45:481, 1959.
---: Serial study of change in a mandibular dimension during
Tanner, J- M.: Genetics of human growth. In Tanner, J. M,: (ed.):
childhood and adolescence, Growth, 25:229, 1961.
Human Growth. vol. 3, Symposia of the Society for the Study
Moss, ... M, L.: Differential growth analysis of bone morphology,
of Human Biology. New York, Pergamon Press, 1960.
Amer. J, Phys. Anthrop., 12:71,1954.
---: The regulation of human growth. Child Develop" 34:817,
---: The functional matrix. In B, S, Kraus and R. A, Riedel, (eds).:
1963.
Vistas in Orthodontics, Philadelphia, Lea & Febiger, 1962.
Thompson, D' Arcy W,: On Growth and Form. [Abridged edition
---: The primary role of functional matrices in facial growth, Am. J.
by John Tyler Bonner.] Cambridge, Cambridge University
Press, 1961.
Moss, M. L. and Salentijn, L.: Differences between the functional
matrices in anterior open bite and deep overbite. Am, ]. Todd, T. W.: Integral growth of the face. Int. ]. Orthodontics,
Orthodontics. 60:264, 1971. 22:321, 1936.
MUller, G.: Growth and development of the middle face. Tracy, W. E. and Campbell, R. A: Dentofacial development in
J. D. Res., 42 (Suppl. 1):385, 1963. children with vitamin D-resistant rickets. ].ADA, 76:1026,
Pyle, S. J., Stuart, H. C, Cornoni, ]" and Reed, R. B.: 1968.
Onsets, completions, and spans of the osseous state of Valadian, 1. Stuart, H. C, and Reed, R. B.: Longitudinal studies of
development in representative growth centers of the child health and development. Pediatrics, 24 (Part II):941,
extremities. Monog. Soc, Res. Child Develop., 26:3, 1961. 1959,
Sarnat, B, G.: Developmental facial abnormalities and the ---: Studies of illnesses of children followed from birth to eighteen
temporomandibular joint. ].AD.A. 79:108, 1969. years. Monog. Soc. Res. Child Develop., 26:127, 1961.
Savin, C, Savara, B. S., and Sekiguchi, T.: Longitudinal von Harnack, C. A: Catch-up growth pattern following illness or
dentofacial changes in untreated persons. Am. ]. Orthodontics, starvation. ]. Pediatr., 62:646,1963.
55:135, 1969. van der Klaauw, C ].: Cerebral skull and facial skul!.
Scott, J. H.: The growth and function of the muscles of mastication A contribution to the knowledge of skull-structure. Arch. eerl.
in relation to the development of the facial skeleton and of the Zool., 7:16,1945.
dentition, Am, ], Orthodontics, 40:429, 1954.
---: The analysis of facial growth, 1. The anteroposterior and Walker, G. F.: A new approach to the analyses of craniofacial
vertical dimensions. Am. [. Orthodontics, 44:507, 1958. morphology and growth. Am. J. Orthodontics, 61 :221, 1972,
---: The growth and function of the muscles of mastication in Weidenreich, F.: Die Kinnbildung bei Menschen. Nat.
relation to the development of the facial skeleton and of the Ariz. Bd., 25: 1904.
dentition. Am. ], Orthodontics, 40:429,1954. ---: The analysis of ---: Das Menschenkinn und seine Entstehung. Eine Studie und
Kririk, Ergebn. D. Anatomie U. Engwicklungsgesch. Ztschr.
facial growth. 1. The anteroposterior and vertical dimensions.
M. D. Ces. at., 31:1, III, Abt., 1934.
Am. J- Orthodontics, 44:507, 1958.
Wein.mann, [. P., and Sicher, H.: Bone and Bones. ed. 2.
---: What determines form of dental arches. Orthodont. Rec., 1 :15,
St. Louis, C V. Mosby, 1955.
1958.
Wieslander, L.: The effect of orthodontic treatment on ,the
---: The role of soft tissues in determining normal and abnormal
concurrent development of the craniofacial complex, Am. ].
dental occlusion. D. Practitioner & D. Rec., 11 :302, 1961.
---: The analysis of facial growth from fetal life to adulthood. Orthodontics, 49:15, 1963,
Angle Orthodontist, 33:110, 1963, Wolff, J.: Ueber die innere Architektur der Knochen und ihre
Scott, J. H., and Symons, N. B. B.: Introduction to Dental Bedeutung fur die Frage vom Knochenwachstum. Virchow. Arch.
Anatomy. Edinburgh, E. & S. Livingstone, Ltd., 1964. Path. Anal. Physiol., 50:389, 1870. ---: Das Gesetz der
'. Seide, L. J.: The relationship of dento-facial growth and ~ Transformation der Knochen.
skeletal maturation to malocclusion. Am. J. Orthodontics, 45:801, Berlin, A Hirschwald, 1892.
1959. Das Gesetz des Knochenschwundes durch vermehrten
Sicher, H.: Oral Anatomy. St. Louis, C V. Mosby, 1965. Slessor, Druck und der Knochenanbildung durch Druckentlastung.
Arch. Klin. Chir., 13:302, 1891.
A., and Wyburn, G. M,: Phospatase and bone formation, Lancet,
Wylie, W, L.: The relationship between ramus height, dental
1 :212, 1948.
height and overbite. Am. J- Orthodontics, 32:57, 1946.
Sognnaes, R. F, (ed.): Calcification in biological systems; A
symposium presented at the Washington meeting of the Zenker, A: Unveranderliche und veranderliche Relationen am
American Association for the Advancement of Science. Skelett der Mundhohle und ihre Spiegelung in den zugehorigen
Washington, D, C, Am. Ass. Adv. Sci., 1960, Weichteilen im Zeitraum zwischen vollendeter erster und
vollendeter zweiter Dentition. Fortschr. Kieferorthopadie,
24:373, 1963.
3
The Functional Matrix and
Clinical Orthodontics
MELVIN L. Moss, D.D.S., PH.D.
The functional matrix concept is the subject of much Functional matrix is a comprehensive term that describes all
discussion in orthodontic circles. The denominative phrase is the tissues, organs, and functioning spaces mentioned above.
included in a recent orthodontic glossary.l-' and textbooks We will consider four examples here: the temporalis muscle,
present the concept, to varying degrees of completeness. the teeth, the brain, and the oral functioning space. But first,
Moorrees recently summarized the matter in this way: "We we must consider another part of the concept. The individual
must also acknowledge that the functional matrix concept has cranial bones do not function or grow as independent
become the theoretical basis for craniofacial morphogenesis structures. For example, the maxilla and mandible do not arise
with some aspects of its formulations existing perhaps as embryologically, grow, function, or remain in being as single
working hypothesis, if you wish. The functional matrix bones. Rather, they are composed of what is called skeletal
concept has brought a fresh approach to studying facial units, each of which is related to a discrete functional matrix.
growth, and the formfunction interrelations can no longer be In the mandible, the form of the coronoid process. is always
neglected in the methodological consideration of future ex- and without exception an accurate reflection of the operational
perimentation or observation of the growth processes. "8 demands of the temporaIis muscle; increased muscle function
Because the clinician usually seeks to apply practically and increases coronoid process size, decreased function decreases it,
uniquely the theories and hypotheses developed to meet and both congenital absence or postnatal muscle ablation is
general conditions, the orthodontic clinician properly may ask followed by a complete loss of the coronoid process. Teeth are
to what extent the functional matrix concept can help in the functional matrix for an alveolar skeletal unit. Congenital or
diagnosis, prognosis, and treatment planning for any individ- surgical absence of teeth produces a secondary loss of alveolar
ual patient. The following pages attempt to answer these bone. The entire specialty of orthodontics depends on the fact
questions by a concise statement of what it is that this concept that if these functional matrices are moved (or alter their
can, and cannot, do at its present stage of development, and functional demands), the alveolar bone skeletal unit will
always within the framework of clinical practice. (hopefully) respond appropriately by altering its size and shape
so as to best continue to provide biomechanical protection and
support to its specific functional matrix.
The growth of the brain case (the calvaria) is another matter.
Here it is the volume of the enclosed and protected neural
mass (brain plus soft meninges plus cerebrospinal fluid) which
determines the growth of the cranial vault. The microcephalic
child has a small cranial vault because the volume of its brain
THE FUNCTIONAL MATRIX CONCEPT is small. Similarly, the growth of the bony orbit is a secondary
At its simplest, this concept is an extension of functional response to the primary role of the growth of the enclosed
anatomy. It attempts to comprehend the relationship between orbital contents (eyeball, muscles, fat, etc.).
form and function. With respect to the head, it is clearly In both of these cases the type of growth produced
stated that the form of all the cranial skeletal tissues (that is,
their size and their shape) is always a response to the spatial,
mechanical, and energy demands of all of the tissues, organs,
and cranial spaces, for whose functioning these same skeletal
tissues provide protection and support. In the form-function
relationship, function is dominant.
25
26 . The Functional Matrix and Clinical Orthodontics
is different from that produced in the skeletal units prehensive, and clinically useful, statement concerning
related to the temporalis muscle and to the teeth. To head growth.
make this point clear we must consider one additional There are, in reality, two types of skeletal tissue
point. There are two types of functional matrices, each of growth: active and passive. The first occurs in response to
which produces a different type of growth. The first of the prior demands of periosteal functional matrices.
these is the periosteal matrix, so called because most Active growth involves any of the growth processes
muscles attach to the fibrous layer of the periosteum. The capable of being described histologically; deposition and
second type is the capsular matrix; the term expresses the resorption of bone and cartilage, for example. The result
location of the calvarial bones completely within a of these growth changes is to alter the form (that is, either
neurocranial capsule (scalp on the "outside" and dura or both the size and shape) of the skeletal unit responsive
mater on the "inside"). The types of growth produced by to that particular periosteal matrix. However, there is a
each type of matrix are as follows. passive type of growth that does not alter the form of the
skeletal unit but rather causes it to move in space. This
type of growth is a response to changes in capsular
matrices. None of the changes occurring in passive
Processes of Cranial Growth
growth can be detected histologically (as deposition or
Classical studies of cranial growth considered that resorption, for example). Obviously, they can be
some combination of three growth processes accounted observed as dimensional or spatial changes. We term the
for the totality of the clinically observable cranial bone active growth (in response to periosteal matrices)
growth: sutural expansion, deposition and resorption, and transformative growth and the passive growth (in
growth of cartilaginous tissues (as in the mandibular response to capsular matrices) translative growth. Both
condyle, the nasal septum, and the synchondroses of the active and passive processes are involved in cranial
cranial base). Cranial bones are not pushed apart as the growth, and it is only by considering both types of
result of a force generated by the growth of the soft growth that we can compre-
tissues within a suture. Rather, we know that the growth hend the totality of head growth. -
observed at the bony edges bordering the several sutures
is in compensation for the movement of these bones
away from each other. In other words, what was thought
to be a cause in reality is an effect. While deposition and Clinical Applications
resorption of bone does occur, frequently in considerable It should be clear that in both active and passive growth
amounts, many analyses have shown that the extent of the functional matrices are the primary part that is
such growth frequently is insufficient to account for all growing. In a phrase, bones do not grow, the are grown.
of the growth observed, and more critically, such From a theoretical viewpoint it is simple to say that if
resorption and apposition often takes place in directions the clinician wishes to alter either the size, shape, or
opposite to those in which the bones are observed to position of a skeletal unit, it is sufficient, and indeed
move. With respect to the cranial cartilages, there is now proper, to treat the specifically related functional matrix,
consensus that the lower jaw is not moved in space (it with the certainty that the skeletal unit will respond
does not "grow") as a result of a primary expansive force appropriately. While this statement is true, it is simply the
generated within the mandibular condylar cartilage. As case that we do not yet possess sufficient information
described below, it is reasonably certain that the growth about the regulation of matrix growth process, nor about
of this cartilage is a response to a lowering of the the direction and magnitude of the matrix growth forces
mandible and not the cause of that same movement. The to make this a generally useful tool of clinical
functional matrix theory postulates the .same secondary orthodontics at this time.
role for the nasal septal and basal ~ynchondrotic The matter is rendered more difficult when we state
cartilages, although this point has not yet been proved. that, for example, both the maxilla and mandible are
In summary, there is good reason to believe that all composed of several skeletal units, each of which
craniofacial growth cannot be accounted for by any responds only to its own functional matrix. Accordingly,
combination of the classical triad of growth processes. to "treat" a mandible one must know which functional
Something else seems to be required. It is one of the matrices are involved, and there may be several.
assets of the functional matrix concept that it permits a However, the picture is really not too bleak. At this point,
description and demonstration of this "other growth it should be clear that when an orthodontist uses a therapy
process" and so permits a com- that applies force only to teeth, he may confidently expect
only the
Mandibular Growth . 27
alveolar skeletal unit to respond directly to that therapy. as it were, after the growth of the jaws, muscles, glands,
To the extent that the clinician knows (really knows) the etc., is complete. On the contrary, the expansion of the
vectorial properties (direction and magnitude) of these oral functioning space is the primary morphogenetic event
tooth-borne forces, he is in some position to estimate the in growth of the lower jaw.
changes in alveolar bone form which are secondary and The expansion in volume of the oral functioning space is
compensatory to the altered demands of the tooth (as a not due to "pneumatic forces." While the processes
periosteal functional matrix). If, for example, changes regulating its growth are not yet understood completely, it
are then found in the coronoid process, these cannot be is reasonable to suggest that this growth is associated with
considered as direct responses of that osseous tissue (as the neurotrophic regulation of epithelial mitosis. In any
a skeletal unit) to the forces imposed upon the teeth. event, the enlargement of the capsule produces a
Rather they are an indication that the temporalis muscle completely passive translative growth motion of the
(as another periosteal matrix) is now altering its mandible which, together with its periosteal matrices,
functional demands, to compensate for altered tooth arises, grows, functions, and is maintained in being while
position or function, and so producing a direct change in totally embedded within the orofacial capsule. One result
its own, nonalveolar skeletal unit. of this "lowering" motion is the tendency to disarticulate
A word of caution: The functional matrix hypothesis the temporomandibular joint, literally carrying the
should not be thought of as a theoretical support for any condylar process away from the articular eminence against
sort of naive myotherapy directed towards treatment of which it functions. For a number of sound physiological
the growing orofacial complex. reasons, the condylar cartilage responds secondarily to this
This sort of therapeutic regimen cannot have a sound passive, disarticulating motion by literally growing upward
conceptual base unless the effects of each muscle on its to continually compensate for the lowering.
particular skeletal unit are understood, the vectors of Parenthetically, we know that bilateral removal of both
muscle force are established, and the idea is clearly mandibular condyles in growing animals and children does
grasped that each facial bone is a composite of several not inhibit mandibular growth; it only causes deformity of
skeletal units. The frequent failure on the part of the condylar process skeletal unit. At the same time, the
clinicians to observe these strictures has made other mandibular periosteal matrices are growing and
"myofunctional" therapy an inconsistent and altering their demands, bringing about all of the many
controversial technique. other active-transforrnative growth changes associated
In summary, the functional matrix concept does not with the totality of mandibular growth as it is observed
provide direct clinical assistance to the orthodontist clinically. It has been shown that the majority of
whose therapeutic intent is only to move teeth within mandibular vertical growth is produced passively, and
alveolar bone. To do this, he need only be adept at the similar statements can be made for maxillary growth.
practice of orthodontics, as it is expressed in the often For the orthodontist there are several practical - clinical
bewildering variety of methods and appliances available implications in these statements and their supporting data.
to alter tooth positions. If, however, the clinician wishes First,' while it might appear that the concepts of orofacial
to do more, then the functional matrix concept may skeletal growth have been complicated by the addition of
prove helpful. To clarify this point, let us study the passive growth processes to the already broadly understood
growth of the lower jaw. active processes of growth, in fact we are now able to com-
prehend the totality of such growth within a unitary
conceptual framework. Second, these same concepts
provide a basis for an extension of therapy into the more
comprehensive field of orofacial orthopedics. Some years
ago Bosma brought the concept of the "airway maintenance
MANDIBULAR GROWTH mechanism" into' focus, demonstrating that the
musculoskeletal apparatus of mandible, hyoid, and larynx
The mandible is a composite of several skeletal units,
function to maintain the volume of the functioning
each responding by direct growth to a distinct periosteal
respiratory space of the oral and pharyngeal regions.' Any
matrix. These skeletal units, together with their periosteal
alteration in the volume of one portion of this respiratory
matrices, are enclosed in an orofacial capsule. The
space produces an attempt to compensate for it in another
capsule is lined and covered with epithelium. As in the
portion, and this by a neuromuscular regula-
case of the skull vault, the orofacial capsule surrounds a
capsular matrix. In this case the matrix is the volume of
the functioning oral space. For many the word "cavity"
has the unfortunate connotation of emptiness. Clinicians
often consider the oral cavity as an empty space, left
over,
28 . The Functional Matrix and Clinical Orthodontics
tion of the location of the several skeletal parts. Indeed, there tioning) of innervated tissues, both afferently and efferently.
is some basis for the feeling that the reported clinical utility of Two recent reviews have focused attention on the specific
several types of removable dentofacial orthopedic therapies is potentiality of this sort of regulation in the regions of
based, in no small part, upon their being successful orthodontic interest." For example, there is, indeed,
applications of the functional matrix hypothesis." (Frankel, considerable reason to suppose that many properties of skeletal
1967). The position in space of the facial skeletal units can be muscles (as periosteal matrices) are specifically regulated by
altered and their compensatory responses predicted within the type of motor neurons innervating them, while it is
clinically useful values. probable that the sensory neurons play some role in the
Further, when we remember the deleterious effects on normal regulation of the growth of the orofacial capsule itself."
orofacial growth of such appliances as the Milwaukee brace, (Henken, 1970). It is reasonable to predict that in the
we can perceive how it might be possible to devise an immediate future we will witness a continually increasing
appliance therapy that 'would assist! and not hinder, the interaction between the theory and practice of orthodontics and
clinician in his the burgeoning field of neurobiology. Such a development is
attempt to restore more normal growth vectors to the patient to be welcomed, for if therapy is to become ever more
with an orofacial deformity. successful, it must be based upon as complete an
We turn! finally, to the subject of prosthetic functional understanding as possible of the biological processes involved.
matrices. In many other cranial regions, it has been
demonstrated repeatedly that skeletal units frequently cannot
"tell the difference" between a normal "vital" matrix and a
suitable prosthesis. As examples we cite the finding of
Hodash and coworkers" that alveolar bone will be maintained
despite tooth extraction and the immediate replacement of a REFERENCES
plastic duplicate! and the use of prostheses to produce normal
1. Bosma, J. F.: Oral and pharyngeal development and
bony orbit growth in children following removal of the orbital
function. J. Dent. Res., 42:375, 1963.
contents.' (Kennedy, 1965). The point is that both periosteal 2. Frankel. R: Funktioris-kieferorthopodie und der Mundvorhof
and capsular functional matrices can be prosthetically als apparative Basis. Berlin VEB Verlag Volk u.
replaced! if done appropriately. It is reasonable to presume Gesundheit, 1967.
that both types of matrices of the orofacial region can also be 3. Graber, T. M. (ed.): Orthodontic Glossary. American
prosthetically substituted. Association of Orthodontics, 1972a.
It is not the purpose of this chapter to provide specific 4. Graber, T. M.: Orthodontics: Principles and Practice. ed.
guidelines nor to advocate specific therapies! but rather to 3. Philadelphia, W. B. Saunders, 1972b.
suggest that the clinician may well be able to expand his 5. Henkin, R. 1.: Manual and oral stereognosis in normal
clinical potentials by considering the potential applicability of volunteers and patients with various abnormalities of taste
the functional matrix concept to his work. That this will and olfaction. In: Bosma, J. F. (ed.): 2nd Symposium on
Oral Sensation and Reception. Springfield, Charles C
require both study and application is certain, but it is sug-
Thomas, 1970.
gested that this effort may well prove rewarding. 6. Hodosh, M" Povar, M., and Shklar, G.: Plastic tooth
Finally, it is not premature to alert the orthodontist to a implants with root channels and osseous bridges, 0.5,;
relatively new field of investigation into the processes O.M., O.P., 24:831,1967.
regulating orofacial growth and, indeed, presumably 7, Kennedy, R. E.: The effect of early enucleation on the orbit
regulating the functional matrices themselves. The broad topic in animals and humans. Trans. Amer. Ophthalmol. Soc.,
of neurobiology is enjoying a period of rapid expansion and 42:459, 1965,
application 8, Moorrees, C. F. A.: Summary and overlook. Acta Morph.
. throughout the health sciences. One significant pora tion of this Neerl.-Scand., 10:145, 1972.
topic concerns neurotrophism: the study of the processes by 9, Moss, M. L.: Neurotrophic processes in orofacial growth, J.
Dent. Res" 50:1492,1971.
means of which the nervous system regulates the growth and
10. ___________ : An introduction to the neurobiology of oro-
structure (not the Iunc- facial growth. Acta biotheoret., 22:236, 1972 .
11. ___________ : Twenty years of functional cranial analysis.
Amer. J. Orthodont., 61:479, 1972.
12. __________: Functional cranial analysis and the functional
matrix. Arner. Speech Hear. Assoc. Rep., 6:5, 1971.
15.
16.
4
Eruption of the Teeth
The age of tooth eruption varies greatly; it is different sides of the jaw also varies, although in statistical
genetically determined but can be modified by local and studies no outstanding variation has been found favoring
systemic factors. Children of the same chronologie age earlier eruption on one side of the jaw over the other.
show variation in the number and type of erupted teeth.
Eruption time of the same teeth on
Fig. 4-1. From V. O. Hurme and Forsyth

Dental Center.
GIRL BOYS
S
MAXILLA
' MEAN AGES OF TOOTH EMERGENCE

.
Yeors WITH PLUS AND MINUS LIMITS OF Yeors
ONE STANDARD DEVIATION
MANDIBLE
GIRLS BOYS
2
9
30 . Eruption of the Teeth
DIFFERENCES BETWEEN TEETH AND BONES 8. Maxillary second molars
1. The teeth crowns calcify in their final size and do not The order of permanent tooth eruption shows
enlarge thereafter. considerable variation. The usual order is as follows:
2. Enamel and dentin, the two principal components of In the mandibular dental arch:
tooth substance, are not normally found in any of the other 1. Central incisors
organs of the body. 2. Lateral incisors
3. Unlike bone, teeth do not macroscopically change in 3. First molars
form once their development is completed except through 4. Canines
caries, functional changes, or other extraneous causes. 5. First premolars
4. Calcification in teeth occurs in early life, but secondary 6. Second premolars
calcifications may occur later in the pulp . chamber. 7. Second molars
5. Teeth are not subject to macroscopic calcium 8. Third molars
withdrawal after they are fully formed.
In the maxillary dental arch:
6. Systemic disturbances in calcification affect the teeth
during their developmental period only: adult teeth are not 1. First molars
affected. 2. Central incisors
3. Lateral incisors
7. Teeth cannot repair themselves nor replace lost
4. First premolars
substance.
5. Canines
8. There are two sets of teeth, deciduous (primary) and
6. Second premolars
permanent.
7. Second molars
8. Third molars
ORDER OF TOOTH ERUPTION DEVELOPMENT OF DENTITION FROM BIRTH TO

AGE 14
Although exceptions are common, the usual order
of eruption of deciduous teeth is as follows: The following is based on means of averages.
1. Mandibular central incisors Deviations of a year or even 2 are within normal range in
2. Maxillary central incisors the absence of pathological, local, or systemic factors.
3. Maxillary lateral incisors
4. Mandibular lateral incisors
5. Maxillary and mandibular 1st molars At Birth
6. Maxillary and mandibular canines In the Maxilla. The maxillary deciduous central and
7. Mandibular second molars lateral incisor crowns are fully formed, and part
Fig. 4-2. (Left) Gums and palate of a fetus 18

weeks old (after West), showing (a) dental
groove, (b) gingival groove, (g') labiobuccal
portion and (g") lingual portion of the gum.
(Right) Gums and palate of a fetus 29 weeks
old (after West), substantially representing
conditions as seen in the newborn. (a) Dental
groove, (b) gingival groove, (1) central
incisor segment, (2) lateral incisor segment,
(3) canine segment, (4) first molar segment,
(5) second molar segment. (Courtesy of M.
F. Ashley-Montagu)
Fig. 4-3. Unerupted teeth at birth. (Courtesy Dr. David Marshall)

Development of Dentition from Birth to Age 14 . 31
(B) Permanent first molars are in the process of calcification.

The alveolar bone overlying them is disappearing. (Courtesy
Dr. David Marshall)
Fig. 4-4(A). Occlusal radiograms of a child of 3 years

show calcification of the permanent incisor crowns near-
ing completion. There is interdental spacing and the de-
veloping permanent incisors are in echelon arrangement,
but not crowded.
of their roots are calcified. The permanent central incisor The mandibular deciduous canine is less advanced in
tooth germs are located lingual to and above the development than the mandibular deciduous incisors. The
deciduous central incisors near the floor of the nasal permanent canine tooth germ lies slightly below the crown
cavity. The permanent lateral incisor tooth germs are of the deciduous canine.
small undifferentiated buds at this stage. The mandibular deciduous first molars show completely
The deciduous canines show one third of their enamel formed crowns and the mandibular second deciduous
formed. The germ of the permanent canine lies in the molar is calcifying. The buds of the mandibular first and
angle between the pyriform nasal opening and the second premolars are small and lie occlusally and lingually
'I
maxillary sinus at a slightly higher level than the adjacent to the deciduous first and second molar crowns. The
permanent tooth germs. mandibular permanent first molar shows the beginning of
The maxillary deciduous first molar crown is fully calcification and is located close to the inner angle of the
formed, and the second deciduous molar is somewhat less mandible.
calcified. The first and second premolar tooth germs are
small epithelial buds located over the occlusal surfaces of
the deciduous molars.
The maxillary permanent first molar shows the
1 Year
beginning of hard tissue formation and is located above
the tuberosity. In the Maxilla. The enamel of all the deciduous teeth is
At Birth completed; the cusps of the permanent first molars are
united, and their crypts are close to the tu berosities of the
In the Mandible. The crowns of the mandibular maxilla. The deciduous central and lateral incisors have
deciduous central and lateral incisors are fully formed. erupted. The crowns of the permanent centrals, canines,
The mandibular permanent central and lateral incisor and laterals show some calcification.
tooth germs lie lingual to the deciduous central and lateral In the Mandible. The enamel of all deciduous teeth is
incisors and show some formation of enamel and dentin. completed. The deciduous central and lateral incisors have
There are normally no erupted teeth at birth. erupted. The permanent central and lateral incisors and canines
show hard tissue forma-
Fig. 4-5. Anterior and lateral views of the skull of a 4year-old

child show the arrangement of the deciduous teeth and the tooth
crowns of the permanent teeth (dark stippling). (Churchill, H.
[ed.]: Meyer's orrnal Histology and Histogenesis of the Human
Teeth and Associated Parts. Philadelphia, J. B. Lippincott)
tion. The deciduous first molar crowns are approaching the

body of the mandible.
2 Years
In the Maxilla. The roots of the deciduous central and
lateral incisors are completed and those of the deciduous
first molars are nearing completion. The crowns of the
permanent first molars show advanced formation of the
enamel. The permanent central and lateral incisors crowns,
the canine and first and second premolar crowns show
calcification.
In the Mandible. Almost all deciduous teeth have
erupted. The roots of the deciduous central and lateral
incisors are 'completed, and those of the deciduous first
molars are almost completed. The permanent first molar
crowns show advanced enamel formation. The permanent
central and lateral incisors, the canines, first premolars, and
occasionally, second premolars show various stages of
calcification. The crypts of the permanent second molars
appear distal to the first permanent molars.
Fig. 4-6. (Left) Occlusal ro-

entgenograms of dentition of a
child, age 4 years. Note: The
mandibular central incisor teeth
show root resorption. The
permanent incisor teeth show
beginnings of root calcification,
and the permanent incisors are
moving forward and outward.
(Right) Lateral jaw
roentgenograms of child, age 4
years. The bone overlying the
occlusal surfaces of the
permanent first molar teeth has
disappeared. The molars have
moved occlusalward. The
mandibular permanent second
molars are now passing the inner
angle of the mandible and the
maxillary permanent second
molars are in the tuberosity. The
pre-
molar tooth crowns show
progress of calcification.
Development of Dentition from Birth to Age 14 . 33
Fig. 4-7. (Left) Occlusal

radiograms of dentition of a
child, age 5 years. Note:
Maxillary deciduous central
incisor tooth roots are resorbing.
The permanent central incisor
crowns have moved forward and
downward. The mandibular de-
ciduous central incisors have
been prematurely exfoliated and
the permanent incisors are
erupting earlier than usual.
(Right) Lateral jaw
roentgenograms of child, age 5
years. The premolars show
progressive calcification. The
permanent first molars show
continuing root calcification and
have moved toward eruption.
The permanent second molar
crowns show continuing
calcification.
Fig. 4-8. (Left) Palatal view of maxilla, of a SY2-year-old. (A) Fig. 4-8. (Right) The left maxilla with the buccal plate removed. (A)
Opening for the gubernaculum into the permanent central incisor Opening for gubernaculum leading to crypt of permanent central
crypt. (B) Crown of permanent lateral incisor as seen through the incisor. (B) Gubernaculum leading to crypt of permanent lateral
opening of the gubernaculum into the permanent lateral incisor crypt. incisor. (C) Gubernaculum leading to crypt of permanent canine. (D)
(C) Opening of the gubernaculum leading to the crypt of the Gubernaculum, to crypt of first premolar. (E) Gubernaculum, to crypt
permanent canine. (D) Incisal suture. (E) Mediam suture. of second premolar. (F) Gubernaculum, to first permanent molar. (C)
Gubernaculum, to second permanent molar.
Note that the crypt of central incisor is in contact with crypts of the
lateral incisor and canine teeth. The crypt of the lateral incisor is in
contact with the central, canine, and first premolar. The first premolar
is in contact with the lateral incisor, canine, and second premolar. The
crypt of the canine contacts the crypts of all teeth from the first
permanent molar to the midline. (Courtesy Dr. Spencer R. Atkinson)
17.
t'
\
>
,I
/
Fig, 4-9(A), Anterior and lateral views of the skull of a child,

age 6 years, with outer layer of bone removed to show the teeth
in various stages of development and eruption. (Courtesy
Churchill-Meyer, Lippincott) (B, left) Occlusal radiograms of
dentition of a child, age 6 years. The deciduous central incisor
teeth have been shed, and the permanent central incisor teeth are
completing eruption. The mandibular permanent central incisors
are erupted. The deciduous lateral incisors are showing the
continuation of root resorption. (Right) Lateral jaw roent-
genograms of child, age 6 years. The premolar crowns show
continuing calcification. The permanent first molars are erupted.
The permanent second molar crowns show continuing
calcification. This eruption pattern is somewhat advanced.
~}
3 Years
are at the sites formerly occupied by the first molars. The
In the Maxilla. All deciduous teeth have erupted and their crowns of the permanent central and lateral incisors, the
roots are fully formed, with the possible exception of the canines, first premolars, second premolars, and second
deciduous canine roots. The crowns of the permanent first molars are in various stages of calcification.
molars are fully calcified and are located in the tuberosity of In the Mandible. Progress is the same as in the maxilla. The
the maxilla, The crypts of the permanent maxillary second crowns of the permanent first molars
molars
18. Development of Dentition from Birth to Age 14 . 35
Fig. 4-10. Top left and top right (Left) Occlusal radiograms of a
child of 7 years. The maxillary and mandibular permanent central
incisor teeth are erupted. The deciduous lateral incisor teeth have
been shed, and the maxillary and mandibular permanent incisor
teeth are erupting. Mandibular incisor calcification is more
advanced than maxillary incisor calcification. (Right) The
premolars and permanent canines show advanced calcification.
The permanent first molars are erupted. The second molar
crowns show continuing calcification. (Courtesy Dr. David
Marshall) (Bottom) Section of specimen approximately 7 years of
age. The cut was made near the level of the roof of the palate.
Note that distribution of cancellous bone is abundant both buccal
and lingual of the second premolar and first permanent molar and
roof of palate; (a) location of first permanent central incisor; (b)
lateral incisor; (c) canine; (d) first premolar; (e) second premolar;
(f) first permanent molar; (g) transverse palatine suture is now
between the first and the second permanent molar; (h) location of
second permanent molar; (i) crypt of developing their molar; (j)
the pterygoid plates. The tuberosity of the maxilla is lateral to the
pterygoid process of the sphenoid. (Bottom Courtesy of Dr.
Spencer R. Atkinson)
are fully calcified and are located almost entirely within permanent first molars is complete. The enamel of the
the mandibular body. The crypts of the permanent second permanent central and lateral incisors may be complete.
molars are now located at the site formerly occupied by Calcification is advanced in the permanent second molars
the first molars. and canines.
In the Mandible. Progress is the same as in the maxilla.
4 Years
In the Maxilla. The deciduous dentition is complete. The
5 Years
crowns of the permanent teeth show further hard tissue
formation. The enamel of the In the Maxilla. Enamel formation is complete in
Fig. 4-10. Top left and top right (Left) Occlusal radiograms of a
child of 7 years. The maxillary and mandibular permanent
central incisor teeth are erupted. The deciduous lateral incisor
teeth have been shed, and the maxillary and mandibular
permanent incisor teeth are erupting. Mandibular incisor
calcification is more advanced than maxillary incisor
calcification. (Right) The premolars and permanent canines
show advanced calcification. The permanent first molars are
erupted. The second molar crowns show continuing calcification.
(Courtesy Dr. David Marshall) (Bottom) Section of specimen
approximately 7 years of age. The cut was made near the level of
the roof of the palate. Note that distribution of cancellous bone is
abundant both buccal and lingual of the second premolar and
first permanent molar and roof of palate; (a) location of first
permanent central incisor; (b) lateral incisor; (e) canine; (d) first
premolar; (e) second premolar; (f) first permanent molar; (g)
transverse palatine suture is now between the first and the
second permanent molar; (11) location of second permanent
molar; (i) crypt of developing their molar; (j) the pterygoid plates.
The tuberosity of the maxilla is lateral to the pterygoid process
of the sphenoid. (Bottom Courtesy of Dr. Spencer R. Atkinson)
are fully calcified and are located almost entirely within permanent first molars is complete. The enamel of the
the mandibular body. The crypts of the permanent permanent central and lateral incisors may be complete.
second molars are now located at the site formerly Calcification is advanced in the permanent second molars
occupied by the first molars. and canines.
In the Mandible. Progress is the same as in the maxilla.
4 Years
In the Maxilla. The deciduous dentition is complete.
5 Years
The crowns of the permanent teeth show further hard
tissue formation. The enamel of the In the Maxilla. Enamel formation is complete in
the permanent central and lateral incisors, first molars and central incisors. The permanent first molars have erupted.
possibly also in the first premolars. Calcification of the The enamel of the permanent central and lateral incisors,
canines and second permanent molars is advanced. The canines, first and second premolars, the first, and possibly
crypt of the permanent canine is in contact, with or second molars is complete. The permanent third molars
connected with the crypt of every unerupted permanent may be beginning to calcify.
tooth crown from the permanent central incisor to the In the Mandible. The permanent central and lateral
permanent first molar. incisors and first molars are erupted. The enamel of the
In the Mandible. Progress is the same as in the maxilla. permanent central and lateral incisors, canines, first and
second premolars, the first and possibly that of the second
molars is complete.
6 Years
8 Years
, In the Maxilla. The permanent first molars may be
erupting into the mouth. The enamel formation of the first In Both Dental Arches. The permanent central and
premolars is complete and possibly also that of the lateral incisors and first molars are fully erupted. All of the
permanent canines and second premolars. permanent teeth, excepting the second molars and third
In the Mandible. The deciduous central incisors may be molars, show completion of enamel formation. The third
displaced by the erupting permanent incisors. The molars are undergoing calcification.
permanent first molars may have erupted. The enamel
formation of the first premolars is complete and possibly
also that of the canines and second premolars.
9 Years
In the Maxilla. The permanent central and lateral
incisors and first molars are fully erupted. The roots of the
7 Years
permanent first molars may be completely formed. Enamel
In the Maxilla. The permanent central incisors are formation is completed in all of the permanent teeth except
displacing or have displaced the deciduous the third molars, which
Fig. 4-11. (A, left) Occlusal radiograms of a child, age 8 years.

The maxillary central incisors are erupted and show advance in root
calcification. The maxillary lateral incisors are erupting. All four
mandibular incisors have erupted, and their roots show advanced
calcification. (Right) The mandibular premolar roots and permanent
second molar crowns are continuing their calcification. (Right view
courtesy of Dr, David Marshall)
Development of Dentition from Birth to Age 14 37
Fig. 4-11. (B) Skull of an

8-year-old child. The roots
of the deciduous teeth and
the tooth germs of the per-
manent teeth (dark stip-
pling) are exposed (Cour-
tesy of Dr. Churchill)
show advanced calcification. The crypt of the third molar is first (and possibly the second molars) also. Crown formation is
now located at the site formerly occupied by the first and later complete in all permanent teeth up to the third molars, which
by the second molar. show advanced calcification. The crypts of the third molars are
In the Mandible. The permanent central and lateral now located at the site formerly occupied by the first and later
incisors, and possibly the canines and first premolars have by the second molars.
erupted. The roots of the permanent central incisors are
complete, and those of the permanent
Fig. 4-12. (Left) Occlusal radiograms of a child of 9 years.

Maxillary and mandibular permanent incisor teeth are erupted
and the roots have calcified. The permanent canines show
advanced calcification. (Right) Lateral jaw radiograms show
premolars erupted or about to erupt. The permanent second
molars show root calcification; the
alveolar bone overlying them has disappeared. The maxillary
third molar crowns are in the tuberosity. The mandibular third
molar crowns have passed the inner angle of the mandible.
38 . Eruption of the Teeth 20.
21.
I ,
c~ ~ ~~c
Fig. 4-13. (A, left) Occlusal radiograms of a child of 10 years. The maxillary
and mandibular incisors are erupted. The maxillary canine teeth are about to
erupt; the mandibular canines have erupted. (Right) Lateral jaw
roentgenograms show first premolars erupted and the second premolars, in
the process of erupting. The permanent first molars are erupted; the
permanent second molars are erupting. The third molar crowns show
continuing calcification.
. Fig. 4-13. (B) Front and side views of the skull of a 10-year-old child .
'.
Roots and tooth germs exposed; the permanent teeth have dark stippling.
(From Churchill-Meyer, Lippincott)
10 Years complete root formation of the permanent incisors and first

molars. Crown formation is complete in all of the permanent
In the Maxilla. The permanent central and lateral teeth except the third molars, which show advanced
incisors, first molars, and occasionally also the first and calcification.
second premolars have erupted. There is In the Mandible. The permanent central and lateral
Fig. 4-14. (Left) Occlusal radiograms of a child, age 11 years.

The maxillary and mandibular incisor and canine teeth are
erupted. (Right) The lateral views show that permanent teeth
beginning with the permanent first molars are erupted. The
second molars are in the process of erupting. The third molar
crowns are in the tuberosity in the maxilla and past the inner
angle of the mandible.
Fig. 4-15. (Left) Occlusal radiograms of the dentition of a child

age 12 years. All permanent teeth with the exception of the third
molars are erupted. (Right) Lateral jaw roentgenograms show
completion of eruption and calcification of all teeth except the
third molars.
incisors, canines, first molars, and occasionally the first Crown formation is complete in all but the third molars.
premolars, have erupted. There has been complete root
formation of the permanent central and lateral incisors
and first molars. Crown formation in the permanent teeth
12 Years
is completed with the exception of the third molars,
which show advanced calcification. In the Maxilla. All the permanent teeth, with the
exception of the third molars, have erupted. There is
completion of the roots of the central and lateral incisors,
first molars, and frequently the first and second
11 Years
premolars.
In the Maxilla. The permanent central and lateral In the Mandible. All of the.permanent teeth, with the
incisors, canines, first molars and frequently also the first exception of the third molars, show complete crown
and second premolars are erupted. Root completion has formation and all teeth mesial to the third molars have
occurred in the permanent central and lateral incisors and erupted. There is completion of the roots of the central
first molars. Crown formation of all of the permanent and lateral incisors, first molars, and possibly the first and
teeth is complete, excepting the third molars, which show second premolars.
advanced calcification.
In the Mandible. The permanent central and lateral
incisors, canines, first premolars, first molars, and 13 Years
possibly the second premolars and second molars have In the Maxilla. Conditions are about the same as at 12
erupted. The roots of the permanent central and lateral years, with further eruption and root completion of th
incisors and first molars are complete. premolars and canines.
In the Mandible. All permanent teeth except the
Fig. 4-16. (Top) Lateral jaw roentgenograms of a

child, age 14 years. The third molars are erupting.
(Bottom) Lateral jaw roentgenograms of the same child
at 16 years showing mandibular left third molar going
into impaction. Third molar teeth may become impacted
during their eruption. To the contrary, teeth that erupt
ectopically may show self-correction and erupt
normally.
The Third Molars . 41
Fig. 4-17. Panradiograms of a

17-year-old. All teeth anterior up
to the third molars have erupted.
The third molars are in the
process of eruption. (Courtesy of
Dr. David Marshall)
Fig. 4-18. Section about cementoenamel junction of molar

teeth. This cadaver was approximately 21 years of age: (a, b, c)
roots of anterior teeth; td, e) of the premolar teeth; (f) the key ridge;
(g) three roots of first permanent molar; (11) the transverse palatine
suture opposite center of the second permanent molar; (i) buttress
of the pterygoid plates directly behind and supporting the dental
arch. The tuberosity in younger persons is not so supported, but
lies lateral to this buttress. Considerable growth takes place in a
posterior direction at the tuberosity of the maxilla, after the
eruption of the maxillary permanent first molars. (Atkinson, S. R:
Am. J. Orthodontics 28:715, 1900)
r.
third molars have erupted, and all except the second and These teeth are less related to general physical
third molars, and possibly the second premolars have development than the rest of the dentition.
completed their root formation.
14 Years Calcification of Deciduous Teeth Roots
In the Maxilla. All permanent teeth have erupted None of the deciduous roots is completely formed until
except the third molars. All teeth except the third molars age 1 Y2 years, when the roots of the mandibular central
and possibly the canines and second molars haye and lateral incisors and maxillary central incisors are
complete roots. complete. The completion of the deciduous maxillary
in the Mandible. All permanent teeth except the third lateral incisors, the deciduous mandibular first molars, and
molars have erupted and excepting the third and possibly the deciduous maxillary first molars respectively occurs
the second molars, all have complete roots. between the ages of 2 and 3. The deciduous second molar
roots are completed at 3 years. The deciduous canine roots
are not complete until about age 3 years and 3 months.
The period of calcification in the deciduous teeth lasts
THE THIRD MOLARS
from about the age of 1 year and 10 months to
The third molars will start to calcify at age 7 in some approximately the age of 3 years and 8 months.
children and not until the 15th year in others.
Calcification of Permanent ooth Roots period of approximately 10 years. The shortest period of
Permanent teeth experience an extended period of complete calcification, including the roots, in the
formation and calcification. Complete calcification of the permanent dentition is that of the mandibular central
permanent incisor crowns occurs between the ages of 4 incisors, which take approximately 8V2 years to calcify.
and 5 years, the rest of the permanent teeth crowns, The longest period of complete calcification is that of the
excepting the 3rd molars, calcify between the ages of 6 canines, which require 12V2 to 14V2 years, although the
and 8 years. third molars may take as long as 15 years.
The third molar in its entirety has a calcification
BIBLIOGRAPHY paction. Arch. Clin. Oral Pathol., 2:125, 1938.

Hock, R B.: Third molars. J.A.D.A., 68:541, 1964 Hoffman, M.
Adler, P.: Die Asymmetrie des Zahnwechsels. (The asymmetry M., and Schour, I.: The rate and pattern of eruption as
of tooth changes). Stoma, 11 :123, 1958. demonstrated by injections of Alizarine Red S. J. D. Res.,
-'--: Effect of some environmental factors on sequence of 19:319, 1940.
permanent tooth eruption. J. p. Res., 42:605, 1963. [oondeph. D. Rand McNeiIl, R W.: Congenitally absent second
Atkinson, S. R: Growth and deJelopment of the teeth; (A) premolars: An interceptive approach. Am. J. Orthodontics.,
mandible (B) maxilla. Am. J. Orthodontics, 26:829, 1940. 59:50, 1971.
Bambha, J. L., and Van Natta, P.: A longitudinal study of Kraus, B. S.: Calcification of the human deciduous teeth.
occlusion and tooth eruption in relation to skeletal maturation. J.A.D.A., 59:1126,1959.
Am. J. Orthodontics, 45:847,1959. Kraus, B. S., and Jordan, R. E.: The Human Dentition Before
Bishara, S. E.: Treatment of unerupted incisors. Am. J. Birth. Philadelphia, Lea & Febiger, 1965.
Orthodontics, 59:443, 1971. Meredith, H. V.: Order and age of eruption of the deciduous
Broglia, M. L.: Malposizioni dei denti permanenti nel casi di dentition. }. D. Res., 25:43,1946.
persistenza dei corrispondenti decidui. Minerva Stomat., 11 Mcorrees, C F. A, et al.: Growth studies of the dentition.
:817, 1962. Am. }. Orthodontics, 55:600, 1969.
Butler, D. J.: The eruption of teeth and its association with early ---: The Dentition of the Growing Child, a Longitudinal Study of
loss of deciduous teeth. Brit. D. J., 112:443, 1962. Dental Development Between 3 and 18 Years of Age.
Dachi, S. F., and Howell, F. V.: A survey of 3,874 routine fuU- Cambridge, Harvard University, 1959.
mouth radiographs. II. A study of impacted teeth. Oral Surg., Ohata, S.: Relationship of eruptions of first and second molars in
Oral Med., & Oral Path., 14:1165, 1961. weight, stature and development of head in exposed children.
DiBiase, D. D.: Mucous membrane and delayed eruption. Atomic Bomb Casualty Commission Report. Washington,
D. Practitioner, 21 :241, 1971. National Academy of Science, 1956.
Fleischer-Peters. A: Ursachliche Zusammenhange bei der Pratt, R. J.: Migration of canine across the mandibular mid-line.
Dentitio Tarda. Fortschr. Zahnheilk, 31 :27, 1970. Brit. D L 119:463, 1969.
Cran, A M.: The prediction of tooth emergence. J. D. Schour, I.: The growth and calcification patterns of the human
Res., 41 :573, 1962. deciduous teeth. Anal. Rec., 70:70, 1938.
Hatton, M. E.: A measure of the effects of heredity and en- Sognnaes, R F. (ed.): Calcification in Biological Systems, a
vironment on eruption of the deciduous teeth. J. D. Res., symposium presented at the Washington meeting of the
34:397, 1955. American Association for the Advancement of Science. Pub.
Hellman, M.: Racial characters in human dentition. Proc. No. 64, Am. Ass. Adv. Sci., Washington, D. C, 1960.
Am. Philos. Soc., 67:157, 1929. Stafne, E. C: Malposed mandibular canine. Oral Surg., Oral
--: Eruption of permanent teeth and accompanying facial Med. & Oral Path., 16:1330, 1963.
changes. In Todd, T. W.: Physical and Mental Growth. Weyman, J.: The effect of irradiation on developing teeth.
Cleveland, Brush Foundation, 1930. Oral Surg., Oral Med. & Oral Path., 25:623,1968.
---: Some aspects of wisdom teeth and their irn-
5 23.
Development of Dental Occlusion
PHYSICAL VARIATION AND OCCLUSION within a group may be normal and still differ one from
another. Appraisal of the normal growth of a child must be
A normal person is one who is sound in body and mind, determined by the fact that he falls within the range of
harmoniously developed physically, mentally, and variability of his or her own potentiality of growth. If a child
emotionally, and consistent with his years in developmental is so situated, he is developing normally, Computers promise
progress. Normalcy is not always the usual or average; nor to be useful in these determinations.
does it mean the best. On the other hand, normal growth and Normal in orthodontics as a basis for classification must be
normal physical morphology imply all of these. All persons based on what is known as biologic con-
Fig. 5-1. A, Monozygous -- Madelyn B,

twins, 11 years of age. B, --Susan Cl
Extreme concordance of the
facial skeletal outline is shown
on the tracings. C, The incisor
alignment is disturbed by early
loss of deciduous teeth and by
space closure in the twin on
the right. D, While the incisors
differ in interarch relation
because of tooth loss, they still
show concordance in tooth
rotations. E, The casts of these
twins show dental arch tooth
alignment changes as a result
of tooth loss, space closure,
and shifting of teeth. Tracings
of lateral cephalograms show
a high degree of concordance
in outline of the skulls. The
twins nevertheless show
concordance of tooth rotations
and interdental spacing. This
is an example of the effects of
environmental factors on the
ex{1ression of the dental gen-
otype. (Courtesy Am. J.
Orthod. and C. V. Mosby Co.)
4
3
44 . Development of Dental Occlusion
that can produce a multiplicity of variations. Occlusion can

be centric, eccentric, mesial, distal, labial, lingual, supra-,
infra-, and of many other forms and combinations.
Dental occlusion is established by the genetic pattern
and modified by intrinsic and extrinsic prenatal and
postnatal environmental factors that are developmental,
physiologic, and pathologic. Tooth arrangement is affected
by muscle pressure. The size and habitual position of the
tongue are especially important in determining normal
occlusion. The size, tonicity and pressure of the lips and
the cheeks and the functional stress of the muscles of
expression and mastication are also important factors in
establishing dental occlusion. Occlusal and axial contacts
and inclinations of the teeth, the manner of swallowing,
speech, and respiration all enter into the forces that can
affect the arrangement and occlusion of the teeth.
Dental occlusion and malocclusion are multifactorial
continuums that cannot be compartmentalized into rigid
categories. It is necessary to accept a range of variations
from the norm for dental occlusion just as we accept
variations, in symmetry in the entire body.
The Adaptive Individual Norm

Orthodontic therapy is required primarily because of
morphologic, spatial, and functional deviations of the teeth
and jaws beyond the limits of normalcy. However, since
Fig. 5-2. Monozygous twin boys, aged 12.6 years, show the law of variation of structure, form, and function is
extreme similarity of malocclusion. Note especially the inherent in the human species, a child with "normal"
maxillary incisors. The mandibular incisors show some- dentition fits no rigid pattern; rather he represents an
what different alignment. Differences in the malocclusion adaptive individual norm within a given range.
of monozygous twins may increase with age through
environmental influences in the use or abuse of the teeth.
Variables in Dental Occlusion
tinuity, that is, the relationship of the teeth and jaws, to
each other and to the entire skull, that is peculiar to man. Sanin, Savara, and Sekiguchi call.attention to the
"Normal" as applied to the human dental occlusion can following variables in occlusion: (1) tooth size and tooth-
evidence itself in differen t ways. arch size relationships; (2) arch widths and their changes
To recognize the abnormal one must be familiar with wi th age; (3) the size of the facial bones and their different
the normal. However, the extreme range of natural patterns of growth; (4) the eruption patterns and shifting of
variation in the human body presents difficulties in deciduous and permanent teeth, plus the effect of
clinical diagnosis, treatment planning, and prognosis. " intercuspation on tooth position; (5) the effect of continual
ormal" as applied to structure, form, and function in abrasion; and (6) the size and growth patterns of the tongue
orthodontic diagnosis falls well within the subjective
and labial musculature, as well as their dynamic effect
response of the individual orthodontist, frequently without
direct relation even to arbitrary definitive criteria or during chewing and swallowing.
norms. Definition of Dental Occlusion. Dental occlusion is the
static and dynamic interrelationships of the opposing
surfaces of the maxillary and mandibular teeth that occurs
during movements of the mandible and when the maxillary
PA TTERNS OF DENTAL OCCLUSION and mandibular dental arches are in terminal
approximation.
The dental occlusion cannot be regarded as a static
condition, since mandibular closure is a continuum
Appositive Relation of the Deciduous Teeth in Normal Terminal Occlusion . 45
24.
Ideal Occlusion. Ideal occlusion requires an un-
blemished heredity, an optimal environmental and
developmental history, and a functional pattern devoid of 1
any accident, disease, or fortuitous occurrences-that would 2
modify the ideal formula of human occlusion. Ideal
occlusion is a condition that does not exist in humans.
Normal Occlusion. Dental occlusion is constantly
changing, especially during childhood. Normal occlusion
is the accepted relationship, for the species, of the teeth in
one jaw to those in the opposing jaw when the maxillary
and mandibular dental arches are approximated in terminal
occlusion.
The Range of Normalcy. There is a range of normalcy
in humans but no exact standard by which the normal can
be measured. Strict adherence to existing standards of
normalcy may actually prove harmful to the patient.
However, because a common base or norm is necessary in
order to classify den tofacial deformities for treatment
purposes, orthodontists have created norms and
classifications. Although all norms have shortcomings, a
biologic norm must be established for any organism so
that abnormalities can be classified. 2
Individual Normal Occlusion. Normal occlusion in the 1
abstract is an invariable pattern according to the accepted
human formula. Since variation of form is characteristic of Fig. 5-3. A diagrammatic representation with lines that
all organisms, no two teeth and no two dentitions can be connect from the cusp or point of a tooth on one dentition to the
exactly alike in morphology, symmetry, and proportion. fossa or point where they occlude in the opposing dentition. Note.
So-called normalocclusions show a range of variation that The arrows indicate the direction in which each cusp or point in
constitute individual normals. There is a norma! for the the mandible moves in the working side, the balancing side and
individual according to age, sex, ethnic background, in protrusion. (After C. H. Schuyler).
somatotype, cranial, and facial patterns.
APPOSITIVE RELATION OF THE DECIDUOUS

TEETH IN NORMAL TERMINAL OCCLUSION
The deciduous dentition consists of 20 teeth, 10 in each
jaw. They are arranged and occlude as follows:
The Maxillary Teeth

Central Incisor. The linguoincisal portion of the central
incisor occludes with the incisal edge of the mandibular
central incisor and the mesial half of the.incisal edge of
the mandibular lateral incisor.
Lateral Incisor. The linguoincisal portion of the lateral
incisor occludes with the distal half of the incisal edge of
the mandibular lateral incisor and the mesioincisal aspect
of the incisal edge of the mandibular canine.
Fig. 5-4. Occlusal relation of deciduous dentition, age 3 years.
Canine. The mesial aspect of the linguoincisal portion
Occlusal surface of mandibular deciduous teeth, with outlines of
of the canine occludes with the distal aspect of the
opposing maxillary teeth, showing points and ridges of cusps.
labioincisal edge of the mandibular canine (Friel, S.: Int. J. Orthodont., 13:322, 1927)
First Molar. The mesial aspect of the mesiobuccal cusp

of the first molar occludes with the distal aspect of the
linguoincisal third of the maxillary canine. The middle
and distal occlusal thirds of the mandibular first molar
occlude with the mesial and the middle thirds of the
maxillary first molar.
Second Molar. The second molar occludes with the
distal aspect of the distobuccal and distolingual cusps of
the maxillary first molar and the entire occlusal surface of
the maxillary second molar.
The mandibular first and second molars may also be on
the same vertical plane with the maxillary molars, in
which case the occlusal surfaces of the molars occlude
opposite to one another and the distal surfaces of the
deciduous second molars are on the same vertical plane
(Fig. 5-9).
APPOSITIVE RELATION OF THE PERMANENT

TEETH IN NORMAL TERMINAL OCCLUSION
The permanent dentition consists of 32 teeth, 16 in
Fig. 5-5. Occlusal relation in the mixed dentition of an 8-
each jaw. They are arranged and occlude as follows:
year-old. The occlusal surfaces of the mandibular deciduous
canines and molars and permanent central and lateral incisors
and first molars, with outlines of opposing teeth, points, and
ridges of cusps. The cusps of the deciduous teeth are worn, and The Maxillary Teeth
the mandibular arch is more mesial in its relation to the
maxillary arch than at 3 years of age. (Friel, S.: Int. ]. Central Incisor. The linguoincisal third of the central
Orthodont., 13:322, 1927) incisor occludes with the incisal edge of the mandibular
central and the mesial half of the incisal edge of the
and the mesial aspect of the mesiobuccal cusp of the mandibular lateral incisor.
mandibular first molar. Lateral Incisor. The linguoincisal third of the lateral
First Molar. The first molar occludes with the middle incisor occludes with the distal half of the incisal edge of
and the distal thirds of the occlusal surface of the the mandibular lateral and the mesial aspect of the incisal
mandibular first molars. edge of the canine. The incisal edge of the lateral incisor
Second Molar. The second molar occludes with the is usually slightly raised, and the teeth are frequently
distal aspects of the mesiobuccal and mesiolingual cusps situated somewhat more lingually than the central
and the remaining occlusal surface of the mandibular incisors.
second molars. Canine. The mesial aspect of the linguoincisal third of
the canine occludes with the distal aspect of the incisal
edge of the mandibular canine, and the distal aspect of
The Mandibular Teeth the canine occludes with the mesial aspect of the buccal
Central Incisor. The incisal edge of the central incisor cusp of the mandibular first premolar.
occludes with the mesial and middle linguoincisal third First Premolar. The first premolar occludes with the
of the maxillary central incisor. distal aspect of the buccal cusps of the mandibular first
Lateral Incisor. The incisal edge of the lateral incisor premolar and the mesial aspect of the buccal cusp of the
occludes with the distal third of the Iinguoincisal third of mandibular second premolar.
the maxillary central incisor and mesial half of the Second Premolar. The buccal and lingual cusps of the
linguoincisal third of the maxillary lateral incisor. second premolar occlude with the distal aspects of the
Canine. The mesial aspect of the incisal edge of the buccal and the lingual cusps of the mandibular second
canine occludes with the distal half of the linguoincisal premolar and the mesial aspects of the mesiobuccal and
third of the maxillary lateral incisor. The distoincisal mesiolingual cusps of the mandibular first molar.
aspect of the mandibular canine occludes with the mesial First Molar. The mesiobuccal cusp of the first molar
aspect of the linguoincisal third of the maxillary canine. occludes in the buccal groove of the mandib-
Appositive Relation of the Permanent Teeth in Normal Terminal Occlusion' 47
Fig. 5-7. The deciduous incisors (a) are arranged more

vertically than the permanent incisors (b); the premolars
usually occupy less space rnesiodistally than the deciduous
molars, and the permanent first molar has to shift forward to
close the space. (Friel, S.: Int. J. Orthcdont., 13:322,1927)
Fig. 5-6. Diagram of the occlusal surfaces of the mandi-

bular deciduous canines, molars and permanent central and
lateral incisors and first molars, with outlines of opposing
teeth, points and ridges of cusps at 8 years of age. The
mandibular molars have not shifted forward. The deciduous
molars and canines have remained in the same relation as at
3 years of age. There is a slight apparent protrusion of the
maxillary incisors, and the maxillary permanent first molar
is rotated so that its mesiobuccal cusp occludes between the
distal cusp of the mandibular second molar and the mesial
cusp of the mandibular permanent first molar. Permanent
distoclusion may be initiated in this manner.
ular first molar, and the distobuccal cusp of the maxillary

first molar occludes between the distobuccal cusp of the first
molar and the mesiobuccal cusp of the mandibular second
molar. The inesiolingual cusp of the maxillary first molar
occludes within the central fossa of the mandibular first
molar.
Second Molar. The mesiobuccal cusp of the second molar
occludes within the buccal groove of the mandibular second Fig. 5-8. Occlusal relation in the permanent dentition.
molar, and the distobuccal cusp occludes between the The occlusal surface of the mandibular permanent teeth with
distobuccal cusp of the mandibular second molar and the outlines of opposing teeth, points and ridges of cusps. (Friel,
mesiobuccal cusp of the mandibular third molar. The S.: Int. J. Orthodont., 13:322, 1927)
mesiolingual cusp of the maxillary second molar occludes
within the central fossa of the mandibular second molar.
Third Molar. The mesiobuccal cusp of the third molar
occludes within the buccal groove of the mandibular third
molar. The Mandibular Teeth
Central Incisor. The incisal edge of the central incisor
occludes with the mesial and middle thirds
Fig. 5-9. Casts of the aspect of the linguoincisal third of the maxillary canine. The
child in Fig. 5-7 taken 2 distal aspect of the buccal cusp of the mandibular first
years later. (Top) The premolar occludes with the mesial aspect of the buccal cusp
maxillary permanent first of the maxillary first premolar.
molar shifted toward the Second Premolar. The mesial aspect of the buccal cusp of
middle after loss of decid- the second premolar occludes with the distal aspect of the
uous molars, causing tem- buccal cusp of the maxillary first premolar. The distal aspect
porarily incorrect occlusion of the buccal cusp of the mandibular second premolar
with mandibular permanent occludes with the mesial aspect of the buccal cusp of the
first molar. (Bottom) maxillary second premolar.
Mandibular permanent first
molar shifted mesially after First Molar. The mesiobuccal cusp of the first molar
loss of mandibular occludes between the maxillary second premolar and the
deciduous molars; it maxillary first molar. The dis tobuccal cusp of the mandibular
occludes correctly with the first molar occludes between the mesiobuccal and dis to
maxillary permanent first buccal cusps of the maxillary first molar.
molar. (Friel. S.: Int. J. Second Molar. The mesiobuccal cusp of the second molar
Orthodont., 13:322,1927) occludes between the distobuccal cusp of the maxillary first
molar and the mesiobuccal cusp of the maxillary second
of the linguoincisal third of the maxillary central incisor. molar. The distobuccal cusp of the mandibular second molar
lateral Incisor. The incisal edge of the lateral incisor occludes between the mesiobuccal and distobuccal cusps of
occludes within the distal third of the linguoincisal third of the maxillary second molar.
the maxillary central and the mesial half of the linguoincisal Third Molar. The mesiobuccal cusp of the third molar
third of the maxillary lateral incisor. occludes between the distobuccal cusp of the maxillary
Canine. The mesial aspect of the incisal edge of the canine second molar and the mesiobuccal cusp of the maxillary third
occludes with the distal half of the linguoincisal third of the molar. The dis to buccal cusp of the mandibular third molar
maxillary lateral. The dis toincisal aspect of the mandibular occludes between the mesiobuccal and dis to buccal cusps of
canine occludes with the mesial aspect of the linguoincisal the maxillary third molar.
third of the maxillary canine.
First Premolar. The mesial aspect of the buccal cusp of the
first premolar occludes with the distal
Brown, Y. P., and Daugaard-Iensen, 1.: Changes in the

BIBLIOGRAPHY dentition from the early teens to the early twenties, a
longitudinal cast study. Acta odont. scand, 9:177, 1951.
Angle, E. H.: Malocclusion ofthe Teeth. ed. 7. Philadelphia. Burstone, C. J.: Lip posture and its significance in treatment
S. S. White, 1907. planning. Am. J. Orthodontics, 53:262, 1967.
Bambha, J. K., and Van Natta, P.: A longitudinal study of Cookson, A. M., Tongue resting position: A method for its
occlusion and tooth eruption in relation to skeletal measurement and correlation to skeletal and occlusal
maturation. Am. J. Orthodontics, 45:847, 1959. patterns. D. Practitioner, 18:115,1957.
Baurne, L. J.: Reihenuntersuchungen tiber die normale DeButts, R. D.: Diagnosis and treatment planning of cases
Gebissentwicklung. Deutsche Zahn. Ztschr., 4:427, 1949. presenting problems due to missing teeth. Am. J.
---: Developmental and diagnostic aspects of the primary Orthodontics, 47:844, 1961.
dentition. Internat. D. J., 9:349, 1959. Dixon, D. A.: An investigation into the influence of the soft
Bluntschli, H., and Schreiber, H.: Zur allgemeinen tissues on tooth position. D. Practitioner, 10:89, 1960.
Gebisslehre. Fortschr. d. Zahriheilk, 4:1, 1928. Downs, W. B.: An analysis of the forces of occlusion. Proc,
Bouvet, J. M.: Les germes supplernentaires en orthodon tie Int. Med., 12:16, 1938.
(Supplemental tooth germs, in orthodontics). Ann. Friel, S. E.: Occlusion, observations on its development from
Odontostomat., 18:61, 1961. infancy to old age. Int. J. Orthodontics & Oral Surg., 13:322,
Brabant, H., Werelds, R., and Klees, L.: Les alterations 1927.
dentaires dans la maladie de Morquio. Rev. stornatol., Gabka, H. J.: Der Einfluss der Chieloplastik auf die Kie-
63:466, 1962. ferform und Kieferstellung. Yierteljahresschrift fur die
Broadbent, B. H.: The influence of the third molars on the wissenschaftl. Zahn. Mund. Kieferheilk, p. 171, 1962.
alignment of the teeth. Am. J. Orthodontics, 29:312, 1943. Garner, L. D.: Tongue posture in normal occlusions. J.
D. Res., 41:771, ]962.
Bibliography . 49
Hatton, M. E.: The process of eruption in relation to skeletal bite in normal subjects between 9 and 17 years. E.O.s., Report of
morphology and the development of occlusion: 43rd Congress, Berne, 1967.
Intra-alveolar tooth movement and clinical eruption. Am. J. McGonigle, R. R.: Loss of teeth as a danger in the development of
Orthodontics, 45:709,1959. (Abstract) occlusion. I.AD.A, 50:57, 1955.
Haupi, K.: Die Enstehung des Milchgebisses und des bleibenden Moorrees, F. A M.: Occlusion. Part II. J. Periodont., 38:751, 1967.
Gebisses. Deutsche Zahn-, Mund-, 1I. Kieferheilk. 5:17, 1953. Muller, G.: Apikale Basis und Vertikalentwicklung.
Helman, M.: Factors influencing occlusion: Development of Fortschr. Kieferorthop., 23:304-311, 1962.
occlusion, Philadelphia, University of Pennsylvania, ]941. Orban, B.: A concept of occlusion in periodontal practice.
---: The phase of development concerned with erupting the J. Periodont., 23:38, 1952.
permanent teeth. Am. J. Orthodontics, 29:507, 1943. Reichenbach, E., and Rudolph, W.: Untersuchungen zur
Higley, Bodine, L.: Mandibular Incisor Jumbling. J. Den. Entstehungsweise des Distalbisses im Milchgebiss. Fortschr,
Children 34:452-453, November 1967. Kieferorthopad., 16:96, 1955.
Jackson, D.: Lip positions and incisor relationships. Brit. Salzmann, J. H.: An analysis and discussion of oral changes as
D. ]., 112:147, 1962. related to dental occlusion. Am. J. Orthodontics, 39 :246, 1953.
[ankelson, B.: Physiology of human dental occlusion. Sanin, C, Savara, B. S. and Sekiguchi, T.: Longitudinal dentofaciaI
J.A.D.A., 50:662, 1955. changes in untreated persons. Am. J. Orthodontics, 55:135,
Leal, B.: Morphologie der Knochen und ihre Funktion. 1969.
Fortschr. Kieferorthop., 24:357, 1963. Sanin, C and Savara, B. S.: The development of excellent
Lundstrom, A: Tooth Size and Occlusion in Twins. occlusion. Am. J. Orthodontics, 61 :345, 1972.
Basle, S. Karger, 1948. Scott, J.: The role of soft tissues in determining normal and
May, G., and Luzi, C: Variations of the overjet and over- abnormal dental occlusion. D. Practitioner, 11:302, 1961.
25.
6
Classification of Normal Occlusion and
Malocclusion
Classification refers to the description of dental 3. Normal position and relation of the individual teeth
occlusion and its deviations according to a common to each other
characteristic, or norm. 4. Normal relation of the dental arches to each other
Characteristics of normal occlusion are: and to the face and cranium.
1. Correct axial position of the teeth Malocclusion is the arrangement of the teeth in a dental
2. Normal overbite and overjet arch, the relation of the arches to each other
A B C 0 E F G
Fig. 6-1. (Top) Lischer's method of designating

malposition of individual teeth. (A) Lateral
incisor in transversion; (B) central incisor in
labioversion; (C) canine in axiversion; (D) central
incisor in torsiversion; (E) lateral incisor in
linguoversion; (F) first premolar in supraversion;
(e) first molar in mesioversion; (H) mandibular
canine in infraversion: (I) first premolar in
distoversion. (Bottom) Normal occlusion and
normal arches in the permanent dentition (Clock-
wise from fop, left) Right side, left side, occlusal
view, anterior view.
5
0
Classification of Normal Occlusion and Malocclusion' 51
26.
Fig. 6-2. (Top) Lateral view of casts (left) 8 months and 14 days; (center) 1 year, 5 months, (right) 1 year and 9 months.
There is a tendency to distoclusion. (Bottom) Occlusal views at same ages as above. At 8 months and 14 days the mandibular
central incisor teeth are erupting. At 1 year and 5 months the maxillary and mandibular central and lateral incisors have
erupted and the mandibular central incisor teeth have moved labially. At 1 year and 9 months the position of the incisor teeth
shows the same axial positions as at 1 year and 5 months. (Courtesy of J. H. Sillman)
Fig. 6-3. Occlusal relation in the deciduous dentition. (Left)

Deciduous dentition with the maxillary teeth in mesial
relationship to the mandibular teeth, as indicated by the arrows.
In these cases the distal surfaces of the second deciduous molars
are on the same vertical plane. If forward adjustment of the
mandibular teeth does not take place, the mandible remains in
distal relation to the maxilla, and the condition may become
progressively worse. (Right) A deciduous dentition with the
maxillary and the mandibular teeth in the usual normal occlusal
relation found in the permanent teeth. All of the maxillary teeth
occlude with two mandibular teeth, except the maxillary second
deciduous molar, which occludes with the mandibular deciduous
second molar only, and the distal surfaces of the deciduous second molars are not on the
same vertical plane. (Courtesy of 5. J. Lewis)
\
52 . Classification of Normal Occlusion and Malocclusion
and to the base of the cranium in a manner different from Individual teeth can be maloccluded in any of the
the accepted human formula. following positional deviations:
1. Linguoversion - toward the tongue
27. 2.Labioversion or buccoversion - toward the lip or cheek
3. Mesioversion - mesial to its normal position in
CLINICAL MANIFESTATIONS OF
occlusion
MALOCCLUSION
4. Distoversion - distal to its normal position in
The diagnosis of malocclusion must be related to occlusion
chronologie, physiologic, and dental age; sex, ethnic 5. Infraversion - higher (in the maxilla) or lower (in the
background, constitutional makeup and general health of mandible) than the line of occlusi,
the patient.
Odd Even
A. Fig. 6-4. Occlusal changes from
deciduous to permanent dentition.
A, Odd (Left) Deciduous occlusal
relation similar to normal in
permanent dentition. A, Even (Right)
Distal surfaces of
the deciduous second molars on
the same vertical plane. B, Odd
(Left) Permanent first molars are
B. erupting. B, Even (Right) Permanent
first molars are erupting. C, (Left)
Permanent central and
lateral incisors and permanent first
molars have erupted and are in
normal occlusion. C, Even
(Right) Permanent molars are still in
cusp-to-cusp relation and permanent
c. central and lateral incisors show
some overjet. D, (Right and Left)
Permanent first molars, central and
lateral incisors and mandibular first
premolars have erupted the incisor
occlusion in D, even (Right) In
cisors show increased overjet. E,
Odd (Left) Permanent first molars,
first premolars and permanent
central and lateral incisors have
D erupted and the occlusion is normal.
. E, Even
(Right) Permanent first molars,
mandibular second premolars,
maxillary and mandibular first
premolars and permanent central
E and lateral incisors are in position.
The occlusion is still in cusp-to-
. cusp relation and the overjet has
increased. F, Odd (Left) All
permanent teeth have erupted
except the third molars. The
occlusion is normal. F, Even (Right)
All permanent teeth except third
molars have erupted and are in
F. Class II division 1 malocclusion.
The Angle Classification . 53
Fig. 6-5. (Top) Lateral view of casts made at

2 years and 4 months. The tooth arrangement
shown in Fig. 5-4 is maintained. (Right) At 3
years and 2 months. (Bottom) Occlusal views
show progressing eruption of the deciduous
dentition at 2 years and 4 months (left) and at 3
years and 2 months (right). The original
occlusal positions of the teeth have been main-
tained. (Courtesy of Dr. J. H. SiUman).
6. Supraversion - below (in the maxilla) or above occlusal adjustment from the deciduous to the permanent
(in the mandible) the line of occlusion dentition:
7. Torsiversion - rotated on its long axis 1. When the deciduous second molars show inter-
8. Axiversion - wrong axial inclination cuspation similar to normal permanent occlusion, the
9. Transversion - wrong sequential order permanent first molars erupt directly into normal
occlusion.
2. When the distal aspects of the second deciduous
CLASSIFICATION IN THE DECIDUOUS molars are on the same vertical plane, normal eruption of
DENTITIO the permanent first molars can be achieved when the
Classification in the deciduous dentition does not premolars erupt and the permanent first molars shift
adhere to the Angle classification because there are two forward, the mandibular permanent first molars shifting
types of occlusion observed. One shows a cusp-to-cusp forward more than the maxillary ones.
relation, and the second shows an intercuspal relation In the deciduous and mixed dentitions classification
similar to that found in the permanent dentition. The can be made by the canine occlusion when the deciduous
termination of the distal vertical plane of the second molars are missing or the permanent molars are not fully
deciduous molars can be caused by the variation in erupted.
mesiodistal width of the deciduous molars.
THE ANGLE CLASSIFICATION

Deciduous Occlusal Adjustment
The Angle classification is a valuable semantic tool for
The following are the mechanisms of normal describing malocclusion. It does not cate-
Fig, 6-6, Side view of the dentition of

modern man shows considerable overlap
of maxillary over mandibular teeth and
the alternating relationship between the
maxillary and the mandibular incisors,
canines and premolars and intercuspation
of cusps between maxillary and
mandibular molar _
Fig. 6-7. Lingual view of dentition

of modern man showing occlusal re-
lation to distolingual cusps of max-
illary first and second molars as in
anthropoids. There is no occlusal
contact between lingual cusp of mand
ibular first premolar and maxillary
canine. Specimen of Fred Peeso. (Figs,
6-6 and 6-7 from Milo Hellman, Univ.
Penn. Press)
gorize the severity of malocclusion or the complexity of modate the teeth in the dental arches in normal alignment
treatment. For example, Class I is not the simplest without reducing the number of teeth by extraction or
malocclusion as it may involve many teeth while the placing the teeth in alveolar procumbency to the
permanent first molar occlusion is normal. mandibular and facial planes.
The following describes the Angle classification as it is
presently accepted:
Class II Malocclusion
In Class II malocclusion the mandibular dental arch
lass I Malocclusion
occludes in distal relation to the maxillary arch by at least
In Class I malocclusion first molar relationship is normal half the width of a permanent first molar or mesiodistal
mesiodistally, but there are deviations of other teeth in the width of a premolar. The mesiobuccal cusp of the maxillary
dental arches such as rotations, crowding, crossbite, permanent first molar occludes in the space between the
overjet, overbite, and openbite, Arch length deficiency is mesiobuccal cusp of the mandibular permanent first molar
usually concomitant and makes it impossible in many and the distal aspect of the buccal cusp of the second
instances to accom- premolar. The
28.
Fig. 6-9. An example of maxillary and alveolar supraclusion

Fig. 6-8. Cast of eugnathic dental anomalies. (Left column) and buccoclusion of a part of the maxilla and the teeth that it
Before treatment, the maxillary right canine is in ectopic eruption and contains, according to Lischers terminology. (Clockwise from top
there is space between the maxillary incisors. (Right) After left) Right side, left side, occlusal view, and anterior view.
treatment; while this is a simple malocclusion, it may be necessary to
move the entire dental arch to obtain normal occlusion.
mesiolingual cusp of the maxillary first molar occludes

mesial to the mesiolingual cusp of the mandibular first
molar.
For more accurate descriptive and semantic purposes
Class II malocclusion is subdivided:
Class II, Division 1. Class II, Division 1 malocclusions
are those in which the maxillary incisors are in
labioversion.
Class II, Division 1, Subdivision. The subdivision refers
to Class II, Division 1, malocclusions in which the distal
relation of the mandibular dental arch is unilateral, the
opposite side being in normal mesiodistal relation as
evidenced by the normal occlusion of the permanent first
molars and dental arch relationship on that side.
Clinical Manifestations. The clinical manifestation of
Class II, Division (Angle) malocclusion can be
Fig. 6-10. Classification of malocclusion

according to Angle.
29.
Fig. 6-11. Class I malocclu-

sion in the deciduous dentition.
There is an openbite and a cross
bite. The molar relation
mesiodistally is normal.
characterized by many cephalo-dento-facial morphologic

deviations to varying degrees and in different
combinations, among which are the following:
1. Forward relation of the body of the maxilla to the
anterior base of the cranium shown in a large sella-nasion-
A-Point (S-N - A). 8. Retrognathic mandibular dental arch, as shown by B-
2. Forward relation of the maxilla to the mandible of Point in relation to A-Point (A-N-B).
normal length as shown by the large sella-nasionB-Point 9. High glenoid fossa with a short ramus, as shown by
(S-N-B) angle. relative parallelism of the S- line and the Frankfort
3. Alveolodental prognathism of the maxillary dental horizontal (F.H.), resulting in a retrognathic mandible, as
arch with the maxilla of normal size and in normal relation shown in a steep (large) Frankfort mandibular angle (F-M-
to the anterior cranial base as shown by normal range of S- A).
N-A and the mandible in normal relation to the cranial 10. Short ramus and a gonial angle over 135, producing
base as shown by S-N-B. a retrognathic (or distally rotated) mandibular relation to
4. Alveolodental prognathism of the maxillary dental the maxilla.
arch with the mandible retrognathic as shown by S-N-B. 11. A long ramus and a short mandibular body, causing
5. Mandibular underdevelopment - a short, retrognathic a retrognathic relationship of the mandible to the maxilla.
mandible as shown by S-N-B, Y-Axis, or the facial angle, 12. Constricted dental arches with tooth crowding and
with a maxilla that is normal in size and relation to the maxillary-mandibular mesiodistal malrelation of the dental
anterior cranial base as shown by S-N-A. arches.
6. A retrognathic mandible of normal size, as shown by 13. Constricted transverse development with crowding
S-N-B, in relation to a maxilla of normal size and in of the maxillary and mandibular dental arches and
normal relation to the anterior cranial base, as shown by S- mesiodistal malrelation.
N-A. 14. Other combinations of the foregoing deviations.
7. Bimaxillary alveolodental prognathism with poor Treatment Plan. Treatment sequence in Class II
mesiodistal dental arch alignment. malocclusion may be summarized as follows:
30. The Angle Classification' 57
Fig. 6-12. Class II, Division 1

malocclusion in deciduous
dentition. Maxillary deciduous
canines are mesial to the man-
dibular deciduous canines. The
deciduous canine relation is a
better indicator of malocclusion
in the deciduous dentition than
the deciduous molars. This child
sucked his thumb. There is an
openbite along with the deep
overbite and abnormal overjet of
the maxillary incisor teeth.
1. Correct molar relation

2.Align the teeth in the mandibular arch and level
overeruption of incisors
Ffg. 6-13. Class II, division 2 3. Align the teeth in the maxillary arch
malocclusion in the deciduous 4.Correct the line of occlusion ("levelling off") .
dentition. Permanent molars 5. Establish normal intermaxillary dental arch
have already erupted. There is a relation
deep overbite and lingual axial 6. Establish normal function by eliminating
inclination of the maxillary mandibular excursive interferences
incisor teeth.
Table 6-1 shows the five principal interrelations
of eight types of Class II, Division 1 mal-
Fig. 6-14. Class III maloc-

clusion in deciduous dentition.
(Courtesy of Dr. Eugene E. West)
r , ,
TABLE 6-1
Types A B C D E F G H
MAXILLA Normal Normal Protracted ormal Retracted Protracted Retracted

MA DIBLE Normal Normal Normal Retracted Retracted Normal Retracted
GONION Normal Normal Acute Obtuse Normal Obtuse Obtuse
PROFILE Short Normal Long Long Long Short Short
RAMUS Short Long Long Short Long Short Short
TABLE 6-2
MAXILLA MANDIBLE GONTON PROF1LE RAMUS
(Facial Angle)
ormal4 Normal 4 ormal 3 Normal 1 Short 4
Protracted 2 Retracted 4 Obtuse 4 Short 4 Long 4
Retracted 2 Acute 1 Long 3
occlusion. An analysis of any Class II, Division 1 Mechanotherapy of the mandibular dental arch is not
malocclusion should take into consideration the variations required when it is not crowded and the teeth are in normal
shown in each type. axial and occlusal relation. If the mandibular incisors are
Table 6-2 shows an analysis of five measurements in the overerupted and occlude on the soft tissues palatal to the
eight types of Class II, Division 1 malocclusion. maxillary incisors, "levelling off" is indicated.
Class II, Division 2. Class II, Division 2 is a Class II In Class II, Division 2 malocclusion the maxillary
malocclusion in which the maxillary incisors are in central incisors, and frequently also the lateral incisors,
vertical axial position or in linguoversion and usually may be in linguoversion. Vertical height of the lower third
show abnormal overbite. of the face is comparatively short, and the chin is usually
Class II, Division 2 malocclusion can be treated by prominent. There is a reduction in total face height when
moving the maxillary incisor teeth labially before any measured from nasion to gnathion. When abnormal
other tooth movement is undertaken in the mandibular overbite is present, the mandible cannot be shifted to an
dental arch. After this stage of treatment is completed the appreciable degree without opening the jaws.
mandible may show rapid forward change of position, Labial surface attrition of the mandibular incisor teeth
especially in the mixed dentition. and attrition on the lingual surface of the maxillary incisors
Distal movement of the maxillary buccal segments is can occur. Periodontal conditions
indicated, especially if space is needed to change the axial
positions of the maxillary incisors.
31.

sion in mixed dentition. The
right central incisors erupted
ectopically because of a su-
pernumerary tooth. The man-
dibular left deciduous canine
was prematurely lost, and the
deciduous canine space has
closed. The mandibular right
deciduous canine is still in
place.
Fig. 6-16. Class II, division 1

malocclusion in the mixed denti-
tion.
32.
subdivision in the mixed
dentition.

malocclusion in the mixed
dentition.
33. The Angle Classification . 61
subdivision in the mixed
dentition.
Fig. 6-20. Class III maloc-

clusion in the mixed dentition.
62 . Classification of Normal Occlusion and Malocclusion 34.
sion in the permanent dentition.
Fig. 6-22. Class II, Division 1 mal-

occlusion in the permanent dentition.
35. The Angle Classification . 63
Fig. 6-23. Class Il. Division 1

subdivision malocclusion in the
permanent dentition.

malocclusion in the permanent
dentition.
36.

subdivision malocclusion in the
Fig. 6-26. Class III malocclusion in

the permanent dentition. Note
presence of open bite.
Reverse Occlusion . 65
may be found as a result of incisor impingement on the situated forward to the zygomatic crest (Key ridge-
gingival mucosa. Deep incisor overbite can be caused by Atkinson); in orthognathic faces the mesial root is at the
overeruption of the incisor teeth, infraelusion of the zygomatic crest. Bimaxillary alveolodental prognathism
buccal tooth segments, or a combination of both. Vertical can occur with normal occlusion of the teeth.
growth occurs during the eruption of the premolars. The
overbite may be overcome at this stage without
orthodontic treatment.
Alveolodental Prognathism
Class II, Division 2, Subdivision. A Class II, Division 2,
malocclusion in which the mesiodistal malocclusion is Dentoalveolar protrusion, in which the teeth actually are
unilateral only. procumbent and the dental arches are situated in a forward
position on the bases of their respective jaws, should not
be confused with maxillary, mandibular, or bimaxillary
Class III
prognathism which is caused by overgrowth in depth of
(n the patient with Class III malocclusion the man- the respective jaws. Dentoalveolar protrusion may be
dibular dental arch and the body of the mandible are in present also in prognathic jaws.
bilateral mesial relation to the maxilla and the maxillary Alveolodental prognathism may be confined to one or
dental arch. The mesiobuccal cusp of the maxillary both alveolar arches in relation to the facial line (N-Pg).
permanent first molar occludes in the interdental space Prognathism of the jaws themselves, i.e., facial skeletal
between the distal aspect of the distal cusps of the prognathism, should be differentiated from alveolodental
mandibular permanent first molars and the mesial aspect prognathism and from deficiency in depth of the middle
of the mesial cusps of the mandibular second permanent third of the face.
molars. For a malocclusion to be classified as Class III, Facial prognathism caused by excessive depth of the
the mandible must be either large or situated mesially to maxilla and length of the mandible is beyond the
an abnormal degree, as evidenced by linguoversion of the ministrations of the orthodontist. This type of prognathism
maxillary incisors and by cephalometric analysis. is influenced by a long anterior cranial base, a long ramus,
Class III, Subdivision. Class III, Subdivision a long maxilla, and especially by a long mandible and an
malocclusion is a unilateral Class III malocclusion. obtuse gonion angle.
INCIDENCE OF THE VARIOUS

REVERSE OCCLUSION
MALOCCLUSIONS
The term apparent Class III malocclusion or reverse
The concensus of findings in the United States on
occlusion refers to anterior incisor crossbite.
frequency of malocclusion, according to the foregoing
Reverse occlusion is characterized by the following:
classifications, indicates Class I, or neutroclusion, to be
1. Mandibular incisors occlude labially to the maxillary
73 per cent; Class II, or distoclusion, 24 per cent; and
incisors.
Class III, or mesioclusion, 3 per cent.
2. Normally developed mandibular arch in normal
relation to facial line, sella-nasion-pogonion (S-N-Pg) is
PROGNA THISM within normal range.
3. The mandible can be retruded forcibly to normal
Bimaxillary Prognathism relationship and overbite or edge-to-edge occlusion wi th
the maxilla. This can be seen when the patient's head is
Bimaxillary prognathism may be considered normal in held backward as far as possible and pressure is applied to
some ethnic groups or group isolates. In prognathic faces the chin with the palm of the hand in a backward and
(facial skeletal prognathism) the distal root of the upward direction.
maxillary first molars are usually
TYPE /J,
MAX. - NORMAL
MANO. - NORMAL
GONION - N01'U1Al.
PROFILE - SHORT
RAMUS - SHORT
Fig. 6-27. (A) Casts and profile photograph of a Type A Class II, Division 1 malocclusion. (B) Tracing
showing principal characteristics of this malocclusion.
Reverse Occlusion' 67
TypE B
MAX. - NOfU'tAL
MHD. - NORMAL
GONION - NORMAL
pROFILE - NORJI.AJ..
RAMUS - LONG
HF
Fig. 6-28. (A) Casts and profile photograph of a Type B Class II, Division 1 malocclusion. (8) The
tracing shows the principal characteristics.
TyPE C
MAX. - PROTRACTED
MAND. - NORMAL
GONION - ACUTE
PROFILE - LONG
IWl.US - LONG
RB
B
Fig. 6-29. (A) Casts and profile photograph of a Type C Class II, Division 1 malocclusion and a tracing
(B) showing the principal characteristics.
38. Reverse Occlusion' 69
TYPE D
MAX. - NORMAL
M..J\ND. - RETRACTED -
SHORT GON:ION - OBTUSE
pROFILE - SHORT
co.
Fig. 6-30. (A) Casts and profile photograph of a Type 0 Class II, Division 1 malocclusion and a (B)
Tracing showing the principal characteristics.
40.
TYPE 1
l.tAX. - NOfol.MAL
r-tt ..... ND. - RETIti\CTED
GONION - OBTUSE
P ROFI LE - LONG
fI,.AlomS - SHORT
MC.
Fig. 6-31. (A) Casts and profile photograph of a Type E Class II Division 1 malocclusion and a (B)
tracing showing the principal characteristics.
41.
42.
Reverse Occlusion . 71
TYPE F"
MND. - RI:."'J."lUJ.CTEb
RAMUS - NG
O.K.
Fig. 6-32. (A) Casts and profile photograph of a Type F Class II, Division 1 malocclusion,
The (B) tracing shows the principal characteristics of this malocclusion.
TYPE G
MAX. - PROTRACTED
.MANO. - NORMAL
GONION - OBTUSE
PROFILE: - SHORT
RAMUS - SHOEn'
KC
Fig. 6-33. (A) Casts and profile photograph of a Type G Class II, Division 1 malocclusion. (B) The
tracing shows the principal characteristics.
44. Reverse Occlusion . 73
'TYPE 'H
MANe. - RETRJl.CTED
GONION - OBTUSE:
PROFILE - SliORT
RAMUS - SHORT
K.F
Fig. 6-34. (A) Casts and profile photograph of a Type H Class II, Division 1 malocclusion. (B) The
tracing shows the principal characterics.
BIBLIOGRAPHY Hoffer, 0.: Disgnozie E Biotipi. Clinic Odontoiatria, 9:1, 1954.

---: Die Individualitat des Gesichtstyps irn lichte der
Fernroentgenuntersuchung. Fortschr. Kieferh., 16:26, 1955.
Linder-Aronson, 5., and Backstrom, A.: A comparison between
,/ Angle, E. H.: The upper first molar as a basis of diagnosis in mouth and nose breathers with respect to occlusion and facial
orthodontics. D. Items Interest, 28:421, 1906. dimensions. Tr. European Orthodont. Soc., p. 62, 1960.
Bjork, A.: The nature of facial prognathism and its relation to Margolis, H. I.: The axial inclination of the mandibular incisors.
normal occlusion of the teeth, Am. ]. Orthodontics, 37:106, Am. ]. Orthodontics & Oral Surg., 29:571,1943.
1951. Reidel, R. A.: The relation of maxillary structures to cranium in
---: Estimation of age changes in overjet and sagittal jaw relation. malocclusion and in normal occlusion. Angle Orthodont.,
Trans. European Orthodont. Soc., p. 42, 1953. 22:142,1952.
---: Variability and age changes in overjet and overbite. Report Ryle, J. A.: The meaning of normal. Lancet, 1:1,1947. Salzmann, ].
from a follow-up study of individuals from 12 to 20 years of age. A.: The Angle classification as a parameter of malocclusion. Am. J.
Am. J. Orthodontics, 39:779,1953. -' --: Bite development and Orthodontics, 51 :465, 1965. ---: Malocclusion as an epidemiologic
body build. D. Record, 75:8,1955. continuum.
Bjork, A., Jensen, E., and Palling, M.: Mandibular growth and third Am. J. Orthodontics, 59:298, 1971.
molar impaction. Acta odont. scandinav., 14:231, 1956. Simon, P. W.: Grundziige einer systematischen Diagnostik der
---: Variations in the growth pattern of the human mandible: Gebiss-Anomalien. Berlin, H. Meusser., 1922. ---: Fundamental
Longitudinal radiographic study by the implant method. J. D. principles of systematic diagnosis of dental anomalies. Boston,
Res., 42 [Suppl. 0.1]:400,1963. Stratford, 1926.
Chapman, H.: otes on classification, prognosis and treatment. D. ---: On the necessity of gnathostatic diagnosis in orthodontic
Record, 57:345, 1937. practice. Int. ]. Orthodontics & Oral Surg., 12:1102,1926.
---: What is normal as regards occlusion. D. Record, 58:364, 1938. ---: System einer biologisch-rnechanischen Therapie der Gebiss-
Dewey, M.: Classification of malocclusion. Int. J. Orthodontia, 1 Anomalien. Berlin, H. Meusser, 1933.
:133, 1915. What is "normal?" ].A.M.A., 133:1011, 1947.
7
Skeletal Classification
FACIAL SKELETAL PATTERN cisors. The lateral incisors may be normal or in labio-
,
version.
Facial skeletal patterns are divided into Class 1, the
profile is orthognathic: Class 2, the mandible is
retrognathic, and Class 3, in which the mandible is Skeletal Class 3
prognathic.
Overgrowth of the mandible and obtuse gonion angle.
Classification of the facial skeletal pattern takes into
The mandible is prognathic.
consideration the relationship of the teeth as follows:
VARIATION OF SKELETAL AND DENTAL

CLASSIFICA nON
Skeletal Class 1
If a malocclusion is described simply as Class II
The bones of the face and the jaws are in harmony with (Angle), it denotes distoclusion of the mandibular teeth
one another and with the rest of the head. The profile is and a retrognathic skeletal pattern. This frequently is not
orthognathic. the case as shown by clinical observation and
Division 1. Local mal positions of incisors, canines, cephalometric appraisal. Many cases of distoclusion have
or premolars. normal skeletal patterns, and the impression of a receding
Division 2. Maxillary incisor protrusion. Division 3. chin can be attributed to soft tissue covering or the size of
Maxillary incisors in linguoversion. Division 4. the nose.
Bimaxillary protrusion. The following analyses of the skeletal patterns of a
mother and son (Fig. 7-13) and of four siblings(Figs. 7-10
Skeletal Class 2 to 7-12) indicate variations between the dental and skeletal
classifications. These examples demonstrate that facial
Distal mandibular relation to the maxilla. Division 1. appearance by itself is no indication of skeletal
Maxillary dental arch is narrower than the mandibular, classification or of the type of malocclusion.
and there is crowding in the canine region, crossbite, and
reduced vertical height, and protrusion of the maxillary
anterior teeth. The profile is retrognathic.
Division 2. Lingual inclination of the maxillary in- Mrs. B., Mother, and Son D.H.
The mother and the son (age 6 years, 8 months)
Fig. 7-1. Classification according to

constitutional body types as developed by
Kretschmer. (A) Leptosomatic typelong
neck, receding chin; (B) pyknic type- short
neck, round face, balanced profile; (C)
athletic type - prominent mandible, tendency
toward prognathism. A B
7
5
76 . Skeletal Classification
Fig. 7-2. Three boys of ap-

proximately the same age and stage
of dental development all had Class
II, Division 1 malocclusions. The
pretreatment profiles and casts (top)
are compared with posttreatment
ones (bottom). (Courtesy of Milo
Hellman and Dr. Walter Dunlap.)
appear to have the same facial profile, but cephalometric slight crowding of the incisors and canine teeth in the
analysis shows two different dentofacial skeletal patterns. mandible. The right side shows a maxillary lingual
Clinical Description. Mrs. B. has a Class I (Angle) crossbite beginning with the second molars and extending
malocclusion. All maxillary permanent teeth, including across to the left side canine region. The remaining teeth
the second molars, are erupted and in normal alignment. on the left side are in normal buccolingual relation.
The mandibular permanent teeth, including the second The maxillary permanent central incisor teeth of Mrs.
molars, are erupted. There is B's son, D.B. are erupted. There is a maxillary
Variation of Skeletal and Dental Classification 77
Fig. 7-3. (Top) Combina-

tions of facial skeletal pat-
terns with prognathic max-
illa.
1. Concave. A-Point, the
anterior limit of the max-
illary basal arch, is ret-
rognathic to B-Point, the
anterior limit of the man-
dibular basal arch. The
maxilla itself is prognathic to
the anterior cranial base
(5-N).
2. Orthognaihic, A-Point and,
B-Point are on the same line,
extending from nasion. The
maxilla is prognathic to the
anterior cranial base (5- ).
3. Reirognathic. B-Point is
retrognathic to A-Point. The
maxilla is prognathic to the
anterior cranial base (5-N).
(Bottom) Combinations of
2
facial skeletal patterns with
retrognathic maxilla.
1. Concave. A-Point, the
anterior limit of the maxil-
lary basa 1 arch, is retro-
gnathic to B-Point, the
anterior limit of the man-
dibular basal arch. The
maxilla is retrognathic to the
anterior cranial base
(5- ).
2. Orthognathic. A-Point and
B-Point are on the same line
from nasion. The maxilla is
retrognathic to the anterior
cranial base (5-N).
3. Retrognathic. A-Point is
prognathic to B-Point. The
maxilla is retrognathic to the
anterior cranial base
(5- ).
midline diastema. The occlusion of the permanent maxillary

are in postion, and the mandibular left deciduous canine has
central incisors to the mandibular incisors is edge-to-edge,
been exfoliated. There is crowding of the mandibular incisor
but with openbite. The maxillary deciduous lateral incisors
teeth. There is a crossbite on the right and left sides which
and canines have been shed, and the right and left deciduous
includes deciduous first and second molars and the permanent
first and second molars are in position. The maxillary
first molars.
permanent right and left first molars are erupted. The right
Facial Angle. Mrs. B. has a Class 1 facial skeletal pattern.
and left mandibular deciduous first and second molars Her facial angle is 88, slightly above the mean of normal
range. O.B. has a Class 2 facial skele-
Fig. 7-4. Facial types: (top) brachycephalic, (center) mesocephalic, (bottom)

dolicocephalic.
tal pattern. His facial angle of 80 is below normal range facial line N-Pg. In O.B. the angle is -3, which is close to
(82 to 95) which is indicative of a Class 2 facial skeletal the norm and not as retrusive as his mother.
pattern (Fig. 7-13 G, H). A-B Line. In Mrs. B. the A-B line is at +2; in O.B. it is at
Angle of Convexity. Mrs. B. has a -7 angle of convexity; +1. The B-Point is in front of the A-Point in both mother and
this indicates a retrusive anterior limit of the basal arch (A- son.
Point) in the maxilla in relation to the Mandibular Plane to Frankfort Horizontal. In Mrs.
45.
46.
Bone Age Assessment 79
B. the mandibular plane to the Frankfort horizontal is 28,

which is at the steep limit of normal range. In D,B, it is
38, which is beyond normal range in steepness. In Mrs. B.
the ramus is long. A line tangent to the mandibular base BRACHYCEPHALIC
extends at some distance below the occiput. The ramus is
short in D.B. A line tangent to the mandibular base extends
within the occiput.
Y-Axis. In Mrs. B. the Y-Axis is 62-above the mean,
but within normal range. In D.B. it is 66, which is at the
extreme upper limit of normal range. This indicates a
retrognathic mandible in relation to the upper face as
measured at the Frankfort horizontal.
Occlusal Plane to Frankfort Horizontal. In Mrs. B, the
occlusal plane is at 13 to the Frankfort horizontal, which
is within the normal range. In D.B, it is 20 which is above
normal range in steepness.
! to i (Relation of Mandibular to Maxillary Incisors.
In Mrs. B. it is 140, which is within the normal range. In A
D.B. it is 152 because of the vertical axial position of the
maxillary incisor teeth.
'1 to Mandibular Plane. In D.B. the angle of 1 to the
mandibular plane is 76, which is below normal range. In MESOCEPHALIC
Mrs. B. it is 85, which is below the mean but within
normal"range.
S-N-A and S-N-B are 74 and 75 respectively in D.B.
which is indicative of retrusive basal arches in the maxilla
and mandible in relation to the anterior cranial base as
measured from sella to nasion (S-N). Mrs. B.'s S- -A is 82,
which is at the mean of the normal range. While the
mandibular basal arch at 84 is mesial to the maxillary
basal arch, the body of the maxilla itself is not deficient.
Her S-N-B is 84, showing that the length of the mandible
is above the mean of normal range, but since her facial
angle is 88 she is considered to have a Class 1, not a Class
3, facial skeletal pattern.
Gonion Angle. D.B.'s gonion angle is 133 at the obtuse
limit of normal range. His ramus is short, as can be seen by
the line tangent to the mandibular plane going through the
occiput. Mrs. B. has a gonion angle of 124- a bout the DOLiOXE PHALIC
mean of the normal range. Dental malocclusion may be
present in an orthognathic face. However, a normal
occlusion may also be present in a face that is not
orthognathic.
BONE AGE ASSESSMENT

-Bone
..
age assessment provides an indication of
skeletal physical development and maturation. The hand,
the wrist, and the distal epiphyses of the ulna and radius
present a large number of centers of postnatal bone
calcification at different ages during childhood and are c
useful for orthodontic purposes. Fig, 7-5. Tracings made from lateral radiograms of a
Carpal evidence of maturation is of value viewed in brachycephalic (A), a mesocephalic (B), and a dolicocephalic
correlation with the states of dental, sexual, (C) head.
80 . Skeletal Classification 47.
48.
49.
Fig. 7-6. Comparison of facial types: orthognathic (A), convex

(B), and concave (C) profiles. (A) The maxilla is retrognathic to the
anterior cranial base (S-N), with angle S-N-A of 76, which is
Straight Prot lie below the mean of 82, The mandible is also retrognathic to the
(retracted maxilla) Iretr anterior cranial base (S-N), with the angle formed by S- -B at
acted mandible)
S'
75, which is below the mean of 80. The A-B difference is 1.
SNA=76 AS (B) The maxilla of the convex profile is prognathic to the anterior
Drf1erence = 1
SN8=75 cranial base (S- ); the angle S-N-A is 87 is above the mean of
820. The mandible is retrognathic to the anterior cranial base,
with the S-N-B at 77, which is below the mean of 80, The
incisors are in alveolodental protrusion to the facial line (N-Pg).
The A-B difference is 10, (C) The maxilla in the concave profile
is retrognathic to the anterior cranial base, with the S- -A at 77,
which is below the mean of 82. The mandible is within normal
range although above the mean to the anterior cranial base, with
the angle S- -6 at 83-above the mean of 80,
A
Convex Prof lie
(protracted rraxnta)
(normal mandible)
SNA'97"
AS D,ffererce=10
SNB=77"
endocrine, and other metabolic development. If the latter

are negative, the retarded or advanced development of
the carpals alone are not to be accepted as an indicator of
maturation.
Bone age is assessed by the stage development of
osseous centers in several regions of the body and
compared with standards developed by Todd, Flory and
Greulich and Pyle. The bone age of males is about 11h
years advanced over that of females. The Flory standard
shown here is typical of boys and girls at 12 months age
Concave Prof lie
(retracted maxilla) intervals.
(normal mandible)
Technique for Making Carpal Radiograms

Exposure. Use two 5" X 7" films for each hand or one 8" X
10" film for both hands. At 36 inches from the source of the
ray to the film without a screen, an exposure of 0.2 second or
less is necessary as a rule. Optimum exposure time must be
ascertained for the x-ray machine used.
Position of Patient. The patient is seated in front of a table
or on the footrest of the dental chair so that he can place his
hands and forearms on the table or the dental chair seat on a
line parallel with his shoulders. The film holder or cassette is
stabilized to prevent shifting during the exposure.
Fig. 7-7. The photographs show the retrognathic maxilla, although

this is obscured by the heavy soft tissue covering. This is a deficiency
of the middle third of the face, not an Angle Class III malocclusion.
The maxilla is retrognathic to the anterior cranial base (S-N) with the
angle sella-nasion-A-Point at 68, which is less than the mean of the
normal range (82). The anterior limit of the mandibular basal arch (B-
Point) is at 74, which is below the mean (80). The facial line (N-Pg)
is about the mean of normal range to the upper face (FH). This is due to
the prominent chin point.
BARI C.
Fig. 7-8. The tracing made from

the radiogram shows that this
patient's skeletal class is 3. The casts
show a Class III malocclusion.
TABLE 7-1. RANGE IN TIME OF APPEARANCE OF OSSEOUS CENTERS IN THE HAND
(AGES GIVEN IN YEARS AND MONTHS EXCEPT AS INDICATED)
Boys Girls
Range of Middle Range of Middle
80 Per Cent 80 Per Cent
I I
50 Per Cent 50 Per Cent
I I
I I I
I
J t Hand J 1
1-8 2-1 3-2 3-11 Metacarpal 1 1-1 1-3 1-10 2-1
1-1 1-3 1-11 2-5 2 0-9 0-11 1-4 1-6
1-1 1-5 2-0 2-9 3 0-10 0-11 1-4 1-9
1-3 1-7 2-6 2-11 4 0-11 1-1 1-5 1-10
1-5 1-8 2-9 3-4 5 1-1 1-2 1-8 1-11
1-11 2-3 3-5 3-11 Proximal 1 1-2 1-4 1-11 2-4
0-11 1-1 1-8 1-11 Phalanx 2 0-7 0-9 1-0 1-4
0-10 1-1 1-6 2-0 3 0-7 0-8 1-0 1-3
]-0 1-2 1-9 2-0 4 0-7 0-9 1-0 1-4
1-3 1-6 2-4 2-10 5 0-10 1-0 1-5 1-8
1-5 1-8 2-7 3-0 Middle 2 0-10 1-0 1-7 1-11
1-3 1-7 2-6 2-11 Phalanx 3 0-9 0-11 1-5 1-10
1-3 1-7 2-6 2-11 4 0-10 0-11 1-6 1-9
2-2 2-7 4-3 5-0 5 1-2 1-5 2-3 2-8
1-0 1-2 1-11 2-7 Distal 1 0-7 0-9 1-3 1-6
2-3 2-8 3-10 4-6 Phalanx 2 1-3 1-7 2-5 2-10
1-8 2-0 2-10 3-4 3 0-11 1-2 1-10 2-1
1-8 2-1 2-11 3-5 4 1-0 1-2 1-10 2-3
2-3 2-8 3-10 4-7 5 ]-3 1-7 2-5 2-10
SoN-A: 86"
5-N-B=90'
A-N-8= -4"
FHN-Pg=96'
+=124'
T-MP=7S'
50.
Fig. 7-9. Class III malocclusion with a skeletal Class 3 facial

pattern. Although the maxilla at 86 is prognathic above the mean
of normal range (82"), the mandible is even more prognathic at
90, which is 100 above the mean of normal range (80"). The B-
Point is forward of the APoint.
53.
51.
52.
Fig. 7-10. Phenotypical resemblance
can be masked. Although these four
children are siblings, their phenotypical
facial appearances differ from their facial
skeletal patterns. (A,B) Robert and Mary
show similar facial outlines. (CD) Their
sibs, Peter and Betsy, also show a strong
resemblance. Comparison of the four
facial skeletal outlines shows that Betsy,
whose facial outline showed a strong re-
semblance to Peter's, has a skeletal pattern
that is actually similar to Robert's. (F) The
tracings show Mary's skeletal pattern to be
like Peter's rather than like Robert's,
although she resembles Robert. (G)
Robert's skeletal Class 1 and Peter's
skeletal Class 2 tracings are
superimposed.
--Peter 5.
-Robert 5
---- Mary 5
---. Betsy 5.
CD
--ROBERT 5
- --- PETER S.
54. Bone Age Assessment . 85
Fig. 7-11. Robert S. has a Class II, Division 1

malocclusion with skeletal Class I. The skeletal
class is illustrated in the roentgenogram and the
tracing made from it. The casts demonstrate the
malocclusion.
55.
Fig. 7-12. The roentgeno-

gram and tracing made from it
show Peter's skeletal class,
Class 2. He has Class II,
Division 2 malocclusion.
56.
57.
Fig. 7-13. Phenotypical appear-

ances can be deceptive with respect
to genetic concordance or
consanguinity. (A,B) Lateral views
show the similar profiles of a mother
and son. (CD) Anterior views show
the prominence of the mandibular
incisors; both have crossbites. On
close examination, the mother is seen
to lack a left lateral incisor. The
closed space could be responsible for
her anterior crossbite. (E,F) Lateral,
cephalometric roentgenograms show
a well-developed mandible in the
mother. The son, on the contrary, has
a sharp antegonial notch, which is
usually more pronounced in retro-
gnathic mandibles. (G) Tracings of
the 6-year-old son demonstrate a
retrognathic mandible, but as the
mandible is one of the last bones to
stop growing, the final decision on
the son was postponed. (H) The
tracings of the mother and the son at
age 14 are superimposed. His face is
retrognathic. (IJ His photograph
shows the mandibular deficiency.
--Mrs. B
-DAVID B. -- -- David B
---MRS. B 14 yrs
-----\..--~~~--~-
CD
Fig. 7-14. Radiograph of hands and wrists on an 8" X 10" film.

Both hands, including the wrists and distal parts of the ulna and
radius, are radiographed.
Fig. 7-15. Skeletal components of the hand and wrist.

A. Epiphyses of distal phalanges of the second to fifth digit. B.
Epiphyses of middle phalanges from second to fifth digit. C.
Epiphyses of proximal phalanges of the second to fifth digit and
piphysis of distal phalanx of the thumb or first digit. D.
Epiphyses of second to fifth metacarpal. E. Epiphysis of proximal
phalanx of first digit. The metacarpals are indicated in Roman
numerals. F. Epiphysis of the first metacarpal. G. Distal epiphysis
of radius. H, Distal epiphysis of ulna.
e Carpals; 1, Pisiform; 2, Triquetrum; 3, Hamate; 4,
Capitate; 5, Lunate; 6, Navicular; 7, Lesser Multangular, and 8,
Greater Multangular,
Fig. 7-16. Radiographic comparison of the hands of a

6-year-old boy (left) and a 6-year-old girl (right). (Left)
The navicular is usually present at age 6, while the
multangulum majus and multangulum minus are just
appearing. Since the order of appearance is not uniform,
at least one of these centers should be present. The
ulnar epiphysis is still absent. There is a first indication
of the saddle-shape formation on the base of metacarpal
II and a squaring off of metacarpal III. The metacarpal
heads have begun to show Dshaped outlines. The
epiphysis on metacarpal V is still quite round. (Right)
The ulnar epiphysis makes its appearance by age 6.
There is an extension of the D-shape in the metacarpal
heads. Roundness may still appear in metacarpal V.
There is a definite increase in the size of the carpal
bones. The shadows of the multangulum majus and
multangulum minus are usually in contact. The
triquetrum is definitely larger than either the lunatum or
navicular. The carpal bones show little indication of
their adult shape; most of them are still relatively round.
The radial epiphysis has extended across the shaft but is
still shorter than the width of the shaft. (Figs. 7-16 to 7-
25 from Flory, C. D.: Osseous Development in the
Hand as an Index of Skeletal Development. Society for
Research in Child Development, ational Research
Council, Washington, D. C.)
Fig. 7-17. Radiographic comparison of the hands of a

7-year-old boy (left) and a 7-year-old girl (right). (Left)
The ulnar epiphysis is present at 7 years. All carpal
bones except the pisiform are present. The
multangulum majus. multangulum minus, and navicular
are still quite small. The carpal area is dotted with
bones although there is still much cartilage in the wrist.
All of the metacarpal heads show a D-shaped flattening.
The saddle-shaped outline on metacarpal II is more
distinct. The radial epiphysis has increased in
':thickness and length. (Right) There is an increAse in
bone size. The radial epiphysis has increased in length
and breadth. Most of the changes are qualitative.
Metacarpal II has developed a definite saddle-shape at
the base. All of the metacarpal heads show a D-shape.
Most of the epiphyses are still shorter than the width of
the bones to which they will unite. 'There is still much
open space in the carpus but some of the shadows
overlap slightly.
Fig. 7-18. Radiographic comparison of the hands of

an 8-year-old boy (left) and girl (right). (Left) The
changes at 8 years are in size and in quality of
ossification. The saddle-shaped outline on metacarpal
II is more mature than at 7 years. There is a definite
parallel between the radial shaft and its epiphysis; the
wedge shape has disappeared. All epiphyses are
distinctly separated from the shafts. Roundness instead
of D-shaped outlines in metacarpal heads is an indi-
cation of retardation at age 8. The multangulum majus,
and multangulum minus shadows are likely to overlap.
(Right) The significant changes are in size and shape.
The radial epiphysis extends along the shaft and has
increased in thickness on the outer side preparatory to
the styloid development. The metacarpal heads are
definitely D-shaped. The lunatum, triquetrum, and
navicular resemble somewhat their adult shapes. They
are about equal in size with an advantage in favor of
the triquetrum. The adult shapes of the capita tum and
hamatum are indicated. The ulnar epiphysis is shorter
than the width of the ulnar shaft. The phalangeal
epiphyses approximate the width of their respective
phalanges.

a 9-year-old boy (left) and girl (right). (Left) All changes
are qualitative but there is increase in size. There is a
definite squaring off of the metacarpal heads on the
ulnar side. The radial epiphysis has grown toward the
ulnar shaft, increased in thickness on the outer side,
and decreased the gap between the shaft and epiphysis.
The adult shapes of the carpal bones are beginning to
appear; especially in the capitatum and navicular. The
triquetrum is less round and more wedge-shaped. The
base of metacarpal II is practically adult in shape. The
ulnar epiphysis is still shorter than the width of the
shaft. (Right) Changes between 8 and 9 are hard to
detect. They correspond to the same stage in boys'
hands between 10 and 11. The pisiform should be just
appearing. Epiphyseal gaps have been reduced. The
multangulum majus and multangulum minus show
overlapping shadows. A closer resemblance to the
adult outline in the shape of the bones may be
observed. The ulnar epiphysis has extended nearly the
width of the shaft.
Bone Age Assessment . 91

a 10-year-old boy (left) and girl (right). (Left) All
changes are in size and quality. The triquetrum,
lunatum, and navicular are about equal in size; prior to
this age the size was in the order named. All epiphyses
are practically equal to the width of the bones to which
they unite. Overlapping of carpal shadows is observed;
especially with the multangulum rnajus and
multangulum minus. Much of the cartilage has been
penetrated by bone. (Right) All carpal bones should be
present. Overlapping of bone shadows is quite
common. The ulnar epiphysis may be the only shadow
untouched by another bone. The multangulum majus
casts its shadow on the second metacarpal and the
hamatum on the fifth metacarpal. The radial epiphysis
has begun to develop its ulnar beak. The ulnar
epiphysis has a definite styloid process. There are
dense lines along the edges of the carpal bones. The
ulnar and radial epiphyses are still round at the outer
edges.

an Ll-year-old boy (left) and girl (right). (Left)
Significant changes are: increase in size, filling of open
space, closer resemblance of the carpals to their adult
outline and an indication of density along the edges of
the carpals. The differences between 10 and 11 are the
most difficult to detect. An increase in length and
width of epiphysis is accompanied by a reduction in
the epiphyseal gap. Overlapping of bone shadows is to
be expected. The carpal shadows may extend over the
metacarpals and the radial epiphysis. The multangulum
majus has definitely lost its roundness. (Right) The
carpal area is so full that the shadows may overlap in
several directions. Epiphyseal gaps have been further
reduced. The radial hook or beak is quite pronounced
though there is still a roundness on the outer side. The
dense lines along the edges of the bones are more pro-
nounced. Practically all of the bones have their adult
shape. The pisiform is usually quite small. The
epiphysis on metacarpal I appears to be in contact on
the outer edge. A sesamoid should be present at the
distal end of the first metacarpal.

a 12-year-old boy (left) and girl (right). (Left) The pisiform
is present at age 12. There is much overlapping of bone
shadows. The carpal area is so full at age 12 that the
ulnar epiphysis is the only ossified portion of the wrist
which stands apart. All epiphyses show a definite
parallelism with the bones to which they will unite.
Dense lines along the edges of the carpals are evident.
The multangulum rnajus and hamatum typically cast
their shadows over metacarpals II and V respectively.
The adult outlines are clear at this age. (Right) The carpal
area is so full of bone that there appears to be
crowding. The metacarpal heads appear to be in
readiness for union. The radial epiphysis has squared
off on the outer edge and extended the ulnar hook
down along the shaft. The gap between the epiphysis
and metacarpal I is disappearing. Phalangeal epiphyses
are in readiness for union. Future development can be
seen only in the changes of epiphyses.

a 13-year-old boy (left) and girl (right). (Left) The
appearance of carpal bones has nothing to contribute
after age 12. Epiphyseal changes are the chief criteria
of development during the teen ages. Signs of
preparation for bone fusion are in evidence. The radial
and ulnar epiphyses are still somewhat rounded at the
edges, though the styloid process on the ulnar epiphysis
and the radial beak are well formed. There is a close
parallelism on the base of metacarpal I between the
metacarpal and the epiphysis. A sesamoid should be
just appearing at the distal end of metacarpal I; it is
present in 50 per cent of the cases. (Right) The
metacarpal heads have started to fuse. The phalangeal
epiphyses are still open. There is a definite parallelism
between radial and ulnar epiphyses and their shafts. All
of the epiphyses are in readiness for fusion. The carpal
area seems filled to adult capacity. The navicular has
come into a functional relationship with the radial
epiphysis.
Fig. 7-24. Radiographic comparison of the hands

of a 14-year-old boy (left) and girl (right) (Lefl) Lines
between epiphyses and phalanges are very narrow.
Metacarpal heads may appear to have begun union.
There is a definite beak on the ulnar side of the radial
epiphysis. The outer side is squared. The saddle shape
in metacarpal II fits closely over the multangulum
minus. Retardation is suggested if the sesamoid at the
distal end of metacarpal I is absent. (Right! All
epiphyses show rapid progress toward union. All
epiphyses in the distal part of the hand show union or
near union. The line along which union is occurring
can be seen. The radial and ulnar epiphyses are still
not united but they have come into contact at several
points. The beaks which turn down on each side of
the radial shaft are quite pronounced.

a 15-year-old boy (lefl) and girl (right). (Left) The radial
epiphysis has turned down on both sides of the shaft.
Bone fusion is well along in the metacarpal heads. All
epiphyseal lines are reduced. The navicular has come
into close relationship with the radial epiphysis and
shows a functional postion. The radial and ulnar
epiphyses are clearly not fused. The carpal area is
practically as full of bone at age fifteen as it is in the
adult male hand. Final maturity involves merely the
completion of epiphyseal fusion. (Right) Practically all
epiphyses except the radial and ulnar epiphyses have
fused. Some of the epiphyses show recent union.
There may be some gaps at the extreme outer edges.
Beginning of fusion is evident in the radial and ulnar
epiphyses. Both of these epiphyses turn down along
the edges of the respective shafts.
BIBLIOGRAPHY and application in orthodontic practice. Int. J. Orthodont. & Oral

Surg., 23:761,1937.
Horowitz, S. L., Osborne, R. H., and DeGeorge, F.: Hereditary factors
Acheson, R. M.: A method of assessing skeletal maturity from in tooth dimensions, a study of the anterior teeth of twins. Angle
radiographs. A report on the Oxford Child Health Survey. ]. Anat., Orthodontist, 28:87, 1958.
88:498, 1954. Hotz, R.: Relation of dental calcification to chronological and skeletal
__ : The Oxford method of assessing skeletal maturity Clin age. European Orthodorit. Soc. Tr, 35:140, 1959.
Orthoped., 10:19, 1957. Johnston, F. E.: Individual variation in the rate of skeletal maturation
Barnbha, ]. K., and Van Natta, P.: Longitudinal study of facial growth between five and eighteen years. Child Develop., 35:75,1964.
in relation to skeletal maturation duri ng adolescence. Am. J. Kennedy, R. L. J.: Precocious skeletal development, J.A.M.A.,
Orthodont., 49:481, 1963. 127:580, 1945.
Gam, S. M., and Shamir, Z.: Methods for research in human growth. Lamons, F. F., and Gray, S. W.: A study of the relationship between
Springfield, Ill., Charles C Thomas, 1958. tooth eruption age, skeletal development age, and chronological
Greulich, W. W.: The relation of skeletal status to the physical growth age in sixty-one Atlanta children. Am. J. Orthodont., 44:687, 1958.
and development of children. In Boell, E. J., (ed.): Dynamics of Lurie, . A., and Levy, S.: Determination of bone age in children; a
Growth Processes. Princeton, Princeton University, 1954. method based on a study of 1,129 white children. J. Pediatrics,
Greulich, W. W., and Pyle, S. 1.: Radiographic Atlas of Skeletal 23:43], ]941.
Development of the Hand and Wrist. ed. 2. Stanford, Stanford Mainland, D.: 1. Evaluation of the skeletal age method of estimating
University, 1959. children's development. 2. Variable errors in the assessment of
Harding, V. S. Y.: A method of evaluating osseous development from roentgenogram. J. Pediatrics, 13:165, 1954.
birth to 14 years. Child Develop., 23: 247, 1952. McKern, T. W., and Stewart, T. D.: Skeletal age changes in young
Harvold, E. P., Trugue, M., and Viloria, J. 0.: Establishing the American males. U. S. Army. Technical report EP-45, 1957.
median plane in postero-anterior cephalograrns. In Salzmann, J. A., Meredith, H. V.: Toward a working concept of physical growth. Am.
(ed.): Roentgenographic Cephalometrics. Philadelphia, J. B. J. Orthodont., 31:440,1945.
Lippincott, 1961. Meredith, H. V., and Knott, V. B.: fIIness history and physical
Hellman, M.: Ossification of epiphyseal cartilages in the hand. Am. J. growth. Am. J. Dis. Children, 103:146, 1962.
Phys. Anthropol.. 11 :223, 1928.
___ : Some biologic aspects: their implications and
8
Stomatognathic Dynamics
THE FORCE-LINKED STOMATOGNATHIC UNIT and manner of masticatory muscle insertion into the jaw
bones. The changes in the periodontal ligament and in the
The stomatognathic complex, as Salzmann (1948)
interdental fibers also must be stabilized. Some, if not all,
pointed out, is a force-linked closed functional unit that
of these changes take longer for their adjustment than it
includes the teeth, the jaws, the temporomandibular
takes to move the teeth into their new positions. Retention
articulation, the tongue, the muscles of mastication and
of moved teeth, therefore, is required until equilibrium is
expression, the bones of the face and cranium, the nerves,
reestablished, if indeed it is ever reestablished. The system
the vascular supply, and other related structures. The
has a wide range of functional accommodation. If it were
stomatognathic system is composed of a number of
otherwise, severe articulatory, occlusal, and functional
interdependent functional matrices as defined by Moss.
orodental disorders would be the rule. Stability of
When an individual tooth or a few teeth are moved, the
orthodontically moved teeth depends on their integration
functional unity of the stomatognathic complex is not, as a
with the rest of the stomatognathic components and is not
rule, disturbed. When extensive changes in tooth position,
limited to the occlusal arrangement of the teeth alone.
occlusion, and jaw relation are effected by orthodontic
Trajectorial forces in the jaws are based on the fact that
therapy, compensatory changes must occur in some, if not
the trabeculae of spongy bone follow in their
all, of the functional components of the stomatognathic
complex. This is necessary to restore its equilibrium and
so avoid relapse of the result obtained in the orthodontic
treatment of malocclusion.
The compensatory changes occur in the functional
pattern, in muscle behavior, and in the actual extent
Fig. 8-2. The basal arches of the maxilla and mandible

Fig. 8-1. Profile of a skull, showing Benninghoff's lines and the distribution of the buttresses of the maxilla. The
of stress or trajectories. basal arches are the shaded portions of the jaws.
9
5
96 . Stomatognathic Dynamics
form and distribution lines of maximum pressure and

tension similar to the trajectories shown in mechanical
structures (Koch, 1817; d'Arcy Thompson, 1953).
Benninghoff's study of force trajectories in the jaws
showed that the hard palate, the walls of the orbits, the
zygomatic bones, the palatine bones, and the lesser
wings of the sphenoid act as crossbeams and buttresses
of the face. This provides the maxilla with a maximum
of strength and a minimum of bulk to withstand the force
generated by mandibular function.
There is a feedback mechanism in mandibular function
so that force exerted by the muscles on the mandible and
the teeth is fed to the jawbones and muscles of
mastication and from there back again to the teeth. This
makes it possible for chewing and mandibular
movements to start as voluntary acts and be continued by
Fig. 8-3. Relationship of the maxillary and mandibular basal proprioceptive stimuli as involuntary functions that do
arches in the adult with the teeth in normal occlusion. (Figs. 8-1 not involve the higher centers of the brain.
to 8-3 After Benninghoff, Bluntschli and Schroeder)
KEY
COMP R ESSI
ON + ~ TENSION
P ASSUMED LOAD
APPROXIMATE STRESS APPLIED TO UPPER
DIAGRAM OF SKULL SECTION 0265 JAW, 100 EACH SIDE
Fig. 8-4. (Left) Section of skull on which the diagram (right) of approximate stress in the skull section is based. The functional design
keeps the various areas in balance with the gross skull growth. The stress analysis is based on the simplified treatment of the skull
components as straight members intersecting to present a symmetrical truss. (Spencer R. Atkinson)
Facial Balance, Muscle Balance, and Orthodontic Therapy' 97
FACIAL BALANCE, MUSCLE BALANCE, the maxillary and the mandibular dental arches when the
AND ORTHODONTIC THERAPY mandible is in rest position. The change in dimension
between the rest position and full occlusion indicates the
The term facial balance refers to facial symmetry and
amount of clearance between the teeth in the opposing
the orthognathic appearance of the face as shown by the
dental arches.
soft tissue profile. The lips mayor may not habitually rest
A large freeway space is related to an abnormal
against the teeth, and "straightening of the profile" may
overbite, as occurs in Class II, Division 2 malocclusion.
not occur when the incisor teeth are moved lingually over
Persons with Class I malocclusion generally have a
so-called basal bone, even after premolar teeth are
smaller freeway space than those with Class II or Class III
extracted. An orthognathic profile after orthodontic
malocclusion.
therapy that includes tooth extraction depends as much,
Centric Relation. Centric relation is the position of the
or even more, on the thickness, tonicity, and habitual
mandible when the condyles are in balanced, retruded, but
posture of the lips ami circumoral musculature as on the
not strained position in the glenoid fossae. It is the basic
orthognathic positioning of the incisor teeth by
position from which all movements normally originate
orthodontic therapy.
and to which the jaw normally returns to rest position.
The force exerted by the tongue on the inner side of
Centric occlusion and centric relation are closely related
the dental arches and the circumoral musculature, the
when the condyles show a minimum of translation when
buccinators, and the muscles of mastication on the outer
the mandible goes from rest position to full occlusion.
side is not equal in amount. Factors in addition to muscle
Centric Occlusion. Centric occlusion is a static
balance responsible for stability of the dentition are the
position. It is the extreme or maximum occlusal and
axial positions of the teeth, the kinesthetics of the
incisal contact position of the teeth in the maxillary and
dentition developed by the proprioceptors, the quantity
the mandibular arches. Centric occlusion is normal when
and quality of the functional forces exerted in the
the teeth occlude according to the accepted human
movements of the mandible, and pressure developed in
formula with maximum intercuspation in terminal
breathing and swallowing. Tongue posture and proper
closure.
function of the mimetic and masticatory muscles are
In normal temporomandibular articulations the condyle
important in maintaining the stability of orthodontically
head is adjacent to the posterior slope of the glenoid
corrected dental occlusion.
fossa, but not at its deepest part, when in centric
occlusion. Centric occlusion can be modified by tooth
eruption, shedding of deciduous teeth, loss of permanent
teeth, attrition of teeth, and wear or lack of wear of teeth
Basic Mandibular Positions contact points. It can be corrected by occlusal
equilibration, orthodontic therapy, and prosthetic
There are five basic positions of the mandible:
appliances.
1. Rest position
Variation in Centric Relation and Centric Occlusion.
2. Centric relation
Abnormal jaw positions of the mandible are caused by:
3. Centric occlusion
4. Terminal hinge position asymmetric jaw growth, changes in tooth position
5. Habitual position following extractions without prosthetic substitutes,
Rest Position. The rest position is a holding position overcontoured fillings, harmful pressure habits,
assumed when a person is at ease and is sitting upright. irregularities in occlusal or cuspal tooth wear, periodontal
While it is accepted as a state of equilibrium of the forces disease, trauma, temporomandibular arthrosis, muscle
responsible for mandibular movement, it varies in each spasms, and other factors.
person with changes in muscle tonicity, body position, Correction or reduction of divergence between centric
and during sleep. The rest position is not necessarily relation and centric occlusion can be obtained by
identical with the usual or, habitual mandibular posture. repositioning the mandible, by correcting the
The temporal musclJ"s maintain the mandibular posture malocclusion, by occlusal equilibration, by prosthesis,
during rest position. The mandible is suspended by the and by restoring vertical dimension.
articular capsule, the suspensory ligaments, and the Interference with Jaw Movements. Interference with
elevator and depressor muscles. Rest position of the lateral or protrusive jaw movements may be caused by
mandible is dependent on the entire skull pattern, extrusion of teeth which may be in complete labio- or
mandibular function, and the occlusion of the teeth. buccoversion, the presence of a convenience bite or a dual
The freeway space is the interdental arch space bite, and the continuous eruption, or elevation, of teeth
between the occlusal surfaces and the incisal edges of without occluding opponents.
Fig. 8-5. The arrows indicate

which of the fi ve muscle
portions are active in: (A)
rotation in habitual closing
movement, (B) translation in
habitual dosing movement,
and (C) rotation in cutting
movement. The thickness of
the arrow for each individual
muscle portion is an indication
of the relative quantitative
activity in that muscle portion
in the various movements. TV,
A B c ventral temporal portion; TO,
dorsal temporal portion; MS,
superficial masseter portion;
Patients undergoing orthodontic therapy should be Mo, deep masseter portion;
examined in centric relation and centric occlusion. The PtM, medial pterygoid muscle;
result of a wide divergence between centric relation and PtL, lateral pterygoid muscle.
centric occlusion can be an unbalanced face and a dual bite, (Carlsoo, S.: Acta Odont.
although the teeth may be in good arrangement. So-called Scandinav., 10 Suppll:, 19 )
relocation of the mandible is a change in its position
intended to allow it to assume a position in which centric
relation and centric occlusion are more closely related, if not
identical.
Fig. 8-6. This girl's face is

unbalanced with the mandible
skewed to the left. She has a
cross bite on the left side; the
midline in the mandible is to
the left. A removable
appliance was used to
reposition the mandible dur-
ing treatment with the edge-
wise appliance. When the
mandible was repositioned it
became necessary to use ver-
tical elastics on one side to
close the resulting openbite.
58.
The Temporomandibular Articulation' 99
Joint cavity THE TEMPOROMANDIBULAR ARTICULATIO

The temporomandibular articulation is a diarthrodial
(ginglymoarthrodial) articulation. It consists of the condyle
of the mandible, the mandibular fossa, the articular
eminence of the temporal bone, and the capsular ligament,
Fibrous which extends obliquely from the lateral extremity of the
capsule -- articular eminence to the posterolateral surface of the neck
- of the mandible. The articulation is divided into an upper
and a lower compartment by the fibrocartilaginous
meniscus, or interarticular disc. The capsular ligament or
Articular' capsule is too loose to hold the mandible in place; it is held
disk by the muscles of mastication.
The temporomandibular articulation has a wide range of
accommodation, and permits a large variety of mandibular
movements. It is not bilaterally symmetrical and is free of
any pressure from chewing. Condylar movements do not
follow fixed paths during mastication, especially in lateral
rig. 8-7. Structure of mandibular articulation. This artic- excursions. There is considerable irregularity in the opening
ulation is modified by the articular disk with which each and closing paths of the condyles. There are different
articular cartilage normally is in contact. (Chaffee, E. and articulating paths during mastication, especially when the
Greisheimer, E.: Basic Physiology and Anatomy. Phila- food is hard and after chewing has advanced beyond the
delphia, J. B. Lippincott, 1969.) first masticatory movements.
Fig. 8-8. Specimens and roentgenograms of the temporomandibular articulations of a 3-year-old

child (left) and an adult (right). Note that the child's articulation is smaller and shallower.
Condyle Movements and Malocclusion the mandibular condyle, and damage of the articular
tubercle. Changes in the temporomandibular articulation
Persons with abnormal overbite and overjet, as in Class
associated with loss of the posterior teeth show
II malocclusion, generally have a large shift of the
themselves in overclosure. flattening of the articular
condyles when the mandible moves from rest position to
eminence, and a more backward positioning of the head of
closed position. During orthodontic treatment the path of
the condyle in the glenoid process. The abnormal
closure of the mandible in Class II, division 1
functioning temporomandibular articulation does not itself
malocclusion changes from upward and backward to
cause dental malocclusion. Contrarily, dental
upward and forward provided condylar growth occurs
malocclusion, loss of teeth, traumatic injuries, arthritis,
during this period. In Class II, Division 1 malocclusion
and other articulation abnormalities can produce
Ricketts found condylar movement to be equally divided
temporomandibular discomfort.
among those who show no change of condylar position
Occlusal equilibration is helpful in restoring normal
on closure from rest position to full occlusion, those who
temporomandibular function. Traumatic occlusions do not
show considerable upward and backward movement, and
always affect the temporomandibular articulation but
those who show only slight movement in these directions.
more often cause periodontal lesions.
Translatory movement predominates in Class II
There are temporomandibular abnormalities in children,
malocclusion, while rotary movement predominates in
especially neglected crossbites in the early mixed
Class III malocclusion. A combination of rotation and
dentition when dental occlusion is taking final form.
translation he found in Class I malocclusion.
Correction of malocclusion does not always produce
lasting relief from temporomandibular pain. Other
etiologic factors are arthritis with skeletal-muscle trigger
areas and neuropsychiatric involvements. Mental and
constitutional factors contribute to dysfunction of the
Temporomandibular Articulation Disorders temporomandibular articulation.
The shape of the glenoid fossa does not correlate fully Diagnosis of Temporomandibular Dysfunction.
with the mandibular condyle or with the type or Diagnosis of temporomandibular dysfunction cannot be
classification of dental occlusion. The ternporo- made on the basis of roentgenographic findings alone if
mandibular articulation can be considered normal when it the dysfunctions are not of a gross nature. Diagnosis
is free of pain, when there is no interference with requires additional clinical findings including the
mandibular movements during speech and deglutition, following:
and when it shows a well-defined image on the 1. Mandibular movements. Dysfunction is charac-
radiogram. A slight translatory movement should be felt terized by irregularity in movement, muscle spasms, pain,
on full jaw opening. The condylar surface shows changes and fatigue.
in growing children. 2. Crepitus. Place forefingers at site of articulations.
Clicking of the temporomandibular articulation is Ask the patient to move the mandible. Clicking can be
usually the result of the condylar ridge slipping over the heard and felt.
anterior or posterior transverse band of the meniscus. 3. Signs of tooth attrition in the mouth and on the casts.
There is a tendency for sounds to occur in all joints. Clicking of the Temporomandibular Articulation.
Clicking alone cannot be taken as a diagnostic sign of Patients may find that they can obtain a temporo-
temporomandibular arthrosis. mandibular articulation click by overopening (sub-
In the absence of temporomandibular arthrosis or other luxating), and by jiggling the jaw to close it. They then
organic disorders, clicking may be caused by a may practice the habit until it becomes a conditioned
combination of jaw "jiggling" and extreme jaw opening reflex. The child should be told of the danger to the
that subluxates the mandible. This should be pointed out articulation of practicing the clicking. The patient should
to the patient with the aid of a mirror, and instruction be taught to open the mouth slowly and to practice
should be given in limiting jaw opening and avoidance of opening and closing without jiggling the jaw and so avoid
jiggling. the clicking noise. Clicks of low register can be heard also
Overclosure of the Mandible. There is a difference in many normal articulations. They are usually associated
between abnormal overbite and overclosure of the with interrupted, irregular movements of the mandibular
mandible. Overclosure occurs when the teeth in the condyle, meniscus, external pterygoid muscles, and
maxillary and mandibular dental arches cannot be temporal muscles.
brought into opposition because of crossbite and in
extensive loss of teeth especially in the molar region.
Overclosure of the mandible causes destruction of the
disk, degenerative and proliferative changes of
-
Bibliography . 101
SPEECH AND MALOCCLUSIO related to speech learning and personality. Specific cause-
Malocclusion is not a major cause of defective speech. One and-effect relationship between malocclusion and speech is
child with severe malocclusion may speak and swallow not known.
abnormally, while another with similar or even more There is wide variation in the ages at which children reach
abnormal malocclusion may speak and swallow normally. specific stages of speech and language development.
Speech defects can be caused by malocclusion only when the Recommendations for speech treatment should be based on a
deformity is so great as to prevent the tongue, lips, or palate thorough clinical evaluation of the child, including
from occluding or constricting the oral and oropharyngeal psychologic tests.
valves during speech. A child with severe malocclusion may Dyslalias are the most common speech disorders
exhibit defective speech that is not related to the influenced by abnormalities of the teeth and jaws. When
malocclusion. sounds are produced incorrectly, omitted, or replaced by
Organic abnormalities of the teeth, the tongue, the .lips, the others, speech is diagnosed as dyslaIic. Common distortions
palate, the auditory mechanism, or the nervous system can can be classified according to the following sygmatisms:
contribute to disorders of articulation. lateral, interdental, strident, palatal, adental, nasal, and
Tongue thrust is found in children with normal speech as laryngeal and pharyngeal.
well as with defective speech. Tongue thrust does not always Clark Starr states that "when a maxillary arch is shorter or
accompany hyperfunction of the lower lip, but it is found narrower than a mandibular arch of normal size, there is a
twice as frequently among tongue thrusters as among normal high pro babiIity that articulation problems will exist or that
swallowers. the acquisition of good articulation will be difficult." He
Openbite is one of the few recognized malocclusions that observes further that, "correction of severe dental deviations
can interfere with speech in some patients. The effect of with a resulting improvement in cosmetic appearance may
openbite on speech depends on the size of the opening, the motivate patients to greater speech improvement, even though
degree of prognathism of the mandible or maxilla, and other potential for adequate speech existed before the corrective
factors, uch as those work."
BIBLIOGRAPHY mandibulaire chez I'hornrne, Rev. Mens. Suisse Odonto-

Stornatol, 73:]34,1963.
Ahlgren, J.: Mechanism of mastication; a quantitative Benninghoff, A.: Spaltlinien am Knochen, eine Methode zur
cinematographic and electromyographic study of Ermittlung der Architektur platter Knochen. Verh. Anat.
masticatory movements in children, with special reference Ges. Supp!. Anal. Anz., 60:189, 1925.
to occlusion of the teeth. Acta odont. scandinav.. 24 ---: Uber die Anpassung der Knochenkompakta am geiinderter
[Suppl.]:44, 1966. Beanspruchung. Ant. Anz., 63:289, ]927. ---: Ueber
---: Pattern of chewing and malocclusion of teeth. Leitsystem der Knochenkompakte; Studien zur Architektur
A clinical study. Acta. odont. scand inav., 25:3,1967. der Knochen, Beitr. der Anatomie funktioneller Systeme.
Anderson, D. J., and Picton, D. C. A: Tooth contact during Morphol, [ahrb., 65:1, 1930. ---: Die Architektur der Kiefer
chewing. J. D. Res., 36:21, 1957.
und ihrer Weichteilbebedeckung. Zahnartzl, Rdsch.,
---: Masticatory stresses in normal and modified occlusion. J.
43:48,1934.
D. Res., 37:312, 1958.
---: Form und Funktion. Ztschrft. f. d. ges. Naturwissenschft,
Ballard, C. F.: A consideration of the physiological back-
H. 4-5, 1935; H. 3, 1936.
ground of mandibular posture and movement. D.
---: Lehrbuch der Anatomie des Menschen. Erster Band.
Practitioner & D. Record, 5:80; Trans. British Soc.
Berlm-Miinchen, Urban & Schwarzenberg, 1949.
Orthodont. 117, 1955.
Blackwood, H. J. J.: Pathology of the temporomandibular joint
---: Some observations on variations of tongue posture as seen
dysfunction. ].AD.A, 79:131, 1969.
in lateral skull radiographs and their signif. icance. Tr. Bloomer, H. H.: Speech defects associafed with dental
European Orthodont. Soc., page 69, 1959. ---: The clinical abnormalities and malocclusion. In Travis R. E. (ed.):
significance of innate and adaptive postures and motor Handbook of Speech Pathology. ew York, Appleton-
behavior. D. Practitioner & D. Record, 12:219,1962. Century-Crofts, 1957.
Baume, L. J., and Derichsweiler, H.: Is the condylar growth ---: Speech as related to dentistry. J. Michigan D.
center responsive to orthodontic treatment? Oral Surg., Oral Ass., 40:258, 1958.
Med. & Oral Path., 14:347, 1961. ---: Speech defects in relation to orthodontics. Am. ].
---: Le developpement de l'articulation tempore- Orthodontics, 49:920, 1963.
Bluntschli, H.: Uber die Kaumuskulatur. Fort. d Zahnheilk. Kydd, W. L., and Toda, J. M.: Tongue pressures exerted on the
Orthop., 51:1,1929. hard palate during swallowing. J.A.D.A, 44:319, 1962.
---: Von den Kraften, welche den Kiefer bewegen und gestalten. Landa, J. 5.: The freeway space and its significance in the
Paradentium, 3, 1929. rehabilitation of the masticatory apparatus. J. Pros. Dent.,
---: Die menschlichen Kieferwerkzeuge in verschiedenen 2:756, 1952.
Alterszustanden. Verh. Ariat. Ges., 35:163, 1926. Lipke, D., and Posselt, U., (eds): Functional anatomy of the
Bluntschli, H., and Winkler, R: Kaubewegunger und temporomandibular joint. I- West. Soc. Periodont., 8:48, 1960.
Bissbildung. 1/1 Bethe, A, von Bergmann, G. et al.: Manly, R S., Hoffmeister, F. S., and Yurkstas, A: Masticatory
Handbuch der Normalen und Pathologis chen Physiologie. function of children with orthodontic disturbances, Am, ].
vol. 3, Berlin, Springer- Vedag, 1927.
Orthodontics, 40:756-764, ]954.
Bolk, L.: Die Entstehung des Menschenkinnes, Ein Beitrag zur Moss, M. L.: Primacy of functional matrixes in orofacial growth.
Entwicklungsgeschichte des Unterkiefers. Amsterdam, 1924. D. Practitioner & D. Record, 19:65, 1968.
Bosma, J. F.: Oral and pharyngeal development and function. J. Perry, H. T.: The temporomandibular joint. Am. J. Orthodontics.,
D. Res., 42lSupp!. No. 1]:375,1963. 52:399, 1966.
---: Evaluation of Oral Function of the Orthodontic Patient. Am. Perry, H. T., [r.: Relation of occlusion to temporomandibular
J. Orthodontics, 55:578,1969. joint. 79:137, 1969.
Brill, N., Lamrnie, G. A., Osborne, J., and Perry, H. T.: Ricketts, R M.: Clinical implications of the temporomandibular
Mandibular positions and mandibular movements, a review. joint. Am. [, Orthodontics, 52:2, 1966.
Brit. D. L 106:391, 1959. Salzmann, ]. A.: The temporomandibular articulation and
Broadbent, B. H.: The face of the normal child: Bolton standards orthodontics. Am. J. Orthodontics, 50:387,1964.
and technique. Angle Orthodontist, 7:183, 1937. Schwartz, L.: Disorders of the Temporomandibular Joint.
Brodie, A. G.: On the growth pattern of the human head from the Philadelphia, W. B. Saunders, 1959.
third month to the eighth year of life. Am. J. Anat., 68:209, ---: The orthodontist's role in the diagnosis and treatment of
1941. temporomandibular joint disorders. Am. I- Orthodontics,
---: Late growth changes in the human face, Angle Orthodontist, 48:747, 1962.
23:146,1953. ---: Diagnosis of temporomandibular joint disorders.
Choukas, N. c., and Sicher, H.: The structure of the D. Radiog. & Photog., 36:84, 1963.
temporomandibular joint. Oral Surg., Oral Med. & Oral Path., Scott, I- H.: The doctrine of functional matrices. Am. J.
13:1203, 1960. Orthodontics, 55:38,1969.
Costen, I- B. A: Syndrome of ear and sinus symptoms dependent Sicher, H.: Temporomandibular articulation: Concepts and
upon disturbed function of temporomandibular joint. Ann. misconceptions. ]. Oral Surg., Anesth. & Hosp. Dent. Serv.,
Otol., Rhin., & Larying., 43:1, 1934. 20:281, 1962.
Cousin, R P.: Embryologie et croissance de Particulation Subtelny, J, D., and Subtelny, [. D.: Malocclusion, speech and
temporo-rnandibulaire. Orthodont. Franc., 31:39, 1960. deglutition. Am. J. Orthodontics, 48:685,1962.
Dorns, Von R, Haupfauf, L., and Langen, D.: Psychosomatische Tappen, . c.: A functional analysis of the facial skeleton with
Aspekte bei funktionellen Kiefergelenkbeschwerden. split-line technique. Am. I- Phys. Anthropol., 11 :503, 1953.
Deutsche Zahn. Zeitschr., 24:337, 1969. ---: Abnormal function of the stomatagnathic system and its
Eschler, J.: Form und Funktion irn Kausystem. Fortschr. orthodontic implications. Am. J. Orthodontics, 48:758, 1962.
Kieferorthopad., 3:247,1963. Thome, H.: The rest position of the mandible in the path of
Findlay, 1. A, and Kilpatrick, S. I-: An analysis of the Sounds closure from rest to occlusion position. Methods of
Produced by the Mandibular Joint. I- D. Res.. 39:1163, 1960. cephalometric determination Acta odont. scand., 11 :141,
Forrest, E. l.: Challenges of the temporomandibular articulation 1953,
in orthodontic treatment. Am. J. Orthodontics, 49:405, 1963. Urist, M., (ed.): Clinical physiology and pathology of bone. Clin.
Haack, D. c., and Weinstein, S.: The mechanics of centric and Orthop., 17:3, 1960.
eccentric cervical traction. Am. J. Orthodontics, 44:346, 1958. von Meyer, H.: Die Architektur des Spongiosa. Arch. Anat.
Haack, D. c.: The science of mechanics and its importance to Physiol., 34:6]5, 1867.
Walkhoff, 0.: Der Unterkiefer der Anthropornorphen und des
analysis and research in the field of orthodontics, Am. I-
Menschen in seiner funktionellen Entwicklung und Gestalt.
Orthodontics, 49:330,1963.
Kydd, W, L.: Psychosomatic aspects of temporomandibular joint Menchen-Affenstudien tiber Entwicklung und Schadelbau,
dysfunction. ].A.D.A, 59:31, 1959. Wiesbaden, 1902.
Kydd, W. L., and Neff, C. W.: Frequency of deglutition of Winders, R I-: Forces exerted on the dentition by the perioral and
tongue thrusters compared to a sample population of normal lingual musculature during swallowing. Angle Orthodontist,
swallowers. J. D. Res., 43:363, 1964. 28:226, ] 958.
---: Recent findings in myometric research, Angle Orthodontist,
32:38, 1962.
9
59.
Etiologic Factors in Malocclusion
Permanence of result in the prevention and correction of postnatal, local, systemic, psychodynamic, traumatic,
malocclusion depends primarily upon the recognition and intrinsic, extrinsic, functional or acquired. Etiology of
elimination of the etiologic factors involved. The Angle malocclusion usually is found clinically in interrelated
classification, radiographic cephalometries, and other causes.
diagnostic aids that describe and classify dentofacial
deviations should not be confused with etiology, the CLASSIFICA nON
actual causative factors involved.
Malocclusion in the individual patient cannot always be
Prenatal
reduced to a simple cause and effect. Basic etiologic
factors such as deleterious genetic and environmental 1. Genetic: transmitted by genes; mayor may not be
influences, childhood diseases, and dentofacial pressure present at birth
habits do not always produce malocclusion. Some 2. Differentiative: engrafted on the body in the
causative factors may no longer be evident at the time the prefunctional embryonic developmental stage
patient is examined, and others may not show themselves a. General or constitutional: affect the body as a
until later in life. Specific general etiological factors are whole including the dentofacial areas
practically unknown in malocclusion. The exceptions are b. Local or dentofacial: affect the face, jaws, and
local, endocrine, and some osteogenic disturbances. There teeth only
are, however, certain causative factors of malocclusion 3. Congrnital: may be hereditary or acquired but are
which must be eliminated or at least checked in their early existing at birth
stages if we expect to prevent malocclusion, or to treat it
successfully once it has manifested itself.
Postnatal
Dental malocclusion is a morphologic, and frequently
also a physiologic, deviation from accepted dentofacial 1. General developmental
norms for the human species. The etiology of a. Abnormalities of relative rate of growth in
malocclusion can be genetic, congenital, dentofacial region
b. Hypo- or hypertonicity of muscles which influence
dentofacial development and function
c. Childhood diseases, nutritional, endocrine,
Fig. 9-1. Diagrammatic representation of the ETIOLOGIC FACTORS IN MALOCCLUSION

interdependence of the etiologic factors in
malocclusion. Each of the prenatal and post-
natal factors is in some manner related to the PRENATAL POSTNATAL
other factors. GENETIC DEVELOPMENTAL
DIFFERENTIATIVE FUNCTIONAL
ENVIRONMENTAL
CONGENITAL
103
104 . Etiologic Factors in Malocclusion
Age 3 1/2
-John M.
---- Noel M.
60.
Fig. 9-2. The phenotypes of monozygous twins show a higher degree of concordance in early life than later, when environmental
influences tend to modify the facial expression. (A,B) The tracings of these 3lf2-year-old monozygous twins show concordance of
craniofacial outlines. (C) Anterior views of their casts demonstrate similarity in the degree of overbite, and the maxillary left central
incisor of each is distally inclined. (D) The boys are not mirror twins. The left lateral and mandibular central incisors show similar
rotation. Interdental spacing is also similar.
and other metabolic disturbances that affect dentofacial 2. Local

growth a. Premature loss or prolonged retention of
d. Radiation and radiotherapy of mother or fetus deciduous teeth
which can produce orofacial clefts and cephalic and b. Loss of proximal contact following tooth loss
dental abnormalities in the offspring c. Temporomandibular articulation disturbances
2. Local dentofacial d. Muscular hypo- or hyperactivity
a. Birth injuries of the head, face, and jaws
b. Micrognathia or macrognathia Environmental or Acquired
c. Microglossia or macroglossia
d. Abnormal frenum labii 1. General
e. Facial hemiatrophy a. Diseases can affect the dentofacial tissues directly
f. Anomalies of tooth development and eruption or indirectly
b. Radiation
2. Local
Functional a. Eruption anomalies
1. General b. Premature loss or prolonged retention of
a. Muscular hyper- or hypotonicity deciduous teeth
b. Neurotrophic disturbances c. Loss of permanent teeth
c. Postural defects of the tongue and jaws d. Periodontal disease
d. Masticatory and respiratory disturbances e. Harmful dentofacial pressure habits
Classification . 105
62.
61.
2/70 -
2/68 BR
-BR M.R
-MR
CD
Fig. 9-3. (A,B) Monozygous mirror twins at 3Vz years of age. The lower right deciduous canine in the girl on the left and the lower left
deciduous canine in the girl on the right can be seen through the open lips. Their faces show the effect of the mandibular shift. Even
their head postures incline in opposite directions. (C,D) The crossbites are on opposite sides; the spacing between the mandibular
central incisors indicates the mandibular displacement to the sides of the crossbites. (E) Tracing of the same twins. ate concordance of
their facial outlines at age 3'h years. Patient 5. R. shows slightly more forward growth in the maxilla. (F) At 5'12 years, B .. R. shows still
more forward growth than M. R, who shows more continuing downward growth than forward growth during the same period of time.
These differences may become greater as the children grow older, or they may show more concordance, depending on environmental
effects on the phenotypes.
f. Trauma almost completed. Hereditary factors are implicated in

g. Infection bimaxillary protrusion, abnormal overjet, overbite, open
h. Temporomandibular disturbances bite, palate width and height, interarch relation, and
microgenia. Siblings usually show similar types of
GENETIC EVIDENCE IN MALOCCLUSION malocclusion. Examination of the occlusion of older
siblings can provide a clue that there was a need for
Studies of twins, especially monozygous twins, indicate interception and early treatment of malocclusion.
the genetic influence on jaw development, dental Hereditary dentofacial characteristics can be masked
morphology, and malocclusion. Lack of phenotype during postnatal development by local or general
concordance does not always indicate that a trait is not environmental factors such as growth, climate, economic
inherited. The comparison of twins to determine zygosity status, hygiene, tooth eruption interferences, shifting of
and hereditary characters is more valid in post- teeth, loss of teeth, crossbites,
adolescence when growth is
Fig. 9-4. Maxillary lateral in-

cisors failed to develop in these
monozygous teen-age girls.
Fig. 9-5. Crossbite on the same side in identical

twin girls 15 years of age.
Genetic Evidence in Malocclusion . 107
Fig. 9-6. The dentition of a girl with orodigitofacial dysostosis. There are many
clefts, fissures, and frenums in the maxillary alveolar process extending into the palate,
as well as clefts in the mandibular alveolar process. The patient has oligodontia and
deformed hands and fingers. These abnormalities are associated with trisomy, a
triplication, of the first chromosome. It can be also an inherited sex-linked syndrome.
(Salzmann; Am. J. Orthod., 61 :437, 1972)
orodental pressure habits, vagaries of jaw growth, and

masticatory and mimetic muscle malfunction.
Malocclusions of genetic origin include the following:
1. Facial size and outline, upper face height, nose
height, head height and bigonial breadth
2. Prognathism
3. Micrognathia
4.Bimaxillary protrusion and bimaxillary atresia
(small mouth and underdeveloped arches)
5. Abnormality of tooth size, number, color and
form; Carabellis cusps
6. Facial clefts; cleft lip and cleft palate
7. Ectodermal dysplasia dental pattern
8. Abnormalities of tooth arrangement
9. Abnormalities of tooth eruption
10.High palate associated with extremely narrow facial
outline.
Branchial Arch Abnormalities. Among the dentofacial
malformations that originate in the first branchial arch are
macroglossia, micrognathia, glossoptosis, cleft palate,
mandibular hypoplasia, macro-
Fig. 9-7. (A) Girl with microtia of both ears, micromaridibular development and a prominent nose. She is not mentally retarded.
This syndrome is associated with trisomy 13, a chromosome aberration in the D group of chromosomes. There is a cleft palate, but
the lips are intact. There is no family history of this syndrome. (B) Open-bite before treatment. (C) Openbite corrected by treatment.
Fig. 9-8. Legend opposite, top.

Genetic Evidence in Malocclusion 109
Fig. 9-8. (Opposite) (A) Monozygous twins, according to blood type, at 8 years of age. One child is an achondroplastic dwarf, possibly
because of chromosomal aberrations. The normal twin was born 10 minutes after the dwarf. At birth they weighed 4 pounds 15 ounces
and 4 pounds 13 ounces, respectively. Chondrodystrophy of this type has no endocrine basis. This and other malformations in one of a
pair of monozygous twins can be caused by chromosome aberrations, mutations, and autosomal dominance. (B) Profile view of the
achondroplastic dwarf shows bossing of the forehead. The bridge of the nose is depressed, and the child has a retrognathic mandible. (C)
Here we see bossing of forehead in the dwarf twin; the base of the skull is shortened by the early synostosis of the sphenoid and occipital
bones. (D) There are knoblike epiphyses of the ulna and radius. While length of long bones is retarded in achondroplastic dwarfs, the
width of the bones reaches normal size. The wide radial epiphyses overlap the ulnar epiphyses and give dwarfs a characteristic hand
posture. They seem to paddle with their hands when they walk. (E,F) Both twins have anterior openbite and anterior crossbite, with the
dwarf showing more openbite and crossbite than her sister. This type of occlusion is usually found in achondroplastic dwarfs because of
middle face deficiency following early closure of the bones in the base of the skull. The occlusion in both twins has also a genetic
reference. Both girls show delayed tooth eruption, the dwarf later than the normal twin.
63.
-AM.age8
-- --Normal age a
~
"~~~
----~_ ....
Fig. 9-9. (A) Girl, 8 years of age, with precocious puberty. There is no endocrine involvement. This syndrome depends on a sex-linked
autosomal gene. It is transmitted by genotypically affected but phenotypically normal males to about half their offspring. Regardless of
whether the parent manifests the trait, it is passed on to half the females, who may transmit it to their sons or daughters who, in turn, act
as carriers. (B) Head size is larger than that of a normal 8-year-old child. (C) Bone age is 16 years, while chronologie age is 8 years. This
rapid skeletal growth will be completed at an early age, as can be seen from the carpals and epiphyses of the ulna and radius, which show
advanced ossification. This prevents the patient from growing into gigantism.
110 . Etiologic Factors in Malocclusion 64.
Fig. 9-10. (Top) Front and
profile views of a 12-year-old
boy with a history of severe
disease and malnutrition.
(Second row) Compare the
development of the patient (leit)
at 12 years with that of his
brothers, 9 (center) and 5 years
(right). The patient is 46 ins. tall
and weighs 46Ibs.; radiogram of
his hand is of a lO-year-old boy,
the norms for his age are 58 ins.
and 84 Ibs. He is of small
stature and has testicular
dysgenesis, low 17-ketosteroids,
and retarded puberty. There is
no endocrine involvement. The
boy shows Klinefelter's syn-
drome: his sex chromosomes are
XXV, not xv. His face and
cranium are much smaller than
normal for a 12-year-old boy.
(Bottom) Roentgenogram shows
his level of dental development
to be that of a normal 10year-
old. (Opposite page) A tracing of
the boy's cephalogram (solid line)
is compared with one of a
normal 12-yearold boy (broken
line).
65. Temporomandibular Disturbances 111
Malocclusions that show significant relationship to

periodontal infection include abnormal vertical incisor
-cc age'2
overbite, cusp interference of posterior teeth, mandibular
NOr mal age 12 incisor crowding, and incisor overjet, and overbite,
especially when the mandibular incisors occlude at the
palatogingival margins of the maxillary incisor teeth.
\~
-, ..........
_ .. --- TEMPOROMANDIBULAR DISTURBA CES
.........
Etiologic factors in temporomandibular disturbances

are (1) birth trauma, which may go unobserved until the
deciduous dentition begins to erupt; (2) multiple tooth
loss and malocclusion; (3) rheumatoid and suppurative
arthritis; (4) osteomyelitis; (5) fractures of the condyle,
neoplasms, and infections.
stomia, microtia, mongoloid facies, hypertelorism, and Endocrine Imbalance Anomalies
other abnormalities of the upper face.
Periodontal Disease. Geiger et al. found more than 86 Anomalies of endocrine origin can manifest them-
per cent of patients who received periodontal therapy but selves dentofacially as follows:
no orthodontic treatment showed malocclusion. Cross 1. Disturbances affecting the periodontium and other
bites are a significant factor in localized periodontal oral structures
disease. Shifting of teeth into spaces occupied by 2. Characteristic changes in facial appearance caused
extracted teeth is a definite cause of malocclusion, by retarded or accelerated growth of the face
gingival pocket formation and periodontitis. Children 3. Changes in the rate and order of eruption, alignment,
with severe gingivitis tend to show a higher caries attack and relationship to each other of the jaws, and individual
rate and a larger number of maloccluded teeth. and groups of teeth in the same jaw or in the opposing
jaws.
Fig. 9-11A. A. . had congenital renal disease and

tubular damage, renal diabetes, chronic loss of
chlorides, and retarded growth and skeletal
maturation. (Right) In the anterior view of his
dentition at 9 years, the mandibular left permanent
central incisor can be seen erupting. No other
permanent teeth have erupted. The dental age is 6
years. (Bottom) Views of occlusion of the
deciduous dentition show normal occlusion and
well-developed dental arches.
66.
Fig. 9-11B. Bossing of the frontal bone is evident in

the lateral roentgenogram of A. N.
\
\
\
\
I
Fig. 9-11D. The radiogram of the patient's hand at
I
, 8 years shows carpal development typical of a 5-
--AN aqe B I
- - - Normal age 8 I
year-old. The wrist of a normal 8-year-old has the
- ;:-"""\
I
following carpal bones: greater and lesser
"' -, \
'-, multangulum, navicular, lunate, hamate, and
"" \
triquetrum. The radial epiphysis is no longer wedge-
shaped. The greater and lesser multangular and
navicular are not formed. The radial epiphysis is
wedge- shaped.
----:;-
,,
,.,. -- -. \ ''-\.
'~. ,\
< , /~'
... I
,, " .
(.'
: .. /?
, Mouth Breathing
Mouth breathing can be associated with all types of
,,
, malocclusion, and with normal occlusion. Mouth
'- , -, , breathing is not as important in producing openbite as
Fig. 9-11C. Cephalometric tracings of A. N. at 8 years and of faulty tongue posture. Mouth breathing does not always
a normal boy of the same age are compared. lead to narrowing of the maxillary dental arch, and the
width of the jaws is not usually affected. When the lower
lip in the mouth breather occludes lingual to the
maxillary incisors, these teeth usually show protrusion,
and there may be narrowing of the dental arches.
Lip Posture
Test for Mouthbreathing. To determine whether a
Incompetent lip posture shows the lips wide apart child can breathe through the nose hold a cardboard with
when the face is in repose. Some incompetent lip small pieces of paper on it under the nose and ask the
postures are the result of bimaxillary protrusion or Class child to bteathe with the lips closed. If
II, Division 1 malocclusion.
Temporomandibular Disturbances . 113
Fig. 9-12. (A) This boy shows

macrogenitosomia praecox: at
age 2 he is 43314 ins. tall (the
mean for 5-yearolds) and
weighs 51 lbs. (the mean for 7
years). Genital development is
also precocious. In the front
view of his dentition, note the
geminated central and lateral
incisors in the mandible. The
maxillary right central incisor
was lost in a fall; the maxillary
left central incisor is devitalized.
By age 2 the entire deciduous
dentition has' erupted. (B) All
permanent teeth, including the
second molars, have erupted.
The patient has gingivitis. (C)
The wrist roentgenograms show
bone age of 7 to 8 years.
(Ouerlea], OJ (Top) All
permanent teeth including the
second permanent molars have
erupted. The patient has
gingivitis (Schmutzpyorrhoe). In
the front and lateral views of the
patient at 9 years the beginnings
of balding can be seen at the
hairline. At 9, he shaves
regularly. (Far right) Body build
and development at age 9.
the pieces of paper are moved by the nasal breathing, the ually over the occlusal and incisal surfaces of the teeth
child can breathe through the nose. This does not mea~, causes openbite. Diastemas of the anterior teeth also may
however, that the child habitually breathes through the be seen in faulty tongue posture.
nose. Tongue- Thrust Swallowing. Rix (1946) described
openbite swallowing in which the lower lip, aided by the
Tongue Posture and Function mentalis and zygomatic muscles presses against the upper
lip forming a firm anterior wall to meet the forward thrust
An enlarged tongue can be the cause of malocclusion, of the tongue between the separated dental arches when
notably of excessive spacing and open bite. Size and swallowing is performed. Tongue thrust disappears in
function of the tongue are important etiologic factors in many children when the occlusion is corrected.
malocclusion. Tongue posture habit-
Fig, 9-12 D
Fig. 9-13. (Top) Tongue-thrusting, interdental tongue posture, and openbite in mother and
son, Tongue-thrusting, jaw posturing, and occlusal mannerisms have been found to show
genetic reference. (Bottom) Another mother and son show the same type of mandibular
incisor crowding. Both had the same mandibular pressure mannerisms and jaw posturing.
68.
Midline Deviations' 115
Fig. 9-]4. (Top) Hereditary

ectodermal dysplasia may
show partial or complete ab-
sence of ectodermal structures
and may include sparse hair
and oligodontia. This boy has
no deciduous or permanent
incisors. Oligodontia,
hypodontia, and anodontia are
of polygenic hereditary origin
and can occur also without the
classic syndrome of general
ectodermal dysplasia. (Bottom)
Dentinogenesis imperfecta
usually occurs with
ectodermal dysplasia.
Inherited as a simple
autosomal heterogenous
dominant trait, it is
characterized usually by an
opalescent discoloration of the
deciduous and permanent
teeth, which are prone to early
fracture and excessive wear.
There is thickening and
protrusion of the lips as the
length of the face decreases
when the teeth wear down.
The maxillary central incisors
shown here are not opalescent.
When the tongue is held habitually between the dental dontic treatment that aligns the maxillary and mandibular
arches over the incisal and occlusal surfaces, openbite is incisors can frequently eliminate tongue thrust.
induced. Tongue thrust is found in persons 'with deep
overbite as well as in those with openbite. Orthodontic
therapy can eliminate tongue thrusting, especially when open MIDLINE DEVIA nONS
bite and overjet are corrected and the tongue is inhibited In the maxilla or in the mandible deviation of the midline in
from resting on the occlusal and incisal surfaces of the teeth. relation to the sagittal plane can be caused by missing teeth
It is the posture of the tongue between the incisal and when the remaining teeth in the mouth shift mesially, distally,
occlusal surfaces of the teeth rather than the tongue thrust lingually, or buccally or when there is a disproportion in the
that is responsible for openbite. Ortho- number of teeth or in the mesiodistal dimensions of the teeth.
Fig. 9-15. Tooth shifting and space closure
without orthodontic guidance can be an etiologic
factor in malocclusion. (Top row, left) Teeth
adjacent to the extracted maxillary permanent
first molar will shift into its space. (Center) The
second premolar begins to shift into the space
left when the mandibular permanent first molar
was lost. (Right> The mandibular first and second
premolars shift distally while the permanent
second molar remains stationary, owing to
interference of the elongated maxillary
permanent first molar. (Bottom row, lejt) The
f ._
, ~.. * mandibular first and second premolars remain
stationary while the second molar is shifting
mesially into the extraction space. (Center) Distal
shifting of the second premolar and mesial
shifting of the second molar closed the
mandibular extraction space. The first premolar
remained stationary, and a space has been
Mandibular midline deviation, in addition, may be opened between the first and second premolars.
caused also by shifting of the mandible caused by (Right> The space of the extracted maxillary
asymmetry especially of the condyles. permanent first molar is completely closed.
Closure was effected by distal shifting of the
teeth anterior to the extraction space and mesial
Diastemas shifting of the second and third molars.
Maxillary midline diastemas can be a normal con-
ditions from infancy until 10 years of age or until the
canines have erupted. The following can be the cause of

abnormal diastemas:
L Tongue, finger, or lip pressure habits
2. Endocrine dysfunction - acromegaly
3. Agenesis of tooth germs
4.A short upper lip accompanied by abnormal overjet
of the maxillary incisors
Fig. 9-16. Outline drawing showing normal dental arches

(heavy solid lines) and shifting of the teeth following extraction of
the permanent first molars and closure of the space (thin broken
lines). In the maxillary arch, there is a shifting of the incisor teeth
to the side from which the permanent first molar was extracted, a
slight distal shifting of the canines and premolars, and a decided
forward shifting of the second and third molars. At the same
time, there is a flattening or collapse of the arch lingually on the
side of the arch from which the first molar was extracted.
In the mandibular arch, there is a slight shifting of the incisor
teeth to the side from which the permanent first molar was
extracted. There is also a lingual collapse of the canine and the
incisor teeth which results in an increased overbite. The
premolars rotate and incline as they shift distally and show
spacing between them. The second and third molars shift
mesially and show some rotation and much forward inclination,
but there is no collapse of the premolars and the molars in a
lingual direction.
70. Midline Deviations 117
Fig. 9-17. (Top) Left-side roentgenogram shows

distal shifting of the mandibular first premolar and
canine following loss of the deciduous second molar
without a succeeding second premolar. (Top, right) The
deciduous second molar on the right side is still in
position; its roots are resorbed but no succeeding
premolar is present. There is no space separating the
mandibular first premolar and canine, as on the left.
(Bottom) Pocket formation after loss of permanent first
molars and shifting of adjacent teeth.
5. Deficiency of tooth structure, such as missing or Occlusal changes after loss of permanent first molars
dwarfed lateral incisors include the following:
6. One or more abnormally large or deformed teeth in 1. Dental arch collapse
the anterior region of the mouth that interfere with or 2.Teeth adjacent to the extraction space show a
disturb normal maxillary tooth alignment. tendency to rotate, incline, and shift their position. The
premolars usually shift distally while the molars shift in a
mesial direction.
3. The median line of the teeth tends to shift in the
Space Loss
direction of the side from which the first permanent molar
Loss of mesiodistal space involving the teeth is caused has been extracted.
by the following: 4. An increase in the incidence and degree of intensity
1. Loss of tooth substance from the mesial or distal of dental caries
aspects of teeth - extraction, premature loss, caries, 5. Loss of the permanent first molar while the deciduous
accidental trauma second molar is still in position can cause the second
2. Faulty contour of fillings premolar to erupt distally in the space left by the extracted
3.Loss of deciduous teeth coincident with missing first molar.
permanent tooth germs Occlusal changes following extraction of perrnanent
4. Disturbances of occlusion following premature loss first molars without orthodontic treatment can be
of deciduous teeth before the permanent successors are summarized as follows:
ready to erupt In the Maxilla. Closure of the space after extraction is
5. Deciduous teeth lost through traumatic injuries can caused by distal shifting of the premolars and mesial
damage the unerupted underlying permanent teet~. shifting of the molars. In Class I (Angle) malocclusion
Accidental loosening of primary teeth rarely affects the with normal molar relationship, the malocclusion may
permanent successors. change to Class II, Division 2 subdivision. There may be
buccoversion of the premolars (occasionally of the
canines) and lateral incisors on the side where the
Loss of Permanent Teeth extraction occurred.
When mandibular permanent first molars are lost in
Loss of permanent teeth can produce various types of Class I (Angle) cases, they may change to Class II,
shifting of the adjacent teeth, initiating or modifying Division 1 or Division 2 subdivision, depending on
existing malocclusion, depending on the type of occlusion whether the loss is unilateral or bilateral and on the
originally present in the mouth.
Fig. 9-18. Orodigital habits can con-

tribute to malocclusion. (Left, top) The
infant bites two fingers of each hand.
(Center) Protrusion and openbite develop
on the side on which this girl habitually
sucks her finger. (Bottom) This boy pulls
on his mandible. The mandible protrudes,
and he has crossbite and open bite.
(Opposite) Three examples of how
thumbsucking can effect the occlusion.
relationship of the lower Lip to the maxillary incisors. If because of the comparatively small amount of distal
the lip rests under the maxillary incisors, the change is to shifting of the premolars and the relatively greater mesial
Class II, Division 1 subdivision. If the lip closes normally shifting of the adjacent second molars. The relative
over the maxillary incisors, the change is to CLass II, protrusion of the maxillary incisors may be increased
Division 2 subdivision. because of the distal shifting of the premolars and lingual
Loss of maxillary first molars in Class II, Division 1, collapse of the mandibular incisors.
(Angle) cases does not result in self-correction When one permanent first molar is extracted in
Supernumerary Teeth 119
Fig. 9-18 (Continued)
C4!ss II, Division 1 malocclusion there is a tendency for tracted permanent first molar and to erupt distally,
the maLocclusion to become a subdivision of the same producing spacing between the premolars.
classification.
SUPERNUMERARY TEETH
Loss of maxillary permanent first moLars in Class III
(AngLe) cases (mesial relation of the mandible) Supernumerary teeth can be responsible for delayed
increases the malocclusion. eruption, norieruption, and spacing of the teeth. Early
If a permanent first molar tooth is lost before the removal of supernumerary teeth is important to prevent
second premolar erupts, there is a tendency for the dental irregularities and dental arch malrelationships.
second premolar to fall into the alveolus of the ex-
Fig. 9-19. Open bite in an adult caused

by lower lip sucking and posture of the
tongue over the incisal surfaces of the
mandibular incisor teeth. Note. The occlu-
sion of the teeth in the lateral jaw seg-
ments is not disturbed. The habit caused
spacing and protrusion of the maxillary
incisor and canine teeth.
The following can serve as a guide in radiographic mean that every child who sucks a thumb or finger will
diagnosis of supernumerary teeth: develop malocclusion. Forceful methods of preventing
1. The supernumerary tooth shows a dense area on the film. thumb- or finger sucking can produce psychological
2. The enamel of the supernumerary tooth may be seen distress in children.
on the radiogram. Thumb-sucking practiced after permanent incisor
3. The pulp chamber of the supernumerary tooth is eruption can cause openbite, maxillary incisor protrusion,
visible on the radiogram. crossbite, distoclusion of the mandibular dental arch, and
4. A radiolucent line of demarcation of the tooth sac is constriction of both dental arches. The type of
visible on the radiogram. malocclusion depends on bone density, on the intensity,
duration, frequency, and method of sucking, and on which
finger is sucked. Malocclusion caused by thumb-sucking
DENTOFACIAL PRESSURE HABITS will correct itself if the habit is stopped while the child is
young. If the maxillary incisors rest on the lower lip when
Pressure habits that interfere with normal growth and
the jaws are approximated, the occlusion will not correct
jaw function include finger-sucking, tongueand lip biting,
spontaneously. A personal appeal to the child, preferably
biting on firm materials, and bruxism.
by someone other than the parent, for cooperation in
Thumb- and Finger sucking eliminating the habit is important. The child thus is given a
sense of responsibility for the ha bi t- breaking effort.
There is a positive correlation between thumb- and
finger sucking and malocclusion. This does not
Dentofacial Pressure Habits' 121
TABLE 9-1. CONDITIONS THAT MAY RESULT FROM LOSS OF A SINGLE TOOTH" (I. HIRSCHFELD)
Food impaction, entailing over 20 ill-effects, including caries and interproximal disease
Periodontal disease, or accentuation of same

Cervical caries (?)
Traumatic.
Acute or chronic inflammation Pulp involvement Referred
occlusion
pain
{ {
Devitalization
Root
Cervical hypersensitiveness
exposure
{
Wasting (abrasion, erosion or cervico-abrasion) Caries
A. Shifting Accentuation of depth of approximal gingival crevice
(mesiodistal Excessive mobility
I
or bucco- Traumatization of tongue
lingual) Interdental Unattractive appearance
spacing Speech defect (social and economic disadvantages)
Traumatization of tongue (inviting malignancy)
Malposition of frenum { Gingival recession
1. A break in labially instead of Accentuation of pyorrheal destruction
continuity interproximally Interference with treatment
of the Temporomandibular disturbances Approximation of jaws
dental arch Traumatic occlusion and
{
Gingival traumatization anteriorly
T. {FOOd impaction
B. orsion Traumatic occlusion
C. Food impaction other than that caused by shifting or torsion
R . I) { Cervical hypersensitiveness
D. oot exposure (approxima Cervical caries

E. Traumatization of tongue (inviting malignancy)
A. Traumatic occlusion
2. Elongation
B. Food impaction
C. Root exposure
D. Proximal bifurcation exposure rendering prognosis of pyorrheal infection negative
E. Shifting
F. Satisfactory restoration made difficult {
Atrophy
3. Diminished Gingivitis Lowering of resistance to infection
A. Diminishing of periodontal circulation
function B. Unhygienic condition Hypersensitiveness
(Local) Caries
{
C. Retardation of occlusal wear
D. Excessive occlusal wear on one side of mouth (inharmonious occlusal relation)
Hirschfeld, Isadore: J. Am. Dent. Assoc. & Dent. Cosmos, 24:67-82, 1927.
Lip Biting Tongue sucking or fingernail biting may be a substitute

habit when thumb-sucking is peremptorily prohibited.
Lip biting or sucking may occasionally develop as',a
variant of or a substitute for thumb- or finger suaking. In
lip sucking the lower lip is turned inward and is caught
between the maxillary and mandibular teeth and pressure is Nail Biting
exerted by the lip. The force produced by the lip can move
the maxillary incisors labially and the mandibular incisors Fingernail biting shows a marked increase in children
lingually. after 6 years of age. There is a constant upward trend until
10 years of age for girls and 12 years for boys. The habit
usually is replaced after adolescence by lip biting, gum
Tongue Sucking
chewing, or smoking. Clinical examination of the incisor
Tongue sucking may be caused by macroglossia. teeth in finger-
Fig. 9-20. The face of this 13-

year-old girl is asymmetrical
owing to finger-sucking and
hand pressure. She had practiced
this habit since early childhood.
The side view shows how
pressure was applied to the face
and mandible. Her occlusion is
fairly normal, but shows
distortion from pressure. There is
an opening in the bite where the
fingers are inserted into the
mouth.
nail biters indicates that the habit is responsible for teeth. Fractured and missing teeth can produce the same
openbite, and rotation of the mandibular incisors. effects on the occlusion as premature tooth extraction.
Traumatic Occlusion
Bruxism
Force exerted on the occlusal or incisal surface of ""
tooth is translated as traction on the periodontal ligament. Bruxism can occur during sleep and in waking hours. The
When the force is greater than it can withstand, some of the most important factor is psychological or emotional
periodontal ligament may be destroyed. The tooth may be tension. It can be initiated by local factors including cusp
loosened, or, if lateral trauma is absent, it may actually interference, loose teeth, high fillings, and any continuing
become ankylosed. stimulus to the afferent nerve endings in the periodontal
tissues, which normally are associated with the reflex arcs
of the rhythmical movements of mastication. Children who
Caries suck their thumbs or bite their nails may
Caries can destroy the mesiodistal contour of

Bibliography' 123
switch to grinding their teeth as adolescents. Treatment

consists of psychiatric intervention and the use of an
activator or a teeth protector.
MANDIBULAR INCISOR CROWDI G

Crowding of mandibular incisors can be caused by the
following:
1. Difference in width between the well aligned
maxillary incisors and wider mandibular incisors that are
crowded in the space lingual to the maxillary incisors
2. Deep overbite that interferes with mandibular incisor
alignment
3. Lip pressure in lip-biting causing deviation from
regular alignment
4. Relapse after the incisors have been moved into
increased procumbency
5. Mesial shifting of the permanent molars that
encroaches on space required by the premolars after
premature loss of deciduous molars. The premolars in
turn encroach on the space required for the canines and
incisors.
Fig. 9-21. Fingers and toes of a girl nail biter.
maturees et leurs consequences au crane et a la face. Rev.

BIBLIOGRAPHY stornatol., 64:97, 1963.
---: Evolutionary and population genetics. Science, 142:1131,
Acheson, R. M.: Effects of nutrition and disease on growth. 1963.
In, Human Growth. Symposia Soc. Hum. Biol., 3:73, 1960. Douglas, B.: The role of environmental factors in the etiology of
Adachi, T., Murai, T., Kikuchi, A, and Yonaga, T.: Effect of so-called congenital malformations. J. Plas. Reconstr. Surg.,
radiation on the hard tissues. Part rn. Effect of radiation on 22:94; 22:214, 1958.
teeth. Bull. Tokyo Med. Dent. Un iv., 4:215, 1957. Elmering, G.: Der Morbus Langdon-Down in seiner Bedeutung
Asbell, M. B.: A study of- the family-line transmission of dental fiir den Stomatologen. Zahn-rned. im Bild., 2:30, 1961.
occlusion. Am. J. Orthodontics, 43:265, 1957. Evans, M. W.: Congenital dental defects in infants subsequent to
Basile, E.: La muscolatura mimica della faccia e il suo ruolo nella maternal rubella during pregnancy. Med. J. Austral., 2:225, 1944.
patagenesi di alcune malocclusioni. Clinica Odontoiatrica, Fassenbender, H. G.: Die Beziehungen des Endokrinismus zu
8:12, 1953. Zahn-, Mund-Und Kiefererkrankungen (The Relationship of the
Benavent, W. J., and Ramos-Oller, A: Micrognathia: report of Endocrines to Teeth, Mouth and Jaw Diseases). 17:184, 1962.
twelve cases. Plast. Reconstr. Surg., 22:486, 1958. Fishbein, M.: Birth defects. Philadelphia, J. B. Lippincott, 1963.
Brabant, H., and Klees, L.: Les anomalies dentaires et rnaxillaires Forest, H., and Graham, A. G.: The Pierre Robin Syndrome, Scot.
dans certaines chondrodystrophies genotypiques. Acta stomat. Med. J., 8:16, 1963.
Belgica., 58:553, 1961. Gaard, R. A.: Ocular hypertelorism of Grieg: a congenital
Burke, P. H.: Unilateral facial hypoplasia affecting tooth size. craniofacial deformity. Am. J. Orthodontics, 47:205, 1961.
Brit. D. J., 103:41, 1957. Gam, S. M.: The genetics of normal human growth, In Gedda, L.,
Calisti, L. J. P., Cohen, M. M., and Fales, M. H.: Correlation (ed.): De Genetica Medica. Part 2, Rome, Gregor Mendel Inst.,
5etween malocclusion, oral habits, and socio-economic level 1962.
of pre-school children. J. D. Res., 39:450,1960. Geiger, A. M.: Occlusal studies in 188 consecutive cases of
Chateau, M., and Petit, H.: Orthopedic Dento-Faciale et periodontal disease. Am. J. Orthodontics, 48:330, 1962. ---:
Parodontopathies, L'Orthodont. Francaise, 32:136, 1961. Occlusion in Periodontal Disease. J. Periodont., 36:387, 1965.
Crigler, J. F., [r., Cohen, M. I., and Wittenborg, M. H.: Geiger, A M., Wasserman, B. H., Thompson, K H., Jr., and
Systemic disturbances in relation to general and den tofacial Turgeon, L. K: Relationship of occlusion and perio-
growth and development in children. Am. J. Orthodontics,
48:1, 1962.
Delaire, J., et al.: Considerations sur les synostoses pre-
don tal disease Part V. - Relation of classification of occlusion Massier, M., and Malone, A. J.: ailbiting-a review. ].
to periodontal status and gingival inflammation. J. Periodont., Pediat., 36:523, 1950.
43:554, 1972. Massier, M., et al.: Epidemiology of gingivitis in children.
Glass, D.: The recognition of bilateral craniofacial deformities. J.A.D.A., 45:319,1952.
Dent. Practitioner., 21:137, 1970. McKenzie, J., and Craig, J.: Mandibulo-facial dysostosis (Treacher
Goodman, R. M., and Gorlin, R. J.: The face in genetic disorders. Collins Syndrome). Arch. Dis. Child., 30:391, 1955.
St. Louis, C. V. Mosby, 1970. Moorrees, C. F. A.: Genetic Considerations in Dental
Gould, A. W.: An investigation of the inheritance of toru palatinus Anthropology. In Witkop, C. J., (ed.): Genetics and Dental
and torus mandibularis. J. D. Res., 43:159, 1964. Health. ew York, McGraw-Hill, 1962.
Crahnen, H.: Maternal rubella and dental defects. Odontologisk Murphy, D. P.: Congenital Malformations. A Study of Parental
Revy, 9:181, 1958. Characteristics with Special Reference to the Reproductive
Greenblatt, R. B., Mateo de Acosta, 0., Vazquez, E., and Mullins, Process. ed. 2. Philadelphia, J. B. Lippincott, 1947.
B. F.: Oral mucosal smears in detection of genetic sex. J ---: The birth of congenitally malformed children in relation to
.A.M.A., 161 :683, 1956. maternal age. Ann. N. Y. Acad. Sci., 57:503, 1954.
Greulich, W. W., et al.: The physical growth and development of eumann, F., and Ostrava, M.: Oversized tongues as causes of
children who survived the atomic bombing of Hiroshima or malocclusion. Int. J. Orthodont. & Oral Surg., 18:467, 1932.
Nagasaki. J. Pediat., 43:121, 1953. iswander, J. D., and Sujaku, C.: Relationship of enamel defects
Gorlin, R. J., and Meskin, L. H.: Congenital hemihypertrophy, of permanent teeth to retention of deciduous tooth fragments. J.
review of the literature and report of a case with special D. Res.. 41:808, 1962.
emphasis on oral manifestations. J. Pediat., 61:870, 1962. Ochiai , 5., Ohmori, I., and Hno, M.: Longitudinal study of jaw
Hirschfeld, I.: The individual missing tooth: a factor in dental and growth concerning total anodontia. Bull. Tokyo M. & D. Univ.,
periodontal disease. JA.D.A. & Dent. Cosmos 24:67, 1927. 8:307, 1961.
Horowitz, S. L., Osborne, R. H., and DeGeorge, E.: Hereditary Osborne, R. H., and De George, F. V.: Genetic Basis of
factors in tooth dimensions, a study of the anterior teeth of Morphological Variation. Cambridge, Harvard University, 1959
twins. Angle Orthodontist, 28:87, 1958. Pottenger, F. M.: The effect of disturbed nutrition on dento-facial
Hunter, W. S.: A Study of the inheritance of craniofacial structures. S. Calif. State D. L 20:18, 1952.
characteristics. Trans. European Orthodont. Soc., p. 59,1965. Poulton, D. R., and Aaronson, S. A.: The relationship between
Hutchinson, J.: On the influence of hereditary syphilis on the teeth. occlusion and periodontal status. Am. J. Orthodontics, 47:690,
Lancet, 9:449, 1855; 10:187, 1856. 1961.
---: Syphilis - diagnosis on the late periods - the teeth. Tr. Patho!. Poyton. H. G.: The effects of radiation on teeth. Oral Surg., Oral
Soc., London, 38:85, 1887. Med., and Oral Path., 26:639, 1968.
1ngervall, B., and Sarnas. K.: Lisping and occlusion. Robin, P.: Glossoptosis due to atresia and hypertrophy of the
Odont. Revy, 13:344, 1962. mandible. Am. J. Dis. Child., 48:541,1934.
Kisling, E.: Cranial Morphology in Down's Syndrome. 1966. Salzmann, J. A.: Preliminary report on tooth movement after loss
Vald, Pedersen's Bogtrykkai, Copenhagen. of first permanent molars in 500 adolescents. Int. J.
Korkhaus, G.: Die Entwicklung des Cesichtsschadcls und ihre Orthodontics, 23:662, 1937.
Storungen, Fortschr. Kiefer-Gesichtschir., 4:13, 1958. ---: Orthodontic changes and caries incidence, in relation to loss of
Korkhaus, G., Ein kieferorthopadisch i nteres antes Zwillingspaar. 941 first molars in 500 adolescents. Bull. Dent. Soc. ew York,
Fortsch. De. Kieferorthopadie, 32:257, 1971. 5:37,1938.
Korkhaus, G., and MUller, G.: Innere Sekretion und ---: Variation in tooth position following extraction of first molars
Gebissanomalien. Fortschr. Kieferorthop. 21:148, 1960. in relation to incidence and distribution of dental caries. J. D.
Kraus, B.S., Wise, W. J., and Frei, R. H.: Heredity and the Res., 19:17, 1940.
craniofacial complex. Am. ]. Orthodontics, 45:172, 1959. ---: Influence of loss of permanent first molar on position of
Kristen, K.: Endokrine Erkrankungen und Gebiss-system. eruption of second premolar, J. D. Res., 21:489, 1942.
Fortschr. Kieferorthop., 21 :182, 1960. ffect on occlusion of uncontrolled extraction of first
'linder-Aronson, 5., and Backstrom, A.: A comparison between permanent molars: prevention and treatment. J.A.D.A., 30:1681,
mouth and nose breathers with respect to occlusion and facial 1943.
dimensions. Tr. European Orthodont. Soc., p. 62, 1960. ---: The rationale of extraction as an adjunct to orthodontic
Masr iera, Sagales, J. M.: Trastornos Endocrinos con Repercussion mechanotherapy and the sequelae of extraction in the absence of
Dentaria. Rev. Espanola Estornatol., 9:21, 1961. orthodontic guidance. Am. J. Orthodontics, 31:181, 1945.
---: Criteria for extraction in orthodontic therapy
Bibliography' 125
related to dentofacial development. Am.]. Orthodontics, 35:584, Stafne, E. C;: Dental roentgenologic manifestations of systemic
1949. disease. Radiology, 58:507, 1952.
---: General growth acceleration and retardation in relation to ---: Chemical disturbances: Significance in orthodontic treatment. Am.
dentofacial development. Am. J. Orthodontics, 40:243, 1954, J. Orthodontics, 47:912,1961, Stallard, K E.: Occlusion: A factor in
---: Basic etiological factors in dentofacial malformations. Am. J. periodontal disease.
Orthodontics, 42:702, 1956. Internat. D. J., 18:121, 1968.
---: Etiology in orthodontic diagnosis. Am. J. Orthodontics, 44:867, Subtelny, J. D.: The significance of adenoid tissue in orthodontia.
1958. Angle Orthodontist, 24:59, 1954.
---: Biology, orthodontics, and the modification of man. Am. J. Thomas, D.: Innere Sekretion und Gebiss-anomalien.
Orthodontics, 47:924,1961. Fortschr. Kieferorthop., 21 :210, 1960.
---: Effect of molecular genetics and genetic engineering on the Thompson, R. H., Jr., Geiger, A. M., Wasserman, B. H., and Turgeon,
practice of orthodontics. Am. J. Orthodontics, 61 :437, 1972. L. K: Relationship of occlusion and periodontal disease. Part III.
Salzmann, ]. A., and Seide, L. J.: Malocclusion with extreme Relation of Periodontal Status to General Background
microglossia. Am. J. Orthodontics, 48:848, 1962. Characteristics. ). Periodontol., 43:540, 1972.
Salzmann, J. A., and Wein, S. L.: Dental correlation in pituitary Todd, T. W., Cohen, M. S., and Broadbent, B. H.: The role of allergy
dwarfism. Am. ). Orthodontics, 38:674, 1952, Sarnat. B. G., Schour, in the etiology of orthodontic deformity. J. Allergy., 10:246, 1938-
1., and Heupel, B.: Roentgenographic diagnosis of congenital syphilis 39. (Abstract)
in unerupted permanent teeth. J.A.M.A., 116:2745, 1941. Triebsch, E.: Wachstumsveranderungen im Zahn-und Kiefer-
Schumacher, G, H., and Dokladal, M.: Ober unterschadliche Gesichtsbereich bei gestorter Schilddrusenfunktion. Fortschr.
Secundarveranderungon am Schadel als Folge von Kieferorthop., 21 :87, 1960.
Kaurnuskelresektonen. Acta Anat., 69:378, 1968. Wagner, R., Cohen, M. M., and Hunt, E. E., [r.: Dental development
Shaw,). H.: Effect of nutritional factors on bones and teeth. in idiophathic sexual precocity, congenital adrenocortical
In Ann. New York Acad. Sci., 60:733, 1955. hyperplasia and adrenogenic virilism. J. Pediat., 63:566, 1963.
Silverman, 5., et al.: The dental structures in primary Walker, D, G.: Malformations of the Face. Edinburgh, E. & S.
hyperparathyroidism. Studies in 42 consecutive dentulous patients. Livingstone, 1961.
Oral 5urg., Oral Med. & Oral Path.. 15:426, 1962. Walsh, J. P.: The Psychogenesis of Bruxism. J. Periodont.,
Smith, D. W., Klaus, P., Therman, E., and Stanley, L.: 36:417,1965.
A new autosomal trisomy syndrome. Multiple congenital Wasserman, B. H., Geiger, A. M., Thompson, K H., [r., and Turgeon,
anomalies caused by an extra chromosome. J. Pediat., 57:338,1960. L. K: Relationship of occlusion and periodontal disease. Part IV.
Spiegel, R. N., Sather, A. H., and Hayes, A. B.: Cephalometric study Relationship of inflammation to general background characteristics
of children with various endocrine diseases. Am. J, Orthodontics, and periodontal Destruction. ]. Periodont., 43:547, 1972.
59:362, 1971. Witkop, C. J., [r., (ed.): Genetics and Dental Health. New York,
McGraw-Hill, 1962.
10
Dentition Anomalies and Malocclusion
NUMERICAL VARIATIONS OF TEETH

relation to jaw or quadrant), mandibular central incisors,
Agenesis of teeth occurs about ten times as frequently as and maxillary first premolars. First molars, mandibular
supernumerary teeth. The age of a person when canines, and maxillary central incisors rarely fail to appear.
supernumerary teeth form or erupt varies. Among causes of Partial or total absence of tooth germs occurs more
supernumerary teeth are the following: hypergenesis of the frequently in the mandible, while supernumerary teeth
epithelial cord, heredity, and developmental aberrations occur more frequently in the maxilla, especially in the
such as cleft palate. Supernumerary teeth include the anterior region.
following:
1. Peg teeth with conical crowns, usually found at the
midline between the .perrnanent maxillary incisors.
2. Multicusped, geminated teeth and teeth of unusual Delayed Eruption
size. Retarded eruption of teeth can be caused by the
3. Duplicate teeth in size and appearance-usually lateral following:
incisors and premolars. 1. Ectopic eruption
Anodontia, the congenital absence of all teeth, is 2. Abnormal distance of tooth germ from its
extremely rare. usual place of eruption
Oligodontia vera, a condition in which a number of teeth 3. Malformation of teeth
fail to form, can be related to ectodermal disturbances and 4. Presence of interfering supernumerary teeth
may show itself in the deciduous or the permanent 5. Trauma or infection of tooth germs
dentition. 6.Displacement of tooth germs or teeth by a neoplasm
The causes of anodontia and oligodontia are as 7. Ankylosis of the tooth with the jaw bone
follows: 8.Systemic diseases such as metabolic and endocrine
1. Hereditary ectodermal dysplasia disturbances
2. Cleft palate, micrognathia, or macrognathia 9. Space closure by adjacent erupted teeth
3.Acute, chronic, or pyogenic inflammations that 10. Heredity.
destroy the tooth germ
4. Birth injuries, rickets, and diseases of the mother
during pregnancy
5. Endocrine disturbances ECTOPIC ERUPTION
Ectopic eruption is the abnormal eruptive position of a

tooth. Ectopic eruption can be caused by the following:
delayed exfoliation of deciduous teeth; presence of
supernumerary teeth, cysts, and other infections; prolonged
Agenesis of Teeth
retention or premature extraction of deciduous teeth
The frequent agenesis of the maxillary lateral incisors without space maintenance; and misplaced tooth germs.
can be linked to an abnormality occurring at the lateral The prolonged retention of deciduous canines that fail to
sulcus of the palate. Agenesis of mandibular central show root resorption can interfere with permanent canine
incisors may be an indication of obstruction or abnormal eruption. The permanent canine may erupt high on the
ossification at the mandibular symphysis. labial surface of the alveolar process.
Agenesis is most frequent in the third molars and is seen Ectopic eruption of second premolars in the mandible is
with decreasing frequency in maxillary lateral incisors, usually found when loss of permanent first
second premolars (without cor-
126
Ectopic Eruption 127
Fig. 10-1. Roentgenograms show apparent

agenesis of second premolar follicles in a
7V2-year-old patient. At 9Y1 years, there is
evidence of second premolar crowns
forming. At lOV2, the second premolar
crowns are calcifying; and at age 13 V2
calcification is continuing.
molar occurs before the second premolar erupts. In these the second deciduous molars to be resorbed prematurely.
cases, the second premolar is often found to Jrupt in the Occasionally the eruptive force of the permanent molar
space formerly occupied by the extracted permanent first will cause exfoliation, or elevate the second deciduous
molar, while a space about the width of the extracted molar into supraclusion.
molar separates the second premolar from the first. Third molar ectopism can be caused by lack of alveolar
Occasionally the second premolar may fail to erupt tuberosity growth and by micromandibular growth. It is
altogether. questionable whether the eruptive force of the third
Ectopic eruption of first permanent molars that brings molars can force the teeth anterior to them out of
them too far mesially can cause the roots of alignment. When the second molar has
128 . Dentition Anomalies and Malocclusion
Fig. 10-2. Roentgenographic evidence of agenesis of tooth follicles: (top row) maxillary permanent lateral incisors
and canines are missing. (Center) The maxillary left central incisor was lost accidentally; the maxillary first
premolars and canines are missing. (Bottom row) Permanent mandibular lateral incisors are absent. The mandibular
right deciduous second molar is displaced into the alveolar process by the inclined permanent first molar (left side).
been moved distally by orthodontic means onto the path of IMPACTIONS

eruption of the third molars there can be recrowding.
-Migration of the mandibular canine to the opposite side An impacted tooth is one that is prevented from eruptirig
occurs when the tooth germ is situated at the symphysis of into position because of malposition and contact with other
the mandible. As the tooth develops horizontally, it finally teeth. Causes of impaction are hereditary factors, space
erupts or is impacted on the side opposite its normal closure after early loss of deciduous teeth, and prolonged
position. retention of deciduous teeth. Although impacted deciduous
Fusion of teeth may involve the crowns only, the roots teeth are rare, any tooth in the mouth may become
alone, or the entire tooth. Union of the tooth germs during impacted.
the developmental process is considered to be responsible Teeth that become impacted, in order of decreasing
for teeth fusion. frequency, are mandibular third molars, maxillary third
molars, maxillary canines, mandibular second
Impactions' 129
Fig. 10-3. The roots of an ll-year-old girl's mandibular second deciduous molar were
resorbed. Her second premolar is absent.
Fig. 10-4. (Bottom) Compare this second deciduous molar that likewise has nosecond
premolar successor. The deciduous molar that shows resorption has received fillings;
the one without resorption has not been filled. Root resorption in deciduous teeth that
are without permanent successors occurs more frequently when the deciduous teeth
are filled and when they are not below the line of occlusion.
premolars, and maxillary second premolars. Unilateral

impactions of third molars are somewhat more frequent
than bilateral. Maxillary canines show a frequent
tendency to unilateral impaction.
Impacted teeth should be examined to determine
whether the periodontal ligament is intact before an
attempt is made to bring them into occlusion. When the
periodontal ligament is absent, the roots are ankylosed
and orthodontic tooth movement without tooth
dislodgement is not possible.
Impaction of Third Molars

The normal position of the calcifying crown of the
mandibular third molar faces mesially. Slight aberration
in posterior growth of the mandible can cause the tooth to
be impacted against the distal aspect of the second molar.
The maxillary third molars are malpositioned less
frequently than are the mandibular ones because the
direction of eruption of the maxillary molars is backward
and downward. Maxillary third molars may erupt
buccally to the second moLars. However, the thickness of
the mandibula.r bone usually prevents lingual and buccal
deviation of the erupting third molar.
Diagnosis of impacted third molars should take into
consideration the age of the patient and the stage of
eruption of the dentition as a whole. Diagnosis is more
certain in the late adolescent stage. The positional
changes in third molars brought about by jaw growth and
eruption can eliminate apparent Fig. 10-5. Agenesis of mandibular
permanent central incisor teeth.
Fig. 10-6. Casts of a girl of 10 years and 5

months show multiple ankyloses of deciduous and
permanent teeth and arrested tooth eruption. The
alveolar process is not growing. (Top left) On the
right side the maxillary permanent first molar (1) is
not completely erupted. (2) The mandibular
2 deciduous second molar is below the line of
occlusion. (Top right) (1) The maxillary permanent
first molar has not erupted. The mesiobuccal cusp
of the maxillary deciduous second molar (2) is
showing through the alveolar mucosa, and the
maxillary deciduous first molar is above the line of
occlusion. The mandibular second deciduous molar
(3) is below the line of occlusion. (Bottom left) The
anterior view shows an abnormally deep overbite.
The occlusal view shows the mesiobuccal cusp of
the maxillary left deciduous second molar (1)
pushing through the gum. The permanent first
molar (2) is almost wholly unerupted. On the right
side of the maxilla the occlusal surface of the
permanent first molar (3) has erupted slightly
above the level of the alveolar mucosa. The
2 mandibular right and left deciduous second molars
are seen to lie below the line of occlusion. (Bottom)
side (left) The mandibular second deciduous molar
(1) lies below the line of occlusion and the second
premolar lies directly below. In the maxilla, the
permanent canine (2) is erupting mesially to
the deciduous canine and the permanent first
molar (3) has not reached the line of occlusion.
(Right) On the left side, the maxillary
permanent second molar (4) has not erupted;
likewise the permanent first molar, (5) except
for the mesiobuccal cusp, which shows through
the gum. The deciduous second molar (6) is
ankylosed, and its crown, except for the
occlusal surface, is covered by bone and gum
tissue. The
4 second premolar crown (7); the first pres molar (8);
the first deciduous molar (9); 6
7 the permanent canine (10); and the de-
s ciduous canine (11) are shown. The man~o
dibular deciduous second molar (12) lies
------ __ II below the line of occlusion, and the second
3 12 premolar is directly below it.
impactions of these teeth. Radiographic examination of the with the surrounding alveolar bone. Tooth ankylosis may
third molars requires occlusal and lateral jaw films to occur either before or after eruption of the tooth and can be
check on buccal deviations. found in the deciduous and the permanent dentitions.
Ankylosis of deciduous teeth can be caused by the
deposition of bone into the partially resorbed roots.
ERUPTION ANOMALIES
Biederman found tooth ankylosis to occur more than twice
Ankylosis of teeth is a fusion of the cementum as often in the man-
71.
Eruption Anomalies . 131
Fig. 10-7. Agenesis of permanent maxillary second and

third molars.
dible as in the maxilla, and far more in the deciduous than

in the permanent dentition.
The teeth most frequently ankylosed are the mandibular
second deciduous molars; then, in decreasing order, the
mandibular first deciduous molars, the maxillary second
deciduous molars, and the maxillary first deciduous molars.
Fig. 10-8. (Top) Right mandibular 2nd molar eruption is
interfered with by 3rd molar crown. Note. A brass ligature
separating wire was used to move the 3rd molar crown
Re-enclosure of Teeth in the Jaws away from the 2nd molar. (Bottom) Right, the 2nd molar is
There are two types of teeth found imbedded in the erupting and its crown is now above that of the 3rd molar
which requires axial correction.
Fig. 10-9. (Left) The second

molar is impacted against the
first molar. (Center) A band
with an extension looped
auxiliary spring is used to
move the second molar away
from the first molar and to
rotate the crown occ1usally.
(Right) The second molar is in
position; the third molar is
impacted.
jaw bones: those that erupted but were later reenclosed, the process continues to grow, what was formerly alveolar
so-called "submerged" teeth, and those that never erupted. process becomes part of the body of the maxilla or the
A re-enclosed ("submerged") tooth is one that fails to mandible.
maintain its position in the developing occlusion. It may
become partially or completely enclosed by the alveolar
mucosa and the alveolar process in the growing child. Prolonged Retention of Deciduous Teeth Prolonged
Failure of these teeth to maintain their height is ascribed to retention of deciduous teeth beyond the chronologie age when
ankylosis of surrounding bone and the tooth. As the these teeth normally are shed is attributed to the following:
alveolar 1. Absence of permanent successors
72.
J
Fig. 10-10. The mandibular left canine lies across
the incisor teeth. An attempt to expose canine
could harm the incisor teeth.
2. Malposition of the erupting permanent teeth

3. Impaction of permanent teeth
4. Ankylosis with the alveolar bone.
Premature Exfoliation Fig. 10-11. Supernumerary teeth interfere with the

eruption of permanent central incisors. This 11-yearold
Premature exfoliation of teeth occurs in premature root
patient's deciduous central' incisors are still in position.
resorption; keratosis palmaris et plantaris in which there is
The permanent lateral incisors have erupted.
loss of alveolar process; reticuloen-
Fig. 10-12. (Left) Supernumerary teeth are situated above and below the unerupted maxillary central
incisor in a child 8 years old. (Right) The maxillary central incisor erupted after supernumerary teeth
were removed. Removal of supernumerary teeth close to unerupted teeth requires special care to
avoid injuring and displacing them.
73. Eruption Anomalies 133
Fig. 10-13 (A) (Top) A and B show maxillary 4th

molars. C shows a horizontal impaction of a mandibular
right 3rd molar. (Center) Supernumerary premolar teeth.
(Bottom) Left, peg tooth in palate. Right, peg teeth in
close proximity to maxillary left permanent central and
lateral incisor teeth. Attempts to remove the
supernumerary teeth can interfere with the vitality of
the adjacent incisor teeth. (B) Three supernumerary
premolars.
dotheliosis which shows osteolytic lesions developing

about the roots; and acrodynia osteonecrosis; and in
severe bruxism when the teeth are forced out of the
alveolar process. Hypophosphatasia with tooth loss
manifests itself in the first few years of life and is more
severe in early infancy. Early maturation, early eruption,
and early exfoliation of both the deciduous and the
permanent teeth have been reported to occur in otherwise
normal patients.
Traumatized Teeth
Trauma of a tooth may cause obliteration of the pulp
canal, resorption at the pulp walls, or resorption of the
tooth surface. The extent of external and internal
resorption depends on the extent to which the hard
tissues have been damaged by loss of nerve and blood
supply.
Asymmetric Root Resorption

Asymmetric root resorption of the deciduous molar
roots may show one root only to be resorbed. Such
deciduous teeth should be extracted to prevent malposi
tion of the succeeding permanent tooth when it is about
to erupt.
Fig. 10-14. In 1961, at age 10, this patient's Retention of Deciduous Tooth Roots
permanent canines were in the normal
eruption space. A year later they began to Retained deciduous roots are more common in the
erupt ectopically and still a year later, they mandible than in the maxilla and are found in
were impacted, (Courtesy M. L. Feldman)
Fig. 10-15. (Left) The deciduous

mandibular right lateral incisor and
canine are geminated as the radiogram
below shows, The right mandibular
permanent incisor follicle failed to form,
a condition frequently seen with
geminated deciduous teeth. (Right)
Casts show geminated maxillary central
and lateral incisors. The radiogram
shows the geminated deciduous left
central and lateral incisors, All
permanent incisors are present.
Root Resorption and Orthodontic Therapy 135
the jaw to be covered by a thick layer of hyperplastic

cementum.
Root Resorption of Permanent Teeth

Factors responsible for root resorption of per-
manent teeth are as follows:
1. Replanted teeth
2. Impacted teeth
3. Pulpless teeth
4.Fractured teeth that were allowed to remain in the
mouth without pulp therapy
5. Teeth in close proximity to tumors and cysts of the
jaws
6. Teeth subjected to excessive trauma
7.Diabetic disturbances, endocrinopathies or other
systemic diseases can show high susceptibility to
resorption of bone and teeth.
ROOT RESORPTION AND ORTHODONTIC

THERAPY
Root resorption can occur in the presence or absence of
orthodontic tooth movement. In orthodontically treated
teeth root resorption is usually microscopic in extent and
is arrested when treatment is completed or discontinued.
If it is not extensive root resorption does not interfere
with the continued functional efficiency of the teeth.
Frequent radiographic examination of teeth undergoing
orthodontic tooth movement is advisable.
Root Resorption and Traumatic Occlusion

Fig. 10-16. (Top) The erupting mandibular third molars are in
Under abnormal occlusal stress the supporting mesioversion in a 15-year-old. (Center) At age 161h the left
structures of the tooth or teeth may become reinforced, mandibular third molar has erupted into normal occlusion, and
enabling the teeth to withstand the excessive stress. the right mandibular third molar shows improved position for
Conversely, the supporting tissues may be damaged and eruption. (Bottom) The maxillary and mandibular third molars
the tooth may be loosened if it is unable to resist the are in normal occlusion fully erupted. In the course of eruption
third molars may show increased torsi version and may even-
force.
tually become impacted. In this case, the third molars erupted
Internal resorption of teeth, characterized by the so-
into normal occlusion. The decision to extract ectopically
called pink spot, is caused by vascular changes in the erupting or impacted third molars during the period of dental
pulp. Internal resorption may follow marginal gingivitis development should be postponed until a series of
with the formation of granulation tissue in the pulp examinations confirm the diagnosis.
chamber which resorbs the tooth structure.
Resorption of "Blocked Out" Teeth. Insufficient rodm
for the permanent lateral incisor to erupt can cause root
resorption and premature exfoliation of the deciduous canine which, consequently, is blocked out. The canine
canine. The permanent lateral then erupts in the eruption usually then erupts labially as the so-called high canine.
path of the permanent canine. As the first premolar Second premolar impaction can occur when the
erupts, it occupies the rest of the space intended for the permanent first molar causes resorption of the roots and
erupting permanent subsequent exfoliation of the second deciduous molar.
The permanent first molar
Fig. 10-17. (Top) Premolars erupted prematurely

after the deciduous molars were lost early. (Center)
There is delayed calcification in the right
mandibular permanent second molar; the left one is
unerupted. (Bottom) Radiograms of an t l-year-old
boy who never developed permanent first molars.
The permanent second molars are calcifying but are
still unerupted.
Fig. 10-18. (Left) Ectopic eruption of the first and second premolars was caused by
overretention of the deciduous first and second molars. (Right) Prolonged retention of
deciduous molars caused buccal cross bite.
Root Resorption and Orthodontic Therapy' 137
Fig, 10-19, (Top) Geminated permanent lateral

incisors interfere with mandibular permanent canine
eruption, (Right) The geminated tooth has been
separated; half was extracted, and the other half was
left in the jaw. There is enough space for the permanent
canine to erupt. (Courtesy of N. C. Gaston) (Center) An
overretained deciduous lateral incisor caused the
permanent successor to erupt ectopically. (Bottom left)
An overretained incisor crown interferes with the
resorption of the permanent lateral incisor. (Right)
Failure of the deciduous lateral incisor to resorb
interferes with the eruption of the permanent lateral in-
cisor.
Fig, 10-20. The patient is a girl age 15 years. Retained

maxillary canines are about to erupt buccally.
Fig. 10-21. (Top left) The radiogram shows extreme

resorption of the right mandibular deciduous second
molar with the succeeding second premolar ready to
erupt. (Top right) A radiogram of the left side shows that
the roots of the second deciduous molar are only partially
resorbed, and the crown of the succeeding second
premolar is not completely formed. The rate of root
resorption of deciduous teeth and development of the
permanent teeth on each side of the jaws of the same Fig. 10-22. (Top) Alveolar bone overlies the crown
patient may show wide variation. (Bottom left! The radio- of the premolar tooth. The premolar still has to
gram shows attachment of the mucosa to the crown of the complete calcification of its crown and begin
deciduous second molar after the roots were resorbed, calcification of its root. The deciduous second
causing prolonged retention of the deciduous molar molar shows root resorption but should be retained
crown and interference with the eruption of the second in position until the premolar is ready to erupt.
premolar. (Bottom right) The radiogram shows an (Bottom) Early loss of the deciduous second molar
unresorbed root of a mandibular deciduous lateral incisor has hastened the eruption of the premolar before it
interfering with the proper occlusal alignment of the actually was ready.
erupted permanent lateral incisor. Roots of deciduous
incisors may fail to resorb and can mechanically interfere
with the eruption of permanent teeth.
Fig. 10-23. (Top) The maxillary permanent first

molar is caught under the deciduous second
molar. (Bottom) Three years later, the permanent
first and second molars have erupted. The space
for the second premolar is closed, and the second
premolar IS impacted. Freeing the permanent
molar from the second deciduous molar and
space retention could have prevented this maloc-
clusion.
Root Resorption and Orthodontic Therapy . 139
Fig. 10-24. An odontoma is interfering with the

eruption of the mandibular canine.
74.
Fig. 10-25. (Left) A peg tooth, also known as a mesiodens, is between the maxillary central incisors.
(Right) Supernumerary teeth in the maxillary incisor area crowd the maxillary incisors.
'j.
Fig. 10-26. Pretreatment view (top

left) and cast (center) show that the
lateral incisors are distal to the
canines. After treatment, the incisors
are aligned, but the lateral incisors
were allowed to remain distal to the
canines (bottom left, right).
75.
Fig. 10-27. (Top) Transversion of

maxillary permanent canine (0 and
premolar (P) teeth: the roentgenogram
shows transversion of the canine and
premolar teeth. (Center) Right and left
canines erupt between the first and second
premolars. (Bottom) A permanent lateral
incisor erupts under the deciduous first
molar: (A) deciduous first molar; (B)
permanent lateral incisor; (C) deciduous
canine.
Fig. 10-28. Radiograms show agenesis of all

four permanent canines in a 15-year-old boy
with hypogonadism and hypopituitarism. The
four deciduous canines are in position and
show failure of root resorption.
Bibliography 141
then erupts mesially usurping some of the space intended opposite side of the mandible. Acta Morph. Acad. Sci. Hung., p.
for the second premolar. With the eruption of the first 7, 1956.
premolar before the second premolar erupts, the space is Del Boca, R.: Considerazioni su cinque casi di transposizione
occupied and the second premolar is impacted or may dentaria. Minerva Stomatol., 8:115, 1959.
Foster, T, D., and Taylor, G. S.: Characteristics of supernumerary
erupt lingually.
teeth in the upper central incisor region, D. Practitioner., 20:8,
Anomalies of Tooth Arrangement. In the permanent 1969.
dentition those teeth most commonly out of position are the Gardiner, J. H.: Supernumerary teeth. Dent. Practitioner, 2:63,
third molars; then, in order of decreasing frequency, the 1961.
maxillary lateral incisors, the mandibular incisors, the Millhon, Jerry A., and Stafne, E. c.: Incidence of supernumerary
second premolars, and the second molars. The first molars and congenitally missing lateral incisor teeth in eighty-one cases
and first premolars are rarely out of position. of harelip and cleft palate. Am. ]. Orthodontics, 27:599, 1941.
Sabes, W. R., and Barthold i, W. L.: Congenital partial anodontia of
permanent dentition: a study of 157 cases. J. Dent. Child.,
29:211, 1962.
Steinberg, A. G., Warren, J. F., and Warren, L. M.: Hereditary
generalized microdontia. J. D. Res., 40:58, 1961.
BIBLIOGRAPHY Tannenbaum, K A, and Alling, E. E.: Anomalous tooth
Book, ]. A.: Clinical and genetical studies of hypodontia. development, case reports of gemination and twinning. Oral
Am. J. Hum. Genet., 2:240, 1950. Surg., Oral Med., & Oral Path., 16:883, 1963.
Boruchov, M. J" and Green, L. J,: Hypodontia in human twins and Yolk, A.: Untersuchungen zur Zahnunterzahl, Fortschr.
families. Am. J, Orthodontics, 60:165, 1971, Bradlow, R.: An Kieferorthopad ie, 24:202, 1963.
inheritance of dwarfed or absent maxillary lateral incisors in three Welsh, J. P.: The psychogenesis of bruxism. J. Periodont., 36:417,
generations. Internat. ]. Orthod. & Dent. Child., 21:439,1935. 1965.
Brekhus, P, J., Oliver, C. P., and Montelius, G.: A study of the Warner, G, R, Orban, B" Hine, M. K, and Ritchey, B.:
pattern and combinations of congenitally missing teeth in man, Internal resorption of teeth: interpretation of histologic findings.
]. D. Res., 23:117, 1944. J.AD.A, 34:468, 1947.
Bruce, K W.: Dental anomaly: early exfoliation of deciduous and Wegner, H.: Uber hypodontia vera der milch und ersatzzahne bei
permanent teeth. J.AD,A, 48:414, 1954. vererbter ekto- und mesoderm- dysplasie. Deutsche Zahn.
Bruszt, P.: On the migration of lower canines to the Ztschr., 17:1019, 1958.
"
11
Examination of the Patient
The child orthodontic patient can be assessed in six lation and centric occlusion. Midline discrepancies should
parameters. The (1) amount, (2) rate, and (3) direction of be noted. When deviations in swallowing are suspected,
dentofacial growth and function of the stomatognathic the patient may be given a biscuit to eat so that the method
system over (4) intervals of time, must be ascertained to of chewing and swallowing can be observed.
determine the status, progress and (as far as possible) the The teeth and gingival tissues should be examined.
terminal state of the occlusion in the individual child. Speech, postural, and functional aspects of the tongue, the
Function (5) is another important parameter in measuring position of the lips in relation to the teeth, and the rest
the development of the dental occlusion, and (6) psycho- position and postural positions of the mandible should be
neurogenic endowment of the child is a dimension which noted.
frequently determines whether the patient will cooperate Serial Examinations. Serial examinations are of special
in the treatment of malocclusion. value during the deciduous- and mixed dentition periods.
The roots of deciduous teeth may be resorbed abnormally,
or the deciduous teeth may be prematurely lost or retained
SCOPE too long. Interferences with continuing normal dentofacial
development should be noted.
Malocclusion is more than a biophysical morphologic Histories. Medical and dental histories of the patient and
deviation that requires the application of mechanical force his immediate family provide information on genetic
only to bring about desired changes in the dentofacial endowment, postnatal development, and growth
area. Diagnosis in the individual patient entails the experience. Medical history obtained from the mother
weighing of many variables which tend to modify each usually is not reliable. Hospital records and information
other and may even cancel out their respective etiologic obtained from the family physician can be useful when
significance. The correlation of chronologie age, skeletal systemic etiologic influences on dentofacial abnormalities
age, and dental age is important for determining optimal are suspected. Height and weight measurements provide a
time for planning and beginning treatment. clue to physical growth and maturation.
The examination must be centered on the patient as a Posture. Correction of throat and neck muscle function
person and not merely on the malocclusion or on the is important in treating some malocclusions and in
dentofacial malformation alone. Above all it should not be avoiding relapse after treatment. Good posture is
based on the "system" of appliances used. The medical comfortable and requires little effort to maintain.
and dental history of the patient and the assessment of his Conformation to a single postural pattern is of no value.
growth are important in order to establish a diagnosis. The Skeletal Signs. Skeletal proportions are indicators of
examination should be complete, but must at all times be maturation. At birth the ratio of the upper and lower body
practical. Only questions that have value in prescribing segments, divided at the symphysis pubis, is 1:1.7, with the
therapy should be asked. upper segment being longer. By age 10 years the ratio is
Mandibular Dynamics Examination. The clinical e 1:1. Unusual skeletal proportions are characteristic of
aluation of mandibular dynamics should be made with the certain sexual aberrations that can exert an effect on dental
mandible in full occlusion and while it is going through its development.
range of motions. The midline deviation should be Bone age is an indication of maturation and physical
observed with the teeth in full occlusion and at rest development of the skeleton and the dentition
position in order to learn whether the mandible is shifted developmental stage. Wrist radiograms are
in going into terminal occlusion from rest position. This
will indicate any discrepancy between centric jaw re-
14
2
Suggestions for Diagnostic Examination Charts 143
considered an adequate indicator of skeletal development. front and in profile, the soft tissues in repose, the habitual
A disparity of 1 or even 2 years in bone age and position of the head in space, and the changes brought
chronologie age based on an accepted standard can (in the about by growth and orthodontic therapy.
absence of other unfavorable systemic symptoms) be Face Masks. Hydrocolloid or other plastics may be used to
considered to be within normal range. Children with less taking the impressions of the face when dramatic changes
than average skeletal development for their age may show have been obtained. A method of making facial casts is as
well developed dental arches, while tall, well developed follows:
children may show deficiency of dentofacial development. 1. Place patient in a horizon tal position in the dental
Dental Age. The stage of dental development is chair.
determined by the order of appearance, the size, and the 2. Cover the face, eyebrows, eyelashes, and hair about
amount of calcification shown by the teeth, deciduous and the temples and forehead with a thin film of petroleum
permanent tooth eruption, and closure of the apices of the jelly.
permanent teeth. The foregoing are compared with standard 3. Adjust the heavy cardboard or metal face frame that
tables of normal dental growth and development. One esti- will serve as a tray for the plaster.
mate of dental age can be made from the number of teeth 4. Prepare a thin mixture of alginate. This is used to
already erupted. A second, more limited cover the face and is applied from the chin upward. Keep it
estimate, can be based on the age at time of calcification of away from the nostrils. Let the thin coating dry.
the permanent mandibular first molars. A third estimate is 5. Straws in the nostrils or between the lips are not
based on the age at the time of completion of calcification necessary, provided you are careful not to pour any loose
of the dentition as a whole. alginate into the nostrils. To strengthen the alginate, a
gauze covering may be incorporated into it before it is fully
set.
6. Prepare a mixture of fast-setting plaster and pour it
over the alginate, being careful not to occlude the openings
ORAL EXAMINATION at the nostrils. Pour plaster over the entire surface of the
alginate to a thickness of about lh to V2 inch.
In addition to charting dental defects and missing teeth, 7. After the plaster has set, ask the patient to contract the
information should be obtained on the sequence of eruption, muscles of the face, and then remove the alginate slowly.
velocity of eruption, the time of shedding of deciduous 8. Pour the impression in dental stone. The entire inside
teeth, and the presence of infection in the teeth and gums. surface of the impression should be poured to the desired
The teeth should be examined in occlusion, when the jaws thickness of the cast to be made.
are opened, and when the mandible is in motion. Attention
should be given to the appearance and texture of the oral
mucosa and the alveolar and gingival tissues. A physical
count of the teeth should be made to detect missing,
supernumerary, over retained or prematurely lost teeth. A
pulp-vi tali ty examination is of value before orthodontic
appliances are placed on the teeth.
Radiograms. Cephalometric radiograms help to obtain a SUGGESTIONS FOR DIAGNOSTIC
quantitative analysis which aids in localizing the EXAMI A TION CHARTS
malocclusion. Cephalometric analysis shows the pattern of The following can serve as suggestions of items
facial growth, arch length, and relative position of the that may be included in examination charts:
dental arches, among other data, as found at the time the 1. Name, sex, age at examination
radiogram was obtained. 2. Address
Dental radiograms and casts can aid in obtaining 3. Parent responsible for patient
information on the following: (1) the direction in which the 4. Medical History
teeth are to be moved, (2) changes required in axial position a. Parents and siblings
of teeth, (3) an analysis of overbite, overjet, openbite, b. Patient
crossbite, and the line of occlusion. The type of dental arch, 1. Diseases of infancy and childhood
whether tapering, round, or square, can be determined. 2. Operations involving dentofacial area
Photographs. Photographs can show the face full 3. Accidents involving dentofacial area
4. Present state of health
5. Specify any current treatments
6. Malformations, hereditary and congenital
144 . Examination of the Patient
5. Dental History 12. Abnormalities of teeth: size; shape: square, ovoid or

a. Age at eruption of deciduous teeth tapering; hypoplasia or hyperplasia of enamel; grooved,
b. Age at beginning of eruption of perman~nt mottled, color, stains, translucency; oligodontia;
teeth supernumerary teeth
c. Extractions 13. Anomalies of dental development: state of eruption,
d. Periodontal condition root resorption, prolonged retention or premature loss of
e. Oral hygiene deciduous teeth, delay or eruption of permanent teeth
f. History of traumatized teeth 14. Anomalies of position of individual teeth: rotation,
6. Clinical Dentofacial Examination axial inclination, transversion (labial, buccal, lingual,
a. Facial musculature: normaL- hypotonic __ mesial, distal, etc.)
hypertonic __ 15. Anomalies of groups of teeth: protrusion, retrusion,
b. Labial condition - competent- incompetent-; mesiodistal crowding, constructed dental arch,
Upper lip: normal __ short __ functionaL- infraclusion, supraclusion, crossbite.
nonfunctionaL-; Lower lip: functional __ nonfunctional 16. Habits interfering with proper dentofacial
__ development: persistent thumb or finger sucking, nail
7. Congenital Defects biting, lip biting, tongue posture, tongue thrusting,
a. Clefts, abnormal frenums orofacial pressure habits
b. Muscle abnormalities 17. Vitality test of the teeth as determined by their
c. Tongue abnormalities response to an electric pulp tester
8.Functional impairment - difficulty in swallowing, 18. Radiographic examination
chewing, jaw movements, tongue movements a. Intraoral
9. Speech defects 1. Individual dental radiograms
10.Clinical Dental Examination number of teeth 2. Bite-wing radiograms
present __ missing __ carious __ 3. Occlusal radiograms
. a. Teeth: carious extracted, nonvital, and filled. b. Extraoral and cephalometric radiograms
Caries susceptibility 1. Lateral (profile) radiograms
b. Mucous membranes: pale, pink, congested, 2. Posteroanterior radiograms
swellings, ulcers, fistulas 3. 45 cephalometric radiograms
c. Periodontal condition: gingivitis hyper- 4.Temporomandibular articulation radiograms
trophy, infections
19. Carpal or skeletal radiograms to obtain skeletal
d. Oral hygiene: goo~ fair __ poor __
maturation rating
e. Quantity and quality of saliva
20. Dental impressions and casts
f.Type and condition of previous dental work
11. Malocclusion 21. Photographic examination
a. Abnormalities of dental arches in form, size, and 22.Anteroposterior
position: maxilla, mandible. 23.Profile
Intermaxillary: curve of occlusion, overbite, 24.Close-up of teeth, occlusion
openbite, dual bite 25.Anomalies of individual teeth
b. Classification: Angle, skeletal
12
Guidance of Occlusal Development
SCOPE Treatment of malocclusion while the dentition is

undergoing active development can be corrected only to
The scope of occlusal guidance includes the following'
the given stage of development. When all permanent teeth
1. Correction of anteroposterior or lateral maloc-
have erupted, there may be a need for additional
clusions and malrelations of the dental arches
orthodontic treatment. Definitive orthodontic treatment
2. Prevention of space loss following premature loss of
must be postponed until all of the deciduous teeth in have
deciduous teeth and loss of permanent teeth
been shed and the permanent teeth, with the exception of
3. Extraction of overretained deciduous teeth
the third molars, are in the terminal stage of eruption.
4.Recognition and treatment of habits that affect
Treatment cannot be considered completed until jaw
position, relation,' and function of the dentofacial
growth is completed. In some patients mandibular growth
components
may not be completed until late adolescence or early
5. Elimination of dental caries, especially those that
adulthood. When this occurs the orthodontic result may
cause the child to occlude the teeth off-centric in order to
show relapse and require retreatment.
avoid pain and facilitate mastication
Etiology, classification of the malocclusion, and age of
6. Extraction of supernumerary teeth that interfere with
the patient are interdependent factors that determine time
the establishment of normal occlusion
and type of treatment. A malocclusion at one
Malocclusion can be intercepted in the incipient stage,
developmental age level may be considered normal at
especially when it is of local etiology. There are various
some other level and vice versa. A form of treatment
interceptive measures that can guide the developing
indicated at one stage of dentofacial development may be
dentition into normal occlusion and forestall the need for
contraindicated at another. As long as malformation and
extended orthodontic treatment.
malfunction continue, they contribute to making the
malocclusion worse.
TYPES OF ORTHODONTIC TREATMENT

Forms of orthodontic treatment can be described DENTOFACIAL ORTHOPEDICS
as follows: The correction of abnormalities and deviations from the
1. Preventive orthodontics normal range in the facial and oral tissues is the concern of
2. Interceptive orthodontics dentofacial orthopedics. Classical orthodontic therapy is
3. Corrective - early and late limited to the correction of alveolodental abnormalities
4. Posttreatment maintenance or retention that do not involve the bodies of the jaws themselves.
5. Dentofacial orthopedics Dentofacial orthopedics is an extension of orthodontics
that includes the treatment changes in the jaws.
REEV ALUA TION OF TREATMENT PLANS Baume has reported changes in the mandibular growth
vector following the application of pressure at the
Since the dentition of the child is in a dynamic st~te, mandibular condyle.
and especially since the extent and quality of response to Examples of orthopedic measures in orthodontics
treatment varies among patients, treatment planning must include the following:
be reevaluated from time to time and modified in 1. Palatal suture opening
accordance with the response of the patient to the 2.Palatal expansion for widening the palate in cleft
treatment and not in relation to a preconceived "system" palate
of appliance therapy. Diagnosis and treatment should not 3. The extraoral appliance for influencing the vector of
be applianceoriented. growth of the maxilla and mandible
145
146 . Guidance of Occlusal Development
4. The chin cap with cervical anchorage to reduce the Early Treatment
forward extension of the mandible Early treatment of gross malocclusions is conducive to
Types of malocclusion in order of decreasing frequency better esthetic and functional results. Occlusal guidance
are: without the use of mechanical appliances may be
1. Intramaxillary irregularity of tooth arrangement undertaken on patients of any age when indicated.
2. Intermaxillary deviations of the dental arches with or However, care should be exercised to avoid interfering
without jaw abnormalities in size and shape with inherent growth when using mechanical appliances
3. Abnormalities of jaw development during the mixed dentition period.
4.A combination of dental irregularities, lack of Contra indications to early orthodontic treatment
development, and malrelation of the jaws include the following:
Irregularities of tooth position evidence themselves 1. Minor malocclusions in the deciduous dentition
clinically in crowding, spacing, rotations, and proximal which may correct themselves by continuing dentofacial
contact abnormalities. Irregularities may result from growth and development
premature shedding or prolonged retention of deciduous 2. Rampant caries and oral sepsis, which should be
teeth, the presence of supernumerary teeth, congenitally eliminated before orthodontic treatment is undertaken
missing buds of teeth, and postnatal loss of teeth. In the 3. Dentofacial conditions that primarily require surgery
deciduous dentition spacing is the most common problem; 4. A patient in a highly emotional state
in the permanent dentition, crowding occurs most fre-
5.Disturbances of general health that would interfere
quently.
with continuity of orthodontic treatment
THE AGE FACTOR IN TREATMENT OF

MALOCCLUSION
DIFFERENCES I RESPONSE TO TREATME T
The Ages of a Child
Differences in response to treatment can be caused by
The decision to initiate orthodontic therapy should be the following:
based on the presence of a condition that interferes with 1. Timing of treatment. The best results are obtained
the continued normal development and function of the during the active growth period, provided growth is
dentition of the child, regardless of age. A child has many favorable.
ages - chronologie, skeletal, dental, physiologic, 2. Bone resistance, the osteogenic quality of the alveolar
maturative or developmental, and mental-which mayor process. The haversian systems tend to make bone
may not coincide with his chronologie age. Standards of anistropic, so that it is more responsive to force in some
growth and development do not apply precisely to the directions than in others. (For example, it is more
individual child. responsive when teeth are moved in the direction that
growth naturally proceeds.)
3. Failure to eliminate local and systemic etiologic
Prevention Before Tooth Eruption factors that interfere with normal tooth arrangement or
actually produce abnormalities
Preventive measures can be instituted even before the
teeth actually erupt into the mouth. Malocclusion can be
initiated by improper selection of a feeding nipple for the Self-Correcting Malocclusion
bottle-fed baby and by improper position of both the When the distinction is made between stages of growth
infant and the bottle during feeding. A nipple long enough and developing malocclusion, there are actually few
to rest on the anterior third of the tongue should be used, instances of self-correction. Malocclusion may show
and small openings should be punctured in the sides of the change to normal occlusion or to different types of
bulb of the nipple instead of at the end only. This will malocclusion during dentofacial growth and development.
prevent the infant from squirting the milk directly into the Examples of self-correction may be found in lingually
pharynx. With this type of nipple there is more spreading erupting lateral incisors and in rotations of individual teeth
pressure on the jaws when the baby is nursing; this which may show a delayed tooth eruption pattern, but
eliminates compression caused by sucking with the nipple which eventually find proper positions in the dental
held between the gum pads. arches. Spontaneous correction of rotated teeth sometimes
occurs while the roots are undergoing
Differences in Response to Treatment 147
completion. Self-correction in mesiodistal arch relation can

occur during the eruption of the permanent first molars and
during the eruption of the premolars and permanent second
molars.
Self-correction has been observed in children with midline
incisor diasternas on completion of the eruption of the
permanent dentition. Self-correction can occur in protrusion
of maxillary incisors when the incisors do not rest on the
lower lip when the mandible is in rest position, or when the
teeth are in full occlusion.
When the maxillary incisors are displaced forward and the
lower lip falls lingual to the maxillary incisors: it continues
their forward displacement. Incisor malocclusion usually
corrects spontaneously if thumb- or finger sucking is
Fig. 12-1. The casts on the left, made at the age of 6 years
discontinued by age 4 to 6 years, provided inherent growth is
and 6 months, show a stage of dental development that may
favorable; that is, if: (1) the lower lip does not rest lingual to
be mistaken for an openbite condition. Casts on left at 8 years
the maxillary incisor teeth, (2) the tongue does not habitually
of age show elimination of openbite as teeth continued to
lie in the interarch space over the occlusal and incisal
erupt. The child's dentition, beginning with the eruption of the
surfaces of the teeth, and (3) there are no other developmental
permanent teeth, is in a highly dynamic state. Development
defects or interferences with dental occlusion.
and growth changes in relation to age are important factors in
the diagnosis of malocclusal tendencies.
fied as malocclusion at the transition from the deciduous to

Transitional Malocclusion the permanent dentition may, in fact, be phases of normal
growth. For example, deep overbite in the deciduous
Conditions in the child patient that can be classi- dentition at 3 or 4 years may
A 6VRS.5 MO. B 8VRS.1 MO. c 9YRS. 0 MO.
D 10YRS.O MO. E 11YRS. 0 M F 12vRS.OMU

o, ages show the change in inclination of the incisors and
Fig. 12-2. Posteroanterior roentgenograms of a child at successive
the path of eruption of the maxillary canines. Failure of the canines to change their eruption path results in their impaction.
(B. Holly Broadbent)
disappear as the mandible is rotated forward during growth. 3. The mandibular cast is elevated to approximate normal
Teeth coming into occlusion, especially in the incisor region, occlusion with the maxillary incisors.
may appear to be, and frequently are, in malocclusion. Such 4. An acrylic sheet is trimmed clear of the maxillary and the
cases should receive periodic reexaminations to ascertain mandibular mucobuccal folds and frenums and extended to the
whether these teeth are actually in malocclusion. Serial distal surface of the second deciduous or permanent first
clinical examinations are especially valuable during the transi- molars.
tional dentition period, when the deciduous teeth may be 5. The screen is bent slightly away from the buccal dental
abnormally resorbed, prematurely lost, or over-retained. segments so that it rests on the protruding anterior teeth. If the
screen is to be used for lip exercises, a wire ring is inserted on
the labial surface at the level of the edge of the upper lip.
7. The screen is trimmed and polished.
The Vestibular Screen 8.The patient is instructed to place the appliance in the
mouth as long as possible before going to bed. Usually by the
When the lower lip rests lingual to the maxillary incisors third night the screen can be worn comfortably. The screen
they are propelled into increasing protrusion. This can be may be used during active treatment with appliances in the
alleviated with a vestibular screen. The screen is a sheet of mouth and during retention.
plastic adapted to fit over the teeth that makes it impossible to A lip bumper may be used as a means of avoiding extraction
bite the lip or place it lingual to the maxillary incisors. The in so-called borderline cases. The lip bumper is inserted prior
screen can be used to keep the tongue from producing open to loss of the deciduous mandibular second molars. Thus the
bite by resting over the maxillary and the mandibular dental leeway space is maintained, and the actual distal movement of
arches. It can be used also to reduce maxillary incisor the permanent first molars provides sufficient space for regular
abnormal overjet. The screen makes it impossible for the child alignment of the anterior teeth and mandibular dental arch.
to introduce the fingers or thumb into the mouth and suck Headgear therapy may be used on the maxillary permanent
them. The screen should be worn as much as possible. It molars in conjunction with the lip bumper.
should be placed in the mouth at least 1 hour before bedtime;
otherwise, it will annoy the child and keep him awake.
The vestibular screen is constructed as follows:
1. Maxillary and mandibular impressions that extend to the
mucobuccal folds are taken.
2. Stone casts are poured. SPACE MAINTAINERS
Space loss after a deciduous molar is exfoliated is more
marked in the maxillary than in the man-
Fig. 12-3. (Top, left) Completed vestibular screen.

(Top, right) Vestibular screen in position. (Bottom)
Method of using vestibular screen for exercising the
orbicularis oris muscle.
Prevention of Dental Arch Collapse 149
dibular dental arch. Space closure is greater after loss of a

deciduous second molar than after loss of other deciduous
teeth.
A space maintainer is a passive and frequently an active
orthodontic appliance. Space maintenance, if not properly
applied, can interfere with the time scale of occlusal
adjustment in the mixed dentition. The space maintainer
should receive inspection and adjustment at frequent
intervals and should be removed when no longer needed to
avoid interference with the succeeding erupting permanent
tooth and the establishment of normal permanent
occlusion.
Indications
The following can serve as a guide for the use of space

maintainers:
1. When the space shows signs of closing as determined
by actual measurement of the space required for the
succeeding permanent tooth.
2. If retention of the space will make eventual treatment
of malocclusion when necessary less involved.
The following conditions should be met by a space
maintainer:
1. It should maintain the desired mesiodistal dimension
of the space.
2. It should not interfere with the eruption of the
occluding teeth.
3. It should not interfere with speech, mastication, or
functional movement of the mandible.
4. It should not interfere with the eruption of the
permanent teeth.
5. It should provide sufficient mesiodistal space opening Fig. 12-4. Construction of the vestibular screen.
for the normal alignment of the permanent teeth. (Top, left) Casts show protrusion of the maxillary
Space maintainers are contraindicated under the central and lateral incisors. (Top, right) Same casts
following conditions: with the mandibular cast raised to approximate the
1. When there is no alveolar bone overlying the crown maxillary incisors prior to the construction of the
of the erupting tooth and the space is sufficient to permit vestibular screen. (Center, left) Vestibular screen
its eruption. constructed of acrylic or plexiglass with wire handle
inserted. (Center, right) Vestibular screen in position
2. When the space left by the lost deciduous tooth is in
excess of the mesiodistal dimension of its permanent with casts approximated in proper relationship.
successor, as "Shown by measurement on the radiogram, (Bottom, left) Occlusal view showing the vestibular
and where repeated examinations show that the space is screen fitted to rest on the incisor teeth. (Bottom, right)
not closing. Anterior view of vestibular screen with wire prongs
inserted to overcome tongue thrusting and resultant
3. When retention of the space is contraindicated
openbite.
because of a general lack of sufficient dental arch length,
requiring eventual extractions, and where space PREVENTION OF DENTAL ARCH COLLAPSE
maintenance would further complicate existing Decrease in mandibular arch length can be avoided by
malocclusion. using a stabilizing lingual arch appliance when the
4. When the permanent succeeding tooth is absent and it deciduous molars and the premolars that replace them
is necessary to close the space by orthodontic treatment. show comparatively little difference in mesiodistal
diameter, or "leeway" space.
The stabilizing arch is removed when the greatest
diameters of the crowns of the premolars and
Fig. 12-5. (A) Space maintainer, consisting of a

band on permanent first molar and a wire running
along the mucosa and on the distal aspect of the
first premolar. (B) Space maintainer with adjusta
ble loop, which permits beginning of eruption of
second premolar without interference of the space
maintainer. (C) Side view of B. (0) This lingual
appliance is used to prevent collapse of the dental
arch and tooth shifting following loss of deciduous
molars. (E) Cast for which the appliance was made.
permanent canines have erupted through the alveolar 3 .. Abnormal eruption of central incisors
mucosa. When an excess of interdental spacing is present, 4. Supernumerary teeth'
the removal of the stabilizing lingual arch permits the 5. Oligodontia, especially agenesis of permanent
mandibular first molars to shift forward and close the lateral incisors
spaces. 6. Tooth shifting following loss of teeth
Stabilizing lingual arch construction 7. Genetic factors
1. Bands with vertical half-round tubes soldered Separation of the central incisor teeth may not, and
lingually are fitted to the permanent molars. frequently does not, have any relationship to a large
2. The lingual arch is bent to lie in contact with the frenum. Separation between the central incisors can persist
linguogingival margins of the mandibular teeth and the after frenum excision under the following conditions:
gingivae of the mandibular incisors. 1. When the ligament connecting the frenum with the
3. Vertical half-round posts are fitted on the lingual incisor papilla lies in an opening in the alveolar bone.
archwire to fit into half-round tubes attached to the molar 2. When the alveolar bone between the incisors is a
bands. square single mass of bone. When an excessive amount of
The lingual arch may be soldered directly to the molar bone is present between the central incisors, the excision of
bands when so desired. The lateral segments of the arch the frenum has no effect on the space.
should be adjusted so that they do not interfere with the The foregoing anomalies require active orthodontic tooth
erupting permanent teeth. movement to approximate the central incisors. This usually
causes the frenum to recede. The teeth should be retained in
approximation until the canines have erupted.
TREATMENT OF LABIAL FRENUMS
Separated Maxillary Central Incisors
Separation of the maxillary central incisors during
childhood is a normal occurrence in dental eruption.
Practically all maxillary permanent central incisor teeth
erupt spaced at some distance from one another but Periodontal Treatment in Malocclusion
eventually come together. Angle advised excision of the Poor arch relationship with dental irregularities can result
frenum. Mershon pointed out the dangers of unnecessary in gingival and periodontal trauma. Periodontal
surgical excision of frenums. Abnormal midline frenums disturbances in children are usually caused by diabetes,
may have a wide base or they may be thin and fibrous. allergy, endocrine and digestive disturbances, disorders of
Both types can be responsible for spacing. circulation and avitaminosis. Although prevalence and
The following conditions may be found with abnormally severity of periodontal disease increase with age, the onset
spaced maxillary central incisors: of destructive lesions occurs early in life. Young girls are
1. Abnormal maxillary midline frenum
more severely affected than boys. In later years men show
2. Presence of peg-shaped lateral incisors
more periodontal disease than women.
Treatment of Labial Frenums' 151
B
A
Fig. 12-6A. (Top left) Stabilizing lingual arch to reenforce
anchorage. Note. This arch can be used also to maintain dental
arch length after premature loss of deciduous teeth. B. (Top, right)
Lip-plumper appliance with contoured plastic vestibular portion
and closed coil spring stop. e. (Bottom, right) Intraoral view of lip
plumper in position. First permanent molars banded with combination
tubes, 0.018 by 0.025 inch, and 0.045 inch round tubes. Tubes
positioned parallel to occlusal plane. Lip plumper adjusted 2 to 3 mm.
labial to lower anterior teeth and 2 to 3 mm. above depth of vestibule.
Fig. 12-6D. Case 1. Pre-

treatment view. ote incisor
crowding and right canine
.nalposition, (Courtesy Faustin
Weber)
Fig. 12-6E. Posttreatment

view. Note improvement in
alignment and arch form. Lip-
plumper treatment only used in
lower arch. (Courtesy Faustin
Weber)
152 . Guidance of Occlusal Development 76.
A B c o
Fig. 12-7. Various lypes of bone formation in abnormal
frenum labii. (A) man, 44 years of age; (B) girl, 9.7 years of
age; (C) man, 50 years of age, permanent separation; (D)
woman, 44 years of age, permanent separation. (After H.
Chapman.)
Fig. 12-8. (Top) Maxillary permanent

central incisor teeth are widely spaced
and root formation is just beginning.
(Bottom) Mandibular permanent incisor
teeth show advanced eruption with root
formation just beginning. Moving teeth
with roots in the early stages of
calcification leads to root distortion.
Fig. 12-9. (Left) Diastema in

an adult who has no lateral
incisors. (Right) The teeth
show evidence of traumatic
occlusion in the widened pe-
riodontal space and occlusal
grinding to overcome trauma,
since there was an edge-toedge
occlusion.
Orthodontic tooth movement in some children, especially periodontally involved teeth. The periodontally affected
where mouth hygiene is poor, may show thickening of the permanent tooth, when moved into a new and more favorable
gingival mucosa. Proper mouth hygiene and massage with a location and then sufficiently stabilized, will frequently
water pulsating device will return the gingival tissues to become firmer than before it underwent tooth movement.
normal in the absence of other etiologic factors. Periodontal treatment may be carried on simultaneously with
Extremely light force should be used when moving orthodon tic therapy.
Treatment of Labial Frenums' 153
Fig. 12-10. (Top left) An

abnormal frenum caused a wide
diastema between the central
incisors. With the eruption of
the lateral incisors (which are
undersized) the diastema almost
closed (right). When the
permanent canines erupt the
diastema may close entirely
without orthodontic therapy. In
this case, retention will be con-
tinued until the permanent
canines have erupted. (Bottom)
Radiograms before (left) and
after (right) eruption of the
permanent lateral incisor teeth.
Retention will be continued
until the permanent canines are
erupted.
Fig. 12-11. Thumbsucking caused

openbite and diastema between the
maxillary central incisors. The space
was closed by orthodontic therapy.
Note the closure of the midline suture
in the alveolar bone.
DENTAL ARCH AND JAW DISCREPA CIES Basal

Arch Discrepancy
The basal arches are the areas at the most constricted

part of the body of the maxilla and the mandible. Basal
arch discrepancies in relation to dental arch space
requirements for normal tooth arrangement can be
unimaxillary or bimaxillary. As a result of basal arch
discrepancies there may be crowding, impaction, and
procumbency of the incisor teeth.
Large Basal Arches

When the maxillary or mandibular basal arch is too large
in relation to the mesiodistal space required by the dental
arch, spacing and diasternas can occur. The arrangement of
the teeth in the dental arches then will depend primarily on
muscular pressure, tongue size, jaw relationship and
function, and dentofacial pressure habits.
When treating spaced teeth in the presence of a large
basal arch, the dental arch should not be constricted.
Spaces should be closed by moving the teeth along the
same arc described by the spaced dental arch.
Constricted Basal Arches
If the basal arch is constricted or too small in relation to

the coronal arch, the mandibular incisors and other teeth
Fig. 12-12. (A) The central incisors are
will be crowded out of normal alignment. If there is
still separated in this adult whose frenum
normal dental arch alignment, the incisors will show a
labii was cut in childhood. (B) Incisors are
procumbent relationship to a plane tangent to the base of
crowded in an adult whose median maxil-
the mandible.
lary frenum was completely excised in
Arch length deficiency may not be responsible for tooth
childhood.
crowding in Class I malocclusion when the entire dentition
is in a forward position in relation to the body of the jaws
themselves.
Fig. 12-13. Front and side views

of casts showing areas covered by
the basal arches.
78. Abnormal Overbite' 155
Fig. 12-14. (Top) Edge-to-edge occlusion before and after

treatment. (Second row) A removable appliance with a top
flange was used in treatment. (Third row) A mandibular
removable appliance with an anterior flange was used in a
12-year-old girl who had a tendency to relapse into Class III
(Angle) malocclusion after termination of treatment for that
condition. (Right) With the appliance in position, the
maxillary and mandibular arches are slightly separated and
the maxillary incisors are allowed to become elongated to
increase the overbite,. (Bottom) The lateral view of the
appliance on the cast shows the anterior portion trimmed
away from the lingual surfaces of the mandibular incisors.
(Right) View of appliance from below,
caused by lack of growth at the tuberosity of the maxilla or

at the inner angle of the ramus and body of the mandible.
Crowding in the molar region may occur independently or
in conjunction with crowding or procumbency of the
incisor and other teeth in the mandible and in the maxilla.
ABNORMAL OVERBITE
Crowding of Teeth and Basal Arch Size Overbite refers to the vertical relationship of the
maxillary to the mandibular incisors. Normal overbite
While the size, form, and relationship of the jaws are usually occurs when the sequence of eruption is canine,
independent of the size of the teeth, tooth arrangement is first premolar, second premolar in the mandibular arch and
greatly dependent on the size of the jaws and on the first premolar, canine, second premolar in the maxillary
relationship of the jaws to each other. Therefore, teeth arch. Incisor overbite develops independently of molar
moved into apparently normal arraqgement by orthodontic height. Variations in the degree of overbite in normal
means will not stay in position when the basal arches of occlusion can be attributed primarily to the axial position of
the jaws are too small to permit such teeth to occupy the the incisor teeth; vertical position of the maxillary incisors
new locations, since they are thus in conflict wi th the in- encourages deep overbite, alveolar growth and mandibular
trinsic lines of functional stress of the jaws. Extraction incisor height.
then becomes a necessary adjunct to the orthodontic Abnormal overbite may be inherited. It is present when
therapy. the incisor overlap extends vertically more than one third
Crowding of the molars, especially the second and the over the opposing tooth crowns. In the mixed and
third molars, can be found in arch inadequacy permanent dentitions overbite de-
Fig. 12-15. (Top row) A removable appliance for bite opening seen from the tissue surface (left), the lingual surface (center), and in place in
the maxillary dental arch (right). (Second row) Pretreatment casts (lefl) and the teeth after treatment (right). (Third row) The appliance with a
labial wire to aid retention: (leit) in place in the mouth and (right) from the lingual aspect. (Fourth and fifth rows) Comparison casts of a case of
persistent open bite. Lateral, anterior, and occlusal views of two sets of casts. In each set, these on the left were made at age 4 and those on
the right, at age 15.
Open bite . 157
Fig. 12-16. (A). Casts of open bite in a

woman caused by tongue posture over the
incisor and lateral series of teeth. (B) The casts
of a different patient, show overjet and
overbite.
pends primarily on the extent of mandibular forward trusion, (2) forward overdeveloprnent of the maxilla, (3) a
growth during the eruption of the mandibular permanent retrognathic or undersized mandible, (4) difference in the
incisor teeth and on the axial relation of the incisors. amount of alveolar prognathism in the respective jaws, (5)
Abnormal overbite is most prevalent in the mixed the presence of abnormal labial inclination of the maxillary
dentition. Openbite is comparatively more prevalent in the incisors, (6) pressure of a large tongue, and (7) lip biting,
deciduous and early mixed dentition and tends todisappear finger sucking, and other orodental pressure habits.
in the later mixed dentition period. After the eruption of the
permanent canines and premolars the overbite in the
permanent dentition is established. Molar eruption is not
Extraction in Abnormal Overjet or Overbite
the determining factor in severity of overbite.
Abnormal overjet and overbite are not contraindications
to extraction. Tooth extraction in orthodontic treatment is
not a reason for increase in overbite or openbite. Errors in
ABNORMAL OVERJET
orthodontic therapy can cause these conditions.
Overjet refers to the horizontal protrusion of the
maxillary incisors in relation to the mandibular incisors.
Abnormal overjet can be caused by (1) anterior OPEN BITE
maxillary alveolar overgrowth and incisor pro- Openbite is the failure of the occluding surfaces of the
teeth to achieve contact when the teeth are
Fig. 12-17. This adult's openbite was

caused by lower lip sucking and posture -of
the tongue over the incisal surfaces of the
mandibular incisors. The occlusion in the
lateral jaw segments is not disturbed. The
habit produced spacing and protrusion of
the maxillary incisors and canines.
Fig. 12-18. Plumper used to over-

come lip sucking habit.
brought into full closure. The cause of open bite, in the mandibular angle, a short ramus, or downward bending of
absence of gross jaw bone deformities, is interposition the mandible at the antegonial notch can cause openbite.
between the dental arches of the tongue, the lip, the fingers, Patients with short rami, obtuse gonion angles, and short
or other objects for periods of sufficient duration, and mandibles without tongue posture over the occlusal
frequency generating sufficient force to interfere with the surfaces, do not show openbite. They do show extremely
establishment of normal occlusion or to affect the alveolar long anterior mandibular height from infradentale to
bone and move the teeth out of occlusion. Tongue posture menton.
over the occlusal and incisal edges of the teeth is a causa- Treatment should be directed primarily to eliminating the
tive factor of open bite. In total openbite, the tongue may causative factors. The curve of occlusion of the mandibular
overlie the occlusal surfaces so that the premolars and teeth should be corrected, and the maxillary teeth should be
molars are prevented from achieving full occlusion without brought into vertical alignment. The use of an activator
overclosure of the mandible. appliance 12 to 14 hours per day will tend to close the
Incomplete eruption and alveolar deficiency are results openbite because the tongue cannot rest over the incisal
of open bite, not causes, except in arrested eruption of edges of the teeth. A plumper appliance keeps the lower lip
ankylosed permanent teeth. There is no evidence that from being held on the occlusal surfaces of the teeth. When
posterior supraclusion, an obtuse orthodontic appliances are used
Tongue Thrusting 159
Fig. 12-19. Front view showing extremely long distance from gnathion to incision.
Note. Openbite in the absence of tooth ankylosis is caused by an object which
intervenes between the teeth. Otherwise, the teeth seek antagonists and continue to
erupt with or without elongation of the alveolar process. The obtuseness of the gonial
angle is not a factor in openbite.
79.
80.
vertical elastics are employed to close the open bite and
keep the lower lip from resting on the incisal edges of the
mandibular teeth.
TONGUE THRUSTING
Tongue thrusting and the deficient function of the upper
lip and of the hyoid suspensory musculature are
indications of possible lack of neuromuscular maturation
and may be etiologically related to the other muscle and
neurogenic problems.
Examination and treatment of tongue thrusting should
include the following:
1. The posterior pharyngeal wall, fauces, and soft
Occlusal rest, upper first premolars Fence construction, no interference, all

excursions of mandible
Palatal bar clears

anterior teeth
Occlusal rests, upper first

premolars
Hayrake clears upper and

Platform clears palate
lower anterior teeth
Fig. 12-20. (Left) The palatal bar acts as a habit reminder by breaking the seal that would otherwise create suction. (Right) The hayrake is
a mechanical device with a "fence" that interferes with the pleasure of thumb-sucking. (Klein, E. T.: Am. J. Orthodont., 59:286, 1971.
should be checked to determine presence of lateral occlusal

deviations.
4. The presence of grimacing during swallowing is
usually an indication of tongue thrusting.
5. A blunt instrument should be used to show the patient
and parent where the tip of the tongue should press when
swallowing.
6. The patient should be told to put the tip of the tongue
at the junction at the gingivolingual aspect of the maxillary
incisor teeth, to pronounce the word lay, and to repeat that
sound until he realizes that the tongue contacts the area
where it should be during the act of swallowing. Some
openbite swallowers will produce the lay sound with the
tongue farther back on the palate or against the mandibular
incisor teeth. The patient's attention is directed to observe
that the lay sound is produced at the linguogingival margin
of the maxillary incisors.
7. When the patient knows where to place the tongue, he
is told to bring the teeth into full occlusion, press hard with
the tip of the tongue, and swallow. After a series of
exercises, this pattern of swallowing becomes habitual and
involuntary.
8. The patient may be asked to bring the teeth into full
Fig. 12-21. (Top) A large tongue and a forward occlusion and flatten the tongue to reach the lingual
tongue posture resulted in openbite and cross- surfaces of his premolars and molars, as in pronouncing k,
bite. (Bottom) A lingual appliance with maxillary and to swallow keeping the teeth and tongue as indicated.
springs was used to widen the maxillary arch to The swallowing exercise should be practiced by the
correct crossbite. A grid was attached to the patient at least 25 times before each meal. Lingual alveolar
appliance to confine the tongue. speech sounds in such words as lady, today, tonight, or the k
sound should be practiced.
palate should be examined to rule out neurogenic For psychologic reasons it is best not to magnify
functional interferences.
2. Intrinsic and extrinsic tongue muscle action should
be checked.
3. Position of the mandible when swallowing
Fig. 12-22. (Top) Habitual lip- and tongue

biting created this openbite. The patient thrust
the tongue under the lingual appliance that
was fitted to correct the habit (right). (Bottom)
An appliance was then constructed on the
mandibular arch that successfully confined
the tongue. When the patient continued to bite
the lip, a plumper was constructed to help
overcome that habit.
The Split-Plate Appliancr . 161
the tongue thrusting habit in the mind of the child patient

but to seek cooperation from the patient and the mother in
practicing the swallowing exercise. The correction of
incisor malocclusion frequently eliminates the tongue
thrusting.
Activator appliances that confine the tongue are helpful
in correcting tongue thrust. The rake appliance affixed to
molar bands on a palatal or lingual arch also may be used.
Regardless of the appliance used, the habitual tongue
thruster who does not cooperate will manage to bring the
tongue past the obstruction placed in its path, and the
tongue thrusting will persist.
'An appliance is made of a 0.030-inch round archwire
attached to the upper first molar bands with an anterior
platform which clears the palate by about Vs inch. This
keeps the thumb or finger from exerting pressure on the
soft tissue of the palate. An occlusal rest on the occlusal
surface of the upper first premolars prevents the palatal bar
from settling into the soft tissue. The seal is broken, and
the pleasure of thumb sucking is destroyed. The bar must
be so designed that it will not prevent the teeth from
closing normally.
Fig. 12-23. These photographs show tongue

thrusting, interdental tongue posture, and open
THE SPLIT-PLATE APPLIANCE bite in a mother and her son. Tongue thrusting,
jaw posturing, and occlusal mannerisms have
The use of expansion plates was mentioned by Robin in
been found to show genetic reference.
1902 and Badcock in 1911, and now many types are used.
(Salzmann, J. A.: Am. J. Orthodont.,
The average distance per quarter turn of the expansion
61:466,1972)
screw expands the plate from 0.18 to 0.1 mm. Activation
should not exceed one turn a week. It is inadvisable to turn felt by the patient. Expansion screws with springs have not
the screw only because the sensation of tension on the teeth been shown to have any advantage over rigid expansion
is not screws.
Fig. 12-24. This tongue-thrusting patient was

treated for Class II, Division 1 malocclusion, and
was 3 years out of retention when the photo-
graphs were taken. Note that satisfactory oc-
clusion has been maintained in spite of tongue
thrusting. Tongue posture and lip sucking, rather
than tongue thrusting, are etiologic fac-
tors in anterior open bite. .
Fig. 12-25. (A, lop). Casts of patient who showed

that the right mandibular lateral incisor had been
extracted. Note abnormal overbite and cusp-to-cusp
occlusion on the right side where the lateral incisor
was extracted. (Bottom) Occlusion after treatment.
Normal intercuspation and opened anterior overbite.
(B, lefl) Occlusion before treatment. (Right) Occlusion
after treatment. Note. The right permanent cani.ne
was moved forward to serve in place of the extracted
lateral incisor.
Orthodontic expansion screws should have high instances by moving the crown of one tooth against that
mechanical efficiency, minimal bulk, and a transverse of the adjacent tooth and by applying spring force
dimension of at least 4 mm. The HawleyRussell 999 gingivally. the tooth can be moved to a more vertical
screw is recommended where 4 mm. or less widening or position. Gore successfully closes extraction spaces by
expansion is required. For distances exceeding 4 mm, the this method with the Crozat appliance.
Hawley-Russell 666 screw is recommended. Control of the axial inclination of teeth is an important
consideration when moving them by means of biteplates.
When incisors protrude and there is no need to change the
position of their roots, the biteplate and other removable
THE HAWLEY RETAINER
appliances can be used with a flat plane, opening the bite
Biteplanes used for tooth movement produce tipping. sufficiently to free interlocking of the cusps (3fs-inch).
Sometimes the root will tend to follow the crown, but Wire springs attached to plates should be cut to size when
this usually takes a long time. In some
The Higley Stabilizing Plate' 163
the appliances are fitted in the mouth. The ends of the 2. Opening of the bite, diminishing the overjet of the
wire can then be rounded by adding a drop of solder or anterior teeth
by turning the end of the spring on itself. 3. Elevation of the posterior teeth; the anterior teeth
Springs should be activated so that the appliance is may be slightly depressed or both changes may occur
opened or closed by a distance somewhat less than the 4. A more normal anteroposterior relationship of
width of the tooth to be moved. If the appliance is to be the occlusion
used for closing spaces in extraction cases, impressions 5. Retention after correction of distoclusion
should be taken and the appliance constructed before the 6. With myofunctional therapy
extractions are made. Distal movement of premolars can 7.Relieve locking of individual teeth or groups of teeth
best be obtained by freeing the occlusal surfaces and by 8. To eliminate tongue habits, lip biting, thumb-
opening the bite so that the maxillary and mandibular sucking and other deleterious habits
teeth are not brought into actual contact. Note. In Class II, Division 2 (Angle) malocclusion the
Distal movement of molars can be performed with interference of the anterior and other teeth should be
finger springs attached to a plate. Space closure in the removed before the biteplane is used. Biteplanes should
mandible is not easily accomplished with a removable not be used where there is a tendency toward an openbite.
appliance when there is need for bodily movement of the 9. To retain space in premature loss of teeth
mandibular incisors. 10.With additional spring attachments, to move groups
Using biteplates for tooth movement seems easy. and individual teeth
While it is easily accomplished, retention is important, as 11. In correcting the mesial position of the mandibular
is control of axial position of the teeth. Removable teeth in the deciduous dentition
appliances require exact knowledge of appliance Increase in face height following the use of biteplanes
manipulation as do the fixed appliances. The use of a due to vertical increase in the posterior dental region,
biteplate to correct excessive overbite frequently fails mostly in the maxillary posterior teeth. Increase in
when the correction of excessive overbite requires vertical dimension is accompanied by change also in the
changes in the axial relations of the maxillary to the mandibular position.
mandibular incisors. This cannot easily be accomplished
with biteplates.
Biteplates make it possible for the posterior teeth to
elongate by continuing eruption and alveolar process
elongation. Whether they will relapse to their former
height after the plate is removed is uncertain. If the
masticatory muscles, especially the strong masseter THE HIGLEY STABILIZING PLATE
muscle, are stretched when the posterior teeth are A stabilizing plate can be used as a means for obtaining
elongated, there will be a tendency for the vertical anchorage in orthodontic tooth movement. An acrylic
dimension to return to its original size. The intrusion of plate, similar to a Hawley retainer, is made for either the
mandibular incisors into the alveolar process will not maxilla or mandible, as required in treatment. The plate,
remain when the plate is removed if the mandibular devised by Higley and Moyers, is constructed so that it
incisor teeth do not have proper contact and angular lies in lingual contact with the teeth and covers as much
relation with the maxillary incisor teeth. The maxillary- of the soft tissues lingually as possible. The plate is
mandibular incisor angle should not be allowed to remain supplied with wire extensions to which are soldered
excessively obtuse in deep overbite. vertical round or half-round shafts that insert into lingual
If a biteplane (like. the Oliver guideplane) or a Hawley half-round tubes soldered to the molar bands. These help
retainer is used, the inclined plane should be constructed to hold the plate in position.
in the mouth of quick-setting acrylic. The retainer should The stabilizing plate makes it possible to move the
then be removed. When the quick-setting acrylic is canines and the incisors distally without also moving the
hardened, it is trimmed so that the mandibular incisor posterior teeth mesially in extraction cases. The plate
teeth fit directly against the inclined plane. may be cut away from the lingual surfaces of the incisor
Among the changes that can be effected by means of teeth which may then be moved distally by means of
biteplanes are the following: intramaxillary elastics attached to wire extensions on the
1. Forward positioning of the head of the mandibular plate distal to the canine proximal contact points. When
condyle repositioning the mandible especially in growing reciprocal movement of posterior teeth mesially and
young children anterior teeth distally and lingually is desired the plate is
removed and intramaxillary elastics are used.
Construction of Stabilizing Plate CONSTRUCTION OF ACRYLIC RETAINERS

1. Construct the molar bands taking care to solder the 1. Form the wire attachment according to the type of
lingual half-round tubes perpendicularly. Solder appliance required. Remove the attachment before
intermaxillary hooks on the buccal surfaces. painting the cast with acrylic separating medium.
2. Take an impression with the uncemented bands in 2. Carefully replace the wire attachment in its proper
place on the teeth. position and apply acrylic powder and liquid. If
3. Remove molar bands from the teeth and seat them necessary, the wire may be held temporarily in position
in their proper position in the impression. with sticky wax or other material added on the buccal and
4. Pour the impression in stone. the labial surfaces not to be covered by acrylic.
5.Construct a wire framework. Process in quicksetting 3. Build the palate by alternately applying the acrylic
acrylic; a broad contact of acrylic with the teeth is powder and liquid. Work only on relatively small areas,
desirable. It is advisable to cover the lingual surface of in order to maintain better control overall. Begin
the molar bands or overlay them with a layer of heavy construction of the palate by distributing a layer of
tinfoil before processing. This facilitates the removal of acrylic powder with the dispensing bottle. Spread powder
the band from the acrylic. uniformly.
6. Remove the molar bands from the plate and cement 4. Saturate the powder with acrylic liquid from the
them in place on the teeth. dropper bottle. Use liquid generously; too much does no
7. Polish the plate and insert in the mouth after bands harm, and too little may result in an unsatisfactory bond.
are cemented. Build the area to the desired thickness by repeating the
process.
5. The center of the palate is built last because excess
THE CHINCAP lateral material tends to gravitate toward the center.
6. Turn the cast down on its occlusal surface and
The chincap was used by Cellier (1802) and by Fox
permit it to remain in this position for about 15 seconds.
early in the 19th century. Tomes described it in 1873;
This prevents soft material from drifting into the center of
Victor Hugo Jackson (1890) used it. Angle, Case, and
the palate.
Oppenheim and other used the chincap early in this
7. When the material is tacky turn the cast over and
century.
smooth out rough spots with a finger. If the acrylic has
The chincap can inhibit forward translatory growth of
set too fast, soften it by adding a few drops of liquid and
the mandible. Maxillary growth can then be expected to
smooth it over.
overcome the disproportion in forward growth. The
8. Allow the appliance to cure on the cast at room
chincap should not be used in an attempt to retract the
temperature for 30 to 45 minutes. This prevents warping
mandible; its purpose is to exert a holding effect. It
and shrinking. The acrylic plate may be lifted out of the
should fit snugly but should not exert appreciable
cast with a knife or any other sharp instrument.
pressure. It is of value primarily during the active growth
9. Trim and smooth the excess material from the
period in the young child. Changes produced by the
interdental spaces with burs and disks. For the best result,
chincap can be compared to the skull changes brought
soak the appliance in water overnight to further cure the
about by certain South American Indians who flattened
material and eliminate unpleasant taste.
the heads of children, producing cranial deformities.
The changes produced occur in the vector of growth
but not as a result of inhibition of growth. Gentle
pressure on the chincap should be directed in a backward
rather' than an upward direction. Pressure against the
temporomandibular articulation should not be directed
for the purpose of inducing changes in the glenoid fossa.
Armstrong found that young children with Class III REPAIRING RETAINERS
dental incisor relation show an appreciable improvement
when the chincap is used. It inclines the incisors 1. Place the retainer on original cast or construct an
lingually. The chincap should be worn 12 to 14 hours a index so that the retainer lies passive.
day. Oppenheim was the first to use force to move 2. Clean, trim, and smooth the irregular edges along
maxillary teeth mesially by means of extensions from a the break with a bur or stone.
chincap to which intermaxillary elastics are attached. 3. Acrylic separating medium is applied on the palatal
area of the cast and the broken parts are replaced on the
cast. From this point on, the standard procedure is
followed by adding quick-setting
Bibliography 165
acrylic until the break is completely filled. When the Duyzings, J. A C: Nasenatmung bzw. Mundatmung und ihre
acrylic is set the retainer is trimmed and polished. Folgen fur die Form des Gesichtes wie auch die Form und
Funktion des Gesamtk6rpers. Fortschr. Kieferorthopadie,
3:289,1963.
BIBLIOGRAPHY Emslie, K D.: Malocclusion and periodontal health. Report of
the 30th Congress. European Ortho dont. Soc. p. 271. The
Alldritt, S.: Gingivitis and imbrication. D. Practitioner, 22: 60, Hague. Holland, 1954.
1972. Englehardt, H. G., and Hammer, H.: Pathologie und Therapie
Andersen, W. S.: The relationship of the tongue-thrust der Zahnwurzelfrakturen. Deutsche Zahn. Ztschr., 17:1278,
syndrome to maturation and other factors. Am. J. 1961.
Orthodontics, 19:264, 1963. Epstein, L. 1.: Trauma tic injuries to anterior teeth in children.
Anderson, D. L., Thompson, G. W., and Popovich, F.: Oral Surg., Oral Med., and Oral Path., 15:334, 1962.
Relation of socioeconomic level to sucking habit and tooth Geiger, A M.: Occlusal studies in 188 consecutive cases of
eruption. Program and Abstracts of Papers, Fiftieth G;eneral periodontal disease. Am. ]. Orthodontics 48:330, 1961.
Session, IADR, March 1972. Cranerus, K: Some clinical aspects of the problems of impacted
Ast, D. B., Allaway, ., and Draker, H. L.: The prevalence of upper canines. Tr. European Orthodont. Soc., annual, 1961.
malocclusion related to dental caries and loss of first Hallett, G. E. M., and Weyman, ].: Fourteen cases of congenital
permanent molars in a flouridated city and a fluoride- absence of canines. Brit. Dent. J., 97:228, 1954.
deficient city. Am. J. Orthodontics, 48:106, 1962. Haryett, R. D., Hansen, F. C, Davidson, P.O., and Sandelands,
Backlund, E.: Facial growth, and the significance of oral habits, M. L.: Chronic thumbsucking: The psychologic effects and
mouthbreathing and soft tissues in malocclusion. A study on the relative effectiveness of various methods of treatment. Am
children around the age of 10. Acta odont. scandinav.,21 ]. Orthodontics, 53:569, 1967.
[Supp.]: 36, 1963. Hennis, 1.: Zur Frage der Genese und Therapie des unechten und
Ballard, C F., and Bond, E. K.: Clinical observations on the echten Diastemas. Stoma, 17:150, 1964.
correlation between variations of jaw form and variations of Holloway, P. J., Swallow, J. N., and Slack, G. L.: Child Dental
oro-facial behaviour, including those for articulation. Speech Health, A Practical Introduction. Baltimore, Williams &
Path. & Therapy, 3:55, 1960. Wilkins, 1969.
Benjamin, L. S.: Non-nutritive sucking (thumbsucking) and Ingervall, B.: The influence of orthodontic appliances on caries
dental malocclusion in the deciduous and permanent teeth of frequency. Odont. Revy., 13:175, 1962.
the rhesus monkey. Child Dev., 33:29, 1962. James, P. M. C: Survey of dental and gingival conditions in
Beresford, J. S.: Orthodontic Diagnosis. Bristol, England, John school children. Proc. Roy. Soc. Med., 56:620, 1963. [ann, H.
White & Sons, Ltd., 1965. W., [ann, G. K, Malone, H. D., and Ward, N. M.:
Bhaskar, S. ., et al.: Water jet devices in dental practice. Visceral swallowing and malocclusion. J. Speech & Hearing
J. Periodcnt., 42:658, 1971. Dis., 26:334, 1961.
Bishara, S. E.: Management of diastemas in orthodontics. Johnson, E., and Taylor, K C: A surgical orthodontic approach
Am. J. Orthodontics, 61:55, 1972. in uprighting impacted mandibular second molars. Am J.
Bowden, B. D.: A longitudinal study of the effects of digit- and Orthodontics, 61:508, 1972.
dummy-sucking. Am. J. Orthodontics, 52: 887, 1966. Johnson, R., and Baldwin, C, Jr.: Maternal anxiety and child
Chandler, T. H.: Thumbsucking in childhood as a cause of behavior. J. Dent. Children. 36:87, 1969.
subsequent irregularity of the teeth. Boston Med. & Surg. J., Kantorowicz, A: Die Bedeutung des Lutschens fur die
99:204, 1878. Entstehung erworbener Fehlbildungen. Fortschr. Kiefer-
Clinch, L. M., and Healy, M. J. R.: A longitudinal study of the orthopaed, 15:109, 1955.
results of premature extraction of deciduous teeth between 3- Kingsberg, J.: Effective management of juvenile periodontitis
4 and 13-14 years of age. Tr. Brit. Soc. Study Orthodont, p. (periodontosis): Case report. New York State D. J., 38:71,
109, 1958. 1972.
Clinch, L. M.: A longitudinal study of the results of premature Klein, E. T.: The thumb-sucking habit: Meaningful or empty.
extraction of deciduous teeth between 3-4 and 13-14 years of Am. J. Orthodontics, 59:283,1971.
age. Dent. Practitioner, 9:109, 1959. Kortsch, W. E.: Speech defects in a tongue-thrust group.
Ditto, W. S., and Hall, D. L.: A survey of 143 periodontal J. A. D. A., 67:698, 1963.
'l)ases in terms of age and occlusion (Abstract). Am. J. Kravitz, H.: Lip biting in infancy. J. Pediatrics, 65:136, 1964.
Orthodontics, 40:234, 1954. Linder-Aronson, S.: The effect of premature loss of deciduous
Dixon, D. A: Observations on submerging deciduous molars. teeth. Acta odont. scandinav., 18:101, 1960.
Dent. Practitioner, 13:303, 1963. Lindner, S. L.: Das Saugen an den Fingern. Lippert usw. bei den
Douglas, B. L., and Douglas, W.: Clinical observations on Kindem. [ahrb. f. Kinderh., 14:68, 1879.
replantations of upper anterior teeth. Oral Surg., 7:27, 1954. McClure, F. J.: Diet and dental caries. J. A D. A, 62:511, 1961.
Dunlop, R.: Habits: Their Making and Unmaking. New York. Medina, C A.: Oral manifestations of vitamin deficiencies.
Liveright, 1932. Oral Surg., Oral Med. & Oral Path., 9:1060, 1956.
Nadler, S. C.; Detection and recognition of bruxism. J. A. ---: Orthodontic principles and prevention in the everyday
D. A., 61:470, 1960. practice of dentistry. J, Canad. D. A., 27:81, 1961.
Nizel, A. D.: Nutrition in Clinical Dentistry. Philadelphia, W. B. Salzmann, J. A., and Ast. D. B.: The Newburgh Kingston fluorine
Saunders, 1960. study. IX. Dentofacial growth and development -
Palmer, J. M.: Tongue thrusting: a clinical hypothesis. J. cephalometric study. Am, J. Orthodontics, 41:674, 1955.
Speech Hearing Dis., 27:323, 1962. Scherp, H. W.: Dental caries: Prospects for prevention.
Quintarelli, 1.: Sulla etiopatogenesi del diastema interincisivo Combined utilization of available and imminent measures
superior, Minerva Stornatol., 11:465, 1962. should largely prevent this ubiquitous disease. Science,
Reitan, K.: Orthodontic treatment of patients with psychogenic, 173:1199, 1971.
muscular and articulation disturbances. Tandlaegebladet, 75: Schour, I., and Massler, M.: Effects of dietary deficiencies upon
1182, 1971. the oral structures. J. A. D. A., 32:714; 871; 1022; 1139, 1945.
Rendle-Short, J.: The history of teething in infancy. Proc. Sewerin, I.: Prevalence of variations and anomalies of the upper
Roy. Soc. Med., 48:132, 1955. labial frenum. Acta Odont. Scandinav.. 29:487, 1971.
Rogers, A. P.: Evolution, development and application of Sinclair, V., and Goose, D. H.: The periodontal condition of
myofunctional therapy in orthodontics. Am. J. Orthodontics grammar school children in cheshire. Brit. D. J., 121: 420,
& Oral Surg., 25:1, 1939. 1966.
---: Myofunctional treatment from a practical standpoint. Am. J. Stanhope, E. D.: A "buried" tooth containing an amalgam filling.
Orthodontics & Oral Surg., 26:1131, 1940. ---: A restatement of
Brit. D. L 81:392, 1946.
the myofunctional concept in orthodontics. Am. J. Orthodontics,
36:845, 1950. Suomi, D., et at.: Oral calculus in children. J. Periodont., 42:341,
Rogers, A. P., Dinham, W. R, and Logan, H. L.: Symposium on 1971.
muscle function. Int. J, Orthodontics & Oral Surg., 16:254, Thilander, B., and [akobsson, S. 0.: Local factors in impaction of
1930. maxillary canines. Acta odont. scandinav., 26:145, 1968.
Romans, A. R., and App, G. R: Bacteremia, a result from oral Trott, J. R, Chappell, R, and Borrow, 1.: Gingival health
irrigation in subjects with gingivitis. J. Periodont., 42:757, and dental health attitudes in 766 Winnipeg high
1971. school students. J. Can ad. D. A., 33:319,1967.
Russell, A. 1.: International nutrition surveys: A summary of Tulley, W, J.: Cineradiographic studies of tongue behavior.
preliminary dental findings. J. Dent. Res., 42 [Suppl.], D. Practitioner, 10:135, 1960.
233,1963. Tuverscn, D. 1.: Orthodontic treatment using canines instead of
Salzmann, J. A.: Rate and direction of orthodontic change and missing maxillary lateral incisors. Am. J. Orthodontics,
effect on incidence of caries in 500 adolescents following 58:109, 1970.
caries, filling or extraction of first permanent molars. J. A. D. Warrer, E.: Simultaneous occurrence of certain muscle habits and
A., 26:1991, 1939. malocclusion. Am. J. Orthodontics, 45:365, 1959.
--: Rapid orthodontics. J. A. D. A., 29:1230, 1942. Watson, D. C.: Retraction of upper incisors with the oral screen.
---: Prevention and interception of malocclusion, Am. Brit. D. L 112:501,1962.
J. Orthodontics, 34:732, 1948. Weidemiiller, D., and Weidemiiller, B.: Die kieferorthopadische
---: Developing normal occlusion. ew York State Behandlung hartnackiger Lutscher- ein psychologisches
D. L 18:3, 1952. Problem. Deutsche zahn. Zeitsch., 16: 1045, 1961.
---: Orthodontic approach to the interception and treatment of Whitman, C. 1., and Rankow, R M.: Diagnosis and management
oral habits in children. J. Dent. Children, J. Dent. Children, of ankyloglossia. Am. J. Orthodontics, 47:423, 1961.
19:90, 1952.
---: Effect of postadolescent face growth on orthodontic restults.
Am. J. Orthodontics, 43:698, 1957, ---: Dento-rnaxillo-facial
orthopedics: etiology and prevention. Am. J. Orthodontics,
43:242, 1957.
---: An answer to "How much orthodontics shall the pedodontist
do?" Am. J. Orthodontics, 44:630, 1958.
13
Radiography in Orthodontics
The following information useful in orthodontics can body of the dentist or of the dental auxiliary can be
be gained from radiograms: measured with a film badge.
1. General development of the dentition: pres-
ence, absence, and state of eruption of the teeth
2. Root resorption of deciduous teeth Protecting the Patient
3. Root formation of permanent teeth The following measures should be taken to protect
4. Ectopic eruptions the patient when radiographs are made:
5. Morphologic anomalies of teeth 1. Use high-speed films
6. Pathologic conditions in the dentofacial area 2. Use diaphragms to collimate the x-ray beam
7.Cephalometric lateral radiograms for dentofacial 3. Use a lead apron on the patient
analysis 4.Use as large a film as possible for intra- and extraoral
8. Cephalometric posteroanterior radiograms for radiograms
symmetry analysis 5. Process films carefully to avoid the necessity of
9. Temporomandibular radiograms for diagnosis of reexposure to x-rays.
TM disturbances
10. Character of the alveolar bone
Effect of Therapeutic Radiation on Teeth
11.Evidence of present or past pathologic conditions
or morphologic abnormalities The teeth can be damaged by therapeutic radiation, but
12. Estimate of skeletal age - from radiograms of the not by x-rays used for dental diagnostic purposes. The x-
carpals rays used for therapy are in the 275 to 3,000 kilovoltage
range, the dose range is between 4,000 and 6,000 rads.
The dose for a single dental radiograph varies between
RADIATION CONTROL
0.15 and 4 roentgens.
Protecting the Operator The effect of therapeutic x-rays on fully formed and
erupted teeth is usually seen as a saucer-shaped loss of
Exposure of the operator of a dental x-ray machine to tooth substance. in the cervical region. In most cases
radiation can be minimized by the following procedures: several adjacent teeth are involved. This occurs not only
1. Avoid the direct beam of primary radiation. on the interproximal areas but also on the buccal and
Stand behind a protective barrier to radiation. Use high- lingual surfaces. Both anterior and posterior teeth may be
speed films. Use a long cord on the timer to permit the affected. Cervical tooth degeneration may progress until
operator to stand out of sight of the sources of secondary the crown separates from the root; often the pulp is
radiation. Stand at a 45 angle to the path of the central exposed.
x-ray beam, behind and to the left or the right ear of the
patient.
2. 'Wear a lead apron.
INTRAORAL RADIOGRAPHY
3. Do not hold the tube housing the ray-directing
cylinder or the film during x-ray exposure. Intraoral dental radiograms for orthodontic diagnosis
4. An open-ended, shielded cylinder in place of a should present clear views of the apices of the teeth.
pointed plastic directing cone eliminates, controls, and Bitewing radiograms should be obtained to aid in
confines scattered secondary radiation. ascertaining the need for fillings. Exposure time varies
5. The x-ray machine should be tested for radiation with the x-ray machine used.
leakage. The bisecting angle technic in intraoral dental
6. The amount of x-ray radiation that reaches the radiography is based on the principle that the rays are
directed perpendicularly to an imaginary plane
16
7
168 . Radiography in Orthodontics 82.
that bisects the long axis of the tooth or teeth and the to the center of the packet. The patient immobilizes the
plane of the film. packet with a gentle end-to-end bite.
The uses of periapical and bitewing radiograms are as
follows:
1. For assessing the degree of development and The Mandibular Incisor Region
clacification of the teeth in the deciduous and permanent Insert the occlusal packet with the pebbled side toward
dentitions the lower arch and the long axis coincident with the
2. To measure crowns of unerupted permanent teeth in median plane. Direct the central ray in the horizontal plane
order to estimate dentition jaw length adequacy through the tip of the chin to the center of the packet. The
3. To measure extraction space closure angle formed by the central ray and -the film plane is
4.To recognize the presence of caries and periapical approximately -55. The patient immobilizes the packet
infection with a gentle end-to-end bite.
5. To detect the presence of supernumerary teeth
6. To detect congenitally missing tooth buds,
developing teeth, and missing unerupted teeth
7. To determine jaw bone density The Entire Mandibular Arch
8. To diagnose ankylosed teeth Insert the occlusal packet with the pebbled side toward
9.To evaluate position of developing, unerupted teeth the lower arch and the short axis coincident with the
10. To estimate degree of root resorption median plane. The posterior edge of the packet should be
11. To detect interproximal caries against inner border of the mandible. Direct the central ray
perpendicularly to the occlusal plane, through the inferior
aspect of the mandible to the center of the packet. The
patient's head should be back far enough so that the
occlusal plane is perpendicular to the floor. The patient
immobilizes the packet with a gentle end-to-end bite.
The Maxillary Incisor Region
Insert the occlusal packet with the pebbled side toward
the upper arch and the long axis coincident with the
The Entire Maxillary Arch
median plane. Direct the central ray at a vertical angle of
+65 through the bridge of the nose, The occlusal film is inserted with the smooth
Fig. 13-1. Correct posinon of pa-

tient's head for periapical and
occlusal examinations of maxillary Fig. 13-2. Correct position of
regions, and for interproximal patient's head for mandibular
(bitewing) examination. (From X- periapical examination. (From X-Rays
Rays in Dentistry, published by in Dentistry, published by
Radiography Markets Division, Radiography Markets Division,
Eastman Kodak Company) Eastman Kodak Company)
Extraoral Radiography' 169
83.
Fig. 13-3. To radiograph the central incisors have the patient hold the head vertical and insert the occlusal packet pebbled side
up (A). (B) Direct the central ray at a vertical angle of -HiS degrees through the bridge of the nose to the center of the packet. The
patient immobilizes the packet with a gentle end-to-end bite. (C) This method will yield a radiograph of the maxillary incisor
region. (From X-Rays in Dentistry, published by Radiography Markets Division, Eastman Kodak Company)
Fig. 13-4. To radiograph the entire maxillary arch, the occlusal cassette is inserted with the smooth side adjacent
to the maxillary occlusal surfaces-the short center axis in the median plane and the long axis directed bucally and
the posterior edge abutting the mandibular rami (A). (B) Direct the central ray perpendicularly in the intersection of
the medial plane and a coronal plane through the outer canthi of the eyes to the center of the packet. The patient
immobilizes, the packet with a gentle end-to-end bite. (C) This procedure will yield a film of the entire maxillary
arch.
'.
side adjacent to the maxillary occlusal surfaces, the EXTRAORAL RADIOGRAPHY
short center axis in the median plane, and the long axis
directed buccally with the posterior edge butted against
Body of the Mandible
mandibular rami. Direct the central ray perpendicularly in
the intersection of the median plane and the coronal plane The arm of the dental chair on the side to be examined is
through the outer canthi of the eyes to the center of the lowered so that the patient may sit sideways. Place the film
packet. The patient immobilizes the packet with a gentle holder on the headrest and the chair back so that the film is
end-to-end bite. at an angle of +45.
170 . Radiography in Orthodontics
84.
Fig. 13-5. (AJ To make a film of the mandibular incisor region, insert the occlusal packet with the pebbled side down.
The patient inclines her head upward 45 degrees. Direct the central ray in the horizontal plane through thetip of the chin to the center of
the packet. (B) The angle formed by the central ray and the film plane is approximately -55 degrees. The patient immobilizes the packet
with a gentle end-to-end bite. (e) This method will produce a film of the mandibular incisor region. (From X-Rays in Dentistry,
published by Radiography Markets Division, Eastman Kodak Company)
CR
Fig. 13-6. (A) To make a film of the entire mandibular arch,
/ insert the occlusal packet pebbled side down with the posterior
edge against the rami of the mandible. (B) Direct the central ray
perpendicularly to the occlusal plane through the inferior aspect
of the mandible to the center of the packet. The patient's head
A should be back far enough so the occlusal plane is perpendicular
to the floor. The patient immobilizes the packet with a gentle
end-to-end bite. (e) The film will show the entire mandibular
arch.
The patient holds the film holder in position with hands at

lower corners. The patient's cheek is in contact with the
front of the film holder. The median plane of the head is
rotated until the body of the mandible is in contact with
the center of the film holder, the lower border of the
mandible parallel with its lower edge. Direct the central
ray at an angle of approximately +250 through the lower
molar area on the side being examined to the center of the
film.
Extraoral Radiography 171
Fig. 13-7. (A) To take two lateral jaw views, cover half the 5" x 7"
cassette with a lead sheet. (B) Two lateral jaw roentgenograms were
taken on one 5" X 7" film in a cassette.
c
Fig. 13-8. To make a film of the body of the mandible, the arm of the dental chair is
lowered on the side to be radiographed so the patient may sit sideways. (A,B) Place the film
holder on the headrest of the chair back so that the film is at an angle of +45 degrees. The
patient holds the film holder in position with hands at the lower corrters, The patient's
cheek is in contact with the front of the film holder. The nose should be V2 inch from the
surface of the cassette; the head is extended backward. The median plane of the head is
rotated until the body of the mandible is in contact with the center of the filmholder, the
lower border of the mandible parallel with the lower edge of the cassette. (C) Direct the
central ray at an angle of about 25 degrees above the horizontal and from a point behind
and beneath the condyle so that the central ray passes through the second or third molar on
the side to be radiographed. (0) This procedure produces a film of the body of the
mandible. Figures 13-8A-13-10 (From X-Rays in Dentistry, pubijshed by Radiography
Markets Division, Eastman Kodak Company)
The arm of the dental chair is lowered so that the cassette so that the nose is over the approximate center
patient may sit sideways. The patient rotates the upper with the median plane vertical and coincident with the
trunk to face the cassette. Place the cassette on the long axis of the film holder. Direct the central ray at an
headrest and the chair back in a horizontal position. average angle of +700 in the median plane, through a
Place the patient's nose and chin on the point 1 V2 inches below the
base of the skull toward the center of the film. Use two Temporomandibular Radiography
lateral jaw radiograms on one 5 X 7 film taken in a
Temporomandibular radiograms show the relation of the
cassette. One half of the cassette is covered with a lead
mandibular condyle to the glenoid fossa and are intended to
shield when the exposure is made.
disclose evidence of pathologic and morphologic
deviations. The dense bony structures surrounding the
temporomandibular articulation make it difficult to
The Facial Profile (Lateral View)
radiograph this area.
A line from the tragus of the ear to the ala of the nose is The patient is seated sideways in the dental chair, and the
taken as horizontal. The median plane is vertical. The headrest is adjusted to hold the patient's head stable. A film
occlusion should be in the rest position. The cassette in a cassette is used. The central ray of the x-ray machine is
containing the film is positioned vertically against the focused at 2.5 em. above the border of the ear on a line
lateral aspect of the head, with its lower edge resting on above the external auditory meatus and is directed to the
the patient's shoulder. The center of the film should be opposite condyle head. The central ray of the x-ray
opposite the zygomatic arch. The patient holds the cassette machine is set between 20 and 30 and turned 15 to 20
with the front edge parallel with the median plane of the towards the face.
head. Direct the central ray horizontally and laterally Another method is for the patient to hold the cassette
through the anterior nasal spine to the center of the film. vertically. The side of the face is placed against the cassette
so that the contour of the face touches
Fig. 13-9. To radiograph the temporomandibular articu-

lation, the arm of the dental chair is lowered on the side to
be examined, to allow the patient to sit sideways. The
cassette is placed on the headrest with the chair back in
horizontal position. Center the lateral aspect of the
temporomandibular articulation on the cassette, rotating the
median plane toward the cassette until the zygomatic arch
touches it. The lower border of the mandible is parallel to
the lower edge. Direct the central ray at an angle of about
+75 degrees through the head of the condyle on the
opposite side. (From X-Rays in Dentistry, published by
Radiography Markets Division, Eastman Kodak Company)
85.
86.
Extraoral Radiography 173
the cassette. The central ray is directed downward 15 from a G

point about 2 inches above and behind the external auditory
meatus and towards the condyle nearest to the cassette.
Panradiography
Panradiography is a method for exposing the entire
A_
dentoalveolar and adjacent jaw region on a single film. This is
accomplished by traversing the x-ray tube and film around the
patient's head while making a continuous radiographic
--
exposure during the rotation. The x-ray head is attached to --8
one end of a <horizontal arm while a sliding cassette holder
for cassette and film is attached to the opposite end of the
arm. - --.D F
Distortion error in panradiography can be minimized by Fig. 13-10. An alternate method of taking temporoman-
proper positioning of the patient and rigid stabilization of the dibular radiograms. The temporomandibular articulation is
patient's chin on the chin rest. difficult to radiograph because of the dense bony structures
surrounding it.
Fig. 13-11. Radiogram of the temporomandibular

joint in open relation (Left; and closed relation (Right)
of the jaws. Note the well-contoured fossa and
articular eminence, normal tilt of the condyle head,
and correct terminal relationship in the open and
closed position. When the jaws are opened to the
limit of accommodation the condyle head is seen
directly below the articular eminence of the temporal
bone and is separated from this bone by the articular
disk. In the closed position of the jaws the condyle
head is in slight anterior relation to the fundus of the
fossa. (Courtesy Sidney E. Riesner)
Fig. 13-12A. Panradiogram of a child. The superimposition of intervening anatomic structures are eliminated.
Fig. 13-12 Continued. (B) Conventional lateral jaw radiograms are shown for comparison. (C) Panradiograms of an adult are supplemented
by dental radiograms (below) that focus on the incisors and premolars. (B, C courtesy William J. Updegrave)
Bibliography' 175
Panradiograms show the crown and root relations ---: New method for reduction of gonadial irradiation of dental
clearly. The temporomandibular articulation can be patients. J. A D. A, 65:1,1962.
shown with a minimum at superimposed tissue. Riesner. S. E.: X-ray profiles in orthodontia. Internat. J.
Panradiography is a useful and convenient method to Orthodontia., 15:813, 1929.
Sather, A. H.: A technique for detailed anatomic study of the
supplement intraoral radiography. Panradiography
posteroanterior cephalometric roentgenogram. Oral Surg., Oral
should be used together with intraoral radiography and
Med. & Oral Path., 16:154, 1963.
other radiograms as required. Panradiography is of little Simon, P, W.: Fundamental principles of a systematic diagnosis
value in revealing incipient caries and the finer details of of den tal anomalies. Boston, Stratford, 1926.
dental and osseous structures. Stromberg, N. and Stromberg, c.: Positional variations of the
impacted upper canine. A Clinical and Radiologic Study, Oral
Surg., Oral Med., & Oral Path., 22:711,1966.
Turner, K. 0.: Limitations of panoramic radiography.
Oral Surg., Oral Med., & Oral Path., 26:312, 1968.
BIBLIOGRAPHY Updegrave, W. J.: Roentgenographic observations of functioning
temporomandibular joints. J. A D. A., 54:488, 1957.
Bergerhoff, W.: Wachstum und Bauplan des Schadels im ---; Higher fidelity in intra-oral roentgenography, J. A. D. A, 62:1,
Rontgenbild. Fortschr. Roentgenstr., 79:745, 1953. 1961.
Bjarngard, B., Hollender, L., Lindahl, B., and Sonesson, A: ---: Practical evaluation of techniques. An interpretation in the
Radiation doses in oral radiography. II. The influence of roentgenographic examination of temporomandibular joints.
technical factors on the dose to the patient in full mouth D. Clin. North America, p. 421, 1961.
roentgenography. Odontol. Rev., 11:100,1960. ---: Roentgenology in orthodontics. Am. J. Ortho dont., 48:841,
Burely, M. A.: An examination of the relation between the 1962.
radiographic appearance of the temporomandibular joint and ---: Panoramic dental radiography. D. Radiog. & Photog., 36:75,
some features of the occlusion. Brit. D. J., 110:195,1961. 1963.
Marshall, D.: An X-ray study of the cranial and facial bones in ---: The role of panoramic radiography in diagnosis.
relation to the profile. D. Digest. 71:296, 353, 1965. Oral Surg., Oral Med., & Oral Path., 22:49, 1966.
---: Interpretation of the lateral skull radiograph. Waggener, D. T.: Roentgenographic localization of unerupted
D. Radiog. and Photog., 43:71, 1970. teeth. Oral Surg., Oral Med. & Oral Path., 13:439,1960.
Peyton, H. G.; The effects of radiation on teeth, Oral Surg., Oral Wainwright, W. W.: Filtration for the lowest patient dose
Med. & Oral Path., 26:639, 1968. in dental radiography. Oral Surg., Oral Med., & Oral Path.,
Richards, A. G.: How hazardous is dental roentgenography? 16:561, 1963.
Oral Surg., Oral Med. & Oral Path., 14:40, 1961- Yale, S. H.: Radiographic evaluation of the temporomandibular
--: Shielding requirements for dental installations. joint. J. A. D. A., 79:102,1969.
J. A. D. A, 64:787, 1962.
14
Cephalometric Radiography
USE OF CEPHALOGRAMS x-ray exposure is made unless other positions are desired.
Cephalograms provide a quantitative medium for

describing the dentofacial pattern at the time when a
radiogram is made. It does not present information on the TECHNIQUES
quality of growth and development. Qualitative
Cephalometric radiographic technique requirements
information is obtained from investigation in genetics,
are as follows:
embryology, comparative anatomy, ontogenetics,
1. The sagittal plane of the patient's head should be
physiology, pathology, and other basic related sciences.
oriented to the central ray for lateral views and the rear
Radiographic cephalometries are useful in the view of the patient's head for posteroanterior views.
following:
2. The central ray from the tube should pass through
1. To describe dimensional relationships of the the axis of the ears at porion and strike the x-ray film at a
craniofacial components to establish facial type right angle for taking the lateral view. After the head is
2. To classify and localize skeletal and dental placed in a fixed position, the head of the x-ray tube is
abnormalities adjusted so that the central ray will go directly through
3. To identify cranial base abnormalities and facial the ear rods, which will appear as a circle on the x-ray
asymmetry film. For taking posteroanterior views, the central ray
4. To guide in treatment planning should be on a level with the porion plane or the ear
5.To analyze changes obtained in the hard- and soft holders and at a right angle to the film.
tissue contours by orthodontic therapy, by growth, and
by growth and orthodontic therapy together
6. To evaluate the effectiveness of different ortho-
dontic treatment procedures
7. To determine the effectiveness of retention Accuracy of Cephalograms
8.To measure dentofacial growth changes after
The age of the patient, the thickness and density of the
treatment is completed
bones, and the amount of soft tissue covering affect the
9. To obtain a three-dimensional concept of the face
radiopacity of the radiogram. The x-ray machine head is
and cranium with lateral and posteranterior radiograms.
at a 5-foot focus-image distance. This is the distance at
which cephalometric radiograms are usually made. An
aluminum diaphragm and a lead shield with a %-inch
aperture should be used in the x-ray tube to reduce the
spread of the rays.
THE CEPHALOMETER
The cephalometer- stabilizes the patient's head in
relation to the central ray of the x-ray machine. The Magnification and Distortion
patient is seated on an adjustable chair. The orbital Structures on the side farthest from the film are
pointer and ear rods make it possible to position the magnified more. The finer the focus of the tube, the less
patient's head along the Frankfort horizontal plane. The objectionable the magnification factor. Magnification
teeth should be in full occlusion when the runs 5 to 8 per cent on a cephalogram. This is not
considered significant. Sagittal points should wherever
Margolis called the machine a cephalostar since it stabilizes the head but
possible be used for cephalogram analyses to reduce the
does not actually measure it. effect of magnification.
176
Techniques . 177
Fig. 14-1. (Top left) Margolis ceph-

alometer. (Right) head positioned in
cephalometer. (Bottom left) head in space
in cephalometer. Note. Patient looks at
the pupils of his eyes in a mirror
horizontal with the cephalometer.
Patient fixes his eyes on his eyes in a
mirror on the wall. Right, position of
patient for taking postero-anterior
cephalograms.
", Fig. 14-2. The patient's profile is painted with barium paste before the head is positioned in the cephalometer.
The resulting lateral cephalogram shows the soft tissue outline.
wide open; and (4) with the head in space. The wideopen
Lateral (Profile) Cephalograms
mouth usually affords an outline of the mandibular
Cephalometric lateral radiograms should be taken as condyle from which a template can be made for tracings
required (1) with the teeth in occlusion; (2) with the of radiograms with the teeth in occlusion.
mandible in rest position; (3) with the mouth
178 . Cephalometric Radiography
Determination of Right and Left Sides. In almost all gram. It is approximately 3 mm. above the center of the
lateral cephalometric radiograms (cephalograms), the ear rod as shown on the lateral cephalogram. The external
maxillary left first molar appears closer to the ear rod auditory meatuses used for head fixation are not as a rule
than the maxillary right first molar; the maxillary left on the same plane, and the integuments do not always rest
canine appears closer than the maxillary right canine; the upon the ear posts.
left jugal buttress appears closer than the right; the left
mandibular outline appears closer to the ear rods than the
right. Soft Tissue Radiograms
A sheet of thick paper is placed inside of the cassette
Radiograph of Natural Head Position covering the part of the film on which the soft tissue will
be shown.
The head in space. The patient is instructed to sit Mandibular Rest Position Radiogram. The patient is
relaxed while the head is in the cephalometer and to look seated in the cephalometer, asked to relax and to permit
at the image of the pupils in his own eyes in a mirror the mandible to remain at rest after saying the word
located on a wall directly in front. The center of the Mississippi. The patient is instructed to keep the mandible
mirror should be the same distance from the ground as in this position. The midline can be observed, and the
the ear rods of the cephalometer. amount of opening between full closure and rest position
can be measured.
Posteroanterior Radiograms. Rotate the patient and
Location of the Porion
headholder so that the posterior aspect of the head faces
The porion is not distinguishable on the radio- the x-ray tube. The ear rods should be inserted into the ear
openings. The head should be upright and not laterally
inclined. The nose is brought into contact with the cassette
and the exposure is made. Posteroanterior radiograms of
the head present difficulties in interpretation because of
the many superimpositions of structure.
The posteroanterior cephalometric radiograph to gain
information regarding the height and width of the cranium
and face; to determine the presence of asymmetry of the
face and the landmarks useful in diagnosis and
classification, both dental and skeletal.
Fig. 14-3. A paper strip placed in the cassette makes it

possible to obtain the soft tissue profile.
Fig. 14-4. Lateral radio-

gram with teeth in centric
occlusion (I e!t) , with mandi-
ble in rest position (center),
and with mandible in wide
open position (right).
Tracing Cephalograms . 179
Lateral Cephalograms Without a Cephalometer The head is extended backward as far as possible, and
The cassette is placed vertically against the side of the the side to be radiographed is turned slightly toward the
head parallel with the sagittal plane. The lower edge of cassette so that the ear is in flat contact with the center of
the cassette is held in horizontal position and rests on the film.
the patient's shoulder. The patient's hand is placed Direction of the Central Ray. The x-ray tube is
against the back of the cassette, the other hand holds the inclined at an angle of 150 above the horizontal and
lower anterior corner. directed beneath the mandible so that the central ray
(CR) passes through the second molar of the side to be
radiographed.
Radiographs of the Ramus of the Mandible
Adjust the headrest so that the cassette, when placed TRACING CEPHALOGRAMS
on the headrest, will be supported at an angle of 45" Cephalograms can be traced on traceolene or
above the horizontal. The cassette is held in position at transparent acetate paper of O.003-inch thickness and
the lower corners by the patient's hands. with one matted surface. Tools include a trans-
"
Fig. 14-5. (Top) Left and right

45 degree radiograms. (Bottom)
Lateral oblique radiograms
show distribution of the teeth in
the jaws.
Fig. 14-6. The facial profile

can be radiographed without
a cephalometer. A line from
the tragus of the ear to the ala
of the nose is taken as
horizontal. The median plane
is vertical; the teeth are in
occlusion. The cassette is
positioned vertically against
the lateral aspect of the head,
with its lower edge resting on
the patient's shoulder. The
center of the film should be
opposite the zygomatic arch.
The patient holds the cassette
with the front edge
parallel to the median plane
of the head. The central ray
is directed horizontally and
laterally through the anterior
parent millimeter rule, a small transparent protractor, one nasal spine to the center of
large and one small triangle, long-arm dividers, a T- the film.
square, hard and soft pencils in different colors, a viewing
box, and an artgum eraser.
Pinholes can be made at each landmark and measure
point to make it possible to locate them at the same site
for different tracing purposes. For inking, use the Koh-l- Cephalometric tracing should be started from the outline
Noor Rapidograph No. 2 or the Wrico No.5 or No.6 of the radiogram and continued to the inner parts as
inking pens. Accessory tracing aids are the Wrico letter follows:
pen No.7, VC3/16P lettering guide, Wrico lettering base, 1. The soft tissues, by covering the radiogram, except
and black and red india ink. Cellophane tape can be used for the anterior portion to be traced to intensify the
to attach tracing paper to film during tracing. transparent light
A photo-retouching table or a box can be constructed 2. The bony outline of the profile, including the
with two I-watt fluorescent bulbs and a milk glass cover mandible and posterior border in the ramus
the size of an 8" X 10" film. It should be possible to vary 3. The most prominent maxillary and mandibular
the amount of light. incisor teeth
4. The posterior base of the cranium and the foramen
magnum with the odontoid process of the axis
Technique 5. The sella, starting at the clivus
6.The roof of the orbits to the supraorbital ridges and
Place the radiogram on the tracing table. Place tracing the lower borders of the orbits
paper on top of the film. Attach the lefthand margin of the 7. The anterior portion of the cranial base, including
paper to the corresponding side of the film with the cribriform plate
cellophane tape to permit folding the tracing paper back to 8. The palate, the anterior and posterior nasal spine,
check directly on structural details. Use a hard fine pencil and the floor of the nose
line. While slight asymmetry between the two sides of the 9. The pterygomaxillary junction
mandible should be bisected, severe asymmetry should be 10.The pharyngeal wall and roof of the mouth,
traced as found. Tracing lines should be limited to fhose including the hard and soft palate and the posterior part of
parts necessary for the required information. the tongue.
The temporomandibular articulation and the condyle Tracing of teeth should be confined to those teeth that
cannot be seen on the lateral radiogram when the teeth are are necessary for the desired information. The teeth
in occlusion. They are traced from a template made from usually traced are the permanent first molars, the most
a radiogram taken with the mouth wide open. Height and prominent incisors, and, occasionally, the canines. Actual
depth proportions can be seen on the lateral film. Width tracing of teeth may be done with a template.
and facial symmetry must be obtained from the Posteroanterior tracings should show the follow~ ing:
posteroanterior film. 1. The contour of the cranium
Bibliography 181
2. The mastoid Downs, W. B.: Variations in facial relationships: their

3. The lateral outlines of the ramus significance in treatment and prognosis. Am. J. Orthodontics,
4. The lower border of the mandible 34:812, 1948,
5. The coronoid processes ---; The role of cephalometries in orthodontic case analysis and
6. The orbital lines diagnosis. Am. J. Orthodontics, 38:162, 1952.
7. The lesser wings of the sphenoid ---: Analysis of the denro-facial profile. Angle Orthodontist,
8. The crista galli 26:191, 1956.
9. The nasal septum Gregory, W. K.: Origin of the human face-a study in
10. The lateral walls of the nose. paleomorphology and evolution. Dental Cosmos, 77:334,
1935.
---: The earliest known fossil stages in the evolution of the oral
cavity and jaws. Am. J. Orthodontics, 29:253, 1943.
BIBLIOGRAPHY Higley, L. B.: Application of cephalometric appraisals to
orthodontic diagnosis and treatment. Am. J. Orthodontics,
Baurn, A T.: The direct analysis of cephalometric X-ray films. 37:244, 1951-
Angle Orthodontist, 27:171, 1957. ---: Treatment planning. Am. J. Orthodontics, 49:350, 1963.
Baurnrind, S., and Frantz, R. c.: The Reliability of Head Film Hofrath, H.: Die Bedeutung der Rontgenfern- und
Measurements. Am. J. Orthod. 60:505-512, overnber 1971. Abstandsaufnahme fur die Diagnostik der Kieferanomalien.
Bauza, C. A., and Solovey, G.: Estudio somatometrico e Fortschr. Orthod. 1 :232-258, 1931-
stadistico de 1000 nifios de 0-14 aries mediante el indice Jacobson, B. .: A radiographic cephalometric study of
ancho-alto, Arch. Pediat. Urug., 21:997, 1950. the functioning of the velopharyngeal mechanism in operated
Bjerin, R.: A comparison between the Frankfurt horizontal and cleft palate individuals as compared to that of non-cleft
the sella turcica - nasion as reference planes. Acta odont. individuals. Am. J. Orthodont., 48:390, 1962. (Abstract)
scandinav., 15:1, 1957. Kurth, L. E.: Methods of obtaining.vertical dimension and centric
Bjork, A: The face in profile. Svensk Tandlak. Tidskr., Vol. 40. relation: A practical evaluation of various methods. J.A.D.A.,
1947. 59:469,1959.
---: Cephalometric x-ray investigations in dentistry, Internat. D. Kvam, E. V., and Krogstad, 0.: Variability in tracing lateral head
J., 4:718, 1954. plates for diagnostic orthodontic purposes. A Methodologic
---: Solow, B.: Measurements on radiographs. J. Study. Acta odont. scandinav., 27:359, 1969.
D. Res., 41:672, 1962. Meach, C. L.: A cephalometric comparison of bony profile
Blair, E. 5.: A cephalometric roentgenographic appraisal of the changes in class II division 1 patients treated with extraoral
skeletal morphology of Class I, Class II division 1, and Class force and functional jaw orthopedics. Am. J. Orthodontics,
n division 2 (Angle) malocclusions. Angle Orthodontist, 52:353, 1966.
24:106, 1954. Parker, G. 5., Dreizen, 5., and Spies, T. D.: A cephalometric
Blucher. W. A.: Cephalometric analysis of treatment with study of children presenting clinical signs of malnutrition.
cs,rvical anchorage. Angle Orthodontist, 29:45, 1959. Angle Orthodontist, 22:125, 1952.
Broadbent, B. H.: A new x-ray technique and its application to Pease, C. N.: Facial retardation and arrestment of growth of
orthodontia. Angle Orthodontist, 1 :45, 1931---: The face of the bones due to vitamin A intoxication. J.AM.A., 182:980, 1962.
Salzmann, J. A.: Cephalometries, cephalometrists and orthodontics.
normal child: Bolton standards and technique. Angle
Orthodontist, 7:183, 1937.
---: Doubt and certainty in roentgenographic cephalometries. Am.
---: Ontogenetic Development of Occlusion, Development of
J. Orthodontics, 44:224,1958.
Occlusion. Philadelphia, University of Pennsylvania, 1941-
---: Cephalometries: Resume of the workshop and limitations of
Broca, P.: Instructions craniologiques et craniornetriques.
the technique. Am. J. Orthodontics, 44: 899,1958.
Min. Soc. Anthropol., Paris, II, 1875.
---: The second workshop on roentgenographic cephalometries.
Camper, P.: Dissertation sur les varietes naturelles qui
caracterisent la physionomie des hornrnes des divers climats Am. J. Orthodontics, 45:696, 1959. ---: Cephalometries is work
et des differents ages, sui vie de reflexions sur la beaute, in progress. Am. J.
particulierernent sur celle de la tete; avec une maniere Orthodontics, 47:629, 1961.
nouvelle de dessiner toute sorte de tetes avec til plus grande --- (ed.): Roentgenographic Cephalometrics: Proceedings of the
exactitude. Paris, Francart, 1972. Second Research Workshop. Philadelphia, J. B. Lippincott,
de Coster, L.: Une nouvelle ligne de reference pour l'analyse 1961.
des teleradiographies sagittales dans l'orthodontie, Rev. ---: Limitations of roentgenographic cephalometries.
stornatol., 11-12:937, 1951- Am. J, Orthodontics, 50:169, 1964.
---: A new line of reference for the study of lateral facial
teleradiographs. Am. J. Orthodontics, 39:304, 1953.
Les Consequences eloignees du Traitement
Orthodontique. Trans. Societe Francaise dOrthopedie Dente-
Faciale, 1957.
Selmer-Olsen, R.: Biometrics- biology. Tr. European Sherrington, c.: Man on His Nature. ew York, Macmillan,
Orthodont. Soc. p. 41, 1960. 1941.
Shapiro, H. L.: The anthropologic backgrounds of dental and Simpson, C. 0.: A procedure for obtaining radiographic images
oral morphology. Oral Surg., Oral Med. & Oral Path., 16:458, of the facial profile in the sagittal plane. Int. J. Orthodontics,
1963. 15:79, 1929.
15
Radiographic Cephalometries in
Diagnosis and Treatment
Cephalometries is a valuable tool in clinical ortho- 1. Intervals between serial observations should be kept
dontics. By relating the various parts of the face, the constant.
jaws, and the dentition, information is obtained to aid in 2. Distances between target, subject, and film should
establishing diagnosis, classification, treatment planning, be constant. X-ray film distance of 60 inches is most
and prognosis. However, cephalometries is not to be commonly used.
regarded as a sole parameter for establishing etiology, 3. The patient should be positioned as comfortably as
diagnosis, and treatment planning. Cephalometries possible and placed in the same relative position for
entails the use of cephalometers, x-ray machines, subsequent radiograms. The left side (or the same side)
photographic apparatus, and other equipment. All of the should be toward the cassette for all lateral projections.
foregoing are important in obtaining data for determining 4. Constant occlusal relationships and postural
dynamic changes in the patient and for growth studies in relations of the head should be obtained at all repeated
general. exposures.
Meaningful application of radiographic cephalometries 5. The ear rods should not interfere with positioning
in orthodontic practice depends on the knowledge of the patient. The immobilization of the head with ear rods
normal and abnormal dentofacial growth and introduces a degree of asymmetry proportional to the
development. In addition, it is necessary to know the deviation of the transmeatal ear openings and asymmetry
practical method of cephalometric technique. of facial morphology.
6. The patient and the x-ray machine must be
immobile when the x-ray film is being exposed.
7. The patient should be told to hold his breath when
the film is being exposed.
CLINICAL VALUE 8. Film exposures and development should be
Information obtainable from cephalograms meludes standardized.
the following: 9. Intensifying cassettes with screens should be used,
1. Angular and dimensional relationship of the especially for extraoral films.
craniofacial components. This indicates the extent of 10. The patient should be protected by a leaded apron
dentofacial growth. and any other available safety devices.
2. Indications of skeletal and dental abnormalities, and
jaw and dentition malrelationships. This provides
information on the malocclusion and skeletal
classification.
CEPHALOMETRIC LANDMARKS, LINES,
3. Guidance in treatment planning by indicating the
PLANES AND ANGLES
possibilities and limitations of success in treatment based
on the relation of the dentofacial skeletal and dental
Landmarks
components.
4.. Analysis of changes obtained by growth and Ac. Acanthion. Tip of anterior nasal spine. A-
development and by orthodontic therapy, and changes Point. (Downs. See Ss - Subspinale),
that occur after post-treatment retention. AI. P. Alveolar Point. The lowest point of the alveolar
process at the midline between the maxillary central
incisors.
STANDARDIZATION OF CEPHALOMETRIC ANS Anterior Nasal Spine. The median, sharp bony
TECHNIQUE process of the maxilla at the lower margin of the anterior
The following procedures are helpful in eliminating nasal opening.
variability caused by technical factors: Ar Articulare. (Bjork) The point of intersection
183
184 . Radiographic Cephalometries in Diagnosis and Treatment
of the external dorsal contour of the mandibular condyle

and the temporal bone. The midpoint is used when the
lateral cephalogram shows double projections of the rami.
Ba. Basion. The most forward and lowest point on the
anterior margin of the foramen magnum.
B.P. Bolton Point. The highest point at the notches on
the posterior end of the occipital condyles on the occipital
bone near the foramen magnum.
B.R. Broadbent Registration. Midpoint on a per-
pendicular from the center of sella to the Boltonnasion line
(BP-N).
B-Point (Downs. See Sm-Supramentale).
Ch. Cheilion. The lateral terminus of the oral slit, i.e.,
T the outer corner of the mouth.
Gl. Glabella. The most anterior point on the frontal bone
in the midsagittal plane of the bony prominence joining the
supraorbital ridges.
Gn Gnathion. The lowest point of the median plane in
the lower border of the chin palpated from below. In
cephalometries it is measured at the intersection of the
mandibular base line and Pg (nasionpogonion line).
I.I. Incision Inferius. The most forward incisal point of the
most prominent mandibular central incisor.
I.S. Incision Superius. The most forward incisal point of
the most prominent maxillary central incisor.
Id, Infradentale. The highest interdental point
Gn
Fig. 15-1. Posteroanterior cephalometric landmarks: Tr-
Trichion, GL-Glabella, N-nasion, T - Tragion, Or-orbitale,
Pr -prosthion, Inf. Den.-infradentale, Go-gonion, and Gn-
gnathion.
Fig. 15-2. Lateral land-

marks: N -nasion, T -
Tragion, Or-orbitale, ANS-
anterior nasal spine, A-point
(Downs), Pr-prosthion, ace.
Plane-occlusal plane, Go-
gonion, B-point (Downs),
Pg-pogonion, M-menton.
Or
ANS
Pr A-point
Occ.Plone
B-point
Pg M
Cephatometric Landmarks, Lines, Planes and Angles' 185
Fig, 15-3, Points visible on the posteroanterior

film: 1, crista galli; 2, nasion; 3, cribriform plate;
4, floor of the sella turcica; 5, sphenoidal plane; 6,
lesser wing of the sphenoid; 7, roof of orbit; 8,
foramen rotundurn: 9, orbitale; 10, mandibular
condyle; 11, gonion; 12, gnathion; 13, menton;
14, anterior nasal spine; 15, porion.
on the alveolar mucosa between the mandibular central on the lower margin of the orbit directly below the pupil
incisors. when the patient looks straight ahead.
K.R. Key Ridge. Zygomaxillare- the lowest point of Pg. Pogonion. The most anterior point on the chin.
the zygomaticomaxillary ridge. P. Porion. The midpoint on the upper edge of the
M. Menton. The lowest point on the chin from which external auditory meatus. As a cephalometric landmark it
face height is measured. It is somewhat forward to is located in the middle of the meatal ear rods of the
gnathion. cephalometer as shown on the cephalogram.
N. asion. The middle point on the frontonasal suture PNS Posterior Nasal Spine. Process formed by the
intersected by the median sagittal plane. united projecting ends of the posterior borders of the
O.c. Occipital Condyle. The condyle on the occipital palatine processes of the palatal bones.
bone near the foramen magnum. Pro Prosthion. The lowest interdental point on the
Op. Opisthion. The posterior midsagittal point on the alveolar mucosa in the median plane between the
posterior margin of the foramen magnum. maxillary central incisors.
Ope. Opisthocranion. The posterior midsagittal point Ptm. Pterygomaxillare. The point where the pterygoid
of the greatest cranial length from glabella. process of the sphenoid bone and the
Or. Orbitale. The lowest point on the margin of the
orbit. In orthodontic cephalograms it is located
186 . Radiographic Cephalometries in Diagnosis and Treatment 87.
Fig. 15-4. Points visible on
the lateral film: 1, sella; 2,
posterior clinoid process; 3,
clivus; 4, anterior clinoid
process; 5, tuberculum sellae;
6, sphenoidal plane; 7, lesser
wing of the sphenoid; 8,
greater wings of the sphe-
noid; 9, ethmoid registration
point; 10, cribriform plate of
the ethmoid; 11, roof of the
orbit; 12, lateral margin of
ethmoid and frontal bone; 13,
-13 nasion; 14, orbitale; 15,
pterygo maxillary fissure; 16,
posterior nasal spine; 17, ante-
rior nasal spine; 18, A-Point;
19, prostihor; 20, infraden
ale; 21, B-Point; 22,
pogonion; 23, gnathion; 24,
menton; 25, gonion; 26,
articulate, 27, mandibular
-17 condyle; 28, sigmoid notch;
29, basion; 30, occipital
-18 condyle; 31, Bolton point; 32,
opisthion; 33, porion; 34,
1 sphenooccipital
9 synchondrosis.
I
'20
pterygoid process of the maxilla form the pterygo- Sm. Supramentale. B-Point (Downs). The deepest point
maxillary fissure. The lowest point of the opening is used on the contour of the alveolar process between infradentale
in cephalometries. and pogonion. The anterior limit of the mandibular basal
R. Registration Point. Any point from which arch as seen on lateral radiograms.
measurements are made or from which different T. Tragion. The notch just above the tragus of the ear. It
cephalograms of a single patient are compared. lies 1 to 2 mm. below the spina helicis which can be
S Sella. The pituitary fossa of the sphenoid bone. palpated.
In cephalometries it is the center of the sella turcica. Tr, Trichion. The midpoint of the hairline at the top of
SO Spheno-occipital Synchondrosis. The union of the the forehead.
anterior end of the basilar portion of the occipital bone and T.S. Tuberculum Sellae. Anterior boundary of the sella
the posterior surface of the body of the sphenoid bone. turcica.
Sto. Stornion. The midpoint of the oral slit, when the
lips are closed.
Ss. Subspinale. A-Point (Downs). The deepest point on Planes and Lines
the midline contour of the alveolar process between the
anterior nasal spine and prosthion. The anterior limit of the A line connects two points. A plane connects three or
maxillary basal arch as seen on lateral radiograms. more points.
A-B Line. Relation of A-Point (infraspinale) to B-Point
(supramentale). It represents the anterior
Cephalometric Landmarks, Lines, Planes and Angles 187
88.
Fig. 15-5. (A) The more
variable landmarks are: 1,
Orbitale; 2, pterygomaxillary
fissure; 3, anterior nasal
spine; 4, A-Point; 5, poste-
rior nasal spine; 6, gonion;
7, Bolton point; 8, basion; 9,
porion; 10, sphenooccipital
synchondrosis. (B) The pala-
tal plane mayor may not
coincide with the ANS-
opisthion line. (B Courtesy
C. F. W. Moorrees)
9
..... 10
8-
points of the basal arches of the jaws and is used to

determine the anteroposterior relation of the jaws to one
another and to the facial line.
Camper's Plane. Tip of anterior nasal spine to the
center of the bony part of the external auditory meatus on
the right and left sides.
Camper's Triangle. Camper's line and a line tan-
gent to the facial profile.
Cranial Base Length. Nasion to Bolton Point. Cranial
Length (depth). Glabella to opisthocranion. de Coster's
Line. The planoethmoidal line from
the anterior contour of sella turcica to the roof of the
cribriform plate of the ethmoid and the internal plate of
the frontal bone.
N-Pg. Facial Line. A line from nasion to pogonion.
F.H. Frankfort Horizontal. Plane intersecting right and
left porion and left orbitale. It is drawn
89. Fig. 1S-SC. In the radiogram
at left, the anterior nasal spine is
not visible. In the radiogram on
the right the inner table of the
mandibular symphysis is
obscured by the crowns of the
unerupted permanent incisors
and canines.
roentgenogram where the posterior border of the ramus

intersects the contour of the temporal bone (articulare).
Broadbent-Bolton Line. asion to uppermost
point on occipital postcondylar fossa (Bolton point).
Broadbent's Line. Nasion to sella turcica midpoint on
the lateral cephalogram.
Camper's Line. A line from the tip of the anterior nasal
spine (acanthion) to the external auditory meatus.
Palate Line. Represented in cephalometries by a line
connecting the anterior nasal spine (A S) with the
posterior nasal spine (PNS).
His's Line. Extends from tip of the anterior nasal spine
(acanthion) to the hindmost point on the posterior margin
of the foramen magnum (opisthion) and divides the face
into an upper and a lower or dental part.
Krogman's Nasion Parallel. Sella-nasion parallel to
Frankfort horizontal.
Margolis Line. Nasion to top of sphenooccipital
synchrondrosis.
N-S (S-N) Nasion-Sella Line. Line joining center of
Fig. 15-6. A typical tracing of a lateral cephalometric
sella and nasion as seen on the lateral cephalogram.
radiogram of the skull showing points, planes, angles, and
areas employed by Brodie. (B) Bolton point. The height of
Dec. Occlusal Plane. The occlusal plane of the teeth. A
the curvature between the occipital condyle and the body line drawn between points representing one-half of the
of the occipital bone; 50, sphenooccipital junction; S, sella incisor overbite and one-half of the cusp height of the last
turcica; N, the frontonasal junction; PTM, occluding molars.
pterygomaxillary fissure; PN5, posterior nasal spine; OCe, D.P. Orbital Plane. Perpendicular to Frankfort plane at
the occlusal plane of the teeth; NS, anterior nasal spine; the orbitale.
GN, gnathion; GO, gonion. (Courtesy A. G. Brodie) P.O. Porion-orbitale, The Frankfort plane.
Ptm. Pterygomaxillary Fissure. The fissure formed by
the retromolar tuberosity of the maxilla
on the lateral radiogram or photograph from the superior
margin of the acoustic meatus to orbitale.
B.P.-N Bolton Point-Nasion Line.
Bjork's Line. Nasion to the point on the lateral
Cephalometric Landmarks, Lines, Planes and Angles' 189
90.
Clivus
SphercccipitaI
syro:hondrosis
NS
A GCf1Ion-'-
Fig. 15-7. (A) Landmarks and measure points for clinical use in cephalometries: deCoster's line (the planoethmoidal line) includes
the anterior contour of sella, the cribriform plate, and the internal plate of the frontal bone; orbital plate, the anterior contour of sella
and roof of the orbit; cribriform plate of the ethmoid, the horizontal plate that articulates with the
j, ethmoidal notch of the frontal bone; sphenoid plane. the top of the sphenoid bone; ethmoid registration point, on the sphenoethmoid line
between the greater wings of the sphenoid. The rest of the landmarks and measure points are defined in the text. (after A. W.
Moore) (B) Planes using various craniometric points: 1, Broca's plane; 2, His' plane; 3, Martin's plane; 4, Huxley's plane; 5, Hamy's
plane; 6, Schwalbe's plane; 7, the anonymous plane; 8, Schmidt's plane. (8 Courtesy W, M, Krogman)
and the anterior curve of the pterygoid process of the

sphenoid.
Ramus Line. A line tangent to the posterior border of the
mandibular ramus, from (1) a point posterior to the
mandibular condyle, (2) a point immediately below the
condyle, or (3) from articulare.
Ricketts' Esthetic Line. A line tangent to the tip of the nose
and the most anterior point on the chin.
Salzmann's Basal Arch. The area in the jaws that begins at
the most constricted point on the body of the maxilla and of
the mandible when seen on the lateral cephalogram. It
includes Downs' A-Point (subspinale) in the maxilla and B-
Point (supramentale) in the mandible, Axel Lundstrom's
apical base (which is a line around the apices of the fully
formed permanent teeth) and extends around the ja;""s at the
most constricted portions of the alveolar processes. These are
the areas to which Tweed referred as "basal bone."
S-N Line. Line connecting sella (5), representing the
center of the sella turcica, with (N), the midpoint of
frontonasal junction. This line denotes the anterior portion of
Fig. 15-8. Commonly used landmarks: N-nasion, Cond.
the cranial base in cephalometries.
condylion, Po-pogion, ANS-anterior nasal spine, A-point; B-
point, Pg-pogonion, Go-gonion, Pg-Go-length of the
mandible from pogonion to gonion, and Pg-Cond.-length of
the mandible from pogonion to condylion.
Angles N-A-Pg. Nasion-A-Point (subspinale)-pogonionangle of

facial convexity.
BP-SN (Broadbent). Formed by the lines Sand S-B.P.
S-N-A. Sella-Nasion-A-Point (subspinale). An-
By connecting the points B.P. and N, the Bolton plane
teroposterior relationship of the maxillary basal arch to the
(BP-N) is obtained and the angles S-BP-N and SN-BP
anterior cranial base. This shows the degree of maxillary
may be ascertained.
prognathism.
Convexity Angle (Downs). (N-A-Pg.) - NasionA-Point
SNA-SNB. The angle formed by sella-nasion APoint
(subspinale)-pogonion.
(subspinale) and sella-nasion B-Point (supramentale). It
Facial Angle (Downs). FH-NPg-Frankfort Horizontal
indicates anteroposterior relationship of maxillary and
intersection of nasion-pogonion line (inner lower angle).
mandibular basal arches to the anterior cranial base.
The facial angle establishes the anteroposterior relation of
S-N-B. Sella-Nasion-B-Point (supramentale) shows the
the mandible to the upper face at the Frankfort horizontal.
anterior limit of the mandibular basal arch in relati on to
FMIA (Tweed). Frankfort-mandibular incisor angle.
the anterior cranial base.
This is used to measure the procumbency of the
Y-Axis (Downs). Frankfort horizontal, the sellagnathion.
mandibular incisor to the Frankfort plane.
Downward and forward mandibular growth indicator. It is
MIA. Mandibular plane-mandibular incisor angle.
read at the angle toward the profile of the face below the
This is used to measure the procumbency of mandibular
Frankfort horizontal.
incisors to the mandibular plane.
-S-MP. Projection of line N-S with a tangent to the
mandibular plane. 91.
LIMIT A nONS OF RADIOGRAPHIC
CEPHALOMETRICS
The reliability of landmarks, lines, planes, and angles
employed in cephalometric analysis is subject to
inaccuracies, and misinterpretations because of the
variations in growth and development of the individual
bones over which these are drawn. For example, the sella-
nasion line, which is used to denote the anterior cranial
base to which the upper face is attached extends across the
sphenoid, ethmoid, frontal, and nasal bones.
There is no bilateral morphologic symmetry in the face,
or anywhere else in the body. When the three-dimensional
human face is measured on a cephalogram or tracing which
presents a flat surface, the abnormal variations may be
masked or distorted and the findings cannot be accepted as
I I
, I
\ I
Cribriform Plate I I
Ethmoid ,
t
,
I
, I
Sphenoid ,,' , ,
," I
Platle . /
.,f
, "I
,
Fig. 15-9. Landmarks and measure points for clinical
cephalcrnetrics: 5, sella turcica; N, nasion; 0, orbitale; A S,
anterior nasal spine; A, A-Point; B, B-Point; Pg, pogonion;
Gn, gnathion; M, menton; G, gonion; PNS, posterior nasal
, ~ , t
/; , I
/Re::Jistratlon Po'l n\,

\
. {~
EthmOid ,"
spine; Ptrn, Pterygomaxillary fissure; Bp, Bolton point; P,

porion; SO, sphenooccipital synchondrosis; R, Broadbent
registration point. The BroadbentBolton construction for
" " . ,# ~'
"
"'"
superimposing cephalograms to determine facial growth is Fig./ 15-10.

.... .............
Anterior cranial basereat Wi ngs
registration
" .>and
points .>: Of Sphenoid
lines. (Ethmoid triad, Moore, in
the triangle Bp-5-N; the line Bp-N. The registration point,
R is midway on the line from the sella at right angles to the ,.,,
solid
, lines). Planum sphenoethmoid line inter-
line Bp-N. ,
"
wing registration. (after A. W. Moore.)
I,'
Radiographic Cephalometric Reference Lines' 191
absolutely accurate. Nonetheless, cephalometries serves an

important purpose in clinical orthodontics.
Since the cranial base shows little growth change, the
Broadbent-Bolton construction using "R" point is reliable for
serial growth studies that seek to record dentofacial growth
I changes, especially in the lateral (profile) view.
,
RADIOGRAPHIC CEPHALOMETRIC
REFERENCE LINES
Cranial Base Reference Lines
1. The Bolton line. (Bolton point-nasion BP-
2. The sella-nasion line. (S-N)
3.The spheno-occipital synchondrosis-nasion line. (SO-N)
4. The Frankfort horizontal, because of its close relation to
the cranial base, may also be used. (FH).
Mandibular Reference Lines
Fig. 15-11. Areas of the head: the cranium is shown in
1. A line tangent to the lower border of the mandible.
slanting lines; upper face in stippled area; teeth and alveolar
When the mandibular border shows a decided downward
area in dark horizontal lines, and mandible in vertical lines.
curvature it makes this plane highly variable.
(after W. B. Downs)
2. A line joining gonion and menton. Both points show
changes during growth. Middle Face Reference Lines
3. A line joining gonion and gnathion. These points 1. The palatal plane, joining ANS and PNS. These
change during growth. landmarks are frequently difficult to locate on the lateral
radiogram.
2. The occlusal plane which bisects the maxil-
Fig. 15-]2. Lines and planes. Cranial base planes: S-Na, ANGlfS
lFO< SKELETAL ANALYSIS!
sella-nasion; Bo-Na, Bolton plane; So-Na, sphenoccipital
suture-nasion; Po-Or, Frankfort horizontal. Facial planes: Fig. 15-13. Skeletal criteria. Angles S- a-A and 5- a-B and
palatal, occlusal and mandibular planes. Note 3 possibilities the difference between them for anteroposterior apical base
for mandibular plane; also facial plane, Y axis, orbital plane appraisal. (Downs's facial angle, Fh-Na-Pog, fits into this
and ramal plane. In clinical analyses the orbital plane and the group, too.) Na-A-Pog angle. Palatal, occlusal and
ramal plane are seldom used. mandibular plane angles with any of the base planes.
lary first molar cusps and incisor overbite. Location of the and contributes to the position of the mandible in a
occlusal plane on the lateral radiogram is highly downward and backward direction. Continuing ramus
subjective. growth can produce forward and downward rotation of the
3. One of the mandibular planes may be used, especially mandible.
in relation to mandibular denture changes. Anteroposterior Maxillary Mandibular Relation.
Pterygomaxillary Fissure as a Reference Line. The In addition to being influenced by length of the ramus, the
pterygomaxillary fissure maintains a relatively constant size of the gonion angle, and the positon of the glenoid
position anteroposteriorly in relation to the cranial fossa, anteroposterior relationship may also be modified
landmarks during growth but moves downward in relation when extraoral force is used which can elongate the molars
and force the mandible to assume a more distal rotation.
to sella-nasio or to the Bolton plane. Registration at the
Usually, this change is only temporary. Condylar growth in
pterygomaxillary fissure is used for observing the effect of
the mandible may be upward, backward, or both, and thus
orthodontic treatment on the dentition as well as on the
also influence mandibular position and rotation.
maxillary growth pattern.
Gonion Angle. Cephalometric gonion angle is obtained
on the lateral radiogram by drawing a line tangent to the
postcondylar point and the most distal side on the ramus of
Variations of Landmarks
the mandible and another line on one of the three
All landmarks, planes and angles show variations. mandibular planes used. The gonion angle shows
The more variable landmarks and measuring points are downward change in the later adolescent growth period as
Bolton point, basion, porion, pterygomaxillary fissure, the mandible rotates forward.
orbitale. gonion, anterior and posterior nasal spines, and A-
Point and B-Point (Downs).
Height of the Maxilla. Vertical height of the maxilla
largely determines the height of the face
COMPONE TS OF CEPHALOMETRIC
ANALYSIS
Cephalometric analysis includes profile, skeletal, and
denture analyses. In clinical practice, these
ANGLES (FOR PROFI LE ANALYSIS) PLUS

SOFT TISSUE APPRAISAL
(LIP CONTOUR. POSITION. THICKNESS)
Fig. 15-14. Profile criteria. FH- a-Pog (Downs
facial angle) for anteroposterior mandibular ap- Fig. 15-15. Denture criteria. Inclination of mandibular
praisal. S-Na-A for anteroposterior maxillary incisors with mandibular plane or Frankfort plane. Upper
appraisal. Size and shape of nose; thickness, and lower incisor long axes angle. Upper incisor long axis
length and posture of lips; morphology of tissue angle with anyone of the 4 basal planes. Linear distance, in
over mandibular symphysis.
millimeters, of maxillary incisor tip from facial (Na-Pog)
plane.
92.
Components of Cephalometric Analysis 193
three components are given weight in relation to other

diagnostic aids.
Cephalometric Profile Analysis

This permits an appraisal of the soft tissues that cover
the skeletal facial profile. The appearance of the facial
profile is influenced also by the facial skeletal dimensions,
the amount and tonicity of the soft tissues, and the habitual
posture of the head. Reduction in lip prominence is not
always related to tooth change but depends largely on
muscle thickness and tonicity, mimetic muscle habits,
allergic grimaces, and even psychosomatic involvements.
Alveolar bone changes brought about by orthodontic
therapy mayor may not influence the soft tissue profile.
Mandibular Position Changes. Condylar growth of the
mandible in the glenoid fossa may be upward or backward
or in both directions and thus influence mandibular
position and rotation.
Maxilla to Cranial Base Changes. A-Point, nasion,
anterior nasal spine, and the lowest point of the V in the
pterygomaxillary fissure can be used to construct lines or
planes to denote the relationship of the maxilla proper to
the cranial base. Anteroposterior size of the maxilla and its
relationship to the cranial base and to the mandible
determine the anteroposterior denture relation and the
Fig. 15-16. Registration of the A-Point:
character of the profile and contribute to face height.
1, Limit of septum from anterior nasal
spine; 2, The A-Point is placed on labial
plate shown on the profile cephalogram, as
suggested by A. E. Howes.
Cephalometric Skeletal Analysis

Skeletal analysis is concerned with the recognition of
facial type and the appraisal of anteroposterior basal arch
relations. This is especially important in analyzing and ,
diagnosing Class II and Class III malocclusion. It can be
accomplished by relating Downs A-Point and B-Point to
" \
I
nasion or to a point on the anterior cranial base (S-N). The
I
relative anteroposterior position of A-Point to the cranial
base gives an indication of the amount of the maxillary
bone and basal arch protrusion or retrusion.
Sella-Nasion Line Changes. Sella-Nasion line changes
can occur in upward, forward and downward directions.
These changes influence measurements of the S-N-A, S-
N-B, and S-N-Pg angles. The thickness of the frontal bone
at nasion, which is included in measuring S- ,shows
marked increase to age 7 years and continues to grow at a
lesser rate to adult age as the frontal sinus enlarges. The
posterior portion of the cranial base also increases into
adult age.
A-Point- B-Point. A-Point and B-Point (Downs) express
J
the anteroposterior relationship of the maxil- ___ oJ".'
Fig. 15-17. Superimposition for determining over-all

facial growth using the Broadbent-Bolton construction.
r 94.
93.
would force the apices of the incisor teeth through the
labial bony plate. There is a great difference in the
relationship of A-Point to B-Point and A-Point to the base
A ~,
. ,
of the cranium, dpending on where A-Point is located.
Frankfort Plane Changes. The orbitale moves downward
between age 5 and 7 years; and porion moves downward
y
,ifw and backward relative to the cranial base. The Frankfort-
mandibular angle also changes.
Y-Axis (Downs). The Y-axis extends from sella to
gnathion. This line and the facial line that forms the nasion
and the pogonion are used for measuring the relative
protrusion or retrusion of the mandible and of the dentition
in relation to the facial profile. ALI of these measure points
and landmarks show variability during growth.
Basal Arch Changes. The A-Point and B-Point
landmarks which express the anteroposterior relationship
of the maxillary and the mandibular basal arches and the
Y-axis show the least change with age. The occlusal plane
shows reduction of steepness with age. Tooth and jaw
discrepancies actually are tooth and basal arch inequalities
B ..., which may be unimaxillary or bimaxillary as a result of
,, which there may be crowding and impaction of teeth and
, procumbency of the incisors.
\\ \' ~I
0
1
I ( , I
Frankfort-Mandibular Plane Angle. The Frankfort-
mandibular plane angle is affected by the length of the
mandibular ramus, the position of the glenoid fossa in the
'
vertical dimension, and the length of the facial profile from
) ... J
Fig. 15-18. Two ways of determining nasion to gnathion.
changes in the maxillary dentition: (A)
Superimpose the radiogram at the anterior
nasal spine or (B) at the pterygomaxillary
fissure.
lary and the mandibular basal arches. Both A-Point and B-
Point change during growth. A-Point is on alveolar bone;
B-Point may be on alveolar bone or on the body of the
Cephalometric Denture Analysis
mandible itself. Howes pointed out that attempts to tip the
incisor roots labially through the bony eminence on the Denture analysis includes an appraisal of the
outer edge of the bony septum where A-Point is usually relationship of the maxillary and mandibular dentitions to
located each other and to their respective bony
Fig. 15-19. Superimposed

tracings of the mandible
show changes due to growth
and resorption in the chin
region before and after treat-
ment: (A) superimposed on
pogonion and lower border of
mandible; (B) superimposed
A on posterior and lower
borders of the mandible; (C)
superimposed on inner table
of the chin and lower border
of mandible. C gives an ac-
curate picture of the type of
change that actually occurred
in the mandible. (After C. W.
Adams)
Evaluation of Growth and Orthodontic Therapy Changes' 195
bases. The maxillary-mandibular inter-incisor angle is

subject to functional changes and pressure habits.
95.
EV ALVA TION OF GROWTH AND
ORTHODONTIC THERAPY CHANGES
Superimposition of Cephalometric Tracings.
Registration and superimposition should be related to
areas that show the greatest amount of relative stability.
Landmarks used for investigating changes should be as
close as possible to the area under consideration, rather
than at distant points.
Analysis of Maxillary Dentition Changes. Changes in
the maxillary dentition are measured from the maxillary
central incisor and first molar. These points can be
utilized in establishing the spatial relationship of the
maxillary dentition to the craniofacial complex.
Analysis of Mandibular Dentition Changes. Mandibular
dentition changes are measured in relation to the base of Fig. 15-20. Cephalometric tracing showing Freeman and Rasmusson's
the cranium and the maxilla as follows: 1. Relation of method of determining anteroposterior maxillomandibular basal
pogonion, menton, or gnathion at the intersection of the difference. The line A-X is perpendicular to the S-N plane (anterior cranial
base) and does not depend on the position of the nasion (N). This
mandibular plane and the facial line (N-Pg).
measurement has diagnostic value in treatment planning of Class II and
2. A line at the mandibular plane where it bisects a line Class III (Angle) malocclusions.
tangent to the posterior border of the ramus or from
articulare to gonion.
---
'~
,
,,
......
..... _--~ .....~-...;
.... -
r
/
~
2
...
3 MOS.
YRS. -BI9S9-
STANDARD
MW
Fig. 15-21. Pre- and posttreatment cephalometric tracings Fig. 15-22. Tracings from lateral radiograms show defective
superimposed on the relatively stable S-N line with the point of growth of the face during the first 9 months. The points mark the
registration at S. This shows the combined changes resulting position of the incisal edge of the deciduous central incisor from
from facial growth and orthodontic treatment. Growth changes 3 months to 2 years for a comparison of abnormal with normal
are shown more accurately than orthodontic changes because the growth. Vertical growth is normal but anterior and posterior
superimposition at the anterior cranial base is comparatively development up to 9 months are retarded. (Courtesy B, Holly
remote from the dentition, Broadbent and the Bolton Fund)
3. A line from A-Point (subspinale) to nasion to B- lation of the maxillary and the mandibular basal arch
Point (supramentale), the A-N-B angle. limits at A-Point and B-Point.
Suggested measurements of the axial inclination Mandibular Growth Changes. Registration at the gonion
of the incisor teeth are as follows: area will show condylar growth and forward growth of the
1. The maxillary incisors to Frankfort horizontal body of the mandible, especially at the symphysis. The Y-
2. To the nasion-pogonion (N-Pg) line axis is used for determining the direction of chin growth
3. To the mandibular plane in relation to the upper face.
4. To the sella-nasion (S-N) line Orthodontic therapy changes in the mandible can be
5. To palatal line (ANS-PNS). evaluated by superimposing the cephalometric tracings on
Dental and skeletal growth changes are established as the outer limit of the symphysis, the inner table of the
follows: (1) relationship of the axial inclination of the symphysis, the posterior border of the ramus, or the
maxillary incisors to any of the cranial base lines; (2) mandibular plane. Actual increase in growth of the
relation of the mandibular incisors to the mandibular mandible, condylar growth, and the eruption pattern of the
plane; (3) relation of the maxillary and mandibular teeth can thus be evaluated.
incisors to each other; and (4) relation of the mandibular Ramus, Condyle Changes. Superimposition on the
incisors to the facial line. symphysis of the mandible will show if there was an
Overall Facial Growth Analyses. Overall facial growth increase in the posterior part of the ramus and in the
changes in relation to the base of the cranium are condyle; it also reflects changes in the position of the
obtained by superimposing pre-and posttreatment teeth.
cephalograms on the Broadbent-Bolton Triangle. This is Intramandibular Changes. Intramandibular
defined by R (registration) point situated midway on a changes are obtained by superimposition upon the
line from the center of sella and perpendicular to the symphysis and the lower border of the mandible. Relia bili
Bolton-nasion line. ty decreases posteriorly along the lower border of the
Maxillary Growth Changes. Superimposition is with mandible. Gonion changes not only through backward
anterior nasal spine (ANS) or posterior nasal spine (PNS) growth but also in a vertical and horizontal direction.
as the registration point. With A S registered, are shown Dental Growth Changes. The following registration
the posterior growth changes of the maxilla and maxillary points are used: the anterior nasal spine (ANS), A-Point,
teeth in the direction of the pterygomaxillary fissure. B-Point, and pogonion. Points at the most anterior limits
Superimposition on the pterygomaxillary fissure shows of the facial skeleton are preferred. A-Point and the
whether the teeth have been moved distally and whether pogonion are the most commonly employed. The incisors
the anterior nasal spine, i.e., the alveolar process, has are related to the facial line (nasion-pogonion).
grown forward. When PNS, or the point on the BIBLIOGRAPHY
pterygomaxillary fissure is registered, changes are
observed in the forward growth of the maxilla and the
maxillary dentition.
Angle S-N-A is used as an indication of the antero-
posterior position of the maxilla to the anterior cranial
base. The angle A-B-S-N indicates the re- The bibliography for Chapter 14 covers topics in
Chapter 15 also. Please see page 181.

1 96.
6 Analysis
Cephalometric
THE DOWNS ANALYSIS TABLE 16-1. STANDARDS FOR DOWNS'

Downs' rationale for the basis of his analysis is, FACIAL TYPES
"While individuals vary greatly in facial type and
pattern, those possessing optium oral health, functional C
Facial
balance and esthetics have certain common profile
B Line
characteristics." Facial to
The Downs analysis portrays the interaction and A Line Bolton-
intercompensation of the various line, plane and angular Control Facial to Nasion
dimensions and indicates whether dysplasia outside of Series Angle S-N Line
his range or normal variation is present in the facial Case 82 to 95 74 to 86.5 63 to 75
skeleton, the dentition, or in both. Departure from mean Number Mean, 87,8 Mean, 80 Mean, 69
values consistent with type as outlined by Downs are not
A 82 82 58
to be regarded as indications of abnormality. The range
of values is more significant than the means in the B 88.5 81 64
cephalometric assessment of the jaws and dentition, ac- C 90 87 69
D 96 89 69
cording to Downs.
Downs' Facial Types nathic, protrusive lower face but within normal range;
and (4) true prognathism pronounced protrusion of lower
Downs describes four basic types of faces: (1) ret- face.
rognatic, a recessive lower face; (2) mesognathic, The various facial types differ in the relative
average or ideal facial type (orthognathic); (3) prog- anteroposterior position of the mandible and in
Fig, 16-1. Downs' basic facial

types: (A) Retrognathic, (B)
mesognathic, (C) prognathic, (0)
prognathism. These are oriented
on the Frankfort horizontal. Al-
though the basic facial patterns
are different from each other,
they nevertheless represent
balance and harmony for their
type. B c D
19
7
198 . Cephalometric Analysis 97.
the degree of convexity or concavity of the facial profile.

The lateral (profile) radiogram is outlined according to
the following landmarks, lines and planes:
N
Landmarks Used on Lateral Cephalograms
N Nasion
S Center of sella turcica H
P Porion (cephalometric) I
BP Bolton point
R Broadbent registration point
o Orbitale
A~Point Subspinale
OP Occlusal plane
B- Point Supramentale MEAN
Pg Pogonion 87.8
Gn Gnathion
G Gonion
Lines, Planes and Angles Used on Lateral

Cephalograms
Pg
Pg Facial line
FH Frankfort plane
G-Gn Mandibular plane
820 95 ANGLE
Bo- N Bolton nasion line
Fig. 16-2. Facial angle, the lower and inner
S-Gn Y-axis
angle formed by FH and N-Pg plane, shows the
SN Sella-nasion line Downs range and mean. It expresses the degree
ANS-PNS Palatal line of recession or protrusion of the mandible.
Ba-N Basion-nasion line
N-A-Pg Angle of convexity or concavity The facial angle indicates the degrees of recession or
FA Facial angle protrusion of the mandible in relation to the upper face at
AB Denture base limits the Frankfort horizontal related to the facial line (N-Pg).
SNA Sella-nasion-A-point Angle of Convexity. Downs range: 180 (straight line)
SNB Sella-nasion-B-point + 100 (convex) to -8.50 (concave); mean 180 or 0. The
angle formed by the intersection at A-Point of a line from
Downs' Measurements and Normal Ranges nasion to A-Point and pogonion to A-Point. This angle
measures the degree of protrusion of the maxillary basal
Facial Angle. Downs range: 82 to 95; mean 87.8. arch at its anterior limit (A-Point) in relation to the total
Read at inferior inside angle where facial line (N-Pg) facial profile line (N-Pg).
intersects the Frankfort horizontal (FH). A prominent chin
tends to increase the facial angle.
TABLE 16-2. DOWNS CEPHALOMETRIC STANDARDS
Standard
Minimal Maximal Mean Deviation
Cant of occlusal +1.5 +14 + 3.83

plane II to IT * 130 150. 9.3 5.76
IT to mandibular plane - 5 135.4 3.78
IT to occlusal plane 8.5 + 91.4 3.48
Distance II to facial convexity plane A-Pg +3. 7 +14.5 1.8
5 +2 +
Maxillary central incisor to mandibular central incisor or most protrusive incisors as seen
0 on the lateral cephalogram. 2.7
-1 mm
. + 5 mm.
98. The Downs Analysis 199
I~
II
l II
/z"
_---.!:.H----l. _. _\.
~
o,-!l IIJ
II II
8.5'
II
- 9'
11
JI---- 0
d
"'I~A
q"'"
Fig. 16-3. (Left; The angle of convexity (NAP)
measures the protrusion of the maxilla in relation
to the total profile. It is read in plus or minus
r
degrees from 0, the facial line from N to P. 1 A is
I
anterior to the facial line, it indicates convexity (+x

degrees); if posterior to the facial line, it is a
concavity (-x degrees). (Right) The line connecting
points A (subs pinal e) and B (supramentale) in
relation to the facial line is a measure of the
relation of the anterior limits of the denture bases
to each other and to the profile.
Fig. 16-4. (Top) The mandibular plane angle is employed in
measuring the relationship between the Frankfort plane and a
tangent to the lower border of the mandible. The mandibular
plane angle tends to increase as the facial angle decreases.
When the angle at A-Point is 180, it falls inside of or on (Bottom) The Y axis. A line from the sella turcica to the
the facial line; the maxilla is retrognathic (concave). If the gnathion expresses the direction of facial growth.
angle at A-Point falls to the right or outside of the facial line,
the angle of convexity is designated as plus (+); if to the left
or inside of the facial line it is designated as minus (-).
A- B line. Downs range: 0 when the plane is parallel with
the facial line to -.)0, indicating a position of B-Point to the
left or posterior to A-Point. Mean is --4.8. This line connects
A-Point and BPoint and is used as a measure of the relation
of the anterior limit of the basal arches (denture bases) to
each other and to the facial line. It presents an estimate of the
___ ~- ('-tl-L_(
difficulty to be encountered in obtaining the correct axial
inclination and incisor relationship. It is measured as the
angle at A-Point from the point of intersection of the A-B
line with the facial line.
Mandibular Plane Angle. Downs range: 28 to 17i mean
21.9. This measures the angle formed by a li~e tangent to
the lower border of the mandible and the Frankfort
horizontal. A long ramus tends to decrease this angle.
Y-Axis. Downs range 66 to 53; mean 59.4. A line from
sella turcica to gnathion or the intersection of the facial and
mandibular lines as seen on the lateral cephalogram. The Fig. 16-5. The cant of the occlusal plane to the Frankfort
angle is read at the right inferior angle at the Frankfort horizontal. The occlusal plane is represented as a straight line
horizon tal. This line by bisecting the first molar cusp height and the incisor
overbite. If the incisors are in extreme supraclusion or
infraclusion these teeth are disregarded, and the molars and
premolars are used.
(Y-axis) indicates the degree of downward, rearward, or

forward position of the chin in relation to
200 . Cephalometric Analysis
99.
MEAN 1045
Fig. 16-6. The axial inclina-

tion of the maxillary and man-
dibular incisors measures the Fig. 16-7. The angle of the intersec-
degree of procumbency of the tion of the axial line of the mandibular
incisor teeth. Lines are drawn incisor and the occlusal plane is re- Fig. 16-8. Downs used the lowest
through the long axes of these corded as degrees of deviation from a point at menton in the midsagittal plane
teeth and the inside angle is right angle. Thus 97 is +7D; 81.5" is - as the anterior tangent point to
read. 8.5; and 93.5 is +3.5. (Downs, W. S.: determine the mandibular plane. The
Am. J. Orthodontics, 34:812, 1948) incisor-mandibular plane angle is
formed by the intersection of the man-
dibular plane and the incisor axis.
(Downs, W. S.: Am. J. Orthodontics,
34:812, 1948)
the upper face at Frankfort horizontal. A prominent chin of the mandible at the midsagittal plane (menton). The axial
tends to decrease the Y-axis angle. A long facial profile (N- relation of the mandibular incisor to mandibular plane is
Gn) or retrognathic mandible also tends to increase the Y- indicated as plus or minus from the 90 perpendicular to this
axis angle. base line.
Relation of Dentition to Facial Skeleton

Cant of the Occlusal Plane. Downs range: +14 to 1.50;
mean 9.3. This is the angular relation between the occlusal
plane and the Frankfort horizontal. The occlusal plane may
be located by bisecting the cusps of the permanent first or
second molars, when these are fully erupted, otherwise use
the deciduous second molars and the incisor teeth. Openbite
and extreme overbite tend to modify this measurement.
Interincisor Angle. The interincisor angle shows tile axial
inclination of maxillary and mandibular incisors to each
other. Downs range: 130 to 150.5; mean 135.4. This +- 5
measures the degree of procurnbency of the incisor teeth. .
..,.
Lines are drawn through the axes of the most forward
incisors.
Incisor-Mandibular Plane Angle. Downs range: ----8S to
+70 (81.50 to 97'); mean 1.4 (91.4'). Downs used a line I MEAN +- 1.8 MM
which passes tangent to the mandibular border in the region

of gonion and the lowest point Fig. 16-9. The distance from the maxillary
incisor to the A-P line measures the amount of
maxillary incisor protrusion. (Figures 16-1 to
16-9 courtesy of Downs, W. S.: Am. J.
Orthodontics, 34:812, 1948)
100.
The Downs Analysis . 201
Fig. 16-10. Polygonal portrayal of facial

measurements. (Courtesy W. L. Wylie and
E. L. Johnson)
Fig. 16-11. (Below) In the cephalometric

employed by Ricketts, the mandibular plane is
constructed from the lower border of the angle of
the mandible to the lower border of the
symphysis at the midline, labeled M. In clinical
usage, Gn is located at the point of intersection
of the facial and mandibular planes. Technically,
it is downward and forward in position on chin at
crossing of Y axis (S-Gn). N-Po, facial plane; A-
Po, denture plane. The tip of lower incisor is
related at distance from A-Po plane (4). (After R.
M. Ricketts)
Mandibular Incisor- Occlusal Plane Angle.

Downs range: +3.5 to +20; mean +14.5. This relates
the incisors to their functioning surface at the occlusal
plane. The inferior inside angle is read, and the plus or
minus deviations from a right angle are recorded.
Protrusion of Maxillary Incisors. Downs range: +5
mm. to -1 mm., mean, 2.7 mm. This is the distance of
the incisal edge of the maxillary central incisor to the
line A to Pg; it indicates the amount of maxillary dental
protrusion.
Fig. 16-12. Steps in estimating

changes in the cranial base and
mandible during treatment: (A)
Increases in S-N and S-Ba are
projected, and a new Ba-N is
constructed. (B) Location of the
condyle is shown. (e) The
Pterygomaxillary fissure and
coronoid process are oriented.
8a (D) The condyle axis (RR' plane)
is shown. The degree of bite
c opening is evaluated and the
A B
amount of condyle growth is
predicted. (E) Growth is added to
the mandible. The form of the
ramus and processes are out-
lined. (F) Changes in relation of
the body to the ramus are
forecast and increases from the
condyle axis (point R) to the
symphysis are estimated.
(Courtesy of R. M. Ricketts)
o E F
TABLE 16-3. UNIVERSITY OF WASHINGTON STANDARDS*
Relationship Measurement
Mean Range
Mandible Facial angle 87 82 to 95
to Cranium S-N-Pg 80 72 to 88
A-N-B-Point +2 -1 to +5
Mandible
A-B Line -4.5 0 to --90
to Maxilla Angle convexity 0.0 -8S to
10
Mandible S-N-A N-A 81 75 to 87
to Cranium to FH
90 84 to 96
1 to 1 135 1300 to
Mandibular Dentition Occlusal plane 150
9 P to 14
to Overbite 3mm. 1 to 6 mm.
Maxillary Dentition Overjet 1 to 2 mm. 1 to 4 mm.
Molar relation
Chin Prominence
Pg to -B-Point
("Chin Button") 3mm. 2 to 5 mm.
I to mand. plane 91 82 to 97
MAND ! to ocd. plane 14 3S to 200
Axial . ! to N-B, 23 8 to 40
Inclination degrees
(
1to N-B, +4mm. 1 to 10 mm.
of
110 99 to 121
l
Teeth mm.
18 3 to 31
Ito FH, degrees MAX. I
to N-A, degrees 1 to N-A, 3mm. -2 to 8 mm.
mm. 59 53 to 66
Y-axis Mandibular
Growth plane % of nasal 22 17 to 28
Potential height 43% 3%
Interrela tionshi ps:

a. I to N to B-Point (Angle convexity, Gatti)
I to N to B-Point, to A to N to B-Point (Holdaway)
b. I to FH Plane (65; range 52 to 78, Tweed)
c. I to N to B-Point to Pg to N to B-Point (1-3 mm. or 3-5 mm., Holdaway)
Courtesy of Alton W. Moore.
The University of Washington Department of Orthodontics 85.4 3.7. One degree represents 1.5 mm. of difference in
has established standards based on those of Downs, with position of the chin relative to the nasion point. Downs' mean
modifications, as shown in Table 16-3. is 87.7, and the range is 82 to 95. Facial angles 80 are
retrognathic, those 85 are orthognathic, and 90 are prognatic.
X. Y Axis. A line from sella to gnathion. The X- Y axis is
RICKETTS' ANALYSIS an indicator of facial height. This is measured where the X-
Y axis crosses the basion-nasion line. A difference of
Ricketts established five minimum cephalometric one degree represents almost 2 mm. of height relative to
measurements: (1) facial angle, (2) X- Y axis, (3) maxillary depth. The average angle is 93 or plus 3. The range of
incisors to A-Pg line, (4) relation of mandibular incisors to A- variation is from -12 to +29, with a standard deviation
Pg line, and (5) facial contour, which he calls esthetic plane of 3. This suggests that X- Y measurements less than
(line). This is measured from the tip of the nose to the tip of zero tend towards greater length in facial form as
the chin. opposed to depth.
Facial Angle. As established by Downs, the superior border The X- Y axis is considered plus if it is more than
of the external auditory canal is used in constructing the
Frankfort horizontal. The mean is
101. The Margolis Maxillofacial Triangle' 203
90 and minus if it is less than 90. Those with less than reference line describes facial esthetics and lip position.
90 are retrognathic. The lower lip is, on an average, 0.3 mm. forward of this
Maxillary Incisors to A-Point-Pogonion Line. line with a standard deviation of 3.0 mm. The upper lip is
The A-Paint-pogonion line is an indicator of denture on an average 1.0 mm. posterior to the lower lip when
position in relation to the facial line. This is 5.7 mm., with related to the facial esthetic line. The mean is -7 mm. At
a range from -8 mm. to + 15 mm. One standard deviation age 11 to 14 years there is on an average practically no
is the equivalent of 3 mm. variation of the lower lip to the facial esthetic line. In
Mandibular Incisors to A-Point-Pogonion Line. adults the difference is -4 mm.
The average mandibular incisor tip is located ap-
proximately 0.5 mm. anterior to the A-Pg line. One
standard deviation is 2.7 mm. The range of variation is
THE MARGOLIS MAXILLOFACIAL TRIANGLE
between +10 mm. and -10 mm. The mandibular incisor
inclines on an average 20.5 to the line A-Pg. One The Margolis maxillofacial triangle is a means for
standard deviation of inclination is 6.4. The range of measuring the overall facial growth pattern. It reveals the
angulation is from -11 to +53. The range of standard relative difference in size and relationship of specific
deviation is 15 to 2r. maxillofacial areas to each other.
Facial Contour. This is A-Point related to the facial line.
It is used to determine the relationship of the maxilla to
the mandible as seen in the bony profile. At the usual Lines
distance from nasion to A-Point 1 degree of difference The three sides of the Margolis maxillofacial triangle
from the line N-A to the facial line equals about 1 mm. on are: (1) the cranial base line, N-X; (2) the facial line, N-
an arc from A-Point to the facial line. Therefore, direct M, and (3) the mandibular line, M-X.
measurement from A-Point to the facial line is used to The Cranial Base Line. The cranial base landmarks are
measure variation of the profile from a straight line. A from nasion (N) through the cranial edge of the spheno-
reading of 10 mm. distance from A-Point to the facial line occipital synchondrosis SO.
is about 20 of convexity, as measured by Downs, or The Facial Line. The facial line extends from nasion (N)
about half that of the angular value in millimeters. There through pogonion to the point of intersection with the
is an average of 4.1 mm. and a standard deviation of 2.8 mandibular plane at M.
mm. Faces with a convexity or concavity of not more than The Mandibular Line. The mandibular line runs tangent
2 mm. are regarded as being orthognathic. Those with up to the inferior border of the mandible and intersects the
to 5 or 6 mm. convexity or concavity are classified as facial line at M and the cranial base line at X.
moderately convex or concave. At 10 mm. or over, the
faces are severely convex or concave.
Facial Esthetic Line. The facial esthetic line extends
from the tip of the nose to the end of the chin. This Angles
The angles of the maxillofacial triangle are the
following:
N
Fig. 16-13. The maxillofacial triangle and

other anatomic landmarks: al , long axis of
maxillary incisor; b l, long axis of mandibular
incisor; 2, intersection of a 1 with cranial base,
forming incisor-cranial base angle; 3, cranial x
edge of sphenooccipital synchondrosis; 4,
articulare (Bjork); 5, base of occiput posterior 6
to foramen magnum; 6, projection of occlusal
......-.....
6
surface of maxillary and mandibular first
permanent molars; 7, pogonion -anterior point
on chin protuberance; 8, Bolton point; 9,
projection of gonion on mandibular line; 10,
projection of mental protuberance (pogonion)
on mandibular line; 9-10, length of body of
mandible; 11, intersection of 1 with mandibular
line, forming the incisor mandibular (1M)
angle. (Courtesy H. L Margolis)
The Craniofacial Angle (XNM). The craniofacial angle

shows the anterior development of the body of the
mandible at pogonion. Standard is 72.8 2.36.
The Faciomandibular Angle (NMX). The facio-
mandibular angle shows the extent of vertical growth and
development of the mandible. Standard is 67.4 2.7r.
The Craniomandibular Angle (NXM). The cranio-
mandibular angle also shows the extent of vertical growth
and development of the mandible. Standard is 39.6
3.26.
The Mandibular Base Line. The mandibular base line,
when continued posteriorly, touches the occipital bone
posterior to the foramen magnum or falls above or below
it.
Facial Line: The facial line intersects the lingual
surface of the crown of a mandibular incisor.
Incisor- Mandibular Plane Angle. The incisor-
mandibular plane angle is 90 3. The smaller the angle
at N, the more the chin recedes. A large craniomandibular
angle indicates deviations in vertical development of the
mandible and may indicate a large gonion angle, a short Fig. 16-14. Bjork's facial diagram: N,
ramus, or both. nasion-the midpoint on the frontonasal
suture; S, sella turcica-the saddle angle,
the midpoint on the horizontal diameter
of the sella turcica; A, articulare-the
joint angle, the point of intersection of
BJORK'S FACIAL ANALYSIS the dorsal contour of the mandibular
condyle and the temporal bone as seen
Bjork devised a facial diagram in which the linear and on the profile radiogram; KK, the jaw
the angular configurations determine the amount and angle-the point of intersection between
distribution of facial prognathism. Profile radiograms tangents to the base and the ramus of
taken at a distance of 155 cm. were used. the mandible; DD, chin angle-the point
of intersection between a line tangent to
Bjork's facial diagram includes the following: A line
the base of the mandible and a line
from the apex of the anterior nasal spine to nasion, to the tangent to lD, infradentale, and PG,
center of the sella turcica, to articulare (the intersection of pogonion-the most prominent point on
the dorsal contour of the articular processes of the the chin; GN, gnathion-the lowest and
mandibular condyle and the temporal bone), to the point most inward point on the chin; PR,
of intersection of lines tangent to the ramus and to the prosthion-the lowest point on the
base of the mandible, to a point of intersection between maxillary alveolar process; SP, spinal
lines tangent to the base of the mandible and the point-the apex of the anterior nasal
pogonion, and from there to the infradentale point. spine. (After Bjork)
Change in any of the angles or lines of the facial
diagram devised by Bjork produces the effects on facial
prognathism indicated in Figure 16-14. articulare (6, the joint angle) formed by lines from sella-
Bjork uses a reference line on profile radiograms articulare-gonion (cephalometric, KK) shows the forward
through the cranial base from nasion to sella. The angle and rearward diversion of the mandible. Measurement of
formed at nasion is measured to four points (Fig. 16-15)
the gonion angle (7, KK) is made by a line from articulare
on the facial profile, i.e., (1) anterior nasal spine, (2)
and a tangent to the mandibular base. The angle at DD (8,
prosthion, (3) infradentale, and (4) pogonion. This
the chin angle) is measured by a line from infradentale
provides a method of measuring the facial profile in
passing through pogonion and a line tangent to the base of
relation to the cranial base.
the mandible.
Measurement of the angle at sella (5, the saddle angle)
The position of the head is denoted by an angle formed
formed by lines nasion-sella-articulare, or nasion-sella-
by a line bisecting another line through the anterior and
basion (9) provides a means of measuring the shape of the
the posterior margins of the foramen magnum to the
cranial base. The angle at
cranial base plane through sellanasion (10). A line from
bregma to nasion is bisected
102. Bjork's Facial Analysis . 205
and a perpendicular projected at this point to the forehead,

giving a fixed point on the forehead (11).
Angular Changes
Sella Turcica. Reduction of the angle at the sella
produces forward displacement of the temporomandibular
joint and forward displacement of the jaws with an increase
in prognathism of the facial profile.
Articulare. Reduction of the angle at the articulate
increases the degree of prognathism and shortens the height
of the upper part of the face. This brings the base of the
mandible more parallel with the base of the skull and
increases mandibular prognathism.
The Gonion Angle. Reduction of the gonion angle does
not increase facial prognathism and may actually reduce it.
Chin Angle. Reduction at the chin angle reduces
mandibular prognathism.
Fig. 16-15. This diagram indicates the

method of measuring from a cephalometric
radiogram the angles of prognathism (1-4); the
Linear Changes shape of the cranial base (5-9); the inclination
Shortening of the line from nasion to sella when the of the ramus (6); the jaw angle (7); chin angle
other lines are constant produces pronounced (8); the inclination of the forehead (11); and the
position of the foramen magnum (lD). (Bjork,
A.:
Fig. 16-16. Sassounis Svensk. Tand. Tid., 1947)
method of dentofacial analy-
sis. (Courtesy of V.
Sassouni)
"
increase in prognathism if the length of the face
remains unaltered. Shortening of the line from sella to
articulare increases prognathism and shortens the height of
/
the face, provided articulare remains unchanged. Increase / G
in the line from articulare to KK (the gonion angle)
increases mandibular prognathism. However, if the ramus
/
is parallel to the facial profile, there is no increase in /
./
prognathism. Increase in the length of the line from KK
(the X'
gonion angle) to DD (the chin angle) produces a nathism, according to Bjork, diminishes as growth
pronounced increase in facial prognathism. Increase in continues; the profile becoming straighter and the incisors
facial height produces a slight increase in prognathism. less procumbent.
Causes of Prognathism CROWDING OF THE TEETH
Facial prognathism is caused by the reduction of the Tooth crowding may be the result of the general
angle at sella or at articulare and an increase at the chin, reduction in facial depth, caused by shortening of the jaws
DO, a shortening of the cranial base, or an increase in the and not the result of lack of alveolar growth only. Bjork
length of the body of the mandible. found no difference in the procumbency of the mandibular
The prominence of the facial skeleton, in relation to the incisors in crowded dental arches when compared to arches
brain case, determines the general shape of the- facial with teeth in regular alignment. However, there is more
profile. Facial prognathism may be due to (1) shortening of crowding in shorter jaws.
the cranial base; (2) angular deflection of the cranial base;
(3) a small ramuscranial base angle; and (4) increased jaw
length.
Extraction of teeth in the' presence of facial prog- SASSOUNI'S RADIOGRAPHIC
nathism, as distinct from alveolodental prognathism, is of CEPHALOMETRIC ANALYSIS
little avail in the attempt to reduce prognathism of the
In order to study the structural configuration of the skull
facial profile, other than alveolodental prognathism.
for the purpose of growth analysis, diagnosis, and
On an average, according to Bjork, during growth the
treatment, Sassouni constructed a series of planes, arcs, and
slope of the forehead increases. The angle at the sella
axes on the lateral cephalometric radiogram as follows:
shows a tendency to increase; the angle at the articulare
(Fig. 16-16)
has a tendency to remain constant. The gonion and the
gnathion angles show a tendency to diminish. Variability
is greater in the mandible than in the maxilla. Planes
Alveolodental prognathism is a condition in which the Mandibular Base Plane (OG). The mandibular base
alveolar arches protrude beyond the bony arches of the plane is tangent to the inferior border of the mandible.
jaws themselves. Alveolodental prog- Occlusal Plane (OP). The occlusal plane goes through
the mesial cusps of the permanent first
Fig. 16-17. This diagram shows the relationship

of teeth axes and planes in a Class II
malocclusion. This patient has a Type IA face.
Only the pogonion is posterior to the anterior arc.
The posterior arc passes behind the gonion angle.
The anterior upper face is smaller than the lower;
the posterior lower face is smaller than the upper.
The proportion between the anterior and the
posterior upper arcs is not equal to the proportion
between the anterior and the posterior lower arcs.
(Sassouni. Y.: Clinical cephalometry.
Philadelphia, Univ. of Penna. Press, 1959)
I
I
I
I
I
I
,
,
I /
~/
!,,-
.'
The Moorrees Mesh Diagram . 207
upper and lower molars and incisal edges of the upper and Type I. Anterior cranial base plane does not pass
the lower central incisors. through O.
Palatal Plane (ON). The palatal plane is perpendicular to Type II. Palatal plane does not pass through O. Type III.
the midsagittal plane, going through the anterior and the Occlusal plane does not pass through O. Type IV.
posterior nasal spines (A SPNS). Mandibular base plane does not pass
Anterior Cranial Base. Structurally, the anterior cranial through O.
base is the floor of the anterior cerebral fossa. In the lateral The axial relation of the maxillary and mandibular teeth
radiogram there are two contours: the upper is the roof of to the palatal plane and mandibular plane is such that angle
the orbit, including the lesser wing of the sphenoid, and the M' = angle I' + 10 and angle m' = i' + S.
lower is posteriorly the sphenoethmoid area and anteriorly The angle formed by the ramal-plane with the occlusal
the cribriform plate. plane is equal to the angle formed by the axial inclination
Anterior Cranial Base Plane or Basal Plane (OS'). of the mandibular central incisor with the occlusal plane
The basal plane is parallel to the axis of the upper contour (angle R = angle i).
of the anterior cranial base and tangent to the inferior Since the norm concept cannot be accepted as absolute
border of the sella turcica. for the individual. Sassouni advocates the measurement of
Ramus Plane (RX'). The ramus plane runs tangent to the proportionality in the individual as a base for growth study,
posterior border of the ascending ramus. diagnosis, and treatment planning.
Arcs THE MOORREES MESH DIAGRAM

Anterior Arc. The anterior arc is the arc of a circle, The importance of natural head position in the
between the anterior cranial base plane and the mandibular interpretation of cephalograms is shown in the Moorrees
plane, with 0 as center and O-A S as radius. mesh diagram analysis. In view of the great variation in
Posterior Arc. The posterior arc is between the anterior facial dimensions found in persons with normal occlusion,
cranial base plane and the mandibular plane, of a circle the greatest value of the
with its center at 0 and OSP as (SP is the most posterior
point on the rear margin of sella turcica.)
Axes
1. M,M',M". Axis of Q.
2. 1, I', I". Axis of 1-
3. I, I', I". Axis of T.
4. M,M'.
Axis of 6.
The Sassouni Norm

In a well-proportioned face the four planes, (1) that
tangent to sella and parallel with anterior cranial base, (2)
the palatal plane, (3) the occlusal plane, and (4) the
mandibular plane, meet at O. While an arc from 0 to the
anterior nasal spine (ANS) as a radius will pass also
through the pogonion, the incisal edge of the maxillary
central incisor, the nasion, and the frontoethmoid junction.
If a circle has center 0, an arc that passes through the
posterior wall of the sella turcica will pass also through the
gonion. A dysplasia in anyone part of the- face is reflected
Fig. 16-18. Intracranial reference lines: N-S, nasion to
in the face as a whole.
sella turcica; O-C, the Frankfort horizontal- orbitale to the
The relation of the four planes to the common point, 0,
highest point on the mandibular condyle; ANS-Op, His line
permits the classification of four facial types:
- anterior nasal spine or acanthion to opisthion; Ba-Op,
basion to opisthion. The registration of natural head
position with reference to the vertical is also shown.
105.
mesh diagram is in comparing lateral cephalograms in

longitudinal studies of individual growth and in
determining changes brought about by growth and by
orthodontic therapy during and after treatment. \\\ -?J~
Construction of the Mesh Diagram
On a sheet of tracing cellophane covering a lateral
cephalogram, construct the following lines:
1. Draw the line N-S.
2.Draw Line (A) from nasion (N) at 85 to Line N-S.
(850 is the approximate norm angle of prognathism)
;~ '5
3. Draw Line B at a right angle to Line A, and Line C
at a right angle to Line A and tangent to the lowest point
on the bony chin.
4. Draw Line 0, by transferring the dimension of Line
N-S to Line B and dividing this dimension into three
equal parts. Add the length of one of
~~ A
~
o

I C~
Fig. 16-19. The construction of the Moorrees
mesh diagram (see text)
Fig. 16-20. (A) Analyses and profile photograph of an l l-

year-old boy. Complete masking of a severe protrusion of the
maxillary incisor teeth occurs when the mesh is oriented on the
markedly deflected cranial base (B). The downward inclination
of the cranial base, as well as the protrusion of the maxillary
incisors and the "normal" mandible, are shown by the
distortions of the mesh based on the vertical line (C). These
findings corroborate the clinical evaluation. The Frankfort
horizontal line is perpendicular to the vertical plane and may be
used for cephalometric analysis in this instance. (Figures 16-18
to 16-21 courtesy C. Moorrees)
106.
The Moorrees Mesh Diagram . 209
these parts on Line B to the distance established when the variable intracranial reference line (N -5) and use instead
Line N-5 was marked on Line B. At the point at which the the vertical line as follows:
additional segment ends on Line B, drop a perpendicular 1. Draw a line through nasion, parallel to the vertical
D parallel to Line A to the point where D meets Line C. (line 1).
5. Through the points established on B when the 2. Draw two lines perpendicular to Line 1, one through
dimension of N-5 was marked on it and divided into three nasion and one tangent to the lowest point on the border of
parts, draw perpendiculars to Line C, dividing the the mandible (Lines 2 and 3, respectively).
rectangle into four equal parts. 3. Transfer the distance from the nasion to the sella
6. Divide Lines A and D into four equal parts and turcica on Line 2 and divide it into three parts.
connect these points so that a mesh or - grid of 16 4. The fourth line of the basic rectangle is parallel to the
rectangles is obtained. vertical (Line 1) and perpendicular to Lines 2 and 3. It is
7. Measure the length and width of one of the drawn through a point on Line 2 at a distance from nasion
rectangles. which is 113 more than the length of the distance nasion-
8. After the mesh is completed add the following sella turcica.
landmarks: Two points where the vertical mesh lines 5. The basic rectangle is divided vertically and
intersect the palate and one point where the vertical mesh horizontally to give a mesh diagram of 16 rectangles on
line intersects the base of the mandible. The location of the which the face is inscribed.
selected points are now measured in their vertical and
horizontal locations on the mesh diagram.
Modifications of the Rectangle

When the cranial base has an upward or downward
deflection, it may be necessary to discard the
Fig. 16-21, (A) Photograph of the patient. (B) The mesh

diagram constructed on the nasion-sella turcica line. (C)
Mesh diagram oriented on the vert' cal line. The vertical
line is shown in each illustration. The importance of
natural head position for the interpretation of cephalograms
is shown by the-mesh diagram analysis. Since the cranial
base has a downward inclination in this instance, the
distortions of the mesh diagram based on the line nasion-
sella turicica give an erroneous impression of the facial A
configuration. (c. Moorrees)
. II
r-,
\\
I:'-<,:,\\\
,I
.,
"
,\
B
------\
Fig. 16-22. Note the difference

in profile when the head is ori-
ented along the Frankfort hori-
zontal (left) and in the habitual
posture (right).
Method of Comparing Individual Lateral Margolis, H. I.: A plastic and graphic technique for re-
Cephalograms by Means of the Mesh Diagram cording dental changes and facial growth. Am. J. Ortho-
dontics, 25:1027, 1939.
1. Trace grids and insert landmarks on the "before" and ---: Standardized x-ray cephalographies. Am. J. Ortho-
"after" lateral cephalograms. dontics, 26:725, 1940.
2. Measure the various landmarks on each of the tracings ---: Composite x-ray photographs. Am. J. Orthodontics,
of the cephalograms in relation to the vertical and the 27:717, 1941.
horizontal lines on the grid. ---: A basic facial pattern and its application in clinical
orthodontics. Crania-facial skeletal analyses (cont.) and
3. Changes after treatment or during growth are noted by
dento-cranio-facial orientation. Am. J. Orthodontics,
comparing dimensional distances on the cephalograms
39:425, 1953.
taken at different time intervals. Moorrees, C. F. A., and Kean, M. R.: Natural head position,
a basic consideration in the interpretation of cephalo-
The Head in Space metric radiographs. Am. J. Phys. Anthropol., 16:213,
1958.
The significance of cephalograms taken with the head Moorrees, C. F. A., and Lebret, L.: The mesh diagram in
held by a person in his usual natural position in space, and cephalometries. Angle Orthodontics, 32:214,1962.
when the head is oriented with the Frankfort horizontal, can Ricketts, R. M.: Cephalometric synthesis. An exercise in
be seen when the same person is oriented along the stating objectives and planning treatment with tracings of
Frankfort horizontal in the cephalometer or when the head the head roentgenogram. Am. J. Orthodontics, 46:647,
is held along natural head position. When the inclination of 1960.
---: Cephalometric analysis and synthesis, Angle
the Frankfort horizontal lines differs markedly from the
Orthodontist, 31 :141, 1961.
natural position of the head in space, the profile difference
---: Clinical Cephalometry. Philadelphia, University of
becomes obvious. Pennsylvania, 1959.
---: The Face in Five Dimensions. Philadelphia, University
of Pennsylvania, 1960.
BIBLIOGRAPHY Sassouni, Y.: The Face in Five Dimensions. Philadelphia,
University of Pennsylvania Press, 1960.
Bjork, A.: The face in profile. Svensk. Tand. Tid. 40: o. 5B Savara, B. 5.: A method of measuring facial bone growth in
Suppl., 1947. three dimensions. Hum. Biol., 37:245,1965.
Downs, W. B.: The role of cephalometries in orthodontic Steiner, C. c.: Cephalometries for you and me. Am. J.
case analysis and diagnosis. Am. J. Orthodontics, 38:162, Orthodontics, 39:729, 1953.
1952. ---: Cephalometries as a clinical tool. In Kraus, B. S., and
James, G. A.: Cephalometric analysis of 100 angle class II Riedel, R. A., (eds.); Vistas in Orthodontics. Philadelphia,
division 1 malocclusion with special reference to cranial Lea & Febiger, 1962.
base. D. Practitioner & D. Record, 14:35, 1963. ---: Power storage and delivery in orthodontic appliances.
Johnson, E. L.: The Frankfort-mandibular plane angle and Am. J. Orthodontics, 19:859,1953.
the facial pattern. Am. J. Orthodontics, 36:516, 1950. Wylie, W. L., and Johnson, E. L.: Rapid evaluation of facial
Krogman, W. M., and Sassouni, V.: A syllabus in roent- dysplasia in the vertical plane. Angle Orthodontist,
genographic cephalometry. Philadelphia, Philadelphia 22:165, 1952.
Center for Research in Child Growth, 1957.
17
Interceptive- Preventive Orthodontics
FAUSTIN N. WEBER, D.D.S., M.S.
SCOPE CLINICAL TECHNIQUES
Toe purpose of this chapter is to demonstrate the

ARCH LENGTH - SP ACE AVAILABLE
importance of interceptive-preventive procedures in
treating malocclusion. The practice of interceptive- The space in the dental arches mesial to the first
preventive orthodontics is vital to the dental health of the permanent molars into which the succedaneous
child. The utility and simplicity of most of these (permanent) teeth must fit when erupted is called the
techniques will be demonstrated. space available or the available arch length. In those
Although the terms preventive orthodontics and individuals who have adequate arch length or space
interceptive orthodontics are used here as synonyms, available for the eruption and proper positioning of the
actually there is a difference in the two types of service. succedaneous permanent teeth, alignment of the teeth is
In "Orthodontics: Principles and Policies," a brochure usually uneventful, unless some other environmental or
prepared by the Council on Orthodontic Education of the genetic conditions exist that would interfere with normal
American Association of Orthodontists, interceptive alignment.
orthodontics is defined as follows: Space available usually is in excess of space re-
That phase of the science and art of orthodontics employed to quirements of the succedaneous teeth. The difference
recognize and eliminate potential irregularities and malpositions between arch length and space available was designated
in the developing dentofacial complex. Preventive applies to the by Hays Nance.!" the leeway space.
elimination of factors that may lead to malocclusion in an Nance's studies showed that leeway space in the
otherwise normally developing dentition. lnterceptiue implies that
maxillary arch averaged 0.9 mm. per side, while its
corrective measures may be necessary to prevent a potential
average size was 1.7 mm. per side in the mandibular arch.
irregularity from progressing into a more severe malocclusion.
In a review of 150 different papers on the prevalence Nance emphasized that these values are averages and are
of malocclusion, Young and Zwerner'" reported the not to be applied to the individual patient.!'' A problem
findings of the different investigators to range from 24 to exists where the leeway space is lost through the mesial
91.4 per cent. This suggests that at least one out of every shifting of the first permanent molar and the space
four school-age children needs full or comprehensive available is not large enough to provide room for the
orthodontic treatment that should be given only by the proper eruption and alignment of all the succedaneous
qualified practitioner. If 11 to 12 million of the 70 teeth. The problem likewise exists when there is too small
million school children in the United States need a leeway space to permit the mandibular first permanent
orthodontic treatment and if only seven thousand molar to shift from an end-to-end occlusion to the cusp-
orthodontic specialists are available (1973) to provide the groove relationship normal for first molars. In either case,
treatment, the need for general dentists to practice some the malocclusion with the eruption of all the
form of intercePllive-preventive orthodontics is obvious. succedaneous teeth has its genesis in the lack of arch
The treatment techniques here described can be length for eruption of the succedaneous teeth in normal
applied in a few visits to the dental office over a short alignment.
period of time, at less expense to the patient than the Loss of arch length, occasioned by the premature loss
many visits that are routine in full orthodontic treatment. of one or more posterior primary teeth, is controllable by
Timely application of appropriate interceptive-preventive the timely application of a space maintaining appliance. It
measures can make it unnecessary for the patient to have is important to know how to accurately determine the
full orthodontic treatment or shorten the period of space available, to measure arch length, and to predict,
treatment required. with reasonable accuracy, the sizes of the unerupted
teeth. With such information leeway space can be
determined in advance.
211
212 . lnterceptive-Preventive Orthodontics
Measuring Arch Length assume an ideal arch form without regard for individual
malpositioned teeth. After the wire has been thus adapted
The most accurate method of measuring arch length over the occlusal surfaces and incisal edges of the teeth, it
involves taking impressions, pouring casts, and measuring is removed and straightened, and its length is measured to
the arch length from the casts. A 23-gauge soft brass wire determine arch length or the space available.
is adapted on the cast from the distal surface of the second Another, but less precise, method of measuring arch
primary molar, or the mesial surface of the first permanent length either directly in the patient's mouth, or indirectly on
molar, around the perimeter of the dental arch to the casts is by using a modified Boley gauge (Fig. 17-8).
contralateral tooth (Fig. 17-1). The wire is positioned so Chords of the dental arch are measured beginning at the
that it traverses the contact areas of the molar teeth and the distal of the primary second molar in the buccal embrasure
incisal edges of the anterior teeth; it should not be distorted between this tooth and the permanent first molar, anteriorly
to duplicate the malposition of one or more teeth that may to the embrasure separating the deciduous cuspid and the
be rotated or deflected to the labial or lingual, but should first deciduous molar. The second chord is measured
Fig. 17-1. (A) A soft brass

wire adapted to a mandibular
dental cast is a method of
determining arch length and
the space available for the
eruption of the succedaneous
teeth. (B. C) An alternate
method of measuring arch
length employs a modified
Boley gauge. This method is
less accurate than the brass
wire measurement, but it can
be used on casts or in the
mouth. (0) Sharp-pointed di-
vider are used to measure the
greatest mesiodistal width of
the crowns of the mand i bular
incisors.
108.
109.
107. Clinical Techniques . 213
fllSI U I.At ,tA.I IISIIl sn,
Fig. 17-2. (A) A flush terminal plane relationship of the

maxillary and mandibular second deciduous molars is
IISTll SI I' illustrated. (8) The mesial step terminal plane requires less
forward shifting of the mandibular first permanent molar and,
therefore, less leeway space to enable the erupting lower first
permanent molar to establish the desired mesiobuccal-cusp-in-
buccal-groove occlusion than is the case in the flush terminal
plane-, or the distal step terminal plane relationship. (C) A distal
step terminal plane relationship. Space for considerable mesial
movement of the mandibular first permanent molar must be
available if normal molar relationship is to develop.
x-rays in the manner described by Huckaba.P * the other

utilizes tooth prediction formulas that have been developed by
several investigators, especially Carey," Fonseca,'? Ballard,
Wylie? and Brown."
A versatile prediction chart published by Moyers (Table 17-
1). Table 17-1 is arranged so that one may choose the level of
confidence he wishes in predicting whether the space available
is adequate to accommodate the unerupted teeth. For example,
it is
from this aforenamed embrasure to the midline. Two chords To compensate for the magnification of the tooth image as it appears on the
are measured similarly on the opposite side of the dental arch. x-ray film, Huckaba, Professor and Assistant Chairman, Department of
Orthodontics, U. Term., has suggested the following formula to determine the
size of the crowns of unerupted p rmanent teeth from dental x-rays.
DETERMINING SPACE NEEDED

X= Y or X = X'Y X'
Once the arch length or the space available has been Y'Y
determined, the other vital information required is the space
that will be needed for the unerupted succedaneous teeth. Y' = measured width of the primary tooth on the x-ray film
Y = measured width of the same primary tooth on an orthodontic cast or in the
There are two approaches to determining the sizes of mouth
unerupted permanent teeth: one uses dental x-rays making X = measured width of the underlying permanent succeeding tooth on the x-
ray film
compensation for the magnification factor in the X = actual width of the unerupted permanent tooth
214 . Interceptive-Preventive Orthodontics
Table 17-1.
PROBABILITY CHART FOR PREDICTING THE SUM OF THE WIDTHS OF 345 FROM 21/12
"L21/12 19.5 20.0 20.5 21.0 21.5 22.0 22.5 23.0 23.5 24.0 24.5 25.0 25.5 26.0 26.5 27.0 27.5 28.0 28.5 29.0
95% 21.6 21.8 22.1 22.4 22.7 22.9 23.2 23.5 23.8 24.0 24.3 24.6 24.9 25.1 25.4 25.7 26.0 26.2 26.5 26.7
85% 21.0 21.3 21.5 21.8 22.1 22.4 22.6 22.9 23.2 23.5 23.7 24.0 24.3 24.6 24.8 25.1 25.4 25.7 25.9 26.2
75% 20.6 20.9 21.2 21.5 21.8 22.0 22.3 22.6 22.9 23.1 23.4 23.7 24.0 24.2 24.5 24.8 25.0 25.3 25.6 25.9
65% 20.4 20.6 20.9 21.2 21.5 21.8 22.0 22.3 22.6 22.8 23.1 23.4 23.7 24.0 24.2 24.5 24.8 25.1 25.3 25.6
50% 20.0 20.3 20.6 20.8 21.1 21.4 21.7 21.9 22.2 22.5 22.8 23.0 23.3 23.6 23.9 24.1 24.4 24.7 25.0 25.3
35% 19.6 19.9 20.2 20.5 20.8 21.0 21.3 21.6 21.9 22.1 22.4 22.7 23.0 23.2 23.5 23.8 24.1 24.3 24.6 24.9
25% 19.4 19.7 19.9 20.2 20.5 20.8 21.0 21.3 21.6 21.9 22.1 22.4 22.7 23.0 23.2 23.5 23.8 24.1 24.3 24.6
15% 19.0 19.3 19.6 19.9 20.2 20.4 20.7 21.0 21.3 21.5 21.8 22.1 22.4 22.6 22.9 23.2 23.4 23.7 24.0 24.3
5% 18.5 18.8 19.0 19.3 19.6 19.9 20.1 20.4 20.7 21.0 21.2 21.5 21.8 22.1 22.3 22.6 22.9 23.2 23.4 23.7
PROBABILITY CHART FOR PREDICTING THE SUM OF THE WIDTHS OF 345 FROM 21/12
I21112 19.5 20.0 20.5 21.0 21.5 22.0 22.5 23.0 23.5 24.0 24.5 25.0 25.5 26.0 26.5 27,0 27.5 28.0 28.5 29.0
95% 21.1 21.4 21.7 22.0 22.3 22.6 22.9 23.2 23.5 23.8 24.1 24.4 24.7 25.0 25.3 25.6 25.8 26.1 26.4 26.7
85% 20.5 20.8 21.1 21.4 21.7 22.0 22.3 22.6 22.9 23.2 23.5 23.8 24.0 24.3 24.6 24.9 25.2 25.5 25.8 26.1
75% 20.1 20.4 20.7 21.0 21.3 21.6 21.9 22.2 22.5 22.8 23.1 23.4 23.7 24.0 24.3 24.6 24.8 25.1 25.4 25.7
65% 19.8 20.1 20.4 20.7 21.0 21.3 21.6 21.9 22.2 22.5 22.8 23.1 23.4 23.7 24.0 24.3 24.6 24.8 25.1 25.4
50% 19.4 19.7 20.0 20.3 20.6 20.9 21.2 21.5 21.8 22.1 22.4 22,7 23.0 23.3 23.6 23.9 24.2 24.5 24,7 25.0
35% 19.0 19.3 19.6 19.9 20.2 20.5 20.8 21.1 21.4 21.7 22.0 22.3 22.6 22.9 23.2 23.5 23.8 24.0 24.3 24.6
25% 18.7 19.0 19.3 19.6 19.9 20.2 20.5 20.8 21.1 21.4 21.7 22,0 22.3 22.6 22.9 23.2 23.5 23.8 24.1 24.4
15% 18.4 18.7 19.0 19.3 19.6 19.8 20.1 20.4 20.7 21.0 21.3 21.6 21.9 22.2 22.5 22.8 23.1 23.4 23.7 24.0
5% 17,7 18.0 18.3 18.6 18.9 19.2 19.5 19.8 20.1 20.4 20.7 21.0 21.3 21.6 21.9 22.2 22.5 22.8 23.1 23.4
possible to be certain in using the table that in up to 90% of the second primary molars form a so-called "step"
of cases space will be available in adequate quantity if the terminal plane. The reason for this is shown in Figure 17-
90% level is used in determining the space needs. To use 2B and C.
the table one must know the combined mesiodistal widths If the first permanent molars erupt in a cusp-tocusp
of the crowns of the mandibular permanent incisors. This relationship, there is need for more mesial shifting of the
measurement may be made accurately using sharp-pointed mandibular first permanent molar and, therefore, a greater
dividers (Fig. 17-10). The width of each tooth is meas- need for additional leeway space. Where the entire leeway
ured with the points of dividers and pierced on an index space, regardless of its size, is needed to establish a proper
card. The measurements are added after all four incisors intercuspation of first permanent molars, a space main-
are measured. The total measurement represents the tainer can be a valuable interceptive appliance if one or
combined mesiodistal diameters of the crowns of the more of the primary molars is lost prematurely.
mandibular incisors. Using this value in Moyers' table one Other factors must be considered in deciding whether or
then. is able to determine in what percentage of cases the not a space maintainer will be needed following the
space available in the arch will be adequate for the premature loss of primary molars. The tooth or teeth that
predicted sizes of the teeth that are to erupt. are lost prematurely is an important consideration. The
Some types of occlusion require space maintenace more loss of one or more primary anterior teeth - maxillary or
than others. For example, if the distal surfaces of the mandibularis not nearly as detrimental to the development
opposing second deciduous molars end on the same of normal occlusion as the loss of a primary first or second
vertical plane, (Fig. 17-2A) there will be need for a greater molar. When an anterior tooth is lost, there is little, if any,
amount of leeway space in the mandibular arch than tendency for the permanent
where the distal surfaces
Cross bites . 215
first molars to shift forward and shorten arch length, acrylic deposited on the casts using the "salt-andpepper
when the primary first and second molars are still present spray-on" technique after having first adapted the
and have adequate root structure to resist mesial necessary wires that are to be embedded in the acrylic.
movement of the permanent first molar. While there may In the space maintainer illustrated in Figure 17-3A the
be actual shifting of some teeth immediately adjacent to wires are not used as clasps but are a part of the appliance
the lost anterior tooth, usually there is no forward for the purpose of imparting wearing quality at points
movement of the permanent first molars and, where the acrylic would wear from frequent inserting and
consequently, no loss of arch length. removing the appliance in and out of the mouth.
When a primary first or second molar is lost The acrylic portion which covers the dental area may be
prematurely, such loss is almost always attended by built up to a level sufficient to antagonize the overeruption
mesial shifting of permanent first molars and, therefore, of the teeth in the opposing arch. Acrylic in this area may
loss of arch length. Whenever a primary second molar is also be cut away when the tooth or teeth beneath the
lost prematurely, whether before or after the eruption of acrylic bridge begin to erupt. Thus, the appliance need not
the permanent first molar, there will be a loss of arch be completely discarded until the succeeding teeth are
length due to the mesial position assumed by the erupted a considerable distance and can maintain their
permanent molar. Accordingly, it is advisable where arch own space. The wire extensions from the acrylic can still
length is adequate prior to loss a primary first or second make contact with the teeth mesial and distal to the area
molar to place a space maintainer in order to preserve being retained, even though the acrylic has been cut away.
space adequacy.
SPACE-MAINTAINING DEVICES
SPACE REGAINING APPLIANCES
The importance of maintaining primary (deciduous)
teeth until the appropriate time for their exfoliation has In many instances the patient is seen after a space which
long been realized. While dental health education and should have been retained has already been lost. The use
improved caries prevention have lowered the number of of space regaining appliances often is beneficial. These
children who develop malocclusion because of premature appliances are especially effective to upright teeth that
loss of primary teeth, it is still one of the most common have tipped following the loss of one or more adjacent
controllable causes of malocclusion. teeth when space is available. It eliminates the need for
full-banded orthodontic appliances in such cases (Fig. 17-
3B and
C).
Types of Space Maintainers
Our preference for uprighting tipped teeth that require a
There are two general types of space maintainers: fixed minimum amount of tooth movement is a removable
and removable. Removable space maintainers have the appliance. Accidental loss is circumvented by having the
shortcomings of all removable appliances: they may be patient wear the appliance in the evening and at night only
worn at the whim of the patient and they may be broken for a period of approximately 14 hours daily to obtain the
and easily lost when removed by the patient. This is less necessary tooth movement. The type of removable ap-
likely to occur if the appliance is not worn outside the pliance that has been found most effective employs
home. The space maintainers shown are worn at night Adams clasps and has the springs fabricated according to
only. The patient is told not to take the space maintainer the design suggested by Adams (Fig. 17-3D through H).
from his bedroom except to wash it. It is to be inserted These space regaining appliances also find application
just prior to retiring and removed the following morning in the permanent dentition to regain space and to parallel
as soon as he arises. This is adequate to maintain space tipped teeth prior to the insertion of the fixed or removable
and permit the appliance to function effectively. The dental prosthesis. In the latter situation the space regainers
faithful nightly use of the retainer must be supervised by are more aptly labeled "orthorehabili ta ti ve appliances. "21
a parent or another responsible adult.
Fabrication of Space Maintainers CROSSBITES

The appliances are constructed on stone casts. Crossbite malocclusion may involve single teeth,
The space maintainers are made of quick-curing groups of teeth, or the entire dental arch. Cross-
Fig. 17-3. (A) A removable acrylic space maintainer for maxillary teeth. (8, C)Two views of a
removable space-regaining appliance. The simple helical springs can effectively tip the incisors into
proper position and regain the space lost in the central incisor area. (D) Mandibular removable
appliance for uprighting first molars which tipped mesially following early loss of the deciduous
molars. (E) The Hawley archwire serves as a clasp to hold the appliance in place and stabilizes the
mandibular anterior teeth while the molars are tipped distally and lost arch length (space) is regained.
(F) Springs activated against the mesial surfaces of the first permanent molars as suggested by Adams.
(G) Removable space regaining appliance to move a maxillary molar distally. Left, shows a "C" -
shaped wrought wire clasp; right, an Adams clasp. (H) Palatal surface of the maxillary appliance
shown in C. Note the helical spring embedded in the acrylic used for distal movement of the first
molar as suggested by Adams.
Cross bites . 217
Fig. 17-4. (A) A crossbite malocclusion in the primary dentition involving the teeth on one side from the midline through
the second deciduous molar. Treatment was effected in the primary dentition. (8) Cross bite corrected in the primary dentition
remained stable; occlusion has remained normal in the permanent dentition. (C) A cross bite in the early mixed dentition
produced a lateral shift of the mandible. Note the lack of consonance of the denture midlines. (D) Stability of the crossbite
correction is demonstrated in occlusion 38 months after treatment. The denture midlines are nearly consonant.
bites may occur in the anterior, posterior, or both parts of only teeth and their supporting alveolar processes, broadens
the dentition. All crossbi tes should be treated at the its sphere of influence to include basal portions of the
earliest possible time. Cross bites should be treated in the maxilla and mandible, and can extend to remote areas
primary dentition, in the mixed dentition, and in the affecting the growth and configuration of the condyles of
permanent dentition (Figs. 17.-4A, B, C and D). Once the the mandible. Crossbite malocclusions that were treated in
crossbite has been corrected it is self-retaining and shows the primary dentition and remained corrected in the mixed
no tendency to relapse. and permanent dentition are shown in Figures 17-4A-D and
If the cross bite is not corrected in the primary dentition, SA-G. A crossbite malocclusion that did not receive early
it is almost certain to be found also in the mixed and treatment and was allowed to exert its deleterious influence
permanent dentitions. Furthermore, as time progresses and on the supporting and contiguous structures is shown in
the crossbite remains untreated, the malocclusion tends to
Figure 17-6A-B. While not all crossbites are amenable to
worsen, so that the crossbite which at the outset may have
simple treatment procedures, the early interception and
involved
eliminations
Fig. 17-5. (A) Although the incisors have not yet erupted to the point where their crossbite would be evident, the maxillary and
mandibular central incisors show labiolingual positioning which will result in crossbite if it is not corrected. (/3) Immediate application of
the tongue depressor blade technique (see p. 222) has succeeded in changing the labiolingual relationship of the central incisors. They are
now in edge-to-edge relationship. (C) Additional but irregular use of the tongue depressor blade has moved the maxillary central incisors
barely labial to the mandibular centrals. (D) The maxillary central incisors are now definitely in labial occlusion. Their positions are
maintained and improved by the occlusion of the lower centrals against the lingual surfaces of the maxillary centrals. Note the blanching
of the gingival tissue just above the crowns of the maxillary central incisors, a manifestation of the occlusion-generated labial thrust from
the mandibular central incisors. (E) Continued eruption of the incisors and continued improvement of the crossbite are evident. (F) The
maxillary lateral incisors did not erupt in crossbite. They would have, had the maxillary central incisors been allowed to remain in
crossbite. (G) Eruption of the succedaneous teeth is complete. The occlusion is highly satisfactory. This would not be the case had the
incisor cross bite remained uncorrected.
Cross bites . 219
Fig. 17-6. (A) A long-neglected unilateral crossbite involving all posterior teeth and canines is responsible for the severe
mandibular shift of one and one-half times the width of a lower incisor. This now is a severe malocclusion with facial disharmony.
(B) Unless the malocclusion is corrected it can be expected to accentuate this boy's facial asymmetry.
Fig. 17-7. (A) A functional posterior crossbite. Although the teeth on the patient's left side are in crossbite, the correction shown in
B was achieved by bilaterally expanding the maxillary dental arch. (B) Correcting the cross bite has allowed the path of closure of the
mandible to be undeviated. ote the more consonant relationship of the denture midlines.
of the crossbite prevents a more serious malocclusion from functional crossbites and may offer a more challenging
developing. treatment problem than the functional crossbi tes.
The functional posterior crossbite has its genesis in a lack of
lateral development of the maxillary dental arch, an over
Detection of the "Simple" Posterior Crossbite
development of the mandibular dental arch, or a combination
Functionally generated, a "simple" posterior crossbite can of the two. The consequence is the same in all three instances.
be diagnosed by observing the path of closure of the mandible The dental arch sizes are mismatched, and the resultant oc-
as it moves from a position of physiologic rest, into centric clusion of the posterior teeth is a cusp-to-cusp relation instead
occlusion. As the mandible closes through these few terminal of a cusp-fossa one. Because the cuspto-cusp occlusion is not a
comfortable relation for the teeth and jaws to assume, the
millimeters, its lateral deviation to the right or to the left
proprioceptors in
betrays the functional crossbite. Posterior CfOSSbites that do
not show a mandibular shift are not
A B
Fig. 17-8. (A) Bilateral expansion across the molar areas of the dental arch, and/or the canine regions is easily effected with
the Porter lingual appliance. (B) The Mershon half-round shaft and locking wire secure the appliance to the half-round molar
tubes.
the periodontal ligament of the teeth change mandibular bites when the extent of the movement needed is
posture. The mandible is diverted to the right or left to considerable. A diagrammatic representation of the
bring the teeth into a position of maximum contact and problem of extent of tooth movement and a classification of
comfort, i.e., a cusp-to-groove, cusp-to-fossa or cusp-to- simple versus complex posterior crossbites based on the
embrasure occlusion. A functional posterior crossbite is the extent of tooth movement is shown in Figure 17-9.
result of the lateral shift (Fig. 17-7 A and B).
Anterior Crossbites
Treatment of Cross bites
When an incisor crossbite exists, horizontal
The posterior functional cross bite is treated by bilateral
expansion of the posterior portions of the maxillary dental
arch, or bilateral expansions of those portions of the POSl ERI OR CROSSBIlE
denture that are in crossbite. Treatment is usually
accomplished in a comparatively short time by using a
simple labial or lingual appliance that produces lateral or
buccal movement of the posterior portions of the maxillary
dentition (Fig. 17-8A and B). ~ .~
This appliance is adjusted to produce equal amounts of
pressure on both sides of the posterior teeth to move them
buccally an equivalent amount, even though the crossbite / \
may manifest itself on one side only. Once the posterior
teeth on both sides have been moved buccally, the patient
will adjust the path of closure and no longer deviate the
mandible to the right or to the left and the crossbite will be
corrected by the bilateral tipping of the posterior teeth.
:--i I
- -lJ
Where the cross bite is a structural one, it involves lateral
movement not onl y of the teeth but also of segments of the
A I C
maxilla as well. Segmental lateral movement of the maxilla -----:-\
may be required for elimination of a structural or skeletal
type crossbite; it involves complicated treatment.
v~ ""
A more bodily (translational) type of movement, and less
tipping of the crowns of the teeth, may be necessary for the
.... v/
correction of some posterior cross- Fig. 17-9. Progressively more severe degrees of posterior
crossbite are illustrated from A (normal buccolingual
relationship) through E (complete by-pass bite). Crossbites
in Band C may be characterized as simple, i.e., they require
only tipping movements to effect their correction; those in
D and E are complex problems that require a more
translational type movement.
Crossbites . 221
growth of the mandible is favored, and if there is a

tendency for growth to be hyperactive, the tendency will
be accentuated. If a normal incisor relationship can be
established and maintained, a limiting factor is imposed
that will control some of the horizontal overgrowth of the
mandible. The best time to treat an incisor crossbite is as
soon as it is encountered whether in the primary, mixed, or
There are different degrees of anterior crossbites.
It is important to recognize the characteristics of the so-
called simple incisor crossbite in order that correction of a
complex problem is not undertaken in ignorance. The
features of a simple anterior crossbite are as follows:
A. The vertical depth of the crossbite is not excessive. Fig. 17-10. Examples of "simple" incisor crossbites.
When the posterior teeth are in full occlusion, it is possible The three characteristics of a simple crossbite are shown in
to see at least one-fourth of the clinical crown of the each case.
maxillary incisor.
B. The horizontal overjet is minimal, i.e.. it is possible therefore, not amenable to simple mechanotherapy.
for the patient to forcibly retrude his mandible sufficiently It is important at the outset to be assured that one has a
to achieve an end-to-end or edgeto-edge occlusion in the patient from whom a reasonable amount of helpful
incisor region. cooperation can be obtained and that the crossbite is a
C. Space to permit tipping the teeth out of crossbite is simple one and has the previously mentioned
available. These features of the simple incisor crossbi te characteristics. A certain amount of persuasion is needed to
are shown in Figures 17-10. elicit the desired cooperation from the patient, therefore,
the time spent in explaining the goals of treatment, how it
is to be accomplished, and the alternatives to be faced if the
treatment fails, is time well spent. The routine here sug-
gested has been used with good results.
Techniques for Correcting Simple
The patient and his parents are made aware of the
Incisor Crossbites existence of the crossbi te and shown how it differs from
Simple incisor crossbites may be treated with fixed, the desirable relationship. The necessity for correcting the
removable, or fixed-removable appliances. The simplest crossbite is explained from the cosmetic and functional
type of appliance is the tongue depressor blade. With handicaps it imposes. The traumatic occlusion generated
cooperative patients this can be a very effective means of from incisor crossbite, the attendant periodontal
eliminating the simple incisor crossbite quickly and easily. involvement, and possible early loss of teeth if the
This treatment technique fails when the patient does not crossbite goes uncorrected are discussed. These facts are
follow instructions and cooperate fully and when the in- explained to the patient and the parents. The merits of cor-
cisor crossbite malocclusion is not simple and,
1 to 25, it takes the patient approximately one-half minute

to reach 25. He is then instructed that he may remove the
tongue depressor blade from between his teeth and rest a
while before repeating the exercise (Fig. 17-11).
It must be emphasized that a firm and constant biting
pressure is absolutely essential for the exercise to be
effective. Both the patient and the parents are advised that
if the tongue depressor blade is used in the proper fashion
the teeth will become quite sore after the first day of use,
but that in spite of the tenderness of the teeth, the exercise
must be continued daily without interruption. If the exer-
cise is discontinued for a day or two until the teeth once
more become comfortable, all prior progress will be lost
and the patient will be back where he started.
The daily routine demands that the patient use the blade
in the manner previously outlined, counting from 1 to 25
five times in succession before stopping. This fulfills the
requirements of one session or one sitting. Six sittings are
Fig. 17-11. A tongue depressor blade is applied to cor- required daily. A schedule is suggested, which asks that
rect a crossbite. The blade may be narrowed by splitting it each day before the child goes to school the first sitting be
lengthwise if force is to be directed against a single maxil- completed; the second, immediately upon his return home
lary incisor. from school; the third, just before eating his evening meal;
the fourth, immediately following this meal; and the last
two sessions, sometime in the evening before retiring.
recting the malocclusion with a tongue depressor blade If the patient is consistent in the use of the tongue
are then considered. The patient's cooperation is sought depressor blade, if the exercise is performed properly, and
by explaining that the method proposed for correction will if simple incisor crossbite is involved, correction will be
be the least painful, is a procedure that he may do at effected within a matter of a few days to a few weeks time.
home, does not require the use of complicated appliances, At the initial appointment the patient is given a
and that he himself can accomplish during his leisure generous supply of tongue depressor blades, and he is
asked to return in a week or ten days for a check on his
hours.
progress. At the second appointment, one of three
The parents' cooperation in supervising the treatment is
situations will be encountered: (1) the crossbite will be
sought by explaining that this method requires less chair-
corrected, (2) progress in its correction will have occurred,
time and is the least expensive. Both parties are thus
but the crossbite will not be eliminated, or (3) there will be
motivated to follow the projected treatment plan: the child
no apparent difference from the patient's original
out of a desire to avoid conventional orthodontic
condition. If the second condition prevails, the patient is
appliances and the parents out of a desire to make the
highly praised, told that he has made remarkable progress.
treatment least expensive.
He is encouraged to continue with the exercise, with the
Tongue Blade Technique. A demonstration of the
assurance that within a very short time he will have
tongue depressor blade technique is given to both the
obtained the desired correction. If no apparent progress
patient and the parents. The patient watches the procedure
was made, the patient and his parents are advised that they
while holding a large hand mirror. A tongue depressor
have not followed the instructions and are told they will be
blade is placed lingual to the upper incisor tooth in
given one more opportunity to use the tongue depressor
crossbite, and the patient is instructed to close the lower
blade exercise before fixed appliances are resorted to. The
incisor teeth firmly against the blade while it is held in the
threat of the application of a fixed appliance usually is
position shown in Figure 11. The operator then takes the
enough to elicit from both the patient and his parents the
patient's hand, places it on the tongue depressor blade,
required cooperation.
and guides the blade downward and backward against the
lower lip and the chin, making sure that the firm biting
pressure the child is asked to exert on the tongue
depressor blade is not lessened.
Holding the tongue depressor blade in this position and
biting firmly against it, the patient is instructed to count to
25 as follows: 1001, 1002, 1003, etc. If the prefix 1000 is
added to each numeral from
Crossbites . 223
Limitations of Tongue Blade Therapy. The correction of the

incisor crossbite with the tongue depressor blade is not
recommended when more than two teeth are in cross bite.
When more than two teeth are involved, it is advisable to
employ some other type of treatment. Where a single
tooth is in cross bite it is advisable to split the tongue
blade lengthwise so as to have a narrower blade to contact
the lingual surface of the tooth to be tipped labially. A
popsicle stick can be more effective than the tongue
depressor blade because it is narrower and thicker and
adaptable to a single tooth. Its thickness gives it greater
strength to resist the force exerted when the stick is pulled
down and back against the chin.
Fixed Appliances Fig. 17-12. An inclined plane fabricated from clear, quick-
curing acrylic partly covers the six mandibular anterior teeth
Some patients will not give the cooperation necessary prior to cementing it in place. When the upper incisors occlude
to effect correction with the tongue depressor blade. For against the acrylic plane, the posterior teeth are out of functional
these, fixed appliances are necessary. One effective fixed contact.
appliance employs the principle of the inclined plane.
Formerly, the inclined plane was constructed of metal. In causing any damage to the teeth or tissues. Rarely does the
recent years, quickcuring, self-polymerizing acrylics have appliance need be worn longer.
replaced the metallic inclined plane. After the inclined plane appliance is seated and before
Appliances are fabricated on a stone cast of the the patient is dismissed, both the patient and his parents
mandibular teeth. The acrylic resin is deposited on the are apprised of the difficulty he will have trying to chew
cast with the "salt and pepper technique" and built up to fibrous or hard foods because the posterior teeth are held
the desired form with small additions of the polymer out of occlusion. Only the maxillary incisors receive the
moistened with the monomer, the whole mass being force of occlusion. Force directed against the front teeth is
shaped with the fingers while it is still in a plastic state. by way of the acrylic incline plane. (Fig. 17-12). After the
The inclined plane is formed at a cant of 45 degress to the appliance has been in place a few days to a few weeks,
horizontal, extending upward and lingually to the continued eruption of the posterior teeth will gradually
maxillary incisor teeth that are in lingual crossbite (Fig. reestablish the occlusion and the problems of mastication
17-12). will disappear. However, the overeruption of posterior
The acrylic inclined plane should extend far enough teeth that occurs creates a different problem when the
posteriorly to make it difficult for the patient to bite acrylic inclined plane is removed. The bite is opened by
behind it. After the acrylic incline is formed on the cast, the eruption of posterior teeth, and because of this the
the appliance is removed and shaped with burs and stones vertical overbite in the incisor region may disappear. (Fig.
to approximately its final form in the mouth. 17-13A, B and C). Therefore, there is nothing to oppose
When the inclined plane has been trimmed to the the tendency of the teeth to relapse, and the
proper cant, and the margins given their final contour and reestablishment of a crossbite is always a possibility until
extent, the appliance is polished before being attached to such time as the bite settles, the posterior teeth are
the teeth with dental cement. If it 'is cemented the patient depressed in their alveoli, and the vertical overbite is
cannot remove it. Therefore, the appliance must be worn reestablished. (Fig. 17-13C).
until the operator removes it. The patient is asked to While the bite is settling, the normal vertical overbite is
return for observation 4 to 6 weeks after the appliance is returning and establishing a natural form of retention for
inserted. At that time it is usually possible to remove it the corrected crossbite. It can be helpful for the patient to
because the crossbite will have been corrected. However, use a tongue depressor blade a few minutes each day to
if the tooth or teeth in crossbite have not moved labially a hold the corrected crossbite from relapsing. The acrylic
sufficient amount, the appliance may be left in place for inclined plane is a particularly useful appliance for
several additional weeks without correcting crossbites that involve one or more upper
incisor teeth.
Fig. 17-13. The incisor crossbi te shown in (A) was treated

110. the application of an acrylic inclined plane with the result
by
shown in (B). Note how much the vertical overbite decreased
in the incisor area. (This photograph was taken when the
inclined plane was removed from the lower incisors.) The
bite closed after the inclined plane was removed (C).
Clinical cases treated with the acrylic inclined plane are

shown in Figs. 17-14A, B; 17-15A, B, and 17-16A, B, C, and
D.
Removable Appliances
Removable appliances for the correction of incisor cross
bite are generally attached to the maxillary teeth and consist
of an acrylic base with suitable
B
Fig. 17-14. (A) Simple incisor crossbite in the mixed dentition was treated with an inclined plane appliance. (B) Corrected
crossbite as it appeared following the eruption of all permanent teeth. The treatment result is stable after 28 months.
Crossbites . 225
Fig. 17-15. (A) This type of incisor crossbite in the primary dentition is amenable to correction with the acrylic inclined plane. (B)
Corrected crossbite is shown 13 months after correction. The treatment required less than a month.
Fig. 17-16. (A) Incisor crossbite in the primary dentition is unusually deep in this patient. (B) Correction was achieved after 8 weeks with
the acrylic inclined plane. (C) Six months after the inclined plane was removed, the occlusion was noticeably improved. (D) The patient
continues to benefit from early treatment of the incisor crossbite. The permanent teeth are erupting in normal relation.
clasp attachments. The working part of the appliance is the

111. tipping upper incisor teeth labially and correcting their
auxiliary spring or springs. Adams has devised an effective crossbite relation consists of bands on the last molar teeth,
removable appliance for the correction of crossbites. Several either the primary second molars or the first permanent molars
illustrations of removable appliances used successfully in the when erupted. Horizontal round buccal tu bes are attached to
correction of this type of malocclusion are shown in Figure the molar bands, and a plain labial archwire is fitted into the
17-17. buccal tubes. The archwire can be activated by different types
of auxiliaries, either coil springs or loop stops. The coil spring
or loop advances the labial archwire and exerts force from
lingual to labial against the upper incisor teeth which are
Fixed-Removable Appliances
ligated to the archwire, thus moving the incisors out of cross
Simple fixed-removable appliances that may be used in bite as shown (Fig. 17-18A-B).
correcting incisor cross bites are basically labial or lingual A lingual archwire may also be used if auxiliary springs are
archwires with suitable auxiliary attachments that produce the attached to it to push against the lingual surfaces of the labially
necessary labial or lingual tipping of the teeth in crossbite. tipped upper incisor teeth. If
A simple and yet highly efficient appliance for
Fig. 17-17. (A) A removable Hawley-type appliance for tipping one maxillary central incisor labially out of crossbite. The single
helical spring is the active part of the appliance. (B) The double (recurved) helical spring, which is the active part of this appliance,
may be adjusted (activated) so that the arm, which contacts the lingual surfaces of the central and lateral incisors that are to be tipped
labially, does so with equal pressure on both teeth (C) Double helical springs give this appliance the potential of tipping all the
maxillary incisors labially out of crossbite. The Adams clasps on the molars are augmented by the C-shaped clasps on the bicuspids.
(0) This variation of the helical-type spring is used to tip the maxillary lateral incisors labially out of crossbite,
Elimination and Control of Harmful Oral Habits' 227
Fig. 17-18. (A) The coil spring section on a plain labial archwire, compressed between the molar buccal tube and a stop on the archwire
just distal to the canine, is the active element in this appliance that is being used to tip the maxillary anterior teeth labially and out of their
cross bite relationship. (B) A plain labial arch wire ligated to the anterior teeth that are in crossbite relationship can be activated to tip the
ligated teeth labially and correct the crossbite by flattening the loop stop; this moves the distal, unattached end of the stop into forceful
contact with the mesial end of the molar buccal tube. The effect is the forward movement of the arch wire and the incisor teeth ligated to
it.
the lingual archwire and auxiliary spring assembly is factor in producing malocclusion in the anterior portion of
used, some provision must be made to keep the small the mouth.
spring wire from sliding incisally on the lingual surface of The typical malocclusion that results from thumb or
the upper incisor teeth and destroying the efficiency of finger sucking is characterized by an an terior open bite
this auxiliary. Fixed appliances are indicated for the and protrusion of the upper incisor teeth. The lower incisor
correction of incisor crossbites whenever one is not sure teeth mayor may not be displaced by the abnormal sucking
of patient cooperation. habit. Perhaps the greatest
ELIMINA TIO A 0 CONTROL OF

HARMFUL ORAL HABITS
One of the most common oral activities of the infant
and young child is thumb and finger sucking. Sucking
habits are perfectly normal in infancy. The infant will
suck. on any object brought into contact with his lips.
This reflex behavior lasts for the first several months of
postnatal life. It is an adaptive reflex common to
mammals.
Because it is a normal activity, thumb and finger
sucking may be ignored in infancy. Only when the act is
continued and practiced excessively should one give more
than passing attention to it. Usually the thumb and finger
sucking habit is not considered harmful until it shows no
sign of abatement at age 2% to 3 years. Thumb or finger
sucking that is discontinued by age 2V2 to 3 years
produces no permanent malformation of the jaws or
displacement of the teeth. Continued beyond the time that Fig. 17-19. Anterior openbite was produced by long lasting,
the permanent incisor teeth erupt, it is almost always a vigorous and regularly-practiced thumb sucking. Tongue thrust
during swallowing also contributed to the openbite.
damage that can result from the unmanaged thumbsucking

habit is the tendency for the tongue to perpetuate openbite
(Fig. 17-19). Protruding maxillary incisors and an anterior
openbite favor the forward positioning of the tongue. The
genesis of some tongue thrust swallowing habits may start
in an openbite malocclusion originally produced by the
thumb or finger sucking habit.
The therapeutic procedures that have been suggested
may be classified under three headings: chemical,
mechanical, and psychological.
Chemical Means
The chemical therapy employs either hot-tasting, bitter
flavored preparations or distasteful agents that are applied
to the fingers or thumbs. Such things as cayenne pepper,
quinine, and asafetida have been used to make the thumb or
fingers so distasteful that the child will keep them out of
his mouth. In our experience these preparations are
effective with a limited number of children, and only when
the habit is not firmly entrenched.
Mechanical Means
There are a number of patented devices which may be
purchased to fit over the thumb or finger sucked, or to
cover the entire hand or limit flexion of the arm. The
patented devices that fit over the thumb or finger are
intended to make the establishment of intraoral vacuum
difficult if not impossible and to change the character of the
sucked thumb or finger so that it is no longer desirable.
Devices that completely cover the hand are intended to
make the thumb or finger inaccessible and therefore
eliminate the habit. Appliances that limit flexion of the arm
prevent the child from putting the thumb or fingers in his
mouth. This type of appliance seems cruel and somewhat
dangerous. The child may be unable to protect himself if he
stumbles or falls.
A simple device for controlling thumb or finger sucking
is the application of adhesive tape to the thumb or finger. In
many instances this changes the character of the finger
sufficiently to call the child's attention to the fact that it is
being placed in the mouth. This is important because in
Fig. 17-20. (A) An anti-thumb-sucking intraoral appli-
many instances thumb and finger sucking habits are at the
ance was constructed on a dental cast. After orthodontic
subconscious level of the individual's attention. Even
bands with Mershon-type half round tubes are fitted to the
though there may be some desire on the part of the subject
maxillary second deciduous (or first permanent) molars,
to discontinue the act, he finds it difficult to do so unless he
an impression is taken and the bands are removed and
is made aware when he is sucking his thum b or finger.
fitted into the impression before the working cast is
poured. The first step is adapting a lingual archwire as
shown here. (B) A palatal wire is added to the basic lingual
arch wire. (C) The connection of the anterior portion of the
lingual arch wire to the palatal wire forms the meshwork
of wire designed to prevent the thumb sucker from con-
tacting the palatal gingiva with his thumb.
Elimination and Control of Harmful Oral Habits . 229
The Intraoral Anti-thumb-sucking Appliance. The most

effective mechanical deterrent to thumb and finger
sucking is an intraoral appliance attached to the upper
teeth by means of bands fitted to the primary second
molars or the first permanent molars, if these teeth have
erupted. A lingual archwire forms the base of the
appliance (Fig. 17-20A) to which are added interlacing
wires in the anterior portion in the area of the anterior
part of the hard palate (Fig. 17-208 and C).
An appliance without sharp projections or barbs is as
effective as the so-called "hayrake." The appliance works
because it prevents the patient from putting the palmar
surface of his thumb in contact with the palatal gingiva,
which seems to rob the act of the pleasurable sensation
that is derived from sucking. The appliance currently
preferred is one that follows the design suggested by
Massier (Fig. 17-21). Several variations of this appliance Fig. 17-21. Note the curved wire meshwork in the anterior
are illustrated in Figure 17-22. portion of the hard palate on this preventive thumbsucking
appliance. Barbs are unnecessary and undesirable on such an
appliance.
Psychological
The psychological approach was suggested by Dunlap
at Johns Hopkins some years ago. Dunlap believed that if
a subject can be forced to concentrate on the performance
of an act at the time he practices it, he can learn to stop
performing the act. Forced purposeful repetition of a habit
eventually
Fig. 17-22. (A) This anti-thumb-sucking appliance has a broad

meshwork of wire in the anterior portion of the palate. (B) In the
mouth it prevents the patient from placing his thumb behind the
A appliance. (C) This appliance has a variation in the design of the
meshwork.
112.
Fig. 17-23. (A) A mesiodens (middle tooth) erupted between
the maxillary central incisors. (B) A supernumerary molar is
developing distal to the maxillary third molar. (C) Two palatally-
positioned, unerupted maxillary supernumerary teeth.
associates it with unpleasant, if not painful, reactions and Appearance. Supernumerary teeth are usually smaller
the habit is abandoned. than normal teeth. They may be peg-shaped with thin
short roots, as shown in Figure 17-23A. Those in the
SUPERNUMERARY TEETH region of the maxillary lateral incisors often resemble
normal incisor teeth and frequently approximate the size
Developmental and Etiology
of lateral incisors. Supernumerary teeth that develop in
Location. Supernumerary teeth may be found in any premolar regions are sometimes molariform, small and
dental area, but their most frequent sites are the third amorphous, or they may be shaped like normal premolar
molar region and the maxillary palatal midline. vyhen teeth.
they occur at the maxillary midline they are called Detection. The atypical size and anomalous form of the
mesiodens, (Fig. 17-23A) (Fig. 17-238). Maxillary incisor supernumerary tooth help to identify it. A problem in
midline supernumeraries are most frequently unerupted. detection arises when the extra tooth closely resembles,
Since supernumerary teeth develop late, they are both in size and shape, the primary or permanent tooth
infrequently found in the primary dentition. If they adjacent to it when it erupts in a normal position and does
develop with the primary teeth they usually erupt (Fig. not crowd the adjacent teeth. Unless one has adopted the
17-23C). Supernumerary teeth in the region of the lateral routine of counting each tooth, the supernumerary may be
incisors, either in the primary or permanent dentition, overlooked. (Fig. 17-24A and B). Supernumerary
usually erupt.
Supernumerary Teeth 231
113.
Fig. 17-24. (A) A well-developed extra mandibular incisor is present in this patient's mouth. A superficial examination might overlook the
supernumerary incisor, which is distal to the mandibular right lateral incisor.
Fig. 17-25. (A) Over-retention of the maxillary primary central incisor

is strongly suggestive of the presence of an unerupted supernumerary
tooth preventing eruption of the permanent central incisor. (B) A
supernumerary tooth prevents eruption of the maxillary central incisor.
teeth that erupt in the primary dentition, especially in the

maxillary lateral incisor area, may not produce a space
problem and can easily go unrecognized.
'Since all supernumerary teeth are candidates for crown of a tooth already erupted, are clinical signs that
extraction, radiograms are required to find and localize suggest the presence of supernumerary teeth (Fig. 17-
them for removal. Even without radiograms the presence 27A).
of unerupted supernumerary teeth is often suggested by The characteristic of supernumerary teeth that makes
clinical signs. The overretention of primary teeth (Fig. 17- their detection occasionally difficult is that they begin
25A) and the failure of permanent teeth to erupt; (Figs. their calcification late. Because of this, they may be
17-25B and 17-26A and B), or the axial perversion or indetectable radiographically until age 11 or 12.
rotation of the
Fig. 17-26. (A) The maxillary central incisors have failed to

erupt. (B) Two supernumerary maxillary teeth in close proximity
to the crowns of the permanent incisors have blocked their
eruption.
Supplemental Teeth
Supernumerary teeth which closely resemble the
The supernumerary tooth may also displace permanent
normal tooth alongside which they erupt are "sup-
teeth that are already erupted (Fig. 17-27). When the
plemental teeth." Their development apparently is the
result of an equal splitting of the tooth germ which supernumerary tooth erupts, it is no less a problem as far
produces two teeth rather than one. Supplemental teeth as the development of normal occlusion is concerned. Its
are found most frequently in the maxillary and presence prevents the normal relationship of teeth mesial
mandibular lateral incisor areas. They resemble the and distal to it (Fig. 17-27F).
normal lateral incisor alongside which they erupt. They Unerupted or erupted su pernumerary teeth can displace
may be found in the primary as well as the permanent permanent teeth, cause them to rotate, produce diastema,
dentition. When one finds a supplemental primary tooth, deflect them mesiodistally or labiolingually. and produce
the presence of a succedaneous supplemental tooth in the axial malposition (Fig. 17-28A, B).
same area in the dentition may be expected and should be When unerupted they may also be factors in the
looked for radiographically (Fig. 17-28A and B). development of dentigerous cysts, and in the resorption of
roots of adjoining teeth. Therefore, even though
supernumerary teeth may not produce malocclusion, they
are candiates for removal because of their potential for
precipitating dental pathosis.
Effects
The reason for early detection and prompt removal of

supernumerary teeth is that they almost always contribute
Treatment
to some dental problem, usually a malocclusion. If the
supernumerary tooth is unerupted it may delay or Early detection and prompt removal of all super-
completely prevent the eruption of an adjacent tooth (Fig. numerary teeth is the best management. This not only
17-27C). The failure of a permanent tooth to erupt, if intercepts the development of malocclusions, but may also
unattended, can cause malocclusion as adjacent teeth save permanent teeth from being included in cystic
shift into the area that should be occupied by the degeneration, avoid root resorption and pulp damage for
permanent tooth which is late or has failed to erupt. adjacent permanent teeth. The only supernumerary tooth
Moreover, the supernumerary tooth can be a cause of that may be retained without producing a problem is the
ectopic eruption of teeth, which produces malocclusion supplemental tooth that erupts in the primary dentition.
(Fig. 17-27B).
Supernumerary Teeth . 233
Fig. 17-27. (A) An unerupted midline supernumerary tooth was

responsible for the extreme rotation of the maxillary central
incisor. (B) The ectopic eruption of the maxillary central incisor
was caused by a supernumerary tooth in the midline area. (C) The
supernumerary maxillary lateral incisor has displaced the normal
maxillary lateral lingually and forced it to erupt in torsi version.
The supernumerary tooth is the more distally positioned of the
two lateral incisors. (D) An inverted mesiodens and a super-
numerary tooth located in the path of eruption of the maxillary
central incisor delay exfoliation of the deciduous central incisor,
and account for the ectopic position of
the permanent central incisor and its failure to erupt. (E) Labial displacement of the mandibular central incisor followed the eruption of a
supernumerary (supplemental) lateral incisor. (F) Two maxillary supernumerary teeth erupted in the midline area and prevented the
maxillary central incisors frO!J1 erupting in their normal positions.
234 . In terceptive- Preventive Orthodontics
114.
115.
Fig. 17-28. (A) Two maxillary deciduous lateral incisors are

present on the patient's left side; one is a supernumerary tooth. (B)
Both the normal and supernumerary deciduous lateral incisors
have well-formed, well-positioned, unerupted permanent
successors,
The supplemental primary LateraL incisor may be

retained if there is sufficient room for it. The tooth must
be extracted when the permanent Lateral incisor is ready
to erupt. If there is an extra permanent lateral, it may be
removed at the same time. Identification of a
supplemental tooth that is similar in
Fig. 17-29. (A) A supplemental (supernumerary) maxillary

lateral incisor that has erupted (typically) distal to the normal
lateral incisor. (B) The normal lateral incisor is the larger of the
two laterals shown in the radiogram. Its size more nearly
corresponds to that of the contralateral tooth. Therefore, it should
be kept, and the more distal tooth, identified as the supplemental
tooth, should be extracted immediately.
116. Serial Extraction . 235
form and size to the tooth alongside which it erupts, can be occlusion from becoming severe and lessens the length of
made by looking at the comparable tooth on the opposite side orthodontic treatment.
of the dental arch and removing the one which less closely
resembles in size and shape the normal lateral incisor (Fig.
Indications
17-29A and B). Usually, the more distal of the two teeth is the
supplemental one. Conditions that should prevail when management by serial
extraction is being considered are: (1) Class I molar occlusion;
(2) lack of so-called developmental spacing in the incisor
section of the primary dentition; (3) permanent incisors
SERIAL EXTRACTION erupting labially or lingually to the line of occlusion, often in
Serial extraction is a planned program of early removal of torsiversion; (4) arch length deficiencies of 4 mm. or more per
primary teeth to make room for the eruption and satisfactory quadrant.
positioning of the succedaneous teeth. Extraction rests in the
removal of four permanent teeth, usually the four first pre-
molars. The procedure should not be practiced unless one has
Treatment
a thorough knowledge of orthodontic diagnosis, especially of
dentofacial growth and development. The timed, sequential The need for early removal of some primary teeth may first
removal of appropriate primary and permanent teeth can become apparent when one or both mandibular permanent
prevent a mal- central incisors are forced, for want of space, to assume
malpositions as they erupt
Fig. 17-30. (A) The mandibular permanent central incisors

are erupting lingually and are rotated because of lack of space.
(B) Extraction of the mandibular deciduous lateral incisors
allowed self-correction of the mandibular central incisors. (C)
The early extraction of the six maxillary and six mandibular
deciduous anterior teeth provided enough room for the four
maxillary and four mandibular permanent incisors to align
themselves without treatment.
236 . lnterceptive-Preventive Orthodontics 117.
118.
Fig. 17-31. (A) In the patient who may require

serial extraction, there may be no spacing (I), or there
may be evidence of crowded incisors in the primary
dentition. When the permanent incisors erupt, their
additional crown widths compel them to assume
crowded, irregular positions (II). To permit the
spontaneous incisor adjustment that is accomplished
in phase I of serial extraction procedure (III), early
extraction of the deciduous canines is in order. (B)
The most common sequence of eruption of man-
dibular canines and premolars (I and II) brings the
canines into the dental arch before the premolars.
Therefore, unless space is provided for their distal
INITIAL CONTROL CLASS I positioning as they erupt, and the first premolars are
MALOCCLUSION WITH then allowed to make a similar adjustment, incisor
crowding will reappear (IV). (C) In approximately 80
INSUFFICIENT ARCH
per cent of patients, the mandibular canine erupts
LENGTH A before the first or second premolar (III and IV). (D)
Procedures to follow in serial extraction when the
mandibular canine erupts before the first premolar.
See text. (Courtesy, Dr. Z. Bernard Lloyd.)
~
,
&I ,0
IT
B
UNDESIRABLE RESULTS WHEN TEETH ARE NOT REMOVED AT CORRECT TIME
c
POSSIBILITIES OF MANDIBULAR CANINE AND FIRST PREMOLAR
Sf VENCE OF TOOTH REMOVAL D

WHEN ERUPT OF '-'ANCI8UlAR CANINE PRECE.DES THAT OF 1.1 PREMOLAR
The Lingual Holding Appliance . 237
(Fig. 17-30A). Extraction of the primary lateral incisors eruption sequence is the first premolar before the canine.
affords the erupting permanent central incisors additional Since such sequence occurs in less than 21 per cent of the
space, and spontaneous improvement in their positions population, early removal of the mandibular first
can be expected (Fig. 17-30B). deciduous molar is necessary to make room for the
The next permanent teeth to erupt are the maxillary erupting permanent canine (Fig. 1731D). The early
central incisors. If these teeth are crowded but do not extraction of the second deciduous molar must
cause premature exfoliation of the primary lateral immediately follow to allow enough distal eruption of the
incisors, the laterals should be extracted in order to first premolar (Fig. 17-3'lD) so that it does not crowd
provide the space needed for the satisfactory positioning teeth in the mandibular anterior section of the dental arch
of the permanent central incisors. (Fig. 17-3IB). It is absolutely essential to place a well-
Just prior to the eruption of the mandibular and adapted lingual holding arch wire on the removal of the
maxillary permanent lateral incisors, the premature second deciduous molars. When the first premolar erupts
removal of the primary cuspids in both dental arches is (Fig. 17-31D), it is extracted. The lingual holding
necessary to provide space for the permanent laterals. archwire is not removed until after the second premolars
Once the space becomes available, the spontaneous have erupted.
correction of ectopically erupting and erupted permanent
incisor teeth can be confidently anticipated (Fig. 17-30C).
The next phase, which includes the extraction of THE LINGUAL HOLDING APPLIANCE
permanent as well as primary teeth, requires some
decisions that are final and produces some results that are The lingual holding appliance is constructed on a cast
irreversible. Therefore, an orthodontist should always be a of the mandibular teeth. After orthodontic bands have
consultant on these cases, if attempted by a general been fitted to the mandibular first permanent molars, an
practitioner whose knowledge of dentofacial growth and alginate impression is taken. The bands are then removed
orthodontic diagnosis is limited. from the molars and fitted carefully into the alginate
After the incisors are well-aligned (Fig. 17-31A) the impression before pouring the cast. This working cast
lack of arch length and the inadequacy of the space permits adaptation of 0.040-inch round chrome alloy
available for the eruption of the canine and premolar (stainless steel) wire to the lingual surfaces of the teeth.
teeth becomes obvious. Space now must be provided for The wire is soldered to the molar bands.
the canines, otherwise they will encroach upon the incisor
area as they erupt and cause recrowding (Fig. 17-3IB).
Following exfoliation or extraction of the first Adaptation of the Archwire
deciduous molar, the unerupted first premolar is
extracted. This occurs far enough in advance of the Proper adaptation of the lingual holding arch wire is
eruption of the maxillary canine tooth so that space for its important. It serves three functions: (1) maintains arch
eruption is ample for it to move into position without length until the second premolars have erupted, by
displacing the teeth anterior or posterior to it. preventing forward movement of the first permanent
In the mandibular dental arch, because the sequence of molars following the extraction of the second deciduous
eruption of teeth is different, the serial extraction molars; (2) controls lingual tipping of the mandibular
procedure must be modified. In a study of 236 subjects, incisors; and (3) prevents supra-eruption of these teeth.
representing seventeen different eruption sequences of Rowan's-" study of the positions of teeth during and
mandibular teeth, Moyers and LOl8 found the mandibular following serial extraction showed two highly significant
canines erupted before the first premolars in 79.3 per cent changes involving the mandibular incisors: the vertical
of their sample, therefore, the situation illustrated in overbite increased, owing, in part, to their supra-eruption,
Figure 17:31C III and IV prevails in about 8 of every 10 and the horizontal overjet increased, owing in part, to
individuals. their lingual tipping.
To avoid the undesirable results (Fig. 17-31B) that If the position of the lingual holding archwire is above,
come from failure to remove appropriate teeth at the rather than below, the height of contour of the cingulum
proper time, it is necessary to have radiograms of the of the mandibular incisors, their supra-eruption can be
mandibular canine-premolar region in order to determine prevented. If the archwire is in actual physical contact
the sequential eruptive possibilities of these teeth (Fig. with the lingual surfaces of all mandibular teeth mesial to
17-310). The most favorable the first molars, arch length will be preserved, and lingual
tipping of the incisors will be prevented.
Fig. 17-32. Construction of the Nance holding archwire

for maxillary teeth is shown before the addition of the
palatal acrylic button (A); after the addi tion of the acrylic
(B); and with a maxillary holding archwire in place (C).
guidance over a number of years (as many as 7) before the

program culminates in actual orthodontic treatment, it may
be wiser not to start the procedure at all. An example of this
point is illustrated in Figure 17-33A to E).
SURGICAL EXPOSURE OF TEETH
Dental surgery to uncover the crowns of late erupting

permanent teeth can stimulate them to erupt and forestall
malocclusion. Surgical exposure of the crowns of late
erupting teeth finds its most frequent application involving
The lingual holding archwire is cemented in position and the maxillary canine because this tooth is the one that most
maintained until the mandibular second premolars have often erupts belatedly. The procedure has equal value,
completed their eruption. Where a deep vertical overbite however, in other areas of the denture.
may exist prior to the initiation of the serial extraction
procedure, mechanical assistance beyond that provided by
the lingual holding arch may be needed. Such assistance
could take the form of a palatal acrylic button attached to a Technique
maxillary lingual archwire that antagonizes the vertical The surgical exposure of the crown is accomplished by
eruption of the mandibular anterior teeth. (Fig. 17-32A, B, removing the overlying tissue (hard and soft) to an extent
C). that the greatest diameter of the crown is visible. If the
The limitations of space prevent a complete discussion opening, surgically created, is as large as or slightly larger
of the many important facets of this subject. TQ have a than the crown of the unerupted tooth, eruption will be
better understanding of the potentials for good as well as stimulated. After the tooth has been exposed, it is advisable
harm in a serial extraction program, the reader is urged to to keep granulation tissue from building up and blocking
familiarize himself with the writings of authorities on the the eruption pathway which was .surgically created. A
subject, including: Lloyd,14,15 Dewel,S-9,15 Heath,tt,12 surgical cement is packed into the wound to control
Mayne,t6.17 granulating tissue. The pack is removed 10 to 14 days later.
Craber.!' Rowan.!" Salzrnann'" (See Chap. 18). After such an interval, peripheral healing of the wound will
As a final word of advice, unless the dentist and the have progressed to a point that the opening will persist long
parents understand that serial extraction is a procedure that enough for the tooth to begin erupting. Once the tooth starts
requires continuing supervision and to erupt it
Extraction of Overretained Primary Teeth . 239
Fig. 17-33. (A) Right lateral

view of casts of a patient who
had three premolars removed as
part of a serial extraction
procedure that was neither
planned properly nor followed
by appropriate postextraction
guidance. (B) ote the obvious
lack of space for the anterior
teeth even though three
premolars have already been
removed. (C) In the left lateral
view of the casts, the Class II
relationship of the premolars
and molars is apparent. (D)
Space for proper alignment of
the maxillary teeth will not be
available even if a second tooth
is removed from the maxillary
dental arch. (E) Occlusal view of
the mandibular cast.
will continue to do so without additional surgical or

orthodontic assistance. Delayed eruption involving
maxillary central incisors treated by surgical assistance
is shown in Figures 17-34 and 17-35.
" EXTRACTION OF OVERRETAINED

PRIMARY TEETH
The earlier one can recognize and remove over-

retained primary teeth that may be causing ectopic
eruption of a succedaneous tooth, the better the chances
that a permanent tooth will erupt in a satisfactory
position. Examples of overretained primary teeth that
should be extracted immediately
Fig. 17-34. (A) Failure of the maxillary central incisor to erupt needs immediate investigation and treatment.
Delay will permit the other incisors to tip into the unoccupied space. (B) X-ray examination revealed an
unerupted central incisor in a normal upright position. A possible explanation of its failure to erupt is the
presence of some dense radiopaque tissue inferior to the incisal edge. (C) Surgical removal of hard and soft tissue
overlying the incisal portion of the crown of the central incisor, provided an opening as large as the greatest
circumference of the crown of the tooth stimulated, (D) A radiogram of the exposed tooth 3 months after the
surgical procedure, (E Opposite) The exposed tooth completed its eruption 6 months after surgery.
o orthodontic treatment was necessary. (F) A radiogram of the exposed tooth 6 months after surgery.
are shown in Figures 17-37, 38, The spontaneous and natural in the wake of ankylosed primary molars (Fig. 1736C, D).
improvement that one may expect the permanent tooth to
make following removal of the overretained primary tooth is
illustrated in Figures 17-36A and B. Perhaps the greatest
damage that may result from overretained primary teeth Diagnosis
comes
The ankylosed primary molar may not be recog-
119. Extraction of Overretained Primary Teeth, 241
nized in the very early stage. However, its condition can

readily be diagnosed a short time later because the vertical
level of the occlusal surface of the ankylosed tooth
becomes noticeably shorter than the level of adjacent teeth
(Fig. 17-37), and as time progresses, this difference in
vertical levels becomes more extreme (Fig. 17-38).
Because anklosed teeth seem to be submerging, they
have been called "submerged" teeth (Fig. 1739A, B), but
the term cannot be applied accurately to ankylosed teeth. It
is more appropriate to call them "engulfed" teeth. The
continued vertical eruption of the uninvolved adjacent
teeth and the vertical growth of the alveolar process and
periodontium creates the illusion that the ankylosed tooth Treatment
is submerging. The primary ankylosed molar may be Ankylosed primary molars may be retained as long as
totally engulfed by the continuing vertical growth of the they are maintaining arch length (i.e., preventing mesial
jaw (Figs. 17-39, 40). shifting of the first permanent molars) or as long as they do
not prevent the eruption of the succedaneous teeth (Figs.
17-40A, B).
Fig. 17-35. (A) An un-

erupted maxillary central
incisor similar to the one
illustrat~d in Fig. 17-34B.
The difference is the lack of
space for the tooth's
eruption. (B) Following
orthodontic treatment that
made room for the eruption
of the central incisor, its
crown was surgically
exposed to stimulate the
tooth's eruption.
242 . In terceptive- Preventive Orthodontics
Fig. 17-36. (A) Owing to an interfering supernumerary tooth, a maxillary incisor

failed to erupt. This radiogram was taken after the supernumerary tooth was removed
and the crown of the maxillary incisor was surgically exposed. (B) Late attention to
the problem allowed the incisors to shift into the space needed for eruption of the
central incisor. (C) A removable appliance with simple helical springs was adequate
to upright the tipped incisors and regain space for the unerupted incisor. (D) A view of
the occlusion following surgical exposure and a minor orthodontic procedure.
Fig. 17-37. Immediate extraction of the

overretained maxillary first deciduous molar is Fig. 17-38. The sooner the overrerained mandibular primary
necessary to allow the first premolar to improve lateral incisors are removed, the better the chance that the
its position as it continues to erupt. erupting mandibular permanent lateral incisors will position
themselves properly.
Extraction of Overretained Primary Teeth . 243
Fig. 17-39. (A) The first deciduous molar is ankylosed and is being overretained. This compels the developing first premolar to erupt
mesially to its normal position. (B) Following the extraction of the overretained first deciduous molar, the first premolar improved its
position and is erupting in a normal position.
Fig. 17-40. (A) In the clinical appearance of dental ankylosis at an early stage, a difference in the ocdusallevels of the crown of the first
deciduous molar and those of the adjacent teeth is obvious. (B) The difference in the ocdusallevels of the ankylosed deciduous molars and
the adjacent teeth is evidence that the ankylosis is not a recent development.
Fig. 17-41. (A) The maxillary left second deciduous molar is not clinically evident. The tooth is ankylosed and completely covered by
the continuing vertical growth of the soft tissues. ote that the first permanent molar shows severe mesial tipping. (B) In the radiogram of
the ankylosed second deciduous molar and adjacent teeth, note the severe mesial tipping of the first permanent molar.
244 . Interceptive- Preventive Orthodontics
Fig. 17-42. (A) The ankylosed maxillary second deciduous molar may be retained for a while longer because it is maintaining
arch length by preventing the mesial tipping of the permanent first molar. (B) In this case of long-standing dental ankylosis
involving the second deciduous molar, extreme mesial tipping of the first permanent molar and considerable loss of arch length is
obvious. Immediate and careful removal of the ankylosed tooth is indicated, as well as uprighting the permanent molar and
regaining the lost arch length.
The value of ankylosed teeth as masticatory units of the more dentists should be involved in the interceptive-
dentition is lost early, once the continuing vertical eruption of preventive phase of orthodontics.
the adjacent teeth takes the ankylosed tooth out of occlusion.
However, they may serve for many additional months to
maintain arch length integrity before they are no longer BIBLIOGRAPHY
capable of preventing mesial tipping of the first permanent 1. Adams, C. P.: Design and construction of removable
molars (Fig. 17 -41A and B). orthodontic appliances. ed. 4th. Baltimore, Williams and
Because the union between the cementum of the root of the Wilkins, 1970.
tooth and the bone of the alveolar process is a physically 2. Ballard, M. 1., and Wylie, W. 1.: Mixed dentition case
strong one, ankylosed primary teeth are overretained. analysis - estimating size of unerupted permanent teeth.
Because an overretained tooth often accounts for the ectopic Am. J. Orthodont. O. Surg., 33:754, 1947.
eruption, if not the impaction, of its succedaneous tooth; and 3. Brown, J. E.: Predicting the mesiodistal crown width of
because the ankylosed tooth ultimately is unable to withstand unerupted maxillary canines, first and second premolars.
the mesial shifting of the first molar and the loss of arch Unpublished M. S. thesis, Univ. of Tenn., 1955.
length (Fig. 17-42A and B) the extraction of an ankylosed 4. Carey, C. W.: Linear arch dimension and tooth size.
primary tooth is an effective means of practicing interceptive- Am. J. Orthodont., 35:762,1949.
preventive orthodontics. Of course, if the ankylosed primary 5. Dewel, B. F.: Serial extraction in orthodontics: Indica-
molar must be removed before prompt eruption of the tions, objectives, and treatment procedures. Am. J.
underlying permanent tooth can be expected, and loss of arch Orthodont., 40:906, 1954.
length in excess of the leeway space will follow, a space 6. _________ : Serial extraction: Procedures and limitations.
maintaining appliance must be used. Am. J. Orthodont., 43:685, 1957.
7. _______ : A critical analysis of serial extraction in ortho-
dontic treatment. Am. J. Orthodont., 45:424, 1959.
8. __________ : Serial extraction: Its limitations and contra-
indications in orthodontic treatment. Am. J. Orthodont.,
53:904, 1967.
9. _______ : Prerequisites in serial extraction. Am. J. Ortho-
dont., 55:633, 1969.
SUMMARY 10. Fonseca, C. c.: Predicting the mesiodistal width of the
canine-premolar segments of maxillary dental arches.
The high incidence of malocclusion and the relatively
Unpublished M. S. thesis, Univ. of Tenn., 1961.
small number of orthodontists has created a situation in some
11. Heath, J.: The interception of malocclusion by planned
areas of our country where not only the need but also the
serial extraction. New Zealand D. J., 49:77,1953.
demand for orthodontic treatment has outstripped the supply
12. ________ : Serial extraction and mechanically guided de-
of practitioners to provide the service. While there is no easy
velopment. Melbourne, Verona Press, 1958.
solution to this problem of professional manpower shortage,
13. Huckaba, G. W.: Arch size analysis and tooth size pre-
diction. Dent. Clin. N. Arn., p. 431, 1964.
Bibliography . 245
14. Lloyd, Z. B.: Serial extraction. Am. J. Orthodont., 39:262, 1, Mixed dentition diagnosis and treatment. Am. J.
1953. Orthodont., 39:695, 1953.
15 _____ : Serial extraction as a treatment procedure. Am. 20. Rowan, T. W.: Changes in denture and skeletal patterns
J. Orthodont., 42:728,1956. occurring during and following serial extraction. Unpublished
16. Mayne, W. R.: A concept, a diagnosis and a discipline. M.S. thesis, Univ. of Tenn., 1959.
Dent. Clin. N. Am., p. 281, 1959. 21. Salzmann, J. A.: Practice of Orthodontics. Philadelphia, J. B.
17. _____ : Serial extraction as an adjunct to orthodontic Lippincott, 1966.
treatment. St. Louis, Am. Assn. Orthodontists, 1965. 22. Weber, F. N.: Orthorehabilitative procedures. Dent.
18. Moyers, R. E., and Lo, R. T.: Studies in the etiology and Clin. . Arn., p. 419, 1959.
prevention of malocclusion; 1, Sequence of eruption of the 23. Young, W. O. and Zwemer, J. D.: Impact of present and
permanent dentition. Am. J. Orthodont., 39:460, 1953. future government programs on orthodontic care. In Proffit,
19. Nance, H. .: The limitations of orthodontic treatment; W. R. and Norton, L. A. (eds.): Education for Orthodontics in
General Practice, St. Louis, C. v. Mosby, 1966.
",
18
Extraction in Orthodontic Therapy
CRITERIA crowding), slight distal movement of teeth by means of

extraoral force or by disking the interproximal surfaces of
The criteria for extraction must be evaluated in each the mandibular incisors, may obviate extraction, especially
patient. Preconceived facial patterns are unrealistic. if treatment is initiated during the mixed dentition when
Continued growth of the jaws can change the nature of the growth is active and before the "leeway" space is
facial profile and the size of the basal arches, which are the eliminated by forward shifting of the permanent first
most constricted areas in the maxilla and mandible molars.
containing the Downs A-Point (subnasale) and B-Point The decision to extract teeth for orthodontic purposes,
(supramentale). Tweed refers to the areas as basal bone. In before growth is completed, is not to be based on dental
the mandible the basal arch lies under the tooth-bearing casts alone, or on cephalometric tracings only. Nor can it be
area where it occupies the section between the outer and based on a particular "appliance system." The decision must
the inner cortical plates and contains spongy, medullary be based on specific knowledge of dentofacial growth and
bone. Continued growth can make extraction unnecessary development as observed in clinical observations, in
if not altogether contraindicated. In borderline extraction addition to local factors.
cases (light incisor The amount and direction of jaw growth, the rel-
Fig. 18-1. Class I malocclusion (Angle).

Crowded dental arches in a child 12 years of age.
Attempts to move the teeth into normal alignment
without reducing the mesiodistal dimension of the
coronal arches by extraction will result in
procumbency of the incisors and an unstable
relationship of the teeth.
246
Criteria . 247
ative difference in size of basal arch length in the

respective bodies of the maxilla and mandible, the
soundness, position, and eruption of the teeth, the degree
of alveolodental prognathism, and the age and dental
developmental state of the patient all must be considered
in determining the necessity for extraction. In addition,
there is the question of the thickness and distribution of
the soft tissues covering the facial bones which affect the
orthognathic appearance of the facial profile.
Extraction of teeth in orthodontic therapy is not simply
a shortcut to aligning crowded teeth. It is an adjunct in
treatment where the basal arches are not large enough to
accommodate the teeth in normal alignment without
producing alveolodental protrusion, recrowding of teeth,
and deleterious facial esthetics. While Tweed considered
extraction necessary in practically all cases of
alveolodental prognathism, there are certain
contraindications.
Procumbency of Mandibular Incisors as

a Criterion for Extraction
The mesiodistal relationship of the mandibular dental

arch to the pogonion (the most prominent point on the
chin) is an important factor in determining the need for
extraction where facial esthetics are involved. However,
extraction of teeth does not depend solely on the degree
of procumbency (forward inclination) of the mandibular
incisor teeth in relation to the mandibular plane (the base
of the mandible). The size of the gonion angle, the labiad-
linguad position of the mandibular arch on the body of
the mandible, the presence of tooth crowding, and the
relationship of the incisor teeth to pogonion are more
important factors in determining the need for extraction
as a method of reducing facial prognathism than is incisor
procumbency. When the ramus of the mandible is short,
the mandibular incisors may appear procumbent (forward
inclined more than 90 5) but on lateral cephalogram
Fig. 18-2. Patient K. K. was 15 years old when first ex-
tracing examination they will frequently be found to be
amined. She had been treated elsewhere for 3 years. Com-
90 or less to the mandibular plane.
pare pre-retreatment (A, C, D, G) with casts made at age 18,
Permissible Procumbency. When the lateral ceph-
1 year out of retention (B, E, F, H).
alogram shows a large maxilla (mesiodistally), with sella-
nasion-A-point (SNA) decidedly above normal range, it
may be necessary to permit the mandibular incisors to too forward to the facial line, the line from nasion to
remain procumbent, and otherwise correct the pogonion (N-Pg), it is frequently advisable to extract only
malocclusion in general. This is especially true when the maxillary teeth.
mandibular ramus is long and the gonion angle is not Extraction in Class II, Division 2 malocclusion usually
above 125 to 130. is not required, although second molar extraction may be
In Class II, Division 1 malocclusion when the teeth in required when normal third molars are present and where
the mandibular arch are in normal alignment and A-Point distal movement of the maxillary dental arch would result
is abnormally forward of B-Point, and where the labial in molar crowding because of lack of alveolar space at the
surface of the mandibular incisors is not tuberosity. When the maxillary teeth are moved distally, a
biteplane with an anterior level plane on
248 . Extraction in Orthodontic Therapy 120.
121.
,
KK I
15yrs I
K.K. 78 01~
18
yr~ I
/~'V(-------
\\
--(-?~fO:' I \ \
I '~\
\ \
.; ~ 'e- _ _ _ ____________ ____ _____1- ____ >,.. _ __ __ __ _____- - ~~ - JiL -
<, .:::" \ \ 82~"1
-, ..
' \ ,II
1"1
-_ 1\ \ \
-, _________\1, ______ __ __ ___ _ _ __ -_
"" \: \ --"'--;:;:-,-,tr-
" \ \ \1.~1I
\ '/ '~ I
"" \1300 \
13l~v.(
... I-.:::: \\ .JI1i'
__ /yi/ \
I"', \ tf:'
KK - '0/1' \
<,
15yrs. \~ 96'( '/ \ ":...... / \ ~ ...
- - -18yrs. '~~ v
" .....
'\, CD
Fig. 18-3. Lateral cephalogram tracings of patient K. K.
(see Fig. 18-2) before retreatment (A) 1 year out of reten-
tion (B), and (e). The change was in the dentition only; the
facial growth pattern had not changed.
occlusion present and the amount of overbite and overjet
shown by the patient before treatment. Extraction is not
responsible per se for increase or decrease in overbite.
THE TWEED DIAGNOSTIC TRIANGLE

The Frankfort and mandibular planes are extended on
the tracing of the lateral cephalogram to meet and form
the Frankfort-mandibular angle. The third line is drawn
which the mandibular incisors rest may be used in along the long axis of the most labial mandibular incisor
abnormally deep overbite cases, but it is not usually to meet the other two lines. The angles forming this
required. Axial correction of the anterior maxillary teeth triangle have an important bearing in determining facial
is indicated in most cases of Class II malocclusion. esthetics and are useful determinants in diagnosis,
When the posterior segments of the maxillary arch are classification, treatment planning, and prognosis,
in cross bite to the mandibular dental arch, extraction according to Tweed.
should not be undertaken until buccolingual arch relation Tweed considers the norm of the Frankfortmandibular
of the posterior teeth is established. After this is angle to be 250 in well-balanced faces. The incisor-
accomplished, the necessity for extraction should be mandibular angle in a balanced face he gives a value of
reevaluated. 90 5. The norm of the third angle at the point where
When the dentition must be balanced because teeth are the line through the long axis of the most forward
missing the space should be considered for insertion of an mandibular incisor meets the Frankfort plane (FMIA) is
artificial tooth, or a tooth in the opposite side should be given a mean of 65. When these angles are at variance
extracted and both spaces closed. The decision should be with the above standards, especially the incisor-
based on the dentition as a whole. The effect of extraction mandibular plane angle (IMA) and the Frankfort-
on overjet and overbite depends on the type of the mandibular incisor angle (FMIA) Tweed corrects the
original discrepancy by extraction if there is no other way (See Fig.
18-8).
Effect of Extraction on the Facial Profile . 249
Fig. 18-4. Cross section of the mandible (A)

showing the incisor plane (INC-P) through the long
axis of the central incisor in relation to the
mandibular plane (M-P) and the prementon plane
(PRM-P), a line tangent to pogonion, the most
prominent point on the chin and at right angles to
the mandibular plane. The ramus plane (R-P) is
tangent to the most distal point on the mandibular
condyle and the most distal point on the ramus. The
gonion angle is measured at the intersection of the
planes R-P and M-P. Note the difference in
relationship of the incisor plane (INC-P) to the
mandibular plane (M-P) and the prernenton plane
(PRM-P) in mandible A in comparison to mandible
B. The gonion angle; the incisor plane in relation to
the mandibular plane and the prernenton plane; the
arrangement of the teeth in the dental arches; the
soft tissue covering of the facial skeleton; the facial
profile, and the developmental age of the patient
must be taken into consideration before the decision
is made to extract teeth as part of orthodontic treat-
ment.
EFFECT OF EXTRACTION ON THE dibular incisor procumbency and alveolodental

FACIAL PROFILE prognathism may have little or no effect on the facial
profile in these cases. The facial profile is affected by the
The muscles, skin, and the soft tissues in general play shape and size of the jaws, the length of the ramus,
an important role in facial appearance. The lips in repose dentoalveolar prognathism, the mesiodistal dimension of
do not always rest against the teeth, especially in young the crowns of the teeth, the size of the gonion angle, the
persons, and reduction of man- proximity of the mandibular
Fig. 18-5. Cross sections showing different

stages of development of the mandibular
permanent incisor and growth of the alveolar
process and of the body of the mandible. (A)
2 months; (B) 7 years; (C) 9 years; (0) 11
years; (E) 16 years, and (F) 25 years.
Allowing for the variation in growth patterns
of different jaws, we can observe,
nevertheless, the tendency of the body and
base of the mandible to show increased
growth with age. The growth pattern of the
body of the mandible, especially in an
anterior direction, is an important factor in
determining the presence of a constricted
basal arch. (Atkinson, S. R.: Am. J.
Orthodont.)
Fig. 18-6. Profile photographs of M. A. (A) and C.

M., (B) showing difference in facial profile, due mostly
to differences in the length of the mandibular ramus and
the respective gonion angles. Incisor procumbency is
not a factor in prognathism of the facial profile in these
patients.
M.A:
incisor to the facial line (NPg), and the distribution and First Premolars
amount of the soft subcutaneous tissues of the face.
First premolars are the teeth usually extracted when it is
necessary to obtain stable results in malocclusions with
dental arch-basal arch discrepancies. The choice is
THE CHOICE OF TEETH FOR EXTRACTION modified by the age of the patient (e.g., if less tooth
movement would be required in an adult patient), the
The choice of teeth to be extracted depends on (1) the
presence and severity of caries or extensive fillings in the
direction of jaw growth, and especially lack of jaw
second premolar teeth, and agenesis of other teeth in the
length; (2) the amount of discrepancy between the size of
dental arch. When forward positioning of the molar teeth
the dental arches and the basal arches; (3) the carious
is not required, the first premolars should take precedence
state of the teeth; (4) the anteroposterior position of the
over the second premolars as the teeth to be extracted.
teeth in the jaws in relation to the facial line; (5) the
presence of an orthognathic or a prognathic facial profile;
(6) the degree of alveolodental prognathism; (7) the age
of the patient; and (8) the health of the dentition as a
Second Premolars
whole.
The teeth to be extracted in adults, other conditions Second premolars may be extracted instead of first
being favorable, are those that entail the least amount of premolars if they are unsound or severely carious, are
tooth movement for obtaining favorable results. blocked out of alignment, and would require extended
orthodontic tooth movement to bring them into line, while
the first premolars are already in satisfactory position. If
the space required for tooth alignment will not fill the
Canines
extraction space and considerable mesial movement of the
Canine teeth should not be extracted by choice because molars will be required, second premolar extraction
of their importance in maintaining facial expression and should be considered.
occlusal stability.
123. The Choice of Teeth for Extraction . 251
Fig. 18-7. (Top) Front and

profile view of adult patient 1. B.
(Center) Lateraljaw radiograms
showing mandibular space
closure after loss of permanent
first molars by distal collapse of
teeth anterior into the permanent
first molar extraction spaces.
(Bottom) shows casts of
dentition. (Note) The patient
sucked her lower lip, which
helped in the lingual collapse of
the mandibular dental arch. A
tracing of the cephalogram of the
patient shows that this is an
unusually normal Class 1 facial
skeletal pattern. The anterior
limit of the maxillary basal arch
(APoint) and the mandibular
basal arch (B-Point) are on the
same line. S- -A and S-N-B are
both retrognathic below the
mean at 79 degrees. Extraction
of maxillary premolar teeth
would give the patient a more
concave profile ("dished in").
Treatment in this patient requires
increased procumbency of the
mandibular incisor teeth by
moving the mandibular dental
arch labially.
Permanent First Molars
Extraction of permanent first molars does not lead to

caries reduction. The contrary is true in these cases
according to findings by Salzmann in a survey of 500
adolescents. First permanent molars may be extracted in
preference to premolars when the molars are beyond
repair and the condition of the premolars indicates their
longer usefulness.
When the maxillary or mandibular dental arch is being
moved distally in order to obtain space for
252 . Extraction in Orthodontic Therapy
Fig. 18-8. Tweed's Frankfort-mandibular base-mandibular

incisor triangle (FMIA).
teeth mesial to the first molars, lateral jaw radiograms

should be taken to ascertain that the second molars are
not being forced into buccal occlusion or into ectopic
eruption or impaction. When the foregoing is the case the
decision should be made on the need for extracting
second or third molars. If the third molars are sound and
of normal shape, the second molar should be extracted,
and the third molars should be moved or allowed to come
into occlusion in contact with the first molars.
In Class I or Class II nonextraction cases, alveolar
development distal to the maxillary permanent first
Fig. 18-9. Casts and photographs of face, a tendency to Class III (Angle)
patient, 18 years of age, when first seen. The malocclusion, and mandibular prominence.
maxillary first premolars had been extracted Adequacy of the basal arches had been
by a previous operator who brought the ignored, and the extractions were performed
canines which were blocked out of the arch to aid in overcoming tooth crowding without
into alignment in the first premolar spaces. regard to basal arch growth, facial
Lingual collapse of the maxillary arch appearance and intermaxillary arch
followed with a flattening of the maxillary relationship. The face appears flattened.
portion of the
The Choice of Teeth for Extraction . 253
Fig. 18-10. Profile photograph of a patient before

(A) and after (B) rhinoplasty. Note the change in the
configuration of the mimetic muscles, especially the
orbicularis oris. The patient has not received any
orthodontic treatment, and the intramaxiUary
position and occlusion of her teeth have remained
unchanged. (Courtesy Bruno Griesman)
molars is required frequently to move the maxillary molars 3. The maxillary tuberosity is insufficient to accommodate
posteriorly. Buccal displacement of the maxillary second or both the second and third molars in normal alignment.
third molars can occur when the alveolar process or maxillary 4. The second molars are severely carious and their
tuberosity length is deficient. The second molars may become successful restoration is questionable and the third molars are
impacted against the first molars, or the distal positioning of sound.
the maxillary first molars may cause the second molars to 5. The maxillary third molars are in favorable angulation for
erupt into malocclusion. eruption into the second molar space.
Contraindications to second permanent molar extractions
1. Poor angulation of third molars in relation to
Permanent Second Molars to the second molars
2. Undersized third molars
Conditions favorable to maxillary second molar extraction
3. Absence of third molar tooth buds
and their replacement by mesial movement of the third molars
4. Ectopic or impacted third molars
can be summarized as follows:
1. The patient is past the average physiologic eruption age Enucleation of mandibular third molar tooth follicles in
when the second molars usually erupt. 2. The maxillary third children when it appears that there is not sufficient room to
molars are normal size and shape, and the root area is accommodate these teeth is not recommended, since it is
sufficient for these teeth to serve in place of second molars. impossible to pre-
Fig. 18-11. Profile of patient (left) before and

(right)after rhinoplasty. Note change in entire
facial profile although the patient never re-'
ceived orthodontic treatment. The change in soft
tissue tension was responsible for the change in
profile. (Courtesy A. . Abraham)
Fig. 18-12. The casts of H. K., a girl of 11, were made by a tion to the mandibular first molar and openbite of lateral incisor,
previous dentist before he began treatment. (A) The right side canine, and second premolar. (F, G, H) Casts 1 year out of
shows Class I molar relation with canine unerupted and space retention at age 18 years. (l) Occlusal view taken by dentist before
closed. (B) An anterior view of the casts shows maxillary incisor he started treatment shows spaced maxillary incisor teeth; the
spacing and overbite. (C) The left side shows a cusp-to-cusp right maxillary canine is unerupted and the space is closed; the
molar relation and a crowded second premolar; the canine is left maxillary canine is unerupted and the space is partially
unerupted and the spaces partially closed. Casts taken when the closed. The maxillary left second premolar is crowded and
patient was first seen at age 15 years after having previously had rotated. The mandibular incisors are aligned. The right
4 years treatment elsewhere. The patient had the four first pre- mandibular canine is crowded, and the left mandibular canine is
molars extracted at that time. (D) At the beginning of re- unerupted and the space almost closed. (J) Occlusal view when
treatment, the maxillary first molar showed a cusp-to-cusp the patient was first seen and had previously had 4 years
relation with the mandibular second molar. The maxillary first treatment. The maxillary first premolars had been extracted. The
premolar occludes with the mandibular first molar. The maxillary incisor teeth are spaced. The mandibular first pre-
maxillary canine is erupted and in open bite relation with the molars had been extracted. The mandibular canines are erupted
distal aspect of the second premolar. The mandibular right and are crowded. The mandibular incisors and canines are
canine is still crowded. The maxillary lateral incisor is in lingual crowded. (K) An occlusal view 1 year out of retention at age 18
occlusion and in open bite. (E) The left side shows the maxillary years.
first molar in Class III rela-
The Choice of Teeth for Extraction . 255
124.
H,K.
15yrs.
Fig. 18-13. A lateral cephalogram was taken when H. K. was

first examined (A). It shows the A-Point to be retrognathic to the
HK
B-Point. The facial angle is 87 degrees and is at the mean of the 18yr
Downs normal range. The Y-axis is 63 degrees, which here s
indicates a long facial skeleton since the facial angle at 87
degrees is normal. The mandibular incisor angle is 82 degrees,
but the mandibular incisor relation is still somewhat prognathic.
The facial skeletal pattern is Class 3, and the mandible is in
Class III relation to the maxilla. (C) The interincisor angle is the
same as in B, but the mandibular incisor angle was reduced still
further in order to obtain a normal incisor occlusion.
Fig. 18-14. (Left> Anterior view of H. K. (see Figs. 18-12, 13) when first examined after having been treated elsewhere and (Right> at age
18 years, 1 year out of retention.
Fig. IS-15. (Left) Maxillary second molars have been extracted. (Right) The maxillary third
molars are erupting into position and pre-empting the space of the extracted second molars.
determine the eventual increase in the tuberosity and the tuberosity has a bearing on the need for second molar
course of eruption of these teeth. extraction and replacement by the third molar. Permanent
third molars may find space for eruption during adolescent
growth or even later in the third decade of life. Contrarily,
Impacted Third Molars
some apparently normally erupting third molars may
Impacted third molars that show evidence of interfering become impacted. It is advisable to extract the second
with treatment or retention or that cause reflex pain or molars in the maxillary dental arch and the third molars in
infection, should be extracted. Malformed third molars that the mandibular arch when molar extraction is required.
interfere with occlusion should be extracted during
orthodontic treatment if they interfere with distal
movement of the maxillary dental arch or with retention
after treatment.
Mandibular Incisors
There is a wide variation in the time of eruption of the The intercanine distance of the maxillary and mandibular
third molars, and the development at the teeth should be measured when ex-
Fig. 18-16. (Top) The roent-

genogram shows developing
third molars. (Bottom) Three
years later the mandibular third
molars show horizontal
impaction.
Extraction Without Orthodontic Therapy 257
traction of incisor teeth is contemplated to determine the

amount of excess space that will be left after the crowded
incisors are aligned.
Incisor teeth should not be extracted unless damaged
beyond satisfactory repair, severely crowded, or entirely
excluded from the arch while the rest of the teeth are in
regular alignment. The fact that occlusal surfaces of teeth
can be equilibrated does not always compensate for the
untoward effects of incisor extraction. Dentitions treated
by incisor extraction may show a tendency to develop
abnormally deep overbite and disturbances of the
occlusion of the buccal tooth segments, including cusp-to-
cusp relation on one or both sides.
An incisor may be extracted in certain Class III cases, if
the incisors are crowded and if in the process the incisor
teeth will not have to be extremely lingually inclined in
order to close the space.
There may be a tendency for the space to open when
the alveolar basal arch is large, and for increased
maxillary incisor overjet, and deep overbite to occur.
Retaining appliances may have to be worn indefinitely.
The space left by an extracted incisor should not be
allowed to close by itself because tooth shifting is not
predictable. Active closure of the space is required by
orthodontic means.
Contraindications to extraction include the following:
1. Continuing growth of the face can affect the facial
growth pattern causing the face to appear older.
2. Facial patterns preconceived by the dentist are not
realistic and may prove unacceptable to the patient.
3. Relapse may show itself in spacing in the presence of
a large increment in jaw growth.
EXTRACTION WITHOUT ORTHODONTIC

THERAPY
Extraction for the sole purpose of overcoming crowding
of teeth, without accompanying orthodontic therapy, can Fig. 18-17. (Top) Lateral jaw roentgeno-
be deleterious to the dentition as a whole. Desirable grams just before extraction of first premolars.
shifting of teeth usually does not follow extraction (Second row) Three years later, the mandibular
without the aid of orthodontic mechanotherapy. third molars are changing their course of
The rate and direction of uncontrolled tooth shifting eruption, the crowns inclining mesially and
after extraction are subject to many influences, so that the roots distally. (Third row) One year later than
results are unpredictable. Extraction per se cannot be the second row, the third molars are showing
relied on to correct malocclusion as it manifests itself in more definite tendency to impaction. (Fourth
the various classifications established by E. H. Angle. row) One year later than the third row, third
molars show increasing tendency to impaction.
Uncontrolled extraction may be followed by traumatic
(Bottom row) This roentgenogram was taken 6
occlusion, periodontal disturbances and marked untoward
years after the top row and 2 years after the
changes in the patient's profile and in general facial first premolars were extracted. The mandibular
appearance. third molars now are definitely in horizontal
impaction.
Fig. 18-18. (A) The patient
whose casts are shown here was
treated by having the right
mandibular lateral incisor
extracted. This resulted in
abnormal overbite and cusp-to-
cusp occlusion on the right side
where the lateral incisor was
extracted. After treatment
(bottom row) there is normal
intercuspation and the anterior
overbite has been opened. (B)
Occlusal views before (left) and
after (right) treatment. The right
permanent canine was moved
forward to serve in place of the
extracted lateral incisor. The
distance between the mandibular
left canine and right first pre-
molar was increased. (e) After
treatment the mandibular right
canine serves as a lateral incisor
in place of the one that was
extracted (center). Left and right
views show the occlusion after
treatment. (Bottom) The activator
appliance was used to open the
bite and to position the lateral
series of teeth.
Extraction Without Orthodontic Therapy' 259
126.
127.
33CJ2
Fig. 18-19. The casts were made when patient 1. B. was first examined after having had 4 years treatment elsewhere. (Top) Left side
shows cusp-to-cusp occlusion and first premolar spaces still open. Anterior view shows maxillary incisor deep overbite. Right side
shows cusp-to-cusp occlusion and first premolar spaces still open. (Bottom) The occlusal view shows the teeth are aligned, but the first
premolar extraction spaces are still open after 4 years of treatment. The lateral jaw radiogram shows open premolar extraction spaces and
edge-to-edge occlusion and the intraoral view shows deep overbite.
L.G.
Fig. 18-20. (A) In the profile view of L. B. made at the first examination note the deep (anteroposteriorly) maxilla and retrognathic
mandible. (B) Measurements were made from a lateral tracing of a cephalogram: S-N-A is 85, while the maxillary incisors are in
vertical axial relation at 920 to the Frankfort horizontal. The interincisor angle is 150, which is at the high extreme of the Downs range.
The mandibular incisors are at 87. The normal Tweed range is 90 5. This patient was treated by changing the axial inclinations of
the incisors making the mandibular incisors more procumbent, thus reducing the interincisor angle and rendering the incisors more
stable. The posterior series of teeth were moved forward to close the premolar extraction spaces.
Fig. 18-21. Extraction was the

sole method of treatment, without
orthodontic intervention in this
case. (Top) Lateral views
showing first premolars
extracted; crowding of incisor
teeth, spaces distal to the canine
teeth and the occlusion still in
Class II (Angle) malocclusion.
(Bottom) Anterior and occlusal
views of dentition shown above.
Casts made from impressions
taken on patient's first visi t.
BIBLIOGRAPHY Case, C. 5., et al.: The question of extraction in orthodontia.

(Reprinted from Trans National Dental Association for 1911,
and from Dental Cosmos for Feb., March, and Sept., 1912 and
Adamson, K.: The controversy concerning the first permanent [an., 1913.) Am. J. Orthodont., 50:658, 1964.
molar. Australian D. J., 7:191,1962. Chipman, M. R: Second and third molars: their role in orthodontic
An answer to how much orthodontics should the pedodontist do. therapy. Am. J. Orthodont., 47:498, 1961.
Am. J. Orthodont., 44:630,1958. Dargent, P.: Occlusion dentaire et fonction occlusale ideale et
Berger, H.: The problem of extraction in orthodontics. Am. equilibree. Parodont., 17:65, 1963.
J. Orthodont., 31:557, 1945. Dausch-Neumann, D.: Prognose and Rezidiv. Forrschr.
Bjork, A., Jensen, E., and Palling, M.: Mandibular growth and Kieferorthop, 23:330,1962.
third molar impaction. Acta odont. scandinav., '14:231, ] 956. Derichsweiler, H.: Zur Frage der Extraktion bleibender Zahne bei
Breakspear, E. K.: Indications for extraction of the lower second Eckzahnhochstand. Deutsche Zahn. Ztschr., 10:1055, 1955.
permanent molar. D. Practitioner & D. Record, 17:] 98, 1967. Downs, W. B.: The role of cephalometries in orthodontic case
Brouwer, H.: (Extraction of first permanent molars in orthodontic analysis and diagnosis. Am. J. Orthodont., 38:162, 1952.
treatment). Neder, Tschr., Tand., 69:462, 1962. Fau bien, B. H.: Effects of extraction of premolars on eruption of
Case, C. 5.: Facial and Oral Deformities (1896), Dental mandibular third molars. J. Am. Dent. Assoc., 76:316, 1968.
Orthopedia. Chicago, C. S. Case Co., 1921.
Bibliography . 261
Friel, S. E.: Migrations of teeth following extractions. Proc. Mixed dentition diagnosis and treatment. Am. J. Orthodont.,
Roy. Soc., Med. Sect. Orthod., 38:22, 1945. 39:695, 1959.
---: The development of ideal occlusion of the gum pads and the Pletcher, E. c.: Simplified management of space closure.
teeth. Am. J. Orthodont., 40:196, 1954. Am. J. Orthodont. 45:278, 1959.
---: Determination of the angle of rotation of the upper first Priewe, D. E.: An evaluation of cephalometric analysis and
permanent molar to the median raphe of the palate in different extraction formulas for orthodontic treatment planning. Am. J.
types of malocclusion. D. Practitioner & D. Record, 977: [an., Orthodont. 48:414, 1962.
1959. Reid, P. V.: Extractions in the problem case. Am. J. Orthodont.,
Grieve, G. W.: Manifest evidence of the cause of relapse in many 45:12,1959.
treated cases of malocclusion. Int. J. Orthodont. & Oral Surg., Rottsahl, J.: Zur Frage del' Extraktion von Zahnen beim Deckbiss.
23:23, 1937. Deutche Zitsch. Zahnheilk. Kieferorth., 1 :1145, 1958.
---: Anatomical and clinical problems involved where extraction Salzmann, J. A.: The rationale of extraction as an adjunct to
is indicated in orthodontic treatment, Am. J. Orthodont, & Oral orthodontic mechanotherapy and the sequelae of extraction in
Surg., 30:437, 1944. the absence of orthodontic guidance. Am. J. Orthodont., 31
Halderson, H.: Early second permanent molar extractions in :181, 1945.
orthodontic. Canad. Dent. Am. J., 25:549,1959. ___ : Orthodontic therapy as limited by ontogenetic growth and
Kessel, S. P.: The rationale of maxillary premolar extraction only the basal arches. Am. J. Orthodontics, 34:297, 1948.
in Class II therapy. Am. J. Orthodont., 49:276, 1963. ---: An evaluation of extraction in orthodontics. Am. J.
Lewis, P.O.: Space closure in extraction cases. Am. J. Orthodontics, 51 :928, 1965.
Orthodontics, 36:172, 1950. Tweed, C. H.: Indications for the extraction of teeth in orthodontic
Lundstrom, A. F.: Malocclusion of the teeth regarded as a procedures. Am. J. Orthodontics & Oral Surg., 30:405, 1944.
problem in connection with the apical base. Sv. Tandl.-Tidskr. - __ : Clinical Orthodontics. St. Louis, C. V. Mosby, 1966.
Festskrift. 1923. Waldron, R.: Question of the influence of erupting or impacted
---: Malocclusion of the teeth regarded as a problem in connection third molars on the occlusion of treated and untreated case. lnt.
with the apical base. Svensk. Tand.-Tidsk., Sup. 1923. J. Orthodontics & Dent. Child., 23:221, 1937.
Reprinted, Am. J. Orthodontics, 11:591, 724, 793,933, 1022,
and 1109, 1925.
Nance, H. N.: The limitations of orthodontic treatment; 1,
19
Serial Extraction
The basis of serial extraction is th premise that it is molars is only one of the considerations in determining
possible, in the mixed dentition stage, to predict that space availability in the dental arches. Other factors of
increments in arch size and intercanine width will not be importance are the extent and direction of jaw growth, and
sufficient to accommodate all the permanent teeth in the shape of the dental arch itself.
regular alignment. Serial extraction seeks to guide
eruption of permanent teeth in a favorable direction, INDICA TIO S FOR SERIAL EXTRACTION
reduce malpositions of teeth, and shorten the duration of
orthodontic therapy. Serial extraction requires serial observation of the
One method of determining the ultimate permanent development of the dentition. Teeth generally emerge into
dental arch size is by making measurements of the the mouth when the root is about onehalf to three-quarters
mesiodistal dimensions of the unerupted and the erupted completed. Observation should continute until the
teeth. However, the measurement of unerupted teeth in permanent maxillary central and lateral incisors are erupted
order to determine the need for treatment based on arch and their roots are nearing completion. The position and
length variation of 1, or even 2 or more, millimeters when inclination of unerupted permanent teeth relative to the
jaw growth is still proceeding is of questionable accuracy. alveolar crest and to the adjacent teeth should be evaluated
The actual changes in jaw size that will occur during the to determine what is interfering with their eruption.
growth period when the dentition changes from the mixed When the maxillary permanent lateral incisors are in
to the permanent dentition cannot be estimated with a torsiversion, when the permanent central incisors are in
high degree of certainty. There are marked individual contact or crowded, or when one or both deciduous
variations in actual mesiodistal space required by the canines have been lost and the canine space is closed,
deciduous canines and first and second deciduous molars serial extraction is to be considered.
and the space required by the permanent canines and first In crowded incisor dentitions, when the permanent
and second premolars. canines are not erupting in advance of the first premolars
and the deciduous canines are in position, they should be
The deciduous canines and first and second deciduous
allowed to remain in place. When the permanent canines
molars usually, but not always, are wider than the
show about twothirds of their roots completed and their
succeeding permanent canines and the first and second
crowns are near the alveolar crest, the deciduous canines
premolars. When the permanent buccal series of teeth
and first premolars should be extracted.
erupt a "leeway space" is left. Part of the so-called leeway
Deciduous canines and first molars should not be
space in the transition from the deciduous to the
extracted before the roots of one-half of the succeeding
permanent dentition is preempted by the forward shifting
canine and first premolar have calcified. A relatively rapid
of the permanent molars. When the succeeding
continuing calcification of the roots of premolars and
permanent canine and first and second premolars are of
canines occurs soon after these teeth erupt through the
the same mesiodistal dimension or even greater than the
alveolar mucosa.
deciduous canine arid the two deciduous molars there is
no leeway space for the permanent molar to shift forward.
Therefore, if the permanent deciduous molar is in distal
relation to its maxillary opponent before the deciduous
molars are exfoliated the same condition may prevail CONTRAINDICATIONS TO SERIAL
when the premolars are erupted. EXTRACTION
The relationship between the mesiodistal crown
diameters of the first and second deciduous pre- Serial extraction should not be performed in the
following circumstances:
1. Class I malocclusions where the lack of space is
slight and the teeth show only slight crowding.
262
Nance's Method of Serial Extraction . 263
Fig. 19-1. Mesiodistal size of deciduous molars compared to

the premolars: (Top) The first and second premolars are smaller
than the overlying first and second deciduous molars. This
provides "leeway" space. (Second row) The premolar teeth are
larger than the deciduous molars they will replace. This does not
provide "leeway" and actually may require more than the
available space. (Third row) The first premolar is larger than the
first deciduous molar. The second premolar is the same size as
the second deciduous molar. (Fourth row) The premolars are
smaller than the deciduous molars. (Fifth row) The premolar
crowns have not completely calcified enough to warrant
extracting the first deciduous molars.
2. When there are teeth missing from the dental arch.

3. When there is a deep overbite or an openbite, these
should be treated before undertaking serial extraction.
NANCE'S METHOD OF SERIAL EXTRACTION
The following method was used by Nance for

determining relative mesiodistal widths of the deciduous
teeth and their permanent successors:
1. Measure with a pair of dividers the mesiodistal
widths of the two deciduous molars and the deciduous
canine or the amount of space these teeth occupy, or did
occupy, in the dental arch.
2. Using the dividers, measure the greatest mesiodistal
width of the premolars and the permanent canine as
shown on the radiogram. The accuracy of the
measurements depends on the absence of distortion in the
radiogram. Since exact measurements of the greatest
mesiodistal width of rotated teeth cannot be obtained, the
same type of tooth on the opposite side of the jaw is
measured. The central ray of the x-ray tube should be
focused to pass directly between the contact points of the
teeth radiographed. The contact points of the premolars
and canine teeth should not appear overlapped on the
radiogram.
3. Compare the mesiodistal width of the deciduous
teeth with that of the permanent teeth. The difference
between the two dimensions, when the space occupied by
the deciduous canine and molars exceeds that of the
permanent canine and premolars, is the leeway space.
The amount of leeway space for the measured side is
doubled to obtain the amount of leeway space for the
arch. When there is a deficiency of alveolar arch length
in relation to the dental coronal arch, serial extraction is
to be considered.
264 . Serial Extraction
Fig. 19-2. Photographs of casts (A) and teeth (B) show

development of the dentition as serial extraction proceeded
without active mechanotherapy. (Courtesy B. F. Dewel)
TREATMENT WITHOUT EXTRACTIONCASE mandibular incisor region to accommodate the four

HISTORIES permanent incisor teeth in regular alignment (Fig. 19-5A
top middle and SB left). Orthodontic therapy was not
The following patients were treated without serial initiated at this time.
extraction. Growth was not favorable, but the im- At age 10 years and 3 months (Fig. 19-5A top middle
provement in the occlusion of the teeth remained stable. and SB middle) the occlusion is still Class I (Angle). The
maxillary permanent central and lateral incisors are in
protrusion. There is a diastema between the maxillary
Patient R. M.-Male central incisors.
Clinical description. This is a Class I (Angle) mal- In the mandible, the four permanent incisor teeth have
occlusion at age 7 years. There is a wide diastema between erupted. They show slight irregularity. The right and left
the maxillary central incisor teeth which in turn encroach deciduous canines are in position. The intercanine
on the eruption space of the permanent lateral incisors. dimension increased 3 mm. between age 7 years and age
The eruption space for the mandibular right permanent 10 years and 3 months, at which time treatment began.
lateral incisor is partly closed. There is not sufficient space Serial extraction was not performed.
in the
Trea tment Withou t Extraction - Case Histories . 265
Fig. 19-3. Lack of intercanine and anteroposterior

alveolar growth in the mixed dentition. (Top) The
maxillary permanent central incisors have erupted,
crowding out the deciduous lateral incisors. Eruption
of the maxillary permanent first molars is retarded. The
mesioocclusal edges of the permanent first molars rest
against the distogingival margins of the crowns of the
deciduous second molars. (Bottom left) The anterior
view of the crowded maxillary incisors demonstrates
the lack of space for the mandibular lateral incisors.
The mandibular central incisors have erupted and the
mandibular deciduous laterals have been lost. (Bottom
right) The occlusal view shows the interference of the
maxillary second deciduous molars with the eruption
of the permanent first molars. This is the type of case
in which serial extraction would be beneficial.
At age 13 years, after 1 year out of retention, the maxillary 26 mm. The inter-first molar distance was 29 mm. at age 10
and mandibular dental casts show all permanent teeth except years and 3 months and 33 mm. at age 13 years, 1 year out of
the third molars erupted. The maxillary permanent canines retention. While averages for intercanine width increase have
are still in the process of erupting, but sufficient space is
been presented by a number of investigators, there is wide
present for their eruption. The occlusion is Class I, and the
abnormal overbite and overjet that were present before variation among individuals.
treatment at age 10 years and 3 months have been eliminated Skeletal Classification. The facial skeletal pattern is Class
(Figs. 19-5A bottom, SB right, 5C righ t). 1, but borders on Class 2.
The intercanine space at age 7 years was 16 mm. Treatment Summary. Although mandibular growth was
At age 10 years and 6 months it was 18 mm. Two years and mostly downward, favorable widening of the jaws occurred
(Fig. 19-50) which was of direct benefit in obtaining a
6 months later, the intercanine space was
satisfactory result. This demonstrates the advantage of serial
examina-
Fig. 19-4. (Left) Occlusal view of

the casts of a 6-year-old. The
mandibular incisors are erupting
and show crowding. (Center) At 8
years and 6 months the same
patient shows crowded
mandibular incisors. (Right) At 10
years and 6 months the incisor
crowding has corrected itself.
"
128.
129.
Fig. 19-5. (A) Pt. R. M. treated

by orthodontic therapy without
extraction. (Top) Casts at age 7
years. (Middle) Casts at age 10
years and 3 months. (Bottom)
Casts at age 13 years and 6
months, 1 year out of
retention. (B) (Left) Occlusal
view at age 7 years. (Middle)
Occlusal view at age 10 years,
3 months. (Right) Occlusal view
at age 13 years, 6 months, 1
year out of retention. Note.
Lack of space for the
unerupted permanent incisors
at age 7 years and alignment
of teeth after orthodontic
therapy without serial
extraction at age 13 years and
6 months. (C) (Opposite left)
/II Radiograms show occlusal
''-\.. 4-"
view at age 7 years. (Right)
Occlusal view at age 13 years
and 6 months. (0) Tracings of
lateral cephalometric
r: radiogram superimposed on
the sella-nasion line with sella
as the registration point. Note,
Growth was mostly in a
downward direction,
A
tions before serial extraction is undertaken and of initiating maxillary incisor teeth without resorting to serial extraction.
orthodontic therapy during active growth periods. The The width of the dental arches should be assessed on the
increase in intercanine width provided space for the dental casts as well as the assessment of sagittal change.
alignment of the mandibular and
130.
Trea tment Withou t Extraction - Case Histories . 267
,
'
j
,
i
RM.
_age7yrs.
- - _age 10 yrs ,3mos.
- -, age 13yrs.
-. . -,
"
c , ,
'>. -, ... D
",
Patient R. M.
Age
Age 10 Years, Age
Dimension Downs Range Mean 7 Years 3 Months 13 Years
Facial Angle 82 to 95 87.8 82 83 83
(F.H. to N-Pg)
Angle of Convexity -8.5" to + 10 0 +6 +10 +10
(N-A-Pg)
A-B line to N-Pg -9 to 0 -4,8 -2 -5 -6
Mand. Plane to F.R 28 to 17 21.9 32 32 32
Y-Axis 66 to 53 59.4 63 64 66
Occlusal Plane to F.H, 1.5" to 14 9S 15 14 15
1 to I angle 130 to 150.5 135.4 130 117 133
I to Mandibular Plane 81.5 to 97 91,4 85 94 92
5- -A 82 80 81 82
5- -B 80 77 77 77
Tweed
Gonion Angle 116-135 126 132 132 132
The following patient was treated without extraction, ous canine has been exfoliated, and the space is closed. The
although growth was unfavorable: left first deciduous molar is in position and the left second
deciduous molar has been extracted. The right and left
Patient M. M. (Fig. 19-6) mandibular permanent first molars are erupted. The lower
lip rests lingually to the maxillary incisor teeth.
Clinical Description. A girl, age 8 years and 6 months At age 9 years and 6 months, after 1 year of treatment,
with a Class I malocclusion. There is lingual collapse of the occlusion is Class I (Angle). The incisor overjet has
the mandibular incisor teeth and an abnormal overjet of 12 been reduced to 4 mm. The maxillary right and left
mm. There is interdental spacing of the maxillary permanent central and lateral incisors are in normal
permanent right and left central and lateral incisors. alignment.
The right and left mandibular permanent central and In the mandible the right and left permanent central and
lateral incisors are erupted (Fig. 19-6A). The right lateral incisors are in normal alignment. On the left side the
deciduous canine is in position. The first deciduous molar first deciduous molar is in position and the extraction space
has been exfoliated. The left decidu- of the second deciduous
Fig. 19-6. (A) Patient M. M.

Anterior (top) and occlusal
(second row) views when patient
was first seen at age 8 years and
6 months. There is an overjet of
12 mm. There are space
maintainers (third row, left) at the
right deciduous first molar space
and the left second molar space. (B)
(Top) lateral views before
treatment. (Center) After 1 year
treatment. The overjet and overbite
have been reduced, the mandibular
permanent canines are erupting and
there is sufficient space for the
unerupted premolars. (Bottom)
After 1 year of observation there is
some increase in overbite. Other-
wise, the developing occlusion is
stable. (C) (Opposite page) Anterior
and occlusal views at age 16,4
years out of retention. (0) Lateral
photographs at 8 V2 years (left),
10lh years (center), and at 16
years. Facial growth continued
to be unfavorable with the
mandible showing practically no
forward growth, while the
maxilla continued to grow
forward. However, the dental
arches continued to grow
forward and show indications of
accommodating the permanent
teeth in regular alignment
without extraction. (E) Tracing
of the lateral radiograms at 8lh
years shows that the face is
retrognathic. The maxillary
incisors are in alveolodental
protrusion.
131. Treatment Without Extraction - Case Histories' 269
M.M. 7yrs. ----

-- 12Yrs. _.--
15yrs.
M.M_
-age 6 yrs.,6 mos.
- - -age 9yrs.6 mos.
- - --agelOyrs,,6
mos_
l
'-
132.
133.
134.
molar is available for the eruption of the second premolar. cisor teeth may show self-correction at this time. The
Skeletal Classification. The facial skeletal pattern is second deciduous molars should be maintained in the
Class 2. dental arch to prevent the permanent first molars from
History. When the patient was first examined she had a shifting and inclining forward.
space maintainer at the right mandibular deciduous first Tweed summarizes the philosophy on which his therapy
molar space and at the left mandibular second deciduous is based as follows:
molar space. The left deciduous canine space was closed 1. The mandibular incisor teeth are in normal axial
but the right deciduous canine was permitted to remain in inclination when related to the Frankfort plane at
place. There had been no attention given to the severe approximately 65 (FMIA).
maxillary incisor overbite and overjet. The dynamic 2. The mandibular incisors should be positioned over
dentition of the child cannot be treated piecemeal but must basal bone (the medullary bone of the respective basal
be regarded and treated as a unit. arches) at 90 5 in relation to the mandibular base
(lMPA).
Serial extraction objectives are as follows:
1. Facial balance and harmony
TWEED'S ORTHODONTIC GUIDANCE 2. Stability of the posttreatment dentition
3. Healthy oral tissues
When a discrepancy exists between dental arch and 4. Efficient function
alveolar process length (basal bone) and the patient is
between the ages of 7% and 8 V2 years, Tweed performs
THE TWEED DIAG OSTIC FACIAL TRIANGLE
serial extraction as follows:
At age 8 years all four deciduous first molars are Tweed conceived the diagnostic facial triangle as a basis
extracted. If the mandibular permanent incisors are not for diagnosis and treatment planning. This consists of the
blocked out or severely crowded, the deciduous canines following:
are maintained in position to prevent too early eruption of 1. FMA - the Frankfort-Mandibular Plane Angle.
the permanent canines. When the first premolar teeth erupt 2. IMA- the Incisor-Mandibular Plane Angle.
to about the level of the crest of the alveolar mucosa, they 3.FMIA-the Frankfort-e Mand ibular Incisor Angle. In
are extracted. The deciduous canines also are extracted at addition consideration is given to:
this time. When the premolars are extracted 4 to 6 months A- -B-the A-Point-Nasion-B-Point angle, and S- - the
prior to eruption of the permanent canines, the permanent sella-nasion line.
canines usually shift posteriorly and erupt in the space left
Tweed established 25 as the norm for the Frankfort-
by the extracted first premolars. Slight irregularities of the
mandibular plane angle (FMA), and 90 as a norm for the
mandibular in-
mandibular-incisor-mandibular plane angle (IMA). By
extending the line through the
~<
.
'.'-t>
\
l :1
l",,
,
... -
\,
..
---- _ ... _._-;:~-
-
.\ "
FMIA . Nt.. \ ",
IMPA
"
S2g 6.750
Fl7/60 97.5
fMA IMPA FMIA AHb
3(2)/6)
70D 2,.50
,4
.
80
177.60
30,5 97.5 51" 6.50"
II II 61 31 9~ 57
0
6.5
0 .' ,
I,..
., ~
Fig. 19-7. (Left) Superimposed tracings of patient with a Type A growth trend between 8 years and 5 months (solid line) and
approximately 10 years (dashed line) show that growth was mostly in a downward and rearward. If this direction of growth had
continued, treatment would have been handicapped. (Right) Superimposed tracings at 8 years and 5 months (solid line) and 11
years and 3 months (dashed line) show the favorable changes which produced the orthognathic profile. Growth changed to a
downward and forward direction.
Tweed's Facial Types . 271
138.
136.
135.
137.
"
:
~
FM" IMP" FM,,,

-- 8/13/51 18.5" 111.5" 40" 8'
______ 11/4/58 18.5" lOS' 46.5" n' FMA IMPA FMIA ANb
-- 12"il5fJ 28.5 1050 46.5/J 9.50
Age: ., reefS 9 month.s Q
------1,26\ 21 100,5 So2.5 5
~II:: 9YifII:I's 1 month
Fig. 19-8. (Left) Tracing of a Type B face before treatment was started at age 7 years and 9 months. One year and 4 months later growth
of the mandible was entirely forward. (Right) Tracing after orthodontic intervention. Note. Facial growth changed into a downward
direction only between age 9 years and 1 month, and 11 years and 3 months.
\ .~~ . 'f "
~\t . \
i
-. ~.
",:'.
,'0
FMA IMPA FMIA ANb

--7/6/55 36" 94" 50' 5'
3.75 FMA IMP" FMIA "Nb
----- MOl57 32.5' 94' 53'
" --1120157 32.5' 94" 53' 3.75'
Aile-: 10 yean
/ /
------ 2 4 59 30' 7/' 73' 1.75"
Age; \2 yeor$
Fig. 19-9. (Left) Tracing of a Type C face before treatment, age 10 years, and 1 year and 5 months later. Facial growth was favorable,
downward and forward. (Right), Tracings compared between age 12 years and 14 years. Growth again was favorable in a downward and
forward direction.
axial plane of the mandibular incisor to the Frankfort between the Frankfort and mandibular planes. Tweed used
horizontal plane the third angle, the Frankfortmandibular a template to help locate the apex of the mandibular
incisor angle (FMIA), of 65 is obtained. incisor tooth.
The Tweed diagnostic triangle is traced on the lateral The A-N-B angle indicates the mesiodistal relation of
radiogram as follows: the anterior limits of the maxillary and mandibular basal
L The Frankfort plane connects a point about 4.5 mm. arches. The normal range is from -5 to 0, with 65 per
above the geometric center of the cephalometer ear rod cent of cases examined ranging from -3 to 0.
and an orbital point midway between the left and right S-N line is used for superimposing cephalometric
lowest borders of the orbits. tracings in order to obtain the facial growth changes in
2. The mandibular plane is drawn along the lower patients under observation. The BroadbentBolton
border of the mandible and is extended posteriorly to construction also may be used.
connect with the Frankfort plane. The mandibular plane
goes through menton anteriorly and bisects the vertical
distance between the right and the left lower borders of
the mandible posteriorly in the region of the gonial TWEED'S FACIAL TYPES
angles. Tweed divided the facial skeleton into the following
3. The incisor plane is a line through the axial types by using lateral (profile) radiograms:
dimension of the most forward mandibular incisor Type A. The maxilla and mandible show forward
139.
maxillary dental arch soon after the extraction of the first

premolars.
Type B. The maxilla and mandible grow forward and
downward, with the maxilla growing forward more rapidly
than the mandible. This indicates that the B-point will not
advance in relation to A-point during treatment. The A-point
must be moved posteriorly to reduce the A-N-B angle. When
0
the A-N-B angle is 4.5 or less, the prognosis is favorable. An
extraoral appliance should be used immediately following the
removal of the four first premolar teeth .
FiolA 2JG
IMP" 96 Type B Subdivision. The A-N-B angle is large and is
FMIA 61
.ANa. .sO increasing. Treatment may be long and difficult. Extraction is
Mrn"J] mrn.
required as a rule.
IDF.AL A~CH MEASUREMENTS Type C. The maxilla and mandible grow downward and
R~'fv,,.ecl I I 7i,JS" forward with the mandible growing forward more rapidly
I I I I I I I
"(llf I", ble I 1o. .. ,.::~, .. ,:>1 I 72. than the maxilla. A-N-B angle is decreasing. Growth is
So favorable and treatment is facilitated by growth. Treatment is
not indicated until full eruption of the canine teeth has
L""jtlt /)ISO" jJtt"Cj-..3.1fo occurred.
r/'fR .uo flrt!/r.
Type C Subdivision. The mandible is growing forward
tJ
J!'IPn 9b II"Qd I'IQt e [)/SCU/"''''!J - 7. A"'.
more than the maxilla but only slightly downward.
Fl1fl1 lore;, Tol,d DISCf'~!,q"c.!f - /O.ls....
0
fflYh
S
11/T111.$ 7"'"".
rrC1u,rcd I{reh Le"gtlt. BIBLIOGRAPHY
"va;/oble Ilrch l..etr.9th Ilrclr 72.50 ..,"". Bolton, W. A.: Disharmony in tooth size and its relation to the
LC>1!1fh Dlser'~po"c!1 Heodplo[e - .3. f5" ..,"'. analysis and treatment of malocclusion. Angle
Co,.'-'C.tItHl Total - 7. HI .... Orthodontist, 28:113, 1958.
Carr, L. M.: The effect of extraction of deciduous molars on
D/sct'eptlf1c!J - /DgS ,ofM.
the eruption of bicuspid teeth. Australian D. L 8:130, 1963.
0" 91 Dewel, B. F.: Serial extraction in orthodontics: indications,
Fig. 19-10. Method of establishing required and available objections, and treatment procedures. Internat. J.
arch length: The tracing confirms that the Frankfort-man- Orthodont., 40:906, 1954.
dibular angle at 23 is satisfactory. Therefore, the direction ---: A critical analysis of serial extraction in orthodontic
of growth of the lower face is assumed to be excellent. The treatment. Am. J. Orthodont., 45:424, 1959. ---: Serial
present IMPA of 96 should be reduced to 88 to conform extraction: Its limitations and contraindications in orthodontic
with the principles of the diagnostic facial triangle. This treatment. Am. J. Orthodorit., , 53:904, 1967.
correction will reduce the available arch length 2 X 3.5 mrn., ---: Prerequisites in serial extraction. Am. J. Orthodont., 55:633,
or a total of 7 mm. Required arch length is 76.35 rnm., and 1969.
available arch length is 72.5 mm. There is therefore an actual ---: Precautions in serial extraction. Am. J. Orthodont., 60:615,
arch length deficiency of 3,85 mm. plus 7 mm., or a total of 1971.
10.85 mm. discrepancy. This patient should be examined and Fanning, E. A.: The effect of extraction of deciduous molars
the growth trend determined cephalornetrically to determine on the formation and eruption of their permanent
the type of growth and the corresponding treatment. successors. Angle Orthodontist, 32:44, 1962.
Extraction is indicated now. (Figs, 19-7 to 19-10 courtesy of Hinrichsen, C. F. L.: Serial extraction in mixed dentition
Charles H. Tweed) orthodontics. Australian D. L 6:201, 1961.
Hixon, E. H., and Oldfather, R. E.: Estimation of the sizes of
unerupted cuspid and bicuspid teeth. Angle Orthodontist,
28:236, 1958.
and downward growth while the A-N-B angle remains
Kesling, H. D.: Coordinating the predetermined pattern and
unchanged. The prognosis is good. Treatment is not indicated
tooth positioner with conventional treatment. Am. J.
during the mixed dentition if the A-N-B angle does not Orthodont., 32:285, 1946.
exceed 4S. Kjellgren, B.: Serial extraction as a corrective procedure
Type A Subdivision. The A-N-B angle difference is
greater than 4.5. The headgear is used on the
Bibliography' 273
in dental orthopedic therapy. Tr. European Orthodont. Soc., growth and development of the maxilla and mandible. Am. ].
1947. Orthodont., 53:19,1967.
--: Serial extraction as a corrective procedure in dental orthopedic Sontag, L. W., and Lipford, J.: The effect of illness and other
therapy. Acta Odont. Scandinav., 8:17, 1948. --: Observation and factors on the appearance pattern of skeletal epiphyses. J.
treatment of cases of developing progenia from deciduous Pediat., 23:39, 1943.
dentition to adult age. Tr. European Orthodont., Soc., 1955 Sontag, L. W., and Reynolds, E. L.: Ossification sequence in
Lloyd, Z. B.: Serial extraction as a treatment procedure. identical triplets. J. Hered., 35:57,1944.
Ani.. J. Orthodont., 42:728,1956. Tanner, J. M.: Genetics of human growth. In Tanner, J. M., (ed.):
Lysell, L., Magnusson, B., and Thilander, B.: Time and order of Human Growth. vol. 3. pp. 43-58. Symposia of the Society for
eruption of the 'primary teeth. A longitudinal study. Odont. the Study of Human Biology. New York, Pergamon Press,
Rev., 13:217, 1962. 1960.
Moorrees, C. F. A., Fanning, E. A., and Gran, E.-A.: The Taylor, R. F.: Controlled serial extraction. Am. J. Orthodont.,
consideration of dental development in .serial extraction. 60:576, 1971.
Angle Orthodontist, 33:44, 1963. Todd, T. W.: The roentgenographic appraisement of skeletal
ance, H. N.: The limitations of orthodontic treatment: differentiation. Child Dev., 1 :298, 1930.
I, mixed dentition diagnosis and treatment. Am. J. Orthodont., ---: Atlas of Skeletal Maturation, St. Louis, Mosby, 1937.
33:177,1947. Tweed, C. H.: The diagnostic facial triangle in the control of
---: The limitations of orthodontic treatment: II, Diagnosis and treatment objectives. Am. J. Orthodont., 55:651, 1969.
treatment in the permanent dentition. Am. J. Orthodontics & Zachrisson, B. U. and Zachrisson, S.: Caries incidence and
Oral Surg., 33:253, 1947. orthodontic treatment with fixed appliances. Scand. J. Dent.
Ringenberg, Q. M.: Influence of serial extraction on the Res., 79:183, 1971.
20
Biomechanics in Orthodontic Therapy
140.
141.
142.
NOMENCLATURE Force applied through cervical anchorage of fixed or
Biomechanic terms frequently used in orthodontics include removable appliances can bring about positional changes in
the following: the arrangement of the teeth. The influence of force also can
Force. The influence, such as tension or pressure, exerted act directly on the teeth, as in fix d tooth-borne appliances.
on a body; e.g., if sufficient force is applied to a tooth it tends Strain. The deformation of an orthodontic wire when it
to change its position. Force in orthodontics can be applied by meets resistance, as a result of applied force.
soft tissue covering removable plates and activators that Stress. The resistance a tooth offers to an applied force.
produce alveolar bone changes and so change the position of
teeth.
a. TYPES OF FORCE
Compressive Tensi Ie Shearing
p Strain = Deformation (D) b d

(e) Length (L) Fig. 20-2. The heavy arrow indicates the point of application
Stress = Force (P)
of the force or load; the light arrows the direction of the strain.
(S) Area (A) C - compressive strain; F - force or load; Ttensile strain; N.A. -
neutral axis or plane. (F. G. Evans Figs. 20-1 and 2 Courtesy of
Fig. 20-1. Types of force. (Evans, F. G.: Biomechanical Biornechanical Studies of Musculoskeletal System.
Studies of the Musculoskeletal System. Springfield. Charles Springfield, III. Charles C. Thomas, 1961)
C. Thomas, 1961)
274
Anchorage . 275
143.
Fig. 20-3. (A) In simple anchorage, a stronger tooth supplies resistance for moving a weaker tooth. The force applied may be an elastic
or a wire which is tightened at intervals. (B) Simple stationary anchorage is like simple anchorage except that the square buccal tube
prevents tilting of the molar; it will be moved bodily if at all. (C) Simple reciprocal intramaxillary anchorage links teeth of equal resistance
in the same jaw. (D) Simple reciprocal intermaxillary anchorage involves teeth of equal resistance in opposite jaws.
Deformation. Change in the shape of a wire. Resilience. 2. Stationary: When an appliance is so constructed that
The elasticity of a wire related to the amount of force it the anchor teeth must move bodily, if at all, it is
can withstand without becoming permanently deformed. considered to be stationary anchorage. The occiput, when
Ultimate strength to withstand force increases with wire used for anchorage in extraoral appliances, can be
thickness. considered to be stationary anchorage.
Ductility. The opposite of brittleness; the extent to
which a wire can be stretched without breaking.
Elasticity. The amount of force an orthodontic wire
can withstand and return to its original shape without
deformation.
Tensile strength. Resistance to breakage.
Torque. Force that produces torsion in a direction that
increases resistance.
ANCHORAGE
Resistance is required from which the force required to
move teeth is to originate. This is the principle of
orthodontic anchorage.
Types of Anchorage
The various types of anchorage are as follows:
Intramaxillary resistance is obtained from teeth in one
jaw to move other teeth in the same jaw.
Intermaxillary. Anchorage in one jaw used to move
teeth in the opposing jaw.
Extraoral anchorage. An occipital or cervical ap-
pliance is attached to an intraoral appliance.
Anchorage can be further subdivided as follows: 1.
Fig. 20-4. Compound intermaxillary anchorage. The teeth in
Simple: A tooth or teeth that offer greater resistance to
one jaw are employed as resistance for" moving teeth in the
displacement than the tooth that needs to be moved. opposing jaw. This is accomplished here by means of
intermaxillary elastic bands.
276 . Biomechanics in Orthodontic Therapy
3. Reciprocal: When the force exerted on a tooth or 2. Teeth that have been loosened by trauma offer poor
teeth is evenly distributed and the teeth on bothsides resistance.
move. 3. Teeth undergoing root calcification in the early
mixed dentition offer poor anchorage resistance.
Extraoral Anchorage
Sources
Extraoral or occipital anchorage depends on the
resistance offered by the posterior portion of the skull. It Resistance to orthodontic forces can be derived from
can be used to exert force in combination with different the following:
types of orthodontic appliances. The extraoral appliance 1. The bone in which the teeth are situated. Dense bone
should be worn a minimum of 14 hours a day for best offers greater resistance to change of tooth position.
results. A cloth headcap, a belting fabric, or a rubber 2. Root surface of the teeth. Resistance is directly
tubing on the neck or head is used to hold the active part proportional to root area, all other factors (including the
of the appliance. Elastics are employed for attachment of character of the investing bone) being equal.
the facebow. The intraoral part of the appliance fits into 3. Teeth offer more resistance to movement opposite to
tubes placed on the first molars when these teeth are to the direction of natural growth of the jaws.
be moved distally. 4. Muscular pressure can offer additional resistance to
Extraoral anchorage eliminates the possibility of anchorage or weaken anchorage if the muscular pressure
untoward forward mandibular tooth movement when is in the same direction as the teeth being moved.
mandibular molar anchorage is used with intermaxillary 5. The extent and manner of interlocking of the cusps
elastics. can offer some resistance to orthodontic tooth movement.
Extraoral anchorage can be used for the following 6. Stabilizing removable plates that engage the oral
purposes: mucosa and the teeth enhance anchorage.
1. To provide additional support for intraoral
anchorage
2. To prevent increased procurnbency of the man-
dibular incisor teeth
3. To prevent the buccal series of teeth from shifting
forward Reinforcing Anchorage
4. To move teeth or the entire dental arch distally Anchorage Loss. When anchor teeth show change in
position, they should be allowed to return to their original
positions or be actively moved to their original positions
before treatment continues. Resistance in the maxillary
Stability arch may be greater than in the mandibular arch, causing
While, in theory, a tooth with a greater surface area is an undue amount of forward shifting of the teeth in the
expected to offer greater resistance to force than one with mandible. Change in the line of occlusion induced by
a smaller surface area, this is not always the case in intermaxillary leverage which raises the mandibular
practice. Much depends on the thickness and the quality anchor molars usually is self-correctible in function.
of the alveolar bone, on the amount of leverage applied However, mandibular incisor crowding can be initiated or
on the anchor teeth, on the axial inclinations of the teeth, made worse by anchorage loss. Extraoral appliances can
on the proximal contacts, and on the forces generated in be used to reinforce mandibular anchorage in these cases.
occlusion. Spongy bone with large interosseous spaces or Reinforced or additional anchorage is frequently
poorly calcified bone will not offer as much resistance to required in the following circumstances:
force as will calcified bone. 1. When the lower lip is habitually behind the upper
anterior incisors when the jaws are in rest position.
2. When the tongue is continually positioned over the
incisal and occlusal surfaces of the teeth.
. Resistance 3. When a biteplate is used in Class II malocclusion to
Resistance offered by anchorage depends on many factors unlock a deep overbite.
among which are the following: 4. To prevent loss of mandibular molar stability when
1. The character of the alveolar bone in which the intermaxillary elastics are used.
anchor teeth are situated and the character of the bone
through which a tooth or teeth are to be moved.
144. Steel Wire Force' 277
5. To move teeth distally. Removable Appliances

6.Where orthodontic tooth movement is not required
Removable appliances can be removed by the patient
in the mandibular dental arch.
and are therefore not under the complete control of the
7. In combination with fixed or removable appliances
operator. Anchorage resistance usually depends on the
for tooth movement.
palate and alveolar process although the teeth can also be
engaged. There are certain types of malocclusion in
PASSIVE AND ACTIVE APPLIANCES which the results obtained with removable appliances are
not comparable with those obtained with fixed
Passive appliances produce changes in tooth position
appliances. Crowding and rotation of teeth and space
and jaw relations by force of pressure exerted on them,
closure after extraction are not readily corrected with
but the appliances themselves do not actively initiate the
removable appliances. It should be explained to the
force. Examples are inclined planes on biteplates,
patient that if the appliance is not worn as directed the
activator appliances, and other denture- and tissue-
period of treatment is lengthened.
covering appliances. These are usually removable
appliances without activated attachments.
The teeth and the tissues exert pressure on the
appliances through muscular contraction during STEEL WIRE FORCE
mastication and idle swallowing. The force offered to the
teeth and the jaws by these appliances eventually Stainless steel wire has a maximum deflection ratio of
produces changes in tooth position and jaw relationship. 1.8:1 compared to gold. The deflection rate is lowered by
During posttreatment maintenance or retention, reducing the cross sectional dimension of a wire. For
removable appliances should not exert force but should unidirectional force the most efficient wire is rectangular
maintain the teeth and jaw relation as obtained by with minimum depth and maximum width. Care must be
orthodontic therapy. exercised in soldering
. Active appliances depend on the energy stored 111 them
by deflected wires, elastic ligatures, coil springs, or by
stretched elastics applied intra- or extraorally. These
appliances are attached to teeth used as anchors to
stabilize the appliance and provide resistance to the force
they exert on the teeth to be moved. Anchorage or
resistance can be derived from the teeth, skull, palate, or
jaws. The force can be applied to the teeth themselves or
through brackets or other attachments on bands cemented
to teeth.
Fig. 20-5. (A) A high-pull extraoral appliance. (B) A

cervical appliance attached to the mandibular dental
arch.
278 . Biomechanics in Orthodontic Therapy 146.
145.
~- . -
C d
__ 01 RECTION
OF
A
y
~ \\ -o ... '\ .. [4. c_ _d REF LECTION

\\
\\ ~" "", II
. ~jl .
,~
II
\\ It
\\ II
\\ ~I
\\ I
\\ I
I
LENGTH ~ 1.8 c.rn. \i I
THICKNESS ~ .35 mm. \\ I
DEFLECTION ~ 5 mm. \\ I
\\ II I ' 8 x
c
B
I
'
I
I
FIXATION
POINT o
x
A
Fig. 20-6. (A) Diagram of straight spring fixed at X, free elsewhere, deflected by pressure initially applied along d-e,
(B) Auxiliary spring force. (Left) Direction of action from a-b to d-e between full deflection and position of rest; (center)
coil inserted as near as possible to point of greatest bending stress to distribute stress over greater body of material and
to avoid liability to deformation; (right> progressively unequal movement of teeth from point of fixation of the single
spring. (C) Diagram of double spring, which acts as if it were two single springs, A-B and X- Y. A is point of fixation.
(McKeag, H. J. A.: The teaching of appliance design in orthodontia. Dental Record, 56:260, 1936)
Fig. 20-7. (Left) 1, Rectangular wire; 2, path of

passive rectangular wire; 3, path of wire when
inserted into bracket producing lingual root torque.
(Right) (1) Rectangular wire; (2) path of passive
rectangular wire; (3) path when wire is inserted
into bracket producing labial root torque.
stainless steel to avoid loss of elasticity from the high heat movement and for torquing roots. Round light wires are
applied. most desirable for moving teeth.
Steel Archwire Force Auxiliary Spring Force

The intensity of the force exerted on a tooth by a light Fine spring wires are attached to an archwire or
archwire is limited by the ability of the archwire to resist removable appliance to transmit force through the teeth to
deformation. Lighter wires do not as 'easily become the supporting alveolar bone and thus produce change of
crimped as heavier wires and therefore do not require as position of malposed teeth. When the length of an auxiliary
frequent adjustment. Treatment should be started with spring wire is reduced by one-half, the force is increased
light wires. When the diameter of a wire is doubled, the eight times. When the length of an auxiliary spring is
force is 16 times greater, provided the wire is not crimped doubled its force is one-eighth of the original.
when tied to the brackets or the teeth. The oral environment affects the amount of movement
Rectangular arch wires are used for bodily tooth that a known force will produce on a tooth.
Torque 279
Recurved auxiliary springs permit the movement of teeth of 0.020, 0.016, and 0.010-inch diameter. When heavier
where the point of fixation of the spring is not wires are used there is a greater tendency for the anchor
sufficiently remote from the tooth to be moved to allow teeth to move. The amount of deflection of an arch wire
sufficient deflection of the spring for the amount of or auxiliary spring at each adjustment should not exceed
movement required. 1/16 to V8 inch of space, in order to avoid strong force that
can produce undermining resorption.
Optimum Force
Heavy force can traumatize the periodontal ligament
and adjacent gingival tissues. Laminated archwires ORTHODONTIC APPLIA CE FORCE AND
employ the principle of laminated springs. They have RESISTANCE
increased elasticity over single heavy wires. Hixon et al. The force exerted on the teeth by an orthodontic
found no supporting data to substantiate the existence of appliance depends on the following:
optimal or differential force in moving teeth. The 1. The type of appliance used
maintenance of molar anchor teeth in an upright position 2.The duration of time during which the force is active
is important in maintaining anchorage when retracting 3. The size, location, and character of the investing
canine teeth. tissues of the teeth on which the force acts
Bodily tooth movement is obtained by applying force 4. The origin and point or sites of application of the
at the center of resistance of a tooth. This center is not force on the teeth
accessible because it is located in the root of the tooth. 5. The distance over which the force acts
Torque of the archwire produces a resultant force that 6.The reaction of the oral tissues to the force applied
can pass through the center of resistance of a tooth. 7. The force produced by occlusion of the teeth
DIFFERENTIAL FORCE Methods of Orthodontic Force Transmission
The molars have a larger root area than the incisor or Forces produced by an orthodontic appliance in actual
canine teeth and usually will show more resistance to use in the mouth cannot be readily measured. The same
force and undergo less change of position than teeth with orthodontic appliance exerting the same amount of force
smaller roots and root surfaces. The foregoing depends can show a different rate of response in different patients.
also on the character of the bone surrounding the The amount of force experienced by a tooth depends on
respective teeth and the absence of outside interferences the type, the size, and the location of the tooth, the type
such as the position of adjacent and abutting teeth that and posi tion of the bracket band on the tooth, and the
tend to stabilize or reduce change of position of a tooth size, contour and deflection of the wire used.
or teeth.
Storey and Smith used orthodontic wires with spring
forces of different values to move canine teeth distally
TORQUE
into first premolar extraction spaces. The first permanent
molars and second premolars were used as anchorage. Passive, which does not change the axial relation of the
They found the optimum range of force required to teeth, and active, which produces a definite change in the
produce maximum rate of movement of the canine teeth axial relation and inclination of teeth. A rectangular arch
distally without at the same time producing mesial wire cannot be placed into the brackets if the wire is not
movement of the molar and premolar teeth mesially to torqued without producing undesirable axial movement
range from 150 to 200 grams. When the force is of the teeth.
increased perceptibly, the rate of the canine movement
decreases and appreciably increases mesial movement of
Directions of Torque
the anchor teeth.
Decrease in rate of movement of canines and molars In order for a square or rectangular arch wire to lie
when heavy forces are applied is attributed to passive in the brackets of the permanent teeth the
undermining resorption of the alveolar bone as originally archwire requires a lingual torque. The torque is inclined
shown by Sandstedt. Spring force for moving teeth is more lingually in the mandibular than in the maxillary
best applied by lighter gauge wires dental arch. The amount of torque is diminished in the
archwire
o-
J:~'~;:t
'500 3000 ",,000 1500
1f 4
(~'"' . .,.,...m.)
Fig. 20-8. (Left) Equilibrium diagram. (Top,
right) Passive tip-back bends. (Bottom, right)
Tip-backdirection
in a forward bends applied
so that tothebuccal segment.
premolars have less Orders of Torque
torque (Haack,
than theD.molars
c.:) and the canine torque is almost Differen t orders of torgue - such as labial, buccal,
nonexistent. Torque is eliminated from the arch wire that
lingual, rotative, depressive, and elongating - can be bent
lies in the mandibular and maxillary incisor brackets if
into the rectangular edgewise arch as follows:
root movement lingually or labially is not desired.
1. First order bends are used in forming the ideal
archwire. These bends do not alter the horizontal plane of
the wire. They make possible the engagement of all teeth
directly into the brackets.
2. Second order or "tip-back" and "tip-forward" bends
are incorporated in the archwire in the vertical plane. They
are used in tipping buccal teeth either mesially or distally.
3. Third order bends are used to obtain axial changes in
buccolingual or labiolingual root and crown axes of the
teeth. To be effective, torque in the rectangular arch must
be made so that when the attempt is made to place the
archwire in the bracket on the tooth it must be seated with
a torquing key or a pair of pliers.
COIL SPRING FORCE

Pull-coil springs can be used for space closure by distal
movement of canine teeth in premolar extraction cases.
One end of the pull-coil is attached to the distal end of the
Fig. 20-9. Correct buccal torque in the treatment of arch wire while the anchor molar is stabilized with a stop
Class III malocclusion is shown diagrammatically. Also on the arch wire anterior to the molar tube. The coil is
shown are the correct positioning of the palatal hooks on stretched, and the mesial end of the coil is ligated under
maxillary molar bands and the use of cross elastics. tension to a distogingival staple or to the bracket band on
Torque force corrects undesirable axial inclinations of the tooth to be moved. The anchorage can be reinforced by
individual teeth in buccal segments of both arches. Action using an extraoral appliance on the molars.
in maxillary buccal segments is to move the roots buccally The push-coil is slipped on the archwire and compressed
and the crowns lingually. Action in the mandibular seg- between the brackets of the right and left teeth to be moved
ments is to move the root lingually and the crowns buc- and ligated. The incisor teeth should be without brackets at
cally. this time. The teeth to be moved receive pressure in a distal
Cross-bite can be corrected by expansion of the maxil- direction, but they should be kept from rotating. When the
lary archwire plus the pull of the crossbite elastic, which canines are in proper position, the rest of the anterior teeth
develops the breadth of the maxillary arch. Constriction on are bracketed and brought into alignment.
mandibular archwire plus pull of crossbite elastic
decreases the breadth v. the mandibular arch. This treat-
ment is continued until normal ideal arch form and re-
lationship are obtained.
Archwire Loops . 281
Fig. 20-10. (Top left) Lingual root

torque. Right, labial root torque.
(Bottom left) front view showing
location of wire for lingual root
torque. (Bottom right> Front view
showing location of wire for
labial root torque.
ARCHWIRE LOOPS
The archwire, when first adjusted, possesses a variable
amount of stored energy depending on its spring design.
After insertion there is a gradual loss of force until the
minimum pressure is attained. Loops increase the length of
the wire between attachments, thereby reducing force and
increasing the range of the activity of the archwire.
However, the force exerted by a loop depends on the
amount of deflection it undergoes when it is attached to a
tooth.
Vertical Loops. Vertical loops are intended to increase
the force delivered to the teeth. Vertical loops under
compression have a greater range of activation when not
expanded and then compressed. Excessive expansion of
the loops in the incisor region can cause the anterior teeth
to tip forward. Vertical loops aid in resisting permanent
crimping of wires between attachments, so that variations
in bracket heights and tooth irregularities will not readily
produce permanent distortions of the archwire,
If the distance of the deflection of the wire to the bracket
seat is not increased, vertical loops reduce the force
exerted by the archwire, If loops are placed in the archwire
between the brackets, the length of the' "lever arm" (the
force-producing part) is increased. A lighter force can be
exerted provided the
Fig. 20-11. (Top) Second-order bends in the archwire

produce mesial crown tipping. (Center) Passive arch with-
out second-order bends. (Bottom) Second-order bends pro-
duce distal tipping (tipback bends). ote that two staples are
attached to each band.
148.
Fig. 20-13. (Top) An open-coil spring is in-

serted under compression to open space for
insertion of artificial lateral incisor. (Center) A
sliding jig against the maxillary canine with
intermaxillary elastic moves the canine distally.
(Bottom) Sliding jig against the molar is used with
intermaxillary elastics to move the maxillary
molar distally.
Fig. 20-12. (Top) Contraction coil spring in place on the
sectional appliance. The anterior end of the straight wire the legs of the open loop. When the loop tends to assume its
extending from the spring is secured by wrapping it several
original position, the teeth are moved apart. Loops can also
turns around the ribbon wire portion of the sectional
be used to rotate teeth, since they enable immediate bracket
appliance in front of the canine attachment. The posterior
end is wrapped around a portion of end tubing that is engagement through their increased resiliency. The loop
allowed to project past the distal end of the buccal tube. creates a force of greater duration that rotates the tooth
(Bottom) Contraction coil spring in action. This is activated toward the desired position.
by pulling the tightly wound coil spring open and wrapping A single, closed vertical loop can be used to close space.
the straight wire sections of the spring around the anterior The legs are compressed, and as the loop expands it draws
and posterior ends of the sectional appliance. If the portion the horizontal extensions of the wire arch together along
of the spring to be secured around the ends of the sectional with the teeth. Double vertical loops are used to rotate and
arch wire is softened by heating, it can be closely adapted. to move teeth labial1y and lingually into line.
(Courtesy of F. . Weber) Horizontal Loops. Horizontal loops are used to reduce
force in a vertical or occlusogingival direction permitting
immediate bracket engagement in severely malaligned teeth
distance of deflection is not increased. When the archwire which need to be elevated or depressed.
with a loop is not adapted closely enough to the teeth and the Helical Loops. When a helical loop is used the force is
distance of deflection is increased, the resulting force is reduced, but the range of force activity is
accordingly increased regardless of the small diameter of the
wire.
When a Single vertical loop is used to open space, the
arch wire is fixed in the brackets by compressing
Elastic Force . 283
149.
150.
increased. The amount of force exerted by a helical loop

varies with the size of the loop and the size of the coil.
Open Loops. Open or continuous loops, when activated
by compressing its legs, will tend to push the horizontal
extensions apart, increasing the length of the archwire. A
closed loop or reversed loop, when activated by
compressing its legs, will tend to draw the horizontal
extensions toward one another, shortening the arch wire
length.
Torquing Loops. The torquing loop is a compressed
vertical loop which may be seated between twin brackets
or adjacent to single brackets. It is corttoured to press
against the gingival surface of the crown and is activated
by ligating the archwire in the brackets. When the buccal
segments are stabilized, it tends to exert lingual root
movement. It also stabilizes vertical loops and prevents
their impinging on the labial or gingival mucosa.
Fig. 20-14. (Top) The upper arch is fitted with an anterior

ELASTIC FORCE
retraction mechanism that uses a .010 X .020 flat wire spring. The
Force produced by elastics on a tooth or teeth depends anterior segment is fabricated of .021 X .028 tube in which the
.0lD X .020 spring is placed. A lower base arch is used to depress
on the type of elastic used, the site of application, the
the anterior teeth and reciprocally elevate the posteriors. An
distribution of the force, and the direction, length,
inner wire from canine to canine is being used to level and rotate
diameter and contour of the root of the tooth to which the the anterior teeth. (Bottom) A canine retraction spring. (Courtesy
force is applied, the character of the alveolar process, the C. J. Burstone)
amount of tooth rotation, and the health, age, and
cooperation of the patient.
Rubber elastics, according to Beshara and Andreasen, and the mandibular dental arches to retract the maxillary
maintain a more constant force over a 3week period than dental arch or to bring the mandibular dental arch
plastic" Alastics," and the elastic force produced varies forward. Elastics may be used also vertically to bring
less. Alastics show more deformation. teeth in opposing dental arches into occlusion.
Elastics can be used for intramaxillary and inter- Elastics of the same dimensions are not constant in the
maxillary tooth movement and in combination with amount of pull they exert. They are modified by the
extraoral anchorage. Intramaxillary elastics are used length of time since their manufacture, by the quality of
between two points in the same dental arch. Inter- the latex from which they are made, and by the length of
maxillary elastics are used between the maxillary time they are subjected to the oral fluids.
6.2 oz. 3.4 oz. 9.8 00.
6.6 1IIIIl. 6.
-------1
2.5 11IIII.
0.9 oz.
6
10.5 lUI.
8.1. oz.
0.900.
A
1).7 00,
B
Fig. 20-15. Vector diagrams, with intermaxillary elastics of the mouth closed (left) and open (right). (Courtesy S.
M. Bien)
153.
152.
;
'/
1
Fig. 20-17. (Top) Sliding hook against max-
illary canine with intermaxillary elastic to close
space distal to canine. (Bottom) The space distal
to the canine now is closed.
Fig. 20-16. Space diagrams of intermaxillary elastics with

the mouth closed (top) and open (bottom). (Courtesy S. M.
Bien)
Most of the fixed and some removable appliances rely on

elastic force to varying extents. When intermaxillary elastics
are used during the growth period, there is a greater tendency
for the anchor teeth in the mandible to move mesially.
To move maxillary teeth distally by means of inter-
maxillary elastics, it is necessary to use minimum elastic
force during the day when the mouth is open. Heavier
intermaxillary elastics, the headgear, or both, may be used at
night when the mouth is closed.
Fig. 20-18. Lingual and buccal elastics are used

to close a space; (lop) occlusal and (bottom) side
views. The larger the elastics, the lighter the
force. This produces distal movement of the
canine while the molars remain essentially
stationary. If forward movement of the molars is
desirable, the elastic on the buccal surface is
attached to hooks on the round lingual arch
mesial to the canines, and smaller elastics are
used.
Bibliography 285
When Class II intermaxillary elastics are used (from related forces between plastic elastics and latex elastics.
maxillary incisors to mandibular molars) the mandibular Angle Orthodontist, 40:319, 1970.
incisors and the teeth in the entire dental arch are moved Bien, S. M.: Analysis of the components of forces used to
forward, in many cases to an objectionable extent. The effect distal movement of teeth. Am. J. Orthodontics,
extraoral headgear with spring traction bar exerts the 37:508, 1951.
smallest amount of undesirable force. ---: The mechanism of tooth movement: An investigative
Force exerted by intermaxillary elastics is in an approach. New York J. Dent., 36:191,1966.
Bien, S. M., and Ayers, H. D., Jr.: Solder joints and rustless
anteroposterior direction when the mouth is closed and the
alloys. J.A.D.A., 58:74,1959.
jaws are in rest position. When the jaws are opened, a vertical
Boman, V. R: A radiographic study of response to torquing
component of force is introduced which tends to pull the
spring action. Angle Orthodontist, 32:54, 1962.
posterior part of the maxillary dental arch downward. Born, H. S.: Some facts concerning the open coil spring.
Untoward forces show themselves in a downward Am. J. Orthodontics,41 :917,1955.
displacement of the maxillary molar teeth. Borschke, A.: Vorschlage zur Messung der Kraftwirkung
The force of intermaxillary elastics can cause an increase verschiedener Regulierungs-apparate mit besoriderer
in the angle of the occlusal plane. Those patients who Beri.icksichtigung von intermaxillaren Gummizilgen.
experience the greatest amount of growth during treatment Zeitschr. Stornatol., 18:448, 1969.
exhibit the least change in the inclination of the occlusal Buchner, H. J.: Anchorage considerations in the treatment of
plane, and those that show the least growth during treatment Class II, Division 1 malocclusions. Angle Orthodontist,
show the greatest change in the occlusal plane. Subsequent to 27:217, 1957.
Burstone, C. J.: Rationale of the segmented arch. Am. J.
treatment, the patients exhibiting most growth during
treatment show the greatest tendency of the plane to return to
Burstone, C. L Baldwin, J. L and Lawless, D. T.: The ap-
the original inclination, and those who show the least growth plication of continuous forces to orthodontics. Angle
show less tendency to return to the original inclination. Orthodontist, 31:1,1961.
The attempt to establish normal interarch relation of the Callender, R S.: The effect of heat treatment on resiliency of
teeth by intermaxillary force results in failure when the orthodontic wires. J. D. Res., Abstracts, 1962.
patient brings the mandible forward bodily. A dual bite may Crabb, J. J. and Wilson, J. J.: The relation between orthodontic
be present before orthodontic therapy is started or it may be spring force and space closure. D. Practitioner,
established by the patient when strong elastics are inserted. 22:233,1972.
The patient should be taught how to use the elastics and Drenker, E. W.: Unilateral cervical traction with a Kloehn
should be impressed with the importance of cooperating in extraoral mechanism. Angle Orthodontist, 29:201, 1959.
wearing elastics. Enlow, D. H.: A study of post-natal growth and remodeling of
bone. Am. J. Anat., 110(2):79, 1962
---: Principles of Bone Remodeling. Springfield, Ill.
Charles C Thomas, 1962.
Evans, F. G.: Methods of studying the biomechanical
significance of bone form. Am. J. Phys. Anthropol., 11
:413, 1953.
---: Studies' in human biomechanics. In Miner, R. W., (Ed):
Dynamic Anthropometry. Ann. N. Y. Acad. Sci. 63: Art. 4,
BIBLIOGRAPHY
586-615, 1955.
Adams, C. P.: The soldering of stainless steel for remova ble -. --: Stress and strain in bones. Their relation to fractures and
appliance construction. D. Practitioner, 6:334, 1955. ---: osteogenesis. Springfield, 111. Charles C Thomas, 1957.
Orthodontic doctrine and mechanical treatment methods. ---: Biomechanical Studies of the Musculo-Skeletal System.
Am. J. Orthodontics, 46:811, 1960. Springfield, Ill. Charles C Thomas, 1961.
Aderer, J.: The soldering of half-round points and socalled Flourens, J. P.: Recherches Sur Ie' Developpment des Os et des
finger springs to arch wires. Int. J. Orthodontics, 15:796, Dents. Paris, 1842.
1929. ---: Theorie Experirnentale de la Formation des Os.
Andreasen, G. F. and Bishara, S.: Comparison of alastik Paris, 1847.
chains to elastics involved with intraarch molar to molar Fogel, M. S. and Magill, J. M.: A fundamental re-appraisal of
forces. Am. J. Orthodontics, 60:200, 1971. popular techniques with a collective approach toward
Angle, E. H.: The latest and best in orthodontic mechanisms. appliance therapy. 55:705, 1969.
Dental Cosmos, 70:1143,1928; 71:164,260,409,1929. Freeman, R. S.: Are class II elastics necessary? Am. }.
Armstrong, M. M.: Controlling the magnitude, direction and Orthodontics, 49:365, 1963.
duration of extraoral force. Am. J. Orthodontics, 59:217, Funk, A. c.: Mandibular response to headgear. 53:182, 1967.
1971. Gaston, N. G.: Chrome alloy in orthodontics. Am. ).
Backofen, W. A.: Heat treating stainless steel for ortho- Orthodontics, 37:779, 1951.
dontics. Am. J. Orthodontics, 38:755, 1952.
Beshara, S. E. and Andreasen, C. F.: A comparison of time
Gianelly, A: Mandibular cervical traction in the treatment of class agai, K: Behavior of metals in oral cavity. J, Nihon Univ.
I malocclusion. Am. J, Orthodontics, 60:257, 1971. School Dent., 1:203, 1959.
Goldstein, M. C: Elastic-thread ligature as an auxiliary for tooth agarnoto, G.: Contraction coil spring, its uses and how to make it.
movement. Am. J. Orthodontics, 45:6,1959. Am. J. Orthodontics & Oral Surg., 33:392, 1947. ---: The
Gould, 1. E.: Mechanical principles in extra-oral anchorage. significance of proper mechanical therapy in orthodontic
Am. J. Orthodontics, 43:319,1957. treatment. Am. J. Orthodontics, 35:269, 1949.
Haack, D. C: The science of mechanics and its importance to Nyquist, G.: The biological effect of monomeric acrylic.
analysis and research in the field of orthodontics. Am. J. Internat. D. J., 14:242, 1964.
Orthodontics, 49:330,1963. Paffenbarger, G. C, Sweeney, W. T., and Isaacs, A.:
Haack, D. C, and Weinstein, S.: The mechanics of centric and Wrought gold wire alloys, physical properties, and a
eccentric cervical traction. Am. J. Orthodontics, 44:346, 1958. specification. J,A.D.A, 19:2061, 1932.
Haynes, S., and Jackson, D.: A comparison of the mechanics and Parker, W. S.: A technique for treatment with cervical gear. Angle
efficiency of twenty-one orthodontic expansion screws. D. Orthodontist, 28:198, 1958.
Practitioner, 13:125, 1962. ---: Mechanical principles and orthodontic appliances.
Higley, L. B.: Anchorage in Orthodontics. Am. J. Orthodontics Angle Orthodontist, 30:241, 1960.
55:791, 1969. Poulton, D. B.: The influence of extraoral traction. Am.
Hixon, E. H., et al.: Optimal force, differential force and J. Orthodontics, 53:8, 1967.
anchorage. Am. J. Orthodontics, 55:437, 1969. Rauch, E. D.: Torque and its application to orthordontics.
Luffingham, J. K: Pressure exerted on teeth by the lips and Am. J. Orthodontics, 45:817, 1959.
cheeks. D. Practitioner, 19:6], 1968. Rogers, A. P.: Myofunctional treatment from a practical
Iyer, V. S.: Reaction of gingiva to orthodontic force: a clinical standpoint. Am. J, Orthodontics & Oral Surg., 26:113], ]940.
study. J. Periodont., 33:26, 1962. Salzmann, J, A.: The biophysics of bone and success in
Janssen, M.: On Bone Formation. Its Relation to Tension and orthodontic therapy. Am. J. Orthodontics, 45:606, 1959.
Pressure. London, Longmans, ]920. Sandstedt, c.: Einige Beitrage zur Theorie der Zahnregulierung.
Johnson, A L., Appleton, J, L. T., and Rittershofer, L. S.: Nordisk. Tand. Tid., 5:236, ]904; 6:]41, 1905.
Tissue changes involved in tooth movement. Int. J, Orthodont., Sather, A H., Mayfield, S. B. and Nelson, D. H: Effects of
Oral Surg., & Oral Radiog., 12:889, ]926. muscular anchorage appliances on deficient mandibular arch
length. Am. J. Orthodontics, 60:68, ]971.
Joffe, B. M.: Galvanic current generated by an orthodontic
appliance. J.D.A South Africa, 17:78,1962. Simon, P.: System einer biologischmechanischen Therapie der
Gebiss-Anomalie. Berlin, H. Meusser, 1933.
Jolly, M.: The formation of bone. D. J. Australia, 25:133, 1953.
Kaletsky, T.: An additional report on further studies in electric Smith, R., and Storey, E.: Optimum force for optimum tooth
pulp testing. New York J. Dent. 7:81, 1937. ---: Management of movement. Australian J, D., 56:291, 1952.
traumatized pulps. Am. J. Orthodont. & Oral Surg., 30:93, 1944. ---: The importance of force in orthodontics, design of cuspid
King, E. W.: Cervical anchorage in Class II, Division 1, retraction springs. Australian J. D., 56:291, 1962.
treatment, a cephalometric appraisal. Angle Orthodontist, Sorensen, O. J,: The sectional arch in CLass II extraction cases.
27:98, 1957. Angle Orthodontist, 30:174, 1960.
Kloehn, S. J,: Guiding alveolar growth and eruption of teeth to Stevenson, W.: Extraoral anchorage and traction in orthodontics.
reduce the treatment time and produce a more balanced Brit. J, D., 122:309, 1967.
denture and face. Angle Orthodontist, 17:10, 1947. Stoner, M. M.: Past and present concepts of anchorage
---: An appraisal of the results of treatment of Class II preparation. Angle Orthodontist, 28:176, 1958.
malocclusion with extraoral forces. Tr. European Orthodont. -,--: Force control in clinical practice. I. An analysis of forces
Soc., p. 112, 1961. currently used in orthodontic practice and a description of new
Krebs, A: Expansion of the midpalatal suture studied by means of methods of contouring loops to obtain effective control in all
metallic implants. Trans. European Orthodont. Soc., 34:163, three planes of space. Am. J. Orthodontics, 46:163,1960.
1958. Storey, E., and Smith, R.: Force in orthodontics and its relation to
Kressner, A: Die Umstellung zur Nasenatmung durch die tooth movement. Australian J. D., 56:11, 1952.
Gaumennahterweiterung, vom Standpunkt des Rhinologen. ---: Bone changes associated with tooth movement:
Fortschr. Kieferorth, 15:228,1951. 'Lindquist, J. T.: Indirect band A radiographic study. Australian J. D., 57:57, 1953.
technic. Angle Orthodontist, 29:11, 1959. Susarni, R., and Akiyama, K: Some physical properties of rubber
Lischer. B. E.: Mechanical treatment of dental anomalies. elastics. J. Osaka Univ. Dent. Soc., 4:485, 1959.
J.AD.A & Dent. Cosmos 25:397, 1938. Sved, A.: The behavior of arch wires in fixed attachments.
Luffingham, J. K: Pressure exerted on teeth by the lips and Int. J. Orthodontics & Oral Surg., 23:683,1947.
cheeks. D. Practitioner, 19 :61, 1968. ---: The application of engi neeririg methods to orthodontics. Am.
J, Orthodontics, 38:399, 1952.
Taylor, N. 0.: Problems involved in the study of wrought
Bibliography 287
gold alloys for orthodontia. Int. J. Orthodontics, 17:1033, Weinstein,S.: Minimal Forces in Tooth Movement. Am.
1931. J. Orthod., 53:881-903, Dec. 1967.
Thorne, H.: Experiences on widening the median maxillary Weinstein,S., and Haack, D. c.: Theoretical mechanics in
suture. Report of the 32nd Congress, European Orthodont. practical orthodontics. Angle Orthodont., 29:177, 1959.
Soc. Annual 1956. Weinstein,S., et al.: On an equilibrium theory of tooth position.
Timoshenko, 5.: Strength of Materials. ed. 3. New York, Van Angle Orthodontist, 33:1,1963.
ostrand, 1955.
Wilkinson, J. V.: Some metallurgical aspects of orthodontic
Tirnoshenko, 5., and Young, D. H.: Engineering Mechanics. ew stainless steel archwires. Am. J. Orthodontics, 48:192, 1962.
York, McGraw-Hill, 1956. Williams, R. V.: Orthodontic metallurgy. Int. J. Orthodontics,
Tweed, C. H.: The soldering technic for steel arch wire. 15:219, 1929.
Angle Orthodontist, 11 :68, 1941.
---: Orthodontic alloys. Int. J. Orthodontics, 11 :1,1935. Ziegler,
Van der Linden, F. P. G. M.: The removable orthodontic J. T.: The comparative merits of cementing orthodontic bands on
appliance. Am. J. Orthodontics, 59:376, 1971. non-dehydrated and air-dried teeth:
Waldron, R.: The dynamics of the new Angle mechanism, as A clinical study (Abstract). Am. J. Orthodontics, 45:869,
observed by a non-Angle man. Int. J. Orthodontics, Oral 1959.
Surg. & Radiog., 17:1113, 1931.
21
Appliance Construction and Use
An orthodontic appliance is a means to an end. It is not Overlapping portions of bands on the occlusal surface of
an end in itself as is the case with operative and teeth should be removed. All excess cement, especially on
prosthetic appliances that replace lost dental and oral gingival and occlusal surfaces, should be removed. All
tissues. Some appliances are more effective than others in loose bands should be recemented without delay.
producing desired results in specific types of
malocclusion. Placement of appliances in the mouth
should be accomplished gradually, and active force
LINGUAL APPLIANCES
should be postponed until the patient has become
accustomed to the presence of the appliances in the The fixed appliance is attached to the teeth; it is
mouth. The patient should be advised that some removable by the operator. Anchorage is dependent on
temporary tenderness may develop. Appliances should be the resistance offered by teeth (anchor teeth).
removed when not absolutely necessary. Bodily movement and rotation of teeth with
labiolingual appliances are not easily obtained although
they readily permit tooth movement by tipping.
Functional freedom of the teeth is more possible with
BASIC REQUIREME S OF ORTHODONTIC
labiolingual appliances than witl"~ multi banded
APPLIANCES
appliances that keep the teeth in a more rigid state.
Appliances should possess the following qualities: 1. Space closure with labiolingual appliances does not
Permit control of the degree, distribution, duration, and lend itself readily to paralleling the roots of teeth. When
direction of the force they exert gentle pressure is used, teeth can be moved with only
2. Be harmless to the oral tissues and not adversely slight axial inclination. Teeth adjacent to an extraction
affected by oral secretions space should be banded in order to obtain parallel root
3. Allow teeth and soft oral tissues to function movement. Axial inclinations of the moved teeth adjacent
normally to an extraction space will correct themselves
4. Allow wearer to maintain oral hygiene. occasionally when a retaining appliance is worn.
5.Exert sufficient force or offer sufficient anchorage Another method of space closure is to bring the tooth to
resistance to induce histologic bone changes necessary be moved into the extraction space into contact with the
for desired orthodontic tooth movement tooth on the opposite side of the extraction space. Light
6. Respond to the control of the operator spring pressure then is exerted at the gingival margin of
7.Allow movement of individual teeth or of groups of the tooth being moved, while the adjacent tooth acts as a
teeth in desirable directions stop, until the axial inclination of the moved tooth is
corrected.
Safety Measures in Appliance Therapy Rotation of Teeth. While auxiliary springs can be of
Appliances should be examined to note that the bands assistance in rotating teeth, lingual appliances require
are properly soldered, aligned, and cemented in proper bands to be cemented to the teeth to be rotated. Brackets
position in order to avoid undesirable movement of teeth, or staples are attached to the mesial and the distal thirds
caries formation, and unnecessary interruption of of the band for ligating the teeth to the arch wire in order
treatment. Archwires should be examined for brittleness to obtain rotation. Elastic or steel ligatures also may be
and unwanted crimping. used.
Irritation of the mucous membranes can result from To correct tooth irregularities in the mandibular arch, a
rough ends or archwires, Small, smooth wires soldered to lingual archwire (0.036 inches) with loops can be used.
the lingual surface of bands afford a grip for the band By bending the archwire slightly down-
remover and facilitate removal.
28
8
Lingual Appliances . 289
Fig. 21-1. To separate teeth

for banding, the elastic liga-
ture is drawn through with
dental floss (left) and tied
tightly (center and right).
Fig. 21-2. The Mershon lingual and the labial arch.

A, buccal tube, the inner dimension varies with the type of
archwire used, usually for .040 in. wire; B, stop spring or
Porter loop, a .022 in. diameter wire; C, labial arch wire,
diameter varies but is usually .040 in.: D, intermaxillary
hook, usually .036-in. diameter; E, Mershon half-round
vertical molar tube, .10 long; F, half-round wire post to fit
the 'half-round tube; G, lingual arch lock wire, .022-in.
diameter; H, auxiliary spring may be .022-in. or .020
diameter; I, lingual arch, .040 in. or lesser diameters may be
used; J, auxiliary spring stabilizer wire, .022-in. diameter;
K, anterior band material, .040- or .003-in. thick and
.1Bo-in. wide. L, ligature stop .020-in. diameter; M,
band material, .006-thick and .1BO-in. wide.
ward close to the molar bands compensation is obtained to at intervals during dental development. He did not consider
prevent shifting the molars forward when intermaxillary treatment completed before the eruption of the permanent
elastics are used. Intermaxillary elastics are not to be used dentition is completed. Mershon advocated correcting molar
until individual tooth irregularities in the mandibular dental relationship before aligning other teeth.
arch are eliminated. Construction. 1. Adapt bands to the second deciduous
molars, or in their absence, to the first permanent molars.
Solder half-round vertical tubes to the lingual surface of the
The Mershon Lingual Appliance maxillary molar bands
Mershon advocated lingual appliances and treating
, Fig. 21-3. (Left) Types of locks used in removable lingual arch

appliances. (Right) Labial arch loops used as stops. These can
be brought against or away from the molar buccal tubes.
p, ~ (Courtesy Lowrie J. Porter)
"
C ~
CF= SOlDER .032 LOCK WIRE
ON LlNGI/IU SUIfFRC OF BaSE WIRE
G
D ~i 8UXlUlun .sPRING ,q7TIICHI1ENT
HOTe PROTECT/ON BY LOCK
[ ~ H
COIL lD 841X/L IMY .sPItING lOCK
~ TOP:' TOtt!iVE PI/'ICHIltfr
290 . Appliance Construction and Use
Fig. 21-4. (Top left) Lingual

appliance used to replace
maxillary left lateral incisor
tooth, and auxiliary spring to
move the maxillary left canine
mesially. (Top right) Lingual
appliance with auxiliary springs
to move maxillary right central
incisor and left lateral incisor.
(Bottom left) Lingual appliance.
(Right) Appliance used to move
canine in palatal eruption.
(1'1 USIIiG I/fHF-ROUtiD TURfS

Fig. 21-5. A, B, C and D show compensating bends in
P. II C D the molar region to prevent molar rotation during lingual
arch expansion. E, F, G and H show use of round tubes
" ~
~
which eliminates the necessity of compensating bends.
The round tube is located to overcome adverse rotation.
rof (Courtesy Lowrie J. Porter)
Li
>w "; h '
IXP/flf',OH BEND ~RCH

~~.; A
'O.MPE /1.J.R TINS

'aEHD ': CFFl,r ON
DESfRED RT PQI/'IT ")C" ro 1'RCVlHT /'tI)L~Ft FtDr~r,()/1
~~
WHl1f NfU IS RlrtACl.D
(2"') USI!IG ROUND rUBES
r l; H
:r , '
rf ': 1
LJ
EXPRri.$rDl1
b 6; ,
~._ t
JlOlJiU rUBE. PLIU,lD RDt/tlD rIJS~
Iir"
1fOUI1D rvBiE.
DE"lIUD ~OR~RIJ) To Cl.IITIR 1fT I'tCJ/RL. oF I'1'OLIIL~ AT Imnu. O~ I'tO'''1f

and to the lingual surface of the mandibular molar bands. 4. Cement the bands to the molar teeth. Attach auxiliary
2. Take an impression with bands seated but not springs of 0.016- or 0.020-inch round wire as desired for
cemented to the molar teeth. Remove the bands from the movement of individual or groups of teeth.
teeth and fit them into position in the impression. Cover Tooth movement is accomplished by means of the
the inner surface of the bands with a thin film of wax to archwire and by auxiliary springs attached to the archwire.
facilitate their removal from the cast to be made. Pour the Attachment of Auxiliary Springs: The following should
impression in stone and separate the cast when set. be observed:
3. Adapt an 0.040-inch archwire around the lingual 1. Attach auxiliary springs on the gingival aspect of the
surfaces of the teeth on the cast. Solder two halfround archwire.
posts to the archwire so that they fit into the half-round 2. Use low-carat solder for soldering auxiliary springs to
tubes attached to the molar bands. Solder lock-wires to avoid removing the temper and elasticity of the spring.
the end of the arch wire. Melt a small piece of solder on the
9.
8.
Lingual Appliances' 291
'.
'
Fig. 21-7. Auxiliary springs on the lin-

gual appliance used to open space for a
lateral incisor.
G H
Fig. 21-6. The Mershon lingual arch with auxiliary springs

as it is positioned to achieve different effects:
A, intercanine expansion; B, expansion of the anterior
portion of the arch; C, expansion of the canine and premolar
region; 0, general expansion of the arch, using recurved
springs; E, opening space for canine; F, anterior movement Fig. 21-8. The lingual appliance is activated to correct
of lateral incisors; G, anterior movement of incisor teeth; H, posterior cross bite.
closure of space between central incisors; I, opening space
for lateral incisor. (Courtesy Lowrie J. Porter)
at an angle of 45 and then bend to the desired position. If
the auxiliary spring raises the main archwire from its passive
position, the auxiliary
spring wire and another piece of solder on the archwire at the .spring is exerting too much pressure. It should then be
point where the spring is to be attached. Attach the spring by readjusted.
joining the solder covered parts. 4. When the original spring force has spent itself, the
3. Attach auxiliary springs to the main arch wire auxiliary springs are again readjusted.
Fig. 21-9. (A) Solid lines show

passive auxiliary spring ar d
dashed lines show activation to \\)\
clove premolars buccally. (B) \\
Active spring moves molars and
premolars, and when spring wire
is extended forward, it moves \\
canines and incisors buccally and 1\I
labially. (C) Active spring moves _.~
molars buccally. (D) Active spring

moves premolars and other .-
anterior teeth wh~n spring wire is
lengthened. B C :i 0
METHODS OF SEP ARA TING TEETH FOR anterior band material use 0.003-inch to 0.005 x 0.018S-
BANDING inch
Labial and lingual archwires 0.038-inch to 0.040inch
Soft brass 0.020-inch ligature wire is used to separate
Buccal tubes (round). Usually one-quarter inch in
molar teeth prior to band fitting. Occasionally separation
length, to fit various gauges of wires as used.
is required in anterior teeth; an O.OlD-inch steel or brass
Lock wires - 0.022-inch soft
wire is used. Elastic or steel spring ligatures may also be
Auxiliary springs - O.OlS-inch or 0.020-inch. Half-round
used (Fig. 21-1).
tube length is 0.010 inches, to fit 15-
Elastic ligatures of light, medium, or heavy thickness
gauge, half-round wire Guideplane wire
may be used for separating teeth before band fitting,
- 0.030-inch Intermaxillary hooks -
tooth rotations, space closure, tooth alignment and canine
0.03S-inch
retraction, and for bringing teeth into the line of
occlusion. The elastic ligature is drawn through the
interproximal space of the teeth with a fine ligature wire
and tied under tension. ST AINLESS STEEL APPLIANCES
Gauges of wires. The following gauges and di- Stainless steel commonly used in orthodontics contains
mensions of wire are used in labial and lingual 18 per cent chromium and 8 per cent nickel. This is
appliances: known as austenetic type steel. Allergic reactions to
Band material. For banding molars use 0.006-inch or stainless steel have been found to occur in some patients.
0.007 X 0.18S-inch or 0.187-inch material. For Stainless steel used in orthodontics should be malleable,
resilient, and impervious to oral fluids; Stainless steel
wires when heated to redness and slowly cooled become
soft. The temper in stainless steel cannot be restored as in
precious metal alloys.
Steel wires have a high tensile strength, therefore, wires
of smaller dimensions should be used to avoid excessive
force. An 0.006-inch steel wire can produce a force of 2S
g. While an 0.020-inch steel wire produces a force of
almost 700 g. High degrees of force reduce the rate of
tooth movement. Initial use of arch wire force should be
confined to light round wires of small diameters. Steel
wires have a tendency to break under increased
manipulation. The wires should be bent slowly if sharp
bends are to be made.
Soldering Stainless Steel
Soldering stainless steel depends on mechanical

adaptation, since there is no alloy union or fusion
.between the parts soldered. Solder for stainless steel
contains potassium fluoride, boric acid, and hydrochloric
acid.
The solder is melted on the part to be soldered.
Low-fusing silver solder and appropriate flux must be
used. The parts to be soldered are brought as close to the
flame as possible to allow the solder to melt without
actually bringing the stainless steel parts to bright redness.
A fine needle flame should be used. The soldering
operation should be accomplished in one heating, and the
soldered joint should immediately be quenched in water.
Light wires to be soldered to heavier wires should be
wrapped around the heavier wire after soldering.
The joint to be soldered should be surrounded by a
plentiful supply of flux, and solder should completely
Fig, 21-10. When stainless steel is soldered, the steel is cover both sides to be joined. Sufficient heat
held close to but not in the flame (top), By winding one
piece around the other to which it is to be soldered, a
stronger joint is obtained (bottom).
10. Soldering Precious Metals . 293
should be applied to just melt the solder; if it is heated too

much the soldered joint has a rough, pitted surface. Care
should be taken to hold the wires in the exact position
desired. High heat should not be used, because it reduces
or destroys tensile strength and hardness.
The surface of the wires at the site to be soldered should
be free of grease and dirt. Soldered joints should not be
polished to the extent of removing the outer layer of
solder, because it tends to lower the strength of the joint.
All flux should be removed but not polished away from a
soldered joint.
When solder is allowed to flow around one or both of
the wires to be joined and the wires are held in proximity,
gentle heat is enough to melt the solder and produce a
satisfactory joint. When the wires to be soldered are
brought near the flame, it should be done slowly to give
the flux a chance to dry by gentle heat and to stay in place
so as to keep clean the area to be soldered. The area to be
soldered should be roughened first with a smooth file or
steel brush. The wire is prepared to take the flux evenly
and hold it in place.
Intermaxillary hooks of stainless steel may be annealed
without losing their usefulness. The solder should be
melted on the wire used for hooks at some distance from
its end and flown onto the archwire. Solder is applied to
both sides to be joined and then fused.
Spot Welding
Spot welding is accomplished by holding the pieces to be
welded together under pressure between hard copper
electrodes and passing a high amperage current through
them for a given length of time. The electrical resistance of
stainless steel is high, so that the temperature generated at
the contact causes fusion, and the pressure of the copper
electrodes completes the weld. Several welds should be
made in welding orthodontic bands. Bracket alignment
should be checked and corrected after the initial weld.
Welded auxiliary springs should be wrapped around the
arch wire.
~~
SOLDERING PRECIOUS METALS Fig. 21-11. (Top) A removable appliance with finger
springs used to move teeth mesially or distally. The plate
Solder of 22 carat is the best for soldering precious has been cut away from the lingual surface of the incisor
metals. Lower carat solders are more brittle. Soldering teeth. A wire has been adapted to help keep the anterior
should be done at the lowest possible temperature. The springs in place. When fine wires are used it is better to
thinner the space between the wires to be soldered, the depend on opening the coil (pushing force) rather than on
stronger the joint will be. Precious metal wires should be closure of the coil (pulling force) for tooth movement. The
softened prior to being shaped. spring is compressed when the coil is tightened. (Center) A
While partially softened wires are less subject to retracting spring for moving canine into first premolar
breakage, the bending operations during appliance extraction space; The free end is flattened and inserted
construction leave highly stressed sections above the mesial contact point. (Courtesy C. P. Adams).
(Bottom) A removable plate with springs is used to close a
first premolar extraction space.
294 . Appliance Construction and Use 11.
sideration when they are moved by means of biteplates.

When incisor teeth are in protrusion and change of the
position of the root is not required, the biteplate can be
used with a flat plane, opening the bite sufficiently to free
interlocking cusps, by grinding away the lingual surface of
the plate at the maxillary incisors and using a 3fs-inch
elastic. Wire springs attached to plates should be cut to
size when fitting the appliances in the mouth. The ends of
the wire can then be rounded by adding a drop of solder or
by turning the end of the spring on itself.
Activation of springs for moving teeth should be a little
less than half the width of the tooth to be moved. If the
appliance is to be used for closing spaces in extraction
cases, impressions should be taken first and the appliance
constructed before the extractions are performed. Distal
movement of premolars can best be obtained by freeing the
occlusal surfaces and by opening the bite so that the
maxillary and mandibular teeth are slightly out of
occlusion.
Distal movement of molars can be performed with finger
springs attached to a plate. Space closure in the mandible
is not easily accomplished with a removable appliance
when there is need for bodily movement of the mandibular
incisors.
While the use of biteplates for tooth movement appears
to be easy of accomplishment, retention is important, as is
Fig. 21-12. This appliance is used to bring the control of axial position of the teeth. Removable
permanent lateral incisors together in order to obtain appliances require exact knowledge of appliance
space for the erupting lateral incisors and to dose the manipulation as do the fixed appliances. The use of a
midline diastema. It is shown below in position in the biteplate to correct excessive overbite frequently meets
mouth. with failure when the correction of excessive overbite
requires changes in the axial relations of the maxillary to
that are more likely to break. These are relieved by heat the mandibular incisors. This cannot be accomplished
treatment and hardening treatment. easily with biteplates.
Biteplates make it possible for the posterior teeth
. to become elongated by continuing eruption.
THE HAWLEY RETAINER
Whether the posterior teeth will relapse to their former
Hawley introduced his retainer in 1919. Biteplanes height after the plate is removed is uncertain. If the
used for tooth movement produce tipping. The tipping masticatory muscles, especially the strong
can be minimized and in some cases the root will tend to
follow the crown if the force in tooth movement is light.
In some instances by moving the crown of one tooth
against that of the adjacent tooth and by applying spring
force gingivaIly, an inclined tooth can be uprighted.
Control of the axial inclination of teeth to be moved is an
important con-
Fig. 21-13. Tissue surface (left) and side view

(right)of mandibular appliance with auxiliary
wires to move crowded incisor teeth into
alignment.
The Hawley Retainer' 295
Fig. 21-14. (Top left) Before

treatment, the maxillary right
central incisor was lost. After
treatment (top right) a retain-
ing appliance with tooth
attached was fitted (bottom).
Fig. 21-15. Mutilated

dentition had caused
crossbite (top left). Treatment
progressed satisfactorily
(center) and cross bite was
corrected (rignt). (Bottom) The
activator type of appliance
was used. It is shown in
position in the mouth at
right.
masseters, are stretched when the posterior teeth are trimmed so that the mandibular incisor teeth fit directly
elongated, there will be a tendency for the vertical against the inclined plane.
dimension to return to its original size. The intrusion of Among the changes that biteplanes can effect are the
mandibular incisors into the alveolar process will not following:
remain when the plate is removed if the mandibular 1. Forward positioning of the head of the condyle of the
incisors do not have proper contact and proper angular mandible; repositioning the mandible, especially in young
relation with the maxillary incisors. The maxillary- children when growth is active
mandibular incisor angle should not be allowed to remain 2. Opening the bite and diminishing overjet of the
excessively obtuse (over 150) in deep overbite. anterior teeth
If a biteplate or a Hawley retainer is used to retain the 3. Elevation of the posterior teeth; the anterior teeth may
mandibular incisor teeth as well, the inclined plane can be be slightly depressed or both changes may occur
constructed in the mouth with quicksetting acrylic. The 4. A more normal anteroposterior relationship of the
retainer should then be removed. When the quick-setting occlusion
acrylic is hardened, it is 5. Retention after correction of distoclusion
Fig. 21-16. (Top) Removable appliance

for bite opening without a wire retainer.
Left, tissue surface. Right, lingual surface.
(Second Row) Appliance in position. (Third
Row) Left, before treatment. Right, after
treatment. (Bottom Row) Left, appliance with
a labial wire in position. Right, lingual view
of appliance.
6. As an aid in myofunctional therapy Bahador and Higley found most of the increase in face
7.Relieve locking of individual teeth or groups of teeth height following the use of Hawley-type biteplates to be
8. Eliminate tongue habits, lip biting, thumb sucking due to vertical increase in the posterior dental region,
and other deleterious habits. NOTE. In Class II, Division 2 mostly in the maxillary posterior teeth. Increase in vertical
(Angle) malocclusion the interference of the anterior and dimension is accompanied by change also in the
other teeth should be removed before the biteplane is mandibular position.
used. Biteplanes should not be used where there is a
tendency toward an openbite.
9. To retain space when teeth are lost prematurely 10. THE REMOVABLE STABILIZING PLATE
With additional spring attachments, to move groups and
individual teeth A removable stabilizing plate was devised by Moyers
11. For correcting the mesial position of the man- and Higley that can be used as a means for obtaining
dibular teeth in the deciduous dentition. anchorage in orthodontic tooth movement in the mixed
dentition when all mandibular permanent teeth are not
fully erupted. An acrylic plate,
The Removable Stabilizing Plate . 297
Fig. 21-17. (Top and Second

Row) Casts show deep overbite
and spacing distal to canine teeth.
This young adult patient was not
seen before these casts were
made. (Third Row) A removable
appliance with auxiliary
springs was fitted to move
canines distally. (The appliance
itself is at bottom right.) (Bot-
tom Row) Left, anterior view
before treatment. Center, after
treatment.
similar to a Hawley retainer, can be constructed for Construction

either the maxilla or mandible as required. The plate is
constructed to lie in lingual contact with the teeth and to 1. Molar bands are constructed with lingual halfround
cover as much of the soft tissues lingually as possible. tubes soldered perpendicularly. Intermaxillary hooks are
The plate is supplied with wire extensions to which are soldered on the buccal surfaces of the bands.
soldered vertical round or half-round extensions that fit 2. Take an impression with the uncemented bands
into lingual round or half-round tubes soldered to the seated on the teeth.
molar bands. These are an aid in holding the plate in 3. Remove the molar bands from the teeth and seat
position. them in their proper position in the impression.
A mandibular plate can be cut away from the lingual 4. Pour the impression in stone.
surfaces of the incisor teeth, which can then be moved 5.Construct a wire framework and process the plate in
lingually by means of intra maxillary elastics attached to quick-setting or blow-on acrylic. A broad, flat acrylic
wire extensions on the plate distal to the canine teeth. surface contacting the teeth is desirable.
Fig. 21-19. (Top) An auxiliary spring of O.028-gauge wire, for

lingual movement of a premolar. (Bottom) A lingual spring,
O.020-gauge, was used for distal movement of a premolar.
Overlying wire guides the activated spring wire. (Adams, C. P.:
Removable appliances yesterday and today. Am. J. Orthodont.,
55:748, 1969)
7. Polish the plate and insert it in the mouth after the

bands are cemented.
Fig. 21-18. The Schwarz arrowhead clasp (top) depends on

interdental spaces gingival to contact points for retention. The ACRYLIC RETAINERS
Adams clasp (center) uses mesial and distal undercuts on a single
tooth for retention; buccal view of Adams clasp is at bottom. Construction
(Adams, C. P.: Removable appliances yesterday and today. Am.
J. Orthodont., 55:748,1969) Form the wire attachment according to the type of
appliance required. Remove wire attachment from the cast
prior to painting the cast with acrylic separating medium.
Carefully replace the wire attachment in its proper
position and apply acrylic powder and liquid. The wire
should be held temporarily in position with sticky wax or
other material added on the buccal and the labial surfaces
not to be covered by acrylic.
It is advisable to cover the lingual surface of the molar Build the palate by alternately applying the acrylic
bands or overlay them with a layer of heavy tinfoil before powder and liquid. Work only on relatively small areas, in
processing. This facilitates the removal of the band from order to maintain better control over all. Begin
the acrylic. construction of the palate by distributing a layer of acrylic
6. Remove the molar bands from the plate and cement powder with the dispensing bottle.
them in place on the teeth.
Acrylic Retainers' 299
Fig. 21-20. (Top) The lower traction plate is clasped to four teeth and has
hooks on the molar clasps. The labial bow is fitted as near as possible to the
incisal edge of the lower incisors. (Bottom) One kind of upper traction
appliance is clasped with four clasps and tubes that will take an extraoral
attachment which can be added for nighttime use. Figures 21-18 to 20,
courtesy (Adams, C. P.: Removable appliances yesterday and today. Am. J.
Orthodont., 55:748,1969)
12.
Spread the powder evenly. Saturate the powder with

acrylic liquid from the dropper bottle. Use liquid
generously; too much does no harm, and too little may
result in an unsatisfactory bond. Build the area to the
desired thickness by repeating the process.
The center of the palate is built last because excess
lateral material tends to gravitate toward the center. Turn
the cast down on its occlusal surface and let it remain in
this position for about 15 seconds. This prevents soft
material from drifting into the center of the palate. When
the material reaches a sticky or tacky stage, turn the cast
over and smooth out rough spots with a finger. If the
acrylic has set too fast, soften it by adding a few drops of
liquid and smooth it over. Allow the appliance to cure on
the cast at room temperature for 30 to 45 minutes. This
prevents warping and shrinking.
NOTE. The acrylic plate may be lifted out of the cast
with a knife or any other sharp instrument.
Trim and smooth the excess material from the in-
terdental spaces with burs and disks. NOTE. Results are an index so that the retainer lies passive. Clean, trim, and
improved if the appliance is soaked in water overnight. smooth the irregular edges along the break with a bur or
This further cures the material and eliminates unpleasant stone.
taste. Apply acrylic separating medium to the palatal area of
the cast and replace the broken parts on the cast. From
this point on, the standard procedure is followed by
adding quick-setting acrylic until the break is completely
Repairing Retainers
filled. When the acrylic is set, trim and polish the
Place the retainer on the original cast or construct retainer.
Fig. 21-21. (Left) Framework for a maxillary stabilizing plate; (center) posterior extension on framework. (Right) Maxillary cast ready
for waxing. Note that the posterior extension is covered by stone which holds the framework in its proper relationship. (Courtesy L. B.
Higley)
Fig. 21-22. Method of applying hooks for inter-

maxillary elastics: 1, band; 2, fashioned hook; 3, hook
soldered on band.
THE EXTRAORAL APPLIANCE Fig. 21-23. Maxillary stabilizing plate with labial archwire.
(Courtesy L. B. Higley)
Extraoral Appliance Force
Malocclusions characterized by forward displacement
of the dental arches can be treated with extraoral force hours daily during the afternoon, evening, and at night.
emanating from occipital or cervical anchorage. The Some children do not mind wearing it all day. The
appliance should be worn 12 to 14 extraoral appliance must feel comfortable
Fig. 21-24. (Top left) Anterior

view of casts for which a
retainer with inclined plane is to
be constructed to prevent a
patient from tongue thrusting.
The appliance is worn after
school, in the evening, and at
night. (Top right) With the wire
framework and bite, the casts are
assembled and joined with sticky
wax. (Bottom left> Anterior view
showing plaster index over the
casts. Petrolatum is applied to
the labial and the buccal aspects
of the casts before the plaster
index is poured. (Bottom right>
The lower cast has been
removed to show the upper cast,
the ends of the wire framework,
and the plaster index. The casts
are now ready for adding
acrylic.
The Exiraoral Appliance' 301
Fig. 21-25. (Left) The lower

cast has been replaced and the
acrylic biteplate can be
constructed. The base of the
lower cast has been cut away
to permit more direct access
when acrylic is applied.
(Right) Lower cast has been
removed to show the com-
pleted plate on the maxillary
dental cast.
,
Fig. 21-26. (Left) Wire is
applied to the maxillary dental
cast before "blow-on" acrylic.
(Right) The finished Hawley
retainer,
to the patient, and the force applied should be in the longer arm of the facebow will receive the greater force.
direction in which the teeth are to be moved. When gentle Lateral forces of small magnitude are always developed
force is exerted by the appliance the teeth anterior to the by an eccentric desgin of the extraoral appliance. These
molars that carry the appliance will also move distally. forces can be controlled or manipulated to obtain lateral
A study by Funk on the effect of headgear treatment on movement on one side or the other by springing the labial
the maxillary dental arch showed that mandibular teeth arch inward or outward. Biologic and morphologic
were uprighted and moved distally, mandibular arch form variables in the dental arch can cause variation of
was improved, and tooth rotations were diminished. The unilateral or bilateral forces. Molar extrusion should be
most favorable changes produced in treatment with avoided especially in retrognathic mandibles, since the
extraoral appliances occur in young patients. The ietrognathism is increased. The arms of the face bow
extraoral appliance is useful in some cases as a sale should not impinge on the cheeks.
method of treating malocclusion and to reinforce
anchorage when intraoral appliances are used.
Facebow Angulation and Direction of Tooth Movement

When the arms of the bow of the headgear appliance
Asymmetrical Extraoral Appliances
are below the occlusal line there is distal tipping of the
force exerted by the extraoral appliance depends on' (1) crowns of the molars. By raising the arms so that they are
the point where the force is applied, (2) the magnitude of parallel with the line of occlusion, crown tipping is
the force, and (3) the direction in which the force is lessened. In this manner the axial position of molar teeth
exerted. When the direction of force from the cervical can be corrected.
appliance is asymmetrical because of the difference in Distal movement of the teeth anterior to the molars
length of the facebow arms with respect to the midsagi usually follows the molars. The interdental fibers of the
ttal line of the face, then the anteroposterior components periodontal ligament help the distal movement of the
of force on the right and left molars are unequal. The buccal series of teeth to move
molar nearest the
Fig. 21-27. (Top) The extra-

oral headgear assembled.
(Bottom) The headgear consists
of a section of clothcovered
rubber tubing (1). Wire end-
pieces (2) are connected by a
large elastic (3). This appliance
follows the design originated by
Crain.
Fig. 21-28. A cervical extra-

oral appliance with extraoral
wires of equal lengths moves
teeth distally at an equal rate on
both sides (left). (Right) The teeth
on the side of the longer extraoral
wire arm will move faster than
those on the side of the shorter
arm.
The Extraoral Appliance . 303
6.3 oz.
5.4 oz.
10.5 rom.
4.0 oz.
Fig, 21-29, (Top left) Chincap with extension hooks for elastics used for Class nr malocclusion from hooks on
the archwire soldered mesial to the molar tubes, (Center) Front view of chincap and headcap to which it is
attached. (Right) Profile showing chin cap in position. (Bottom left) The relationship of the face bow to the arch
effects the force on the molars. When the face bow is parallel with the arch, the force produces a distal body
movement. Bending the face bow below the arch as indicated in the drawing produces a distal crown tipping
force upon the molars. (Center) When the face bow is bent above the arch a distal root force is placed on the
molars. A distal crown tipping force stimulates faster movement and may open the contact between the molar
and the tooth mesial to it. Note, The elastic size is determined by the distance from the end of the face bow and
the hooks on the cervical strap, and tissue response, pain being the indication to reduce pressure by using a
larger elastic. Constant maximum pressure according to the patient's tolerance is important and desirable
according to Kloehn, and can be accomplished by changing elastics several times a week. (After S. J. Kloehn.)
(Right) Vector diagram; headgear with spring traction bar.
distally as a unit. When space develops mesial to the molar there is a tendency for the elongated molars to return to
teeth as distal force is applied, it becomes necessary to their original occlusal height.
move the premolars distally in turn and then to apply force When a biteplate that keeps the jaws apart is used in
on the incisors to move them distally. Spacing mesial to conjunction with an extraoral appliance, the possibility of
the molar teeth may be due also to excessive force. elongating the molars is increased. This is not of value in
Intermaxillary elastics may be used if response to correcting deep overbite, since the vertical height of the
treatment in the permanent dentition is slow when molars cannot be arbitrarily permanently increased. The
extraoral force alone is used. This is especially useful for overbite usually is caused by overeruption of the incisor
lip-biters when the maxillary incisor teeth are pushed teeth.
forward by the lower lip. As the bite is opened there is a tendency for the
Bite opening caused by elongation of molar teeth when mandible to assume a more retrognathic rotation in relation
using an extraoral force depends on the degree and to the maxilla. This appears on the cephalometric tracing
direction of force applied, the nature of the alveolar bone, as a downward and rearward positioning of the mandible.
and muscle activity. When active, vigorous muscular Distal Driving. Extraoral force is a useful aid in
activity is exerted in chewing inhibiting the forward translation of the dentition
The patient, preferably, or the parent in younger

children, is taught how to place the extraoral appliance
into position.
Construction
Cement molar bands onto the deciduous second
molars. If these teeth are missing or if their roots show
advanced resorption place the bands on the permanent
first molars. Solder tubes with 0.040 or 0.045-inch inside
diameter, and attach rectangular tubes to hold an 0.020-
inch archwire to be attached to the bracketbands on the
teeth, as far gingivally and mesialIy as possible, for distal
tooth movement. The labial arch wire should lie opposite
the gingival level of the incisor teeth. The molar tubes
can be adjusted to permit root or crown tipping of the
molars when desired.
The labial archwire is constructed of 0.040-inch or
0.045-inch stainless steel. wire. Soldered or welded fixed
stops are attached to the arch wire to rest against the
mesial ends of the molar tubes, while the arch rests
labially 0.25 inch away from the incisor teeth. A 0.040-
inch spur to receive the traction bar or face bow is
soldered to the labial archwire at the median line. The
face bow or traction bar itself also may be soldered to the
archwire itself. Stops are soldered on the 0.045-inch
labial archwire so that its anterior part is 4 to 5 mm. away
from the incisors. The labial arch may be allowed to rest
against the incisors if it is desired to move the incisors
Fig. 21-30. (Top) A "high pull" extraoral ap- lingually, in which case the stops are placed on the arch
pliance in position; (bottom) a cervical extraoral wire away from the anterior limits of the molar tubes so
appliance in position. that the archwire can slide into the tubes as the incisor
teeth are brought lingualIy. When the incisor axial
and to help stabilize anchorage when Class II in- relation is corrected the stops are replaced on the arch
termaxillary elastics are used. So-called distal driving of wire to rest against the molar tubes to move the molar
the maxillary dental arch serves to inhibit the forward teeth distally. Another method of moving incisor teeth
translation of the dental arch and has been found to lingually is to attach hooks on the archwire of the
modify the vector of growth of the maxilla in general. extraoral appliance distal to the canines and to attach 3fs-
The extraoral appliance can be used in the mandible in inch rubber dam elastics that would exert pressure on the
Class III fashion by moving the mandibular molars incisors.
distally and for providing space for the teeth anterior to The mesiobuccal cusps of the maxillary first molars
the molars. can be rotated buccally by bending the ends of the labial
Shifting of permanent molars caused by premature arch buccally in front of the molar tubes. The traction bar
loss of deciduous molars, with encroachment on the or face bow of 0.070-inch round wire is constructed with
premolar eruption space, can be prevented with the hooked ends to hold the cervical gear.
extraoral appliance. When dental arch-basal arch The cervical gear is made of 1.5-inch wide belting
discrepancy is slight, it is possible by means of extraoral material.
force to move the buccal segments distalIy and
frequently to avoid extraction, especially if treatment is
initiated in the early mixed dentition.
When using force emanating from occipital an-
chorage, it is necessary to guard against impaction of
third and possibly second molars, if the first molars are
tipped too far distally. Additional appliances are usualIy JUMPING THE BITE
needed to complete tooth positioning and rotations. What is known as "jumping the bite" is accomplished
by an abrupt change in the position of the mandible
produced by orthodontic means. This may
Teeth Protectors . 305
be accomplished with strong elastic force, by incorrect use

of the activator appliance, and by stops attached to the
teeth that make it impossible to bring them into full
occlusion without bringing the mandible forward. The
adult temporomandibular articulation does not adapt itself
as a rule to "jumping the bite." Orthodontic bite jumping
especially in the permanent dentition can result in the
establishment of a "dual bite." The method may be
erroneously considered successful where the patient had a
dual bite before treatment. This is a bite in which the
patient brings the mandible forward voluntarily but
occludes distally in a Class II relation when the teeth are
brought together involuntarily. Successful cases of bite
jumping in adults can be attributed to repositioning of the
body of the mandible. In early childhood a change in the
vector of growth of the mandibular condyle is possible,
since the condyle and subcondylar portion of the ramus do
not calcify until late adolescence.
SLIDING JIGS
In constructing a sliding jig, an 0.020- or 0.022inch
round steel wire is used. The use of the sliding jig in
conjunction with intermaxillary elastics makes possible
the distal movement of teeth in series. The jig can be
activated against the tube on the band of the last molar or
tied to any of the teeth anteriorly. It is best to construct the
jig so that the anterior hooked loop is situated just distal to
the canine bracket. As space is opened, the jig is engaged
anteriorly to the canine bracket so that the canine is
activated in a distal direction. The use of the sliding jig
permits serial movement of the teeth distally from the
canines. It permits using the entire mandibular arch as
Fig. 21-31. (Top) Intermaxillary hooks for attaching
stationary anchorage against two teeth at a time, one on
extraoral appliance and for inter- or intramaxillary elastics.
each side of the maxillary jaw, or to move teeth on one
(Second row) Sliding jig used against molar tube to drive the
side of the dental arch distally. Sliding jigs for space
molar distally. The premolar teeth usually move distally
closure after extraction of premolar teeth may be used
with the molars. (Third row) Sliding jig used in front of the
with the headgear to make certain that the molars will not
canine tooth to move it distally. (Bottom) Use of a Pletcher
move forward if forward movement of molars is not
coil to retract the maxillary canine tooth.
desired.
When maxillary molars are moved distally by means of
sliding jigs, the premolars will usually be found to move
distal movement of the teeth for about 6 weeks, until the
distally at the same time. This is true especially in
teeth are again stabilized in the alveolar process.
children who swallow in the normal closed-mouth
manner. In the tongue-thrust or open-mouth swallow
when the tongue rests habitually on the occlusal surfaces, TEETH PROTECTORS
the premolars do not usually move distally with the
Fixed orthodontic appliances need not be removed in
molars. The required direct force can be achieved by tying
order to construct a teeth protector. The impression is
the sliding jigs directly to the premolars and then to the
made with the fixed orthodontic appliance in place and the
canines. The use of lighter elastics is beneficial in
teeth protector is constructed to fit over the appliance. To
maintaining anchorage stability. When anchorage stability
construct a teeth protector alginate impressions of the
is lost, it can be regained by discontinuing
dental arches and a wax bite with the teeth about 3 mm.
apart are taken, and the casts are poured.
Teeth protectors should meet the following requirements: (1) Beresford, J. 5.: Orthodontic springs for removable appliances.
occupy as little space in the mouth as possible; (2) be light and D. Practitioner, 2:178,1951.
easily positioned on and removed from the teeth; (3) do not Block, A J.: Headgear- modifications and admonitions.
impinge on the soft tissues; and (4) do not distort the muscles of Angle Orthodontist, 32:19, 1962.
the face to any great degree. Brock, W. C.; 'The principle of coil spring traction applied to
Teeth protectors may be made of prefabricated rubber with a cervical strap therapy. Am. J. Orthodontics, 46:43, 1960.
thermoplastic lining, or of latex, clear acrylic, or semihard Brodie, A G.: Technique of the pinch-band. AngleOrthodentist,
2:260, 1932.
acrylic shell with a soft acrylic insert. A material of silicon
___ : A discussion of torque force. Angle Orthodontist, 3:263,
vinyl in clear plastic 0.125 inch thick is available in 3" X 6"
1933.
sheets. The material is soft and flexible and is readily formed by
--_: The application of the principles of the edgewise arch in the
softening in heat and molding on a dental cast. The teeth treatment of Class II division 1 malocclusion. Angle
protector is trimmed to about the middle of the crowns of the Orthodontist, 7:3, 1937.
teeth. A second layer can be added to the first by heating the Brousseau, ]. c.: Bilateral Class II division 1 malocclusion
surface of the layers. treated with an occlusal gUide plane. Am. ]. Orthodontist,
38:444, 1954.
Hawley, C. A.: The principles and art of retention. D.
Record, 44:175, 1924.
Holdaway, R. A.: Bracket angulation as applied to the edgewise
BIBLIOGRAPHY appliance. Angle Orthodontist, 22:227, 1952, Hopkin, G. B.: A
case of cutaneous sensitivity to stainless steel. Brit. D. L
Adams, C. P,: The Design and Construction of Removable 98:117,1954.
Orthodontic Appliances. Bristol, John Wright & Sons, 1955, Hopkins, S. c.: Inadequacy of mandibular anchorage. Am. ].
--_: The design of removable appliances for intermaxillary and Orthodontics, 41 :691, 1955.
extra-oral traction. D. Practitioner, 5:244, 1955. --_: Inadequacy of mandibular anchorage-five years later. Am. ].
--_: The design of removable appliances for mesial movement Orthodontics, 46:440, 1960.
of teeth. D. Practitioner, 6:191, 1955. Lewis, P. D.: Principles for use of the edgewise bracket with
--_: Removable appliances yesterday and today. Am. rotation arms. Angle Orthodontist, 29:182, 1959.
J. Orthodontics, 55:748,1969. McKeag, H. J. A: The teaching of appliance design in
Andresen, V.: Ein gnatho- physiognometrisches System als orthodontia. D. Recoral, 56:260, 1936.
asthetische Grundlage der biomechanischen Orthodontie. Mershon, J. V.: The removable lingual arch as an appliance for
Fortschr. Orthod, Vol. 4. 1932. the treatment of malocclusion of the teeth. Int. J. Orthodontics,
--_: Die Gnathophoremethode die ktinstlerische Diagnose und 4:578, 1918.
wissenschaftliche gnathophysiognomische Diagnose. --_: The removable lingual arch and its relation to the
Fortschr. Orthod. Leipzig. Hermann Meusser, 1936. orthodontic problem. Dental Cosmos, 62:693, 1920.
-_: Gnathologische und physiognometrische Proportionslehre - __ : A practical talk on why the lingual arch is applicable to the
als diagnostische Grundlage der Punktionskieferorthopadie, orthodontic problem. D. Record. 46:297, 1926.
Den. norske Tand. Tid, 3: 1938.
The removable lingual arch appliance. Int. ].
Bahador, M. A and Higley, 1. B.: Bite opening: A ceph-
Orthod., Oral Surg. & Radiog., 12:1002, 1926.
alometric analysis. J.AD.A., 31:343,1944.
Moyers, R. E. and Higley, 1. B.: The stabilizing plate, an adjunct
Baldridge, J. P.: Unilateral action with headcap. Angle
to orthodontic therapy. 35:54, 1949.
Orthodontist, 31 :63, 1961. 'PosseH, U,: Bite guards, bite plates, and orthodontic treatment in
Bayne, D. I.: A preliminary study of changes in the lower arch periodontal disease. D. Practitioner, 11 :126, 1960.
subsequent to cervical force treatment in the maxillary arch Rortsahl. ].: Zum Problem der sagittalen Beeinfliissung der
(Abstract). Am. J. Orthodontics, 46:386, 1960. oberen apikalen Basis mit Platten beim umgekehrten
Bell, W.: A study of applied force as related to the use of Frontzahniiberbiss. Fortschr. Kieferorthop, 23:312, 1962.
elastics and coil springs. Angle Orthodontist, 21 :151, 1951.
Salzmann, J. A: The use of removable appliances. Am. ].
22
Diagnosis and Treatment in the
Deciduous Dentition
TYPES OF NORMAL OCCLUSION IN THE deciduous second molars are on the same vertical plane.
DECIDUOUS DENTITION 2. Deciduous molars follow the same relationships as
in normal occlusion of permanent molars, the
Patterns of occlusion in the deciduous dentition that
mesiobuccal cusp of the maxillary deciduous second
may be regarded as normal are the following:
molar occluding into the buccal groove of the man-
1. Distal surfaces of the maxillary and mandibular
dibular deciduous second molar.
The deciduous second molar relationship is not an
invariable base for classification in the deciduous
dentition, since the foregoing two types are both
considered normal. The canine relationship should
A
B
Fig. 22-1. These drawings illustrate
changes in premolar-molar relationship
with the change from the mixed to the
permanent dentition. (A) Top group shows
occlusal relation before loss of the
deciduous second molars. The middle
group shows the relation after the
deciduous second molars are lost; the
mandibular permanent first molar (6) has
shifted forward. The bottom group shows
the final relationship under normal
occlusal adjustment. (B) The middle and
bottom groups show prolonged retention
of the mandibular deciduous molar
interfering with the premolar-molar Fig. 22-2. The entire deciduous dentition has erupted, and
adjustment, initiating a forward permanent incisor teeth are developing. There is interdental
relationship of the maxillary arch. (After spacing in the deciduous dentition. The erupting permanent
A. Kantorowicz) incisor teeth are crowded.
30
7
308 . Diagnosis and Treatment in the Deciduous Dentition
Fig. 12-3. (Top) The maxillary deciduous dentition

has erupted and permanent incisor teeth are calcifying.
(Bottom) Mandibular deciduous teeth have erupted, and
the permanent incisor teeth are calcifying. There is no
interdental spacing in the deciduous incisor area as in
Fig. 22-2. The developing permanent incisor teeth
nevertheless show less crowding than those in Figure
22-2. Deciduous teeth do not become spaced. They
erupt either spaced or in close contact.
be employed in diagnosing mesiodistal arch malrelation in

the deciduous dentition.
In normal dental development the permanent first molars
usually complete their eruption at age 6 to 7 years and
assume their normal relationship, in which the mesiobuccal Fig. 22-4. (Left) Crossbite in deciduous dentition. The
cusp of the maxillary permanent first molar occludes maxillary left deciduous central incisor tooth was lost in an
within the buccal groove of the mandibular permanent first accident. (Right) The dentition after orthodontic therapy.
molar and the mesiolingual cusp occludes at the occlusal
fossa of the mandibular first molar. The permanent molar dentition cannot be predicted on the quality of the
oc.ciusal adjustment occurs while the premolars are occlusion of the deciduous teeth. Likewise, the size of the
erupting. If the occlusal adjustment does not occur, there is deciduous teeth is not an indicator of the size of the
a distal relation of the molars and frequently malocclusion permanent teeth.
of the entire interarch relation. Interception of malocclusal tendencies and correction in
the deciduous or mixed dentition do not necessarily
prevent malocclusion in the permanent dentition. More
than one period of orthodontic treatment may be necessary.
DECIDUOUS DENTITION AS AN INDICATOR OF A
While interceptive orthodontic measures must be applied
NORMAL PERMANENT DENTITION
early in the life of the child, corrective
The normality of occlusion in the permanent
Indications for Treatment in the Deciduous Den~ihon . 309
Fig. 22-5. (Left) At 7'h years

the central incisors are sep-
arated. This patient had no
orthodontic treatment, and at
10 years (right) the central
incisors had come together
and the laterals had erupted.
Treatment, if necessary, will
be initiated in the permanent
dentition.
orthodontic therapy may be instituted at any age when a sufficient root structure to permit banding the deciduous
condition is found to interfere with the continuing normal teeth.
development and function of the dentition. Periodic , Complicated appliances should be avoided in the
examinations are especially advisable during the early deciduous dentition. Treatment should concern itself
stages of the mixed dentition. primarily with functional interferences and the continuing
normal development of the dental arches. Severe
anomalies affecting groups of teeth, the face, and the
relationship of the jaws to each other and to the cranium
INDICATIONS FOR TREATMENT IN THE
should be treated.
DECIDUOUS DENTITION
All obstacles to tooth eruption, such as odontomas,
Treatment in the deciduous dentition should be supernumerary teeth, cysts, etc., should be removed as
instituted when the roots of the deciduous teeth reach early as possible so as not to interfere with the eruption of
their terminal stage of development and before root the teeth.
resorption has progressed to a point where the teeth can Indications for treatment in the deciduous dentition may
be easily dislodged. Mathews found that the position of be summarized as follows:
permanent teeth can be influenced favorably by changing 1. Gross interferences with the establishment of normal
the position of the overlying deciduous teeth, as long as occlusion
there is 2. Loss or impairment of function
Indications for Treatment in the Deciduous Dentition' 309
Fig. 22-5. (Left) At 7lf2 years

the central incisors are sep-
arated. This patient had no
orthodontic treatment, and at 10
years (right) the central incisors
had come together and the
laterals had erupted. Treatment,
if necessary, will be initiated in
the permanent dentition.
orthodontic therapy may be instituted at any age when a sufficient root structure to permit banding the deciduous
condition is found to interfere with the continuing teeth.
normal development and function of the dentition. , Complicated appliances should be avoided in the
Periodic examinations are especially advisable during deciduous dentition. Treatment should concern itself
the early stages of the mixed dentition. primarily with functional interferences and the con-
tinuing normal development of the dental arches. Severe
anomalies affecting groups of teeth, the face, and the
relationship of the jaws to each other and to the cranium
INDICATIONS FOR TREATMENT IN THE
should be treated.
DECIDUOUS DENTITION
All obstacles to tooth eruption, such as odontomas,
Treatment in the deciduous dentition should be supernumerary teeth, cysts, etc., should be removed as
instituted when the roots of the deciduous teeth reach early as possible so as not to interfere with the eruption
their terminal stage of development and before root of the teeth.
resorption has progressed to a point where the teeth can Indications for treatment in the deciduous dentition
be easily dislodged. Mathews found that the position of may be summarized as follows:
permanent teeth can be influenced favorably by 1. Gross interferences with the establishment of
changing the position of the overlying deciduous teeth, normal occlusion
as long as there is 2. Loss or impairment of function
TIMING OF OCCLUSAL GUIDANCE

Timing of occlusal guidance procedures should be based
on serial examinations that include cephalometric, lateral-
jaw, and intraoral radiograms, and dental casts. The time to
start corrective treatment depends on the presence of a
condition which interferes with the continued normal
development and function of the dentition, regardless of
chronologie age of the patient.
Diagnostic records should be obtained during the
following dentofacial development stages:
1. Before the permanent molars and incisors begin to
erupt.
2. After the permanent first molars and incisors are fully
erupted.
3. Before any orthodontic treatment is started.
Malocclusion in the young child is usually progressive.
Consideration should be given to maturative, physiologic,
and dental developmental ages. These do not always
coincide or progress at the same rate even in the normal
child. Chronologie age varies in the individual child but
bears a positive correlation to the number of erupted
permanent teeth, root calcification, and bone age.
ESTIMATES OF DENTAL AGE IN THE

DECIDUOUS DENTITION
Three related estimates of dental age are available in the

Fig. 22-6. Before (left) and after (right) casts of crossbite that deciduous dentition: (1) the number and the type of
was corrected during late deciduous dentition. A removable erupted teeth present in the mouth; (2) the rate of
mandibular appliance was used that had a flange to guide the calcification of the permanent mandibular first molars; (3)
maxillary dentition into alignment (bottom).
the rate of calcification of the dentition as a whole, in
relation to standards of growth.
3. Incipient dental malocclusion and jaw malposition EARLY TREATMENT IN CLASS III
MALOCCLUSION
4. Class I (Angle) malocclusion, when the maxillary
incisors occlude lingual to the mandibular incisors 5. Class Because Class III malocclusion becomes progressively
II, Division 1 malocclusion, when severe enough to affect worse during growth, early treatment is advocated. The
jaw relation in addition to dental arch relationshi p force of occlusion exerted by the lingually occluding
6. Class II, Division 2 malocclusion with severe jaw maxillary incisor teeth on the growing mandible is
malrelation and overbite injurious to maxillary mucosa accepted as tending to encourage its forward progress.
-" 7. Class III malocclusion (should be treated early before Early treatment can influence thevectorof growth of the
root resorption begins in the deciduous mandibular bodyof the mandible.
incisors)
THE CHINCAP
The chincap was used by Cellier (1802) and by Fox

early in the 19th century. Tomes described it in 1873.
Victor Hugo Jackson (1890) used it. Angle, Case, and
CONTRAINDICATIONS TO TREATMENT IN THE
Oppenheim used the chincap early in this century.
DECIDUOUS DENTITION
Forward growth of the mandible can be inhibited when
1. Patient unwilling to cooperate in treatment the chincap is used. Maxillary growth can then
2. Poor prognosis
13. The Chincap . 311
Fig. 22-7. Treatment of this

patient's Class III malocclusion
began when she was 3112 years
old. Compare her appearance
before (A, B) and after (C)
treatment. A chincap (D, E) was
worn and a Ii ngual appliance
were used (F, G, H). The front
view (f) shows the 3/B-inch
elastic ligature in place. Note
that the anterior portion of the
lingual archwire is away from
the front teeth (G). A side view
of the appliance shows buccal
extensions and hooks for the
elastic. Frontal views show the
occlusion before (1), during (j),
and after (K) trea trnent.
(Continued on overleaf)
be expected to overcome the disproportion in forward holding effect. It should fit snugly but should not exert
growth. The chincap should not be used in the attempt appreciable pressure. It is of value primarily during the
to retract the mandible but to exert a active growth period in the young child.
14.
Fig. 22-7 Continued (L) Another
patient, age 4, anterior view. (M)
Dentition before treatment. (N)
Appliance in position with latex
ligature moving the mandibular
incisors lingually. (0) Anterior
view after treatment.
Changes produced by the chincap can be compared to the changes the vector of mandibular growth. The claim that
skull changes brought about by certain South American chincaps will not affect the vector of growth of the
Indians who flattened the heads of children, producing mandible is inaccurate in view of the changes in the
deformities of the cranium. cranium seen in primitive tribes who compress and deform
The changes produced occur in the vector of growth but it.
not as a result of inhibition of growth. Gentle pressure on
the chincap should be directed in a backward rather than INDICATIONS FOR DECIDUOUS
an upward direction. Pressure against the TOOTH EXTRACTION
temporomandibular articulation should not be directed for
the purpose of inducing changes in the glenoid fossa. Indications for extraction of prolonged retained
Armstrong found young children with Class III dental deciduous teeth are as follows:
incisor relation to show an appreciable improvement 1. The root is resorbed while the cervix of the crown is
when the chincap is used. The changes in the incisor attached to the alveolar mucosa and interferes with the eruption of
region when the chincap is used are lingual inclination of the permanent successor.
incisor teeth. The chirrcap should be worn 12 to 14 hours 2. The permanent tooth is ready to erupt as indicated by the
a day. Oppenheim was the first to use force to move degree of completion of its roots and its proximity to the alveolar
maxillary teeth mesially by means of extensions from a bone crest, and the deciduous tooth shows little or no root
chincap to which intermaxillary elastics are attached. resorption.
3. A permanent tooth is erupting through the buccal alveolar
mucosa before the deciduous tooth is shed.
4. The roots of a deciduous molar are resorbed, and the
succeeding premolar shows calcification of onehalf to
Use of the Chincap for Developing Class III two-thirds of its root; there is no overlying alveolar bone;
Malocclusion and the premolar on the opposite side of the dental arch
The chincap is not intended to push the mandible has erupted.
rearward but rather to inhibit its forward growth. At the S. The permanent first molar has erupted past the
same time the maxilla is left unhampered to continue deciduous second molar occlusally and there is wedging of
forward growth. As shown by Baume, the condyle is the deciduous second molar into the
responsive to mechanical force. The chincap does not
inhibit forward growth of the jaw. It
Indications for Deciduous Tooth Extraction' 313
Fig. 22-8. (A) J\nterior

views of patient with man-
dibular dental prognathism in
the late deciduous dentition.
(Center left) (B) Views with
chincap in position. right. (Upper
right) Mandibular dental
prognathism is eliminated. (e)
Lateral view at start of use of
chincap. (OJ Lateral view
showing profile at age 12 years
with permanent dentition
erupted.
alveolar process. The deciduous second molar should be periodic checking to assure proper eruption space for the
extracted and the space retained. Extraction of the premolars.
deciduous molars should be followed by In the absence of a permanent tooth follicle where
the dentition shows crowding and there is jaw length horizontal positioning of the permanent teeth. Thus, they
deficiency, in relation to obtaining normal dental arch help to maintain the line of occlusion and the mesiodistal
arrangement, consideration should be given to extraction arrangement of the dental arches.
of the deciduous tooth and closing the space. The patient Shifting of teeth following premature loss occurs in the
should be kept under supervision to prevent unfavorable deciduous and mixed dentitions. The continuity of the
tooth shifting. Orthodontic intervention usually is dental arch can thus be destroyed and the arrangement
required in the permanent dentition in these cases. and symmetry of the dental arches endangered. The
resulting harm to the later erupting permanent dentition
depends, among other factors, on the length of time
elapsed before the permanent succeeding teeth erupt.
PREMATURE LOSS OF DECIDUOUS TEETH Premature loss of deciduous first or second molars is
Premature loss of deciduous teeth can be responsible not necessarily always followed by space closure and
for the development of malocclusion of the permanent malocclusion. The space left by loss of deciduous molars
dentition, although the premature loss of deciduous teeth may close: it may remain stationary; or it may become
is not a factor in jaw growth itself. The deciduous teeth larger. Early loss of mandibular deciduous molars is more
affect the vertical and frequent than the loss of maxillary deciduous molars.
Spaces should be measured at successive time intervals.
If evidence of closure is found; space maintainers or a
holding lingual arch appliance should be employed. If the
deciduous
Fig. 22-9. (Left) The deciduous second molar is interfering

with the eruption of the first and second premolars. (Right) An
over-contoured filling is causing occlusal trauma evidenced in
the widened periodontal ligament of the premolar teeth that
shifted.
Fig. 22-10. (Top) Radiograms show over-retention of

deciduous second molar crowns in the maxilla. This can
lead to interference with occlusal adjustment in the mixed Fig. 22-11. (Top) Alveolar bone overlies the crown of the
dentition. (Bottom) In the mandibular radiograms the second premolar, which still has to complete calcification. The
deciduous second molar crowns are retained in position by deciduous second molar shows root resorption but should be
their attachment to the gingival mucosa. Deciduous tooth retained in position until the premolar is ready to erupt. (Bottom)
crowns should be extracted when it becomes evident that Early loss of the deciduous second molar has hastened the
they are interfering with the eruption of their permanent eruption of the premolar before it actually had sufficient root
successors. formation.
Effect of Sequence of Tooth Eruption on the Deciduous Dentition' 315
molars are lost prematurely and the space closes only 1 or 2

mrn., there may still be sufficient space to accommodate the
succeeding premolar teeth, provided they are not larger,
mesiodistally. than the deciduous molars. In children with
well-developed arches there is, as a rule, little closure of the
space after the deciduous molars are lost.
Premature loss of maxillary deciduous incisors seldom
affects permanent incisor eruption and tooth arrangement. In
prematurely lost deciduous canines, at or after the eruption of
the permanent incisors, the space usually closes, interfering
with the erupion of the permanent canines.
EFFECT OF SEQUENCE OF TOOTH ERUPTIO o

THE DECIDUOUS DENTITIO
The order of tooth eruption can affect the occlusion of the
permanent canine, depending on the amount
Fig. 22-12. (Top) The maxillary permanent

first molar is impeded in its eruption because it
is caught within the deciduous second molar.
(Bottom) Three years later, the permanent first
and second molars have erupted. The space for
the second premolar is closed and the second
premolar is impacted. Freeing the permanent
molar from the second deciduous molar and
space retention could have prevented this
malocclusion.
Fig. 22-14. (Top) An overretained deciduous second molar

caused ectopic eruption of the second premolar. Roots of the
deciduous second molar are resorbed, and its crown is retained
by attachment to the alveolar mucosa. (Bottom) Uneven
Fig. 22-13. Supernumerary teeth interfere with eruption of resorption of the roots of the deciduous second molar caused
maxillary central incisor teeth. The permanent lateral incisors ectopic eruption of the second premolar. Deciduous teeth
are erupted, while the deciduous central incisors are still in should be extracted when it is evident that they interfere with
position. The cause of delayed eruption and eruption out of the eruption of permanent teeth.
the usual sequence should be investigated.
of space closure. The permanent canine usually is crowded SPACING OF TEETH

out of the arch if it erupts after the premolars. If the
Spacing of the teeth in the deciduous dental arches
maxillary deciduous second molar is lost before the
depends on the extent of growth of the jaws and alveolar
permanent first molar erupts, the space for the second
process, the size of the teeth, the size of the tongue, and the
premolar is usually reduced by the forward shifting of the
tonicity of the circumoral musculature.
erupting permanent first molar.
Locking of permanent first molars against the deciduous
Premature loss of mandibular deciduous second molars
second molar is usually associated with general lack of
may occur before the permanent first molar erupts.
growth of the basal arches of the jawbones and with
Placement of a space retainer should be postponed until
general tooth crowding. Locked permanent first molars
the permanent first molar begins to erupt. Insertion of
may resorb the second deciduous molar at the cervical
spurs through the mucous membrane against the unerupted
portion of the tooth. The distal root may be severed and
molar may actually interfere with its eruption, and
become imbedded in the alveolar process. The permanent
infection may infiltrate through the opening in the mucosa.
molar crown, when caught at the gingival margin of the
Infected deciduous teeth should not be retained in the
deciduous second molar, can be freed by disking the distal
mouth for the purpose of maintaining space. Space
surface of the deciduous second molar crown. If root
maintainers should be inserted when necessary. Permanent
resorption in the deciduous second molar is advanced, the
teeth lost through caries must be replaced in children just
tooth should be extracted and a space maintainer should be
as readily as in adults if malocclusion is to be avoided.
inserted until the second premolar shows eruption.
Ankylosed deciduous teeth should be extracted when
Separation of slightly locked permanent first molars can
the permanent succeeding teeth show about one-half of
be effected by passing a wire or elastic dental floss ligature
their roots to be calcified. If a deciduous ankylosed tooth
through the interdental space. When a wire is used it
has no permanent s.uccessor it can be extracted and the
should be twisted at intervals until separation of the teeth is
space closed, if such treatment is indicated by the general
obtained.
state of the occlusion and jaw growth. Space closure in the
Grinding of incisal tips of deciduous canines is useful to
mandibuler dental arch when a second premolar is absent
permit free lateral excursion of the mandible, to prevent
may leave the opposing third molar in the maxillary dental
interference with forward movement of the mandible, and
arch without an occluding opponent. A large alveolar arch
to correct crossbite in the deciduous and early mixed
and agenesis of some of the teeth in the same arch
dentitions.
contraindicate space closure.
Resorption of ankylosed deciduous teeth roots may be
partial or it may not occur. Root resorption in deciduous
teeth without permanent successors occurs more
frequently when the deciduous teeth are filled and when
their occlusal plane is not below the general line of
occlusion of the teeth. CROSSBITE
Crossbite tends to appear when the deci.duous canine teeth
erupt- between the ages of 18 months and 2 years. The
canines may show cusp-to-cusp relationship while the
mandible slides to the left, 'right, or forward. Crossbite
should be treated in all classifications of malocclusion
before the attempt is
DIASTEMAS IN THE DECIDUOUS DENTITION
made to correct mesiodistal arch malrelation, Crossbite
Two distinct diastemata can be observed in the may be confined to the teeth alone or it may involve the
deciduous dentition-one between the mandibular alveolar process and the jaws. Lingually occluding
deciduous canine and the first molar and the second maxillary incisors and labially occluding mandibular
between the maxillary lateral deciduous incisqr and the incisors should be treated in relation to available space and
deciduous canine. There is no evidence of a continuously arch development.
increasing dimension at intercanine and intermolar width The position and shape of the temporomandibular
or appreciable growth in the completed deciduous articulation and the form of the glenoid fossa can be
dentition. Vertical and horizontal growth of the alveolar affected by the deviation of the mandible, if the crossbite
processes is concomitant with the development of the brings the jaw out of centric relation when the teeth are
permanent teeth. There is vertical, horizontal, lateral occluded.
growth of the jaws, but no shifting of the deciduous Appliances such as modified activators may be used
dentition as a unit. when treating crossbite in the deciduous dentition as early
as age 3 to 5 years. In the mixed denti-
Crossbite . 317
Fig. 22-15. (A) The pattern

of eruption, at 7 years, shows
separation of the permanent
maxillary central incisors and
insufficient space for erupting
permanent lateral incisors,
Treatment of malocclusion is
not warranted at this time,
because natural growth may
overcome deficiencies of this
type, An occlusal view (C)
shows the maxillary left
permanent first molar to be
caught on the distal bulge of
the crown of the second
deciduous molar. Casts made
at age 9 show persistence of
the early eruptive pattern and
lack of development in the
maxillary incisor region (B), In
the occlusal view it can be
seen that (D) the maxillary left
deciduous second molar was
shed and the space was
partially closed by forward
shifting of the first molar.
The radiogram shows the
maxillary permanent first
molar caught on the partially
resorbed crown of the de-
ciduous second molar (EJ.
Space closure occurs after
early loss of deciduous teeth
because the remaining teeth
shift. Often, closure is patho-
gnomonic of a constricted
basal arch pattern rather than
a lack of growth induced by
loss of a tooth. Basal arch
growth in the respective
bodies of the jaws is inde-
pendent of the presence or
absence of teeth.
han, removable appliances are indicated that will not tooth alignment may be achieved in this manner the position
interfere with the natural eruptive process and estab- of the body of the mandible may remain in lateral deviation.
lishment of the occlusion of the permanent teeth. In Therefore, mandibular repositioning may be required prior
posterior cross bites in the permanent molars, cross ~lastics to crossbite correction. An activator appliance can be used
may not prove efficient. While normal for this purpose.
the distance on the casts from the palatine midline

to the teeth on both sides of the dental arch.
THUMB AND FINGER SUCKING

Infantile thumb sucking and other nonnutritive sucking
habits are significantly correlated to malocclusion of both
the deciduous and permanent teeth. In order for sucking
pressure to affect occlusion, the
force exerted has to be stronger than the component of
force that the alveolar and facial bones can withstand. If
this were not so, the face of man would be in a constant
state of startling change, like the face of an
elastic toy that changes grotesquely on the application of
slight pressure.
Circumstances that affect the extent of change that
pressure habits can induce in the orofacial region depend
on the frequency with which the habit is practiced, the
duration of time that the habit has lasted, the osteogenic
development, the genetic endowment, and the general
state of health of the child. These determine the presence,
type, and sever-
ity of the resulting malocclusion.
NAILBITING
Nailbiting is most commonly seen in tense, excitable

children, in contrast to thumb sucking, which is more
likely to occur in children who are outwardly calm and
placid. N ailbiting of the fingers occasionally is
associated with biting the toenails and with picking at the
nails with the fingers. Some nailbiting of a transitory
nature, frequently in imitation of other children, is
observed in early adolescence.
Arousing a new interest in the fingernails such as the
application of fingernail polish has been found helpful in
girls. Boys may be appealed to on the basis of good
sportsmanship or reward for effort in sparing the nails of
Fig. 22-16. (Top) The maxillary per- an increasing number of fingers.
manent first molar is erupting against the , Lip biting may be treated by attaching labial acrylic
deciduous second molar. (Center) The plumpers to a fixed or removable appliance on the
permanent first molar causes resorption on mandibular dental arch.
the deciduous second molar crown and can Use of mechanical devices should be discouraged in
cause it to be shed prematurely. Another
the preschool child. The thumb should not be pulled
result may be impaction of the unerupted
forcefully out of the infant's mouth. There should not be a
second premolar. (Bottom) The deciduous
second premolar is disked to allow the per-
show of disapproval or punishment nor ridiculing,
manent molar to erupt past the distal bulge criticism, or shaming the child.
of the deciduous molar crown. Parents should be advised to observe the following
principles:
1. Promote favorable relation of the child with his
Posteroanterior cephalograms and dental casts can aid immediate environment.
in determining whether the fault of the cross bite is 2. Provide play materials suited to the child's stage of
caused by alveolar and dental deviation in the maxillary development.
arch, the mandibular arch, or both arches. This can be 3. Provide the child with opportunity and space to be
ascertained in the maxilla by measuring active, to experiment, to explore, and to play.
Bibliography . 319
4. Reduce supervision of the child to necessities, and

provide as much freedom as possible.
5. The attitude toward the child should be one of
happiness, sympathy, patience, and understanding.
BIBLIOGRAPHY
Altemus, L. A.: Relationships of tooth material and supporting

bone, D. Progress, 1:36, 1960,
Armstrong, C J.: A Clinical Evaluation of the Chin-Cup.
Australian D. J., 6:338, 1961-
Baker, C R.: The selection of cases for treatment in the
deciduous dentition. Am. J. Orthodontics, 39:273, 1953.
Brock, J. R.: The role of the speech clinician in determining
indications for frenulotomy in cases of ankyloglossia. New
York State D.J., 34:479, 1968.
Bogue, E. A.: Orthodontia of the deciduous teeth. D.
Digest., 18:671, 1912; 19:9, 1913; 25:193, 1919.
Breitner, C, and Tischler, M.: Ueber die Beeinflussung dey
Zahnkeime durch orthodontische Bewegung der Milchzahne.
Ztschr. Stornatol., 32:1383, 1934.
Breitner, c.: The influence of moving deciduous teeth on the
permanent successors. Am. J. Orthodontics, 26:1152, 1940.
- __ : The tooth-supporting apparatus under occlusal changes. J.
Periodont., 13:72, 1942.
Clinch, L. M.: A longitudinal study of the results of premature
extraction of deciduous teeth between 3-4 and 13-14 years of
age. D. Practitioner, 9:109,1959.
Jamison, H. C: Prevalence of periodontal disease in the
deciduous teeth. J.A.D.A., 66:207, 1963.
Leighton, B. C: Serial models illustrating some spontaneous
changes in the deciduous dentition. D. Practitioner,
11:109,1960.
Linder-Aronson, S.: The effect of premature loss of deciduous
teeth. Acta odont. scandinav., 18:101, 1960.
Lysell, L.: Relationship between mesiodistal crown diameters in
the deciduous and permanent lateral teeth. Acta odont.
scandinav., 18:No. 2, 1960,
Mathews, J. R.: Clinical management and supportive rationale in
early orthodontic therapy. Angle Orthodontist, 31:35,1961-
___ : Interception of Class II malocclusion. Angle Orthodontist,
41 :81, 1971.
Meredith, H. V.: Change in the profile of the osseous chin
during childhood. Am. J. Phys. Anthropol., 15:247, 1957.
Meredith, H. V., and Hopps, W. M.: Longitudinal study of
dental arch width at deciduous second molars on children 4-8
years of age. J. D. Res., 35:879,1956.
Qeconomopoulcs, c. T.: The value of glossopexy in Pierre-
'Robin syndrome. New England J. Med., 262:1267, 1960.
Ravin, J. J.: Sequelae of acute mechanical traumata in the
primary dentition, a clinical study. J. Dent. Children, 35:281,
1968. Fig. 22-17, (Top) Lipbiting in the deciduous dentition, (Center)
Sharma, P. S. and Brown, R. V,: The management of young Overjet causes the lower lip to rest behind the maxillary incisors.
dental patients. D. Practitioner, 17:419, 1967. When this becomes a pattern of closure, the permanent incisors
Strock, M. S.: A new approach to the unerupted tooth by surgery will be in abnormal overjet and the faulty lower lip posture may
and orthodontics. Am. J. Orthodontics & Oral Surg., 24:626, initiate a Class II malocclusion. (Bottom) A plumper is attached
1938. to a lingual appliance to interfere with the faulty lower lip
posture.
Thompson, J. R: Early orthodontic treatment. Am. J. --_: Analyses of early Class II, Division 1, treatment.
Orthodontics, 48:758, 1962. Am. J. Orthodontics, 43:769,1957.
West, E. E.: Treatment objectives in the deciduous dentition. Wylie, W.: Assessment of anteriorposterior dysplasia.
Am. J. Orthodontics, 55:617, 1969. Angle Orthodontist, 17:97, 1947.
23
Diagnosis and Treatment in
the Mixed Dentition
SCOPE OF TREATMENT 7. Elimination of dentofacial, abnormal pressure habits

8. Approximation of abnormally spaced maxillary
Treatment in the mixed dentition can be either
permanent central incisors (abnormal midline diastemas)
preventive, interceptive, or corrective. The primary aim
until the permanent lateral incisors and canines are
is to correct dental arch irregularities and occlusal and
erupted.
jaw relation abnormalities and to eliminate functional
9. Expansion of excessively narrow dental arches with
interferences. Positional anomalies of individual teeth in
teeth in lingual or crossbite occlusion.
children with both deciduous and permanent teeth cannot
10. Correction of crossbite, abnormal overbite, extreme
always be diagnosed on the basis of a single dental
overjet, and open bite after the permanent incisors are
examination, since an apparent anomaly actually may be
fully erupted and their roots are in the terminal stage of
a stage in dentition development.
completion.
Knowledge of the time sequence in the development of
When the deciduous molar roots are resorbed, treatment
the child's dentition and ability to recognize the rate and
in the mixed dentition for widening the dental arch is
direction of the general physical maturation of the child
ineffective. Light forces should be applied on deciduous
in relation to the development of the dental growth
teeth at all times when treating the mixed dentition.
pattern are primary requirements, not only in preventive
orthodontics but also in treating the mixed dentition.
Many cases of apparent malocclusion in the mixed
dentition actually are stages in dental development.
Incisor irregularities, including midline diastemas, may ANTEROPOSTERIOR OCCLUSAL CHANGES
be transitory stages in occlusal adjustment. Appliances The following changes occur in the anteroposterior
used and the treatment itself should not interfere with the adjustment of the dental arches from the mixed to the
rapid changes in occlusal adjustment and continuing permanent dentition:
eruption of the permanent teeth. Extensive tooth 1. Anteroposterior dental relation is established when
movement of newly erupted permanent teeth should be eruption of the permanent dentition is complete.
avoided. , 2. The maxillary and mandibular permanent molars shift
forward when the premolars erupt. The mandibular
permanent first molars shift forward more than the
maxillary ones in the establishment of normal molar
occlusion.
INDICA nONS FOR TREATMENT
3. Intercanine space increases with the permanent
Treatment of the following abnormalities may be dentition eruption.
undertaken in the mixed dentition period: Crowding of teeth in the early mixed dentition may be
-.1. Poor relationship of the dental arches, Class I, Class II, treated in the following ways:
and Class III (Angle) malocclusion 1. Expanding the dental arches to permit normal
2. Malposition and malrelation of permanent teeth alignment.
after they have erupted fully 2. Opening the palatine suture to widen the dental arch.
3. Elimination of supernumerary teeth 3. Serial extraction.
4. Treatment of ectopic teeth A fixed and rigid orthodontic appliance that im-
5.Space opening to allow erupting permanent teeth to mobilizes the permanent molars can interfere with
come into occlusion
6. Correction of labioversion of maxiIIary incisors
321
322 . Diagnosis and Treatment in the Mixed Dentition
GENETIC INflUENCE ON DENTOFACIAL

CHANGES IN MONOVULAR TWINS
Twins C.S. and 1.5. (Figs. 23-1, 2)

Clinical Description. Patient C.S. at age 9 years, has a
Class II, Division 1 (Angle) malocclusion. The maxillary
right and left permanent central and lateral incisor teeth
are erupted, spaced, and in protrusion. The mandibular
right deciduous canine has been shed, and the space is
almost completely closed by the shifted mandibular right
lateral incisor. On the right side there is a cross bite of the
deciduous first and second molars and of the permanent
first molars. The mandibular right and left permanent
central and lateral incisor teeth are erupted. The
mandibular dental arch on the left side shows collapse
lingually of the first and second deciduous molars. The
mandibular incisors are spaced and overerupted; they
occlude on the palatal gingivae.
Patient L.S. at age 9 years, before treatment, shows
exactly the same type of malocclusion as twin C.S.,
including the exfoliated mandibular right deciduous canine
and closure of the space, cross bite on the right side, and
lingual collapse on the left side of the mandibular first and
second deciduous molars.
Skeletal Classification. Both twins have a Class I facial
skeletal pattern. The prominent chinpoint helps to bring
the facial angle within low normal range. However, SNA
and SNB are both well below the mean of normal range.
This is usually found in young children when the face
especially the mandible, is still growing.
Treatment Summary. An extraoral appliance was used
to correct the relation of the maxillary and mandibular
dental arches. Edgewise arch brackets and round O.OIS-
inch archwires, followed by 0.020inch archwires, were
used for "leveling off" the occlusal planes and for
eliminating interdental spacing. Activator appliances were
used as retainers to confine the tongue and break the
tongue thrusting habit. The activators were constructed so
that they would not move the teeth or change
Fig. 23-1. Facial growth achievement in monozygotic twins.
intermaxillary or occlusal relations.
(Top) Full face of twins C. S. (left) and L. S. (right) at age 9 years.
The results obtained in treatment are stable. The tongue
(Second row) Profile views at age 9 years. (Third row) Full face of
C. S. (left) and L. S. (right) at age 13 years. (Bottom) Profile views
thrusting habit was stopped. One of the twins began to bite
of C. S. (lefO and L. S. (right) at age 13 years. These twins were her fingernails; this produced slight crowding of her
inseparable. Note the extreme facial resemblance. mandibular central incisor.
At the age of 9 years these monovular twins showed six
similar cephalometric dimensions. They showed a
difference of lOin two dimensions, 20 in two dimensions
Hie development of normal occlusion when the deciduous and 3 in one dimension. After 2 years of orthodontic
molars are being shed and the permanent molars are about treatment, they showed only three similar dimensions; a
to shift forward to occupy the "leeway" space as the difference of lOin four dimensions; a difference of 2 in
premolars are erupting. (The leeway space is the two dimensions,
difference in the mesiodistal diameters of the deciduous
canine and the two deciduous molars, which usually
occupy more space than their succeeding permanent
teeth.)
15.
16.
17.
Genetic Influence on Dentofacial Changes in Monovular Twins' 323
Fig. 23-2. (A, B) Dentitions

of twins in Fig. 23-1 at 9 years
of age. Note concordance in
overbite and cross-bite. (C, D)
Same twins at age 15, 2 years
out of retention. The maxillary
right central incisor in the twin
on the left is inclined mesially,
and the same is true of the
maxillary left central incisor of
the twin on the right. These are
mirror
. twins. The one on the left
developed a nail-biting habit
and disturbed the alignment of
her mandibular left central
incisor. This tends to mask
somewhat the high degree of
dental concordance. (E) Com-
parison of profile tracings at
age 9. C. S. shows more for-
ward growth than L. S. (F) At
age 11, at completion of
treatment, the twins show in-
creased discordance of facial
profiles, with C. S. continuing
to show more forward growth ;)
than L. S., who shows more
downward growth than C. S.
This could be caused by the
orthodontic intervention. (G)
AGE gyro.
--c.s
----LS ~C--~
/' ) J
",- - ~ !
~
There is almost complete facial ;I

profile concordance at age 13. ,,
The genetic growth pattern ,,
reasserted itself, and
,,
environmental effects were not
a factor in these twins. "
CD " -..- .........
"
AGE I" yrs

-cs
---LS ~--- (
~
. ---
and a difference of 3 in one dimension. At age 13 years, 1 Y2 in four dimensions and a difference of 2 in one dimension.
years out of retention, the twins were again alike in six These cases indicate the differences that can occur
dimensions. There was a difference of 10
through orthodontic therapy and the changes through lary and mandibular permanent first molars show a cusp-
genetic endowment and growth. These monovular twins to-cusp relation when viewed from the buccal aspect. This
show a high degree of concordance in their facial growth is frequently seen in the mixed dentition. However, since
patterns. In the final analysis, genetics appears to have the mesiolingual cusps of the maxillary permanent first
the most important role in the determination of the facial molars occlude in the central fossae of the mandibular
growth pattern. permanent first molars, the occlusion is Angle Class I.
There is incisor crowding in the maxillary dental arch.
The right maxillary deciduous first molar interferes with
ORTHODONTIC TREATMENT AND FA the eruption of its succeeding premolar, which has
VORABLE GROWTH CHANGES emerged buccally through the mucosa. The maxillary right
and left deciduous canines and deciduous second molars
are still in position. The maxillary permanent first molars
'Patient A.C. (Fig. 23-3) have erupted.
Clinical Description Before Treatment. The maxil-
Fig. 23-3. (A, top left) Anterior

view before treatment. (Right)
Anterior view of same patient
after treatment. There is a
decided forward growth of the
mandible. (Center left) Profile
before treatment. (Right) Profile
of same patient two years out of
retention. (Bottom left) Anterior
view of dentition before
treatment. (Right) Anterior view
of dentition two years out of
retention. (B, opposite, top) Casts
before treatment. (Center) Casts
after retention. (Bottom) Occlusal
views. (Left) Before treatment.
(Right) After retention. Casts are
oriented along Frankfort plane.
(C) Superimposed tracings of
patient A. C. show decided
forward and downward growth
of the face. (0, top) Tracings
registered on the anterior nasal
spine (ANS). Maxillary dentition
grew downward and incisors
were moved distally. (Bottom)
Mandible registered on the inner
plate of the symphysis. This
shows general growth of the
mandible, especially in a
forward direction.
18.
19. Orthodontic Treatment and Favorable Growth Changes 325
PNS
AC, --
age 11yrs.
-- -age 15yrs.
"
c
Fig. 23-4. (A, top left) Profile

Profile view at age 18 years, 5
years out of retention. (Center)
Dentition before treatment age
10 years. B. Dentition of same
patient at age 18 years, 5 years
out of retention. (Bottom left)
Face before treatment at age
10 years. (Right) Face at age 18
years, 5 years out of retention.
Posterior teeth in good
occlusion. Mandibular incisors
show slight relapse. The
mandible is retrognathic.
(Opposite, B, top) Casts of
same patient as in previous
illustrations before treatment.
(Center) At 5 years out of re-
tention. (Bottom left) Before
treatment and (right) 5 years
out of retention. Casts are
oriented along Frankfort
plane. (C) Tracing of patient
before the beginning of
treatment, age 10 years; at 3
years out of retention; and at
the age of 18 years, 5 years
out of retention. The nasion
kept growing forward as did
the A-Point. The mandible
grew slightly forward but
mostly downward. The man-
dible continued to become
more retrognathic in relation
to the maxilla during growth.
The mandibular right and left permanent central and Skeletal Classification. The facial skeletal pattern is
lateral incisors and permanent first molars are erupted. The Class l.
right and left deciduous canines and first and second Treatment Summary. This patient was treated without
deciduous molars are in position. There is no mandibular extraction. Extraoral force was used to the mandibular and
crowding. The deciduous molars show progressive root maxillary dental arches to align the teeth. Edgewise arch
resorption. bracket bands were used.
20. Orthodontic Treatment and Unfavorable Growth Changes 327
B Fig. 23-4.
Continued.
Round wire, 0.018 inches, followed by 0.020 inch arches

with stops anterior to the molar tubes were used, and
advantage was taken of the leeway space to move the RB. -
<lgel0yrs
mandibular incisors into less procumbency and to level the - - -<ge15 yrs.
- - age 18yrs
mandibular occlusal plane.
Successful therapy depended to a great extent on proper
timing of treatment, which took advantage of the leeway
space. Favorable growth also aided in obtaining a good
result. The occlusion is stable 2 years and 4 months out of
retention.
ORTHODONTIC TREATMENT AND UNFA

VORABlE GROWTH CHANGES
Patient R.B. (Fig. 23-4)

Clinical Description. R.B. had a Class II, Division 1
(Angle) malocclusion in the mixed dentition. The
c
maxillary right and left permanent central and lateral Treatment. Summary. The mandibular incisors were
incisors have erupted and are spaced. There is a 14-mm. allowed to remain procumbent because of the wide (deep)
overjet and a deep overbite. The maxillary deciduous maxilla, which continued to grow forward at the anterior
right and left canines and the first and second deciduous cranial base (SN). The maxilla became wider (deeper) as it
molars are in position. The maxillary right and left continued to grow forward. The anterior cranial base (SN)
permanent first molars have erupted. became longer. The A-. Point continued to show a forward
In the mandible the right and left permanent central and relation when measured at the angle SNA. At age 18 the
lateral incisors have erupted and are spaced. The maxilla had grown forward at nasion more than at the Au.
mandibular deciduous right and left canines, first and Point. The angle of convexity increased at age 15 as the
second deciduous molars are in position. The mandibular maxilla grew forward, while there was progressive
right and left permanent first molars are erupted. The retrognathic change of the mandible in relation to the
mandibular permanent incisors occlude on the palate upper face as shown at Frankfort horizon tal rela ted to the
behind the maxillary permanent incisors. facial line (N - Pg).
Skeletal Classification. The facial skeletal pattern was Five years past the retention, at age 18 years, occlusion
Class 1, at age 10 years but changed to Class II at age 15 is normal except for slight crowding in the mandibular
years because of lack of mandibular growth. incisor region. The second molars have erupted. No teeth
were extracted.
Fig. 23-5 (A, top left) Front view before treatment and (right) front
view after treatment. (Bottom left) Profile before and (right) profile
after treatment. (B, opposite, top) Before treatment. (Center) After
retention. (Bottom left) Occlusal view before treatment. (Right)
Occlusal view after retention. The casts are oriented along the
Frankfort plane. (C) Tracings show growth of the face in a direct
downward and forward direction.
Orthodontic Treatment and Unfavorable Growth Changes . 329
21.
J.S. --
agel'yrs.
The dentition before treatment showed a severe Class - - -age
'5yrs.
II division malocclusion. This was treated without
extraction. After treatment, at age 18, the posterior teeth
are still in normal alignment, although there is some '~
relapse in the mandibular right incisor region. With the
-',
exception of slight mandibular crowding, the occlusion , '
did not suffer, although the mandible continued to .. .. . . -c
....... ~-
become more retrognathic relative to the maxilla.
The nasion kept growing forward as did the A-.
Point, even more than nasion. The mandible showed
only a limited amount of forward translation during
growth. The facial growth pattern may change at any
time, spontaneously or as a result of orthodontic therapy. inserted to' prevent the mandibular permanent molars from
shifting forward and preempting the leeway space which
would remain after the deciduous molars were shed.
Treatment was interrupted and the patient was observed
I FLUENCE OF TREATMENT TIMING ON until the premolars were fully erupted. When the
DENTOFACIAL CHANGES premolars erupted, they were moved distally into contact
J.S. (Fig. 23-5) with each other and with the permanent first molars. The
mandibular incisors were then aligned. By actual
Clinical Description. J.5. has a Class 1 malocclusion in measurement it was found that the space from the middle
the mixed dentition. The skeletal pattern is Class I. The of the permanent canine to the middle of the permanent
maxillary permanent central and lateral incisors and the first molars before the deciduous molars were shed
permanent first molars have erupted. On the right side of amounted to 26 mm. The measurement from the middle of
the maxillary dental arch, the deciduous canine and first the permanent canine to the middle of the permanent first
and second deciduous molars are in position. On the left molar after treatment when the premolars were in position
side of the maxillary dental arch the deciduous canine had amounted to 22 mm. This was equal on both sides and
been shed, and the space is about half closed by the lateral allowed 4 mm. on each side of the arch for the alignment
incisors, which had shifted palatally. The first premolar of the incisor teeth. A line drawn tangent to the pogonion
has erupted. The deciduous second molar was shed, and and at right angles to the mandibular plane showed that the
the space remained intact. distance of the first molars was the same both before and
In the mandible the four permanent incisors and the after treatment, which indicated that the molars had been
permanent canines are erupted and show crowding. The successfully held back. The face itself as seen on the
deciduous first and second molars on the right and left are lateral cephalogram showed forward and downward
in position. The left and right permanent first molars have growth, and the facial outline was parallel to the facial
erupted. outline before treatment.
TWO-STAGE TREATMENT IN
THE MIXED DENTITION
Treatment in the mixed dentition is usually performed CHANGES IN TWO-STAGE THERAPY WITH
in two stages. The patient is treated to remove blocks to FAVORABLE GROWTH
normal dental development, and then treatment is stopped
and the change effected is retained with a removable (or,
E.F. (Fig. 23-6)
occasionally, permanent) appliance until all permanent
teeth, except the third molars, have erupted. If a second Clinical Description. E.F. exhibited an Angle Class I
stage of treatment is required it is instituted then. The malocclusion in the mixed dentition. The skeletal facial
twostage treatment is beneficial in eliminating protruding pattern at age 11 years is Class II. The maxillary right and
maxillary incisors, reducing crowding, and correcting left permanent central and lateral incisor teeth, and the
ectopic eruption. Treatment should be interrupted when it permanent first molars are erupted.
is found advisable to await additional dental development 'The deciduous canines and first and second deciduous
or to ascertain if it will occur, before continuing molars are in position. The maxillary incisors are in
treatment. protrusion, and there is an abnormal overbite.
Extraction of teeth in orthodontic therapy can fre- In the mandible the right and left permanent' central and
quently be avoided by treating the early mixed dentition, lateral incisors have erupted. The right and left deciduous
when crowding is slight. A lingual holding appliance may canines are in position. The right and left first premolars are
be constructed with bands on the permanent first molars erupted. The right and left second deciduous molars are in
to prevent them from shifting forward when the deciduous position. The right and left permanent first molars are
molars are shed thus obtaining additional space and then erupted. There is no crowding in the mandibular arch.
aligning the teeth anterior to the permanent molars. Space reatment Plan. This patient was treated in two stages.
can be obtained also by moving the permanent canines, There was an interval of observation between the ages of
premolars, and molars distally when these teeth are in 12 and 13 years. No teeth were extracted. Growth was
forward axial inclination. favorable. The skeletal pattern at age 16 years is class 1.
Treatment Summary. The patient was treated without This was an important factor in obtaining a satisfactory
extraction. A lingual holding arch was result.
Active orthodontic treatment usually is completed
Prognostic Factors in Treatment in the Mixed Dentition' 331
Fig. 23-6 (A) (Top) Before

treatment. (Center) After re-
tention. (Bottom left) Before
treatment. (Right) Three years out
of retention. Casts oriented along
Frankfort plane. (B) Superimposed
tracings show favorable growth.
See text for detailed discussion.
22.
when patients at 11 and 13 years are experiencing

developmental growth changes which can bring about a
more orthognathic profile. If the dentition is left E.F. -
agel1yr~.
somewhat more procumbent or protrusive, after the first ---age
stage of treatment the effect of favorable growth can tend 16yr~
to eliminate the procumbency of the incisors.
PROGNOSTIC FACTORS IN TREATMENT IN THE

MIXED DENTITION
Favorable prognosis depends on the following:
1: Basal arch size. Dental arches require ample jaw
development. When there is a discrepancy in size of
basal arches and the dental arches, the prognosis is
unfavorable, and relapse tends to occur.
2. Size of the mandibular dental arch should not be
excessive in comparison to the maxillary dental arch and
vice versa. when not far beyond normal range the prognosis is
3. Anteroposterior difference in subspinale (A-. favorable.
Point, Downs) and supramentale (B-. Point, Downs): 4. A favorable vector of mandibular growth in
Patient E. F. (Fig. 23-6)
Age 16 Years
Downs Downs Age (2 Yrs. Out of
Dimension Range Mean 11 Years Retention)
Facial Angle 82 to 95 87.8 82 85
(F.H. to N-Pg)
Angle of Convexity -8.5" to + 10 0 +11 +70
(N-A-Pg)
A-B line to N-Pg _9 to 0 -4.80 -10 -8
Mand. Plane to F.H. 28 to 17 21.90 25 23
Y-Axis 66 to 53 59.4 62 62
Occlusal Plane to F.H. 1.5 to 14 9.3 14 130
1 to '1 angle 130 to 150.50 135.40 139 148
1 to Mandibular Plane 81.5 to 97 91.4 950 93
S-N-A 82 800 8P
S-N-B 800 75 77
Tweed
Gonion Angle 116-135 1260 1200 120
Fig. 23-7. (A, top) Front and

profile views of patient with
microglossia. (Bottom) Occlusion
before (left) and after (right)
treatment. (Opposite B, top left)
Mandibular arch showing
microglossia before treatment.
(Right) Expanded arch during
treatment. The sublingual tissues
are hypertrofied and act in lieu of
the tongue as an aid in speech
and swallowing. (Bottom left)
Appliances with cross-elastics
used in treatment. (Right)
Modified activator appliance
used to open bite, and for
retention. (C, top left) Before
treatment. (Right) After treat-
ment. (Bottom left) Occlusal view
before treatment. (Right) After
treatment.
Treatment in Severe Microglossia and Mandibular Dental Arch Collapse' 333
Fig. 23-78. Continued.
relation to maxillary growth is a basic requirement for

favorable prognosis.
5. Normal muscule function pattern. Success in
correction of openbite, swallowing, occlusal man-
nerisms jaw posturing or mandibular malfunction, lip
or tongue biting, and the position of the tongue in the
oral cavity are all responsible for relapse.
Circumstances beyond the control of the operator or
the patient that interfere with a favorable prognosis
1. Lack of patient cooperation
2. Unexpected illness or accidents
3. Psychologic factors, nervousness leading to
destruction of appliances
4. Persistent harmful dentofacial habits
5. Excessive tongue size and activity
6. Genetic factors that interfere with treatment
7.Poor physical health, endocrine or other deficiency
affecting treatment
's. Root resorption before
treatment was undertaken
TREA TMENT IN SEVERE MICROGLOSSIA A D
MANDIBULAR DENTAL ARCH COLLAPSE
Patient M. A. (Figure 23-7) age 8 years, had micro-

glossia and mandibular arch collapse. She had a full Fig. 23-7C.
334 . Diagnosis and Treatment in the Mixed Dentition 23.
Fig. 23-7D. Tracing before treatment and after retention,

MA -- Growth of the anterior cranial base continued in a forward
age8
---age16 direction while the mandible continued to grow downward and
backward. There was no molar ~r premolar collapse in the
mandible although the patient did not wear the retainer as
instructed,
Kessler, W.: Zur Frage der Haufigkeit von Nonokklusion von

Milchmolaren und bleibenden Mclaren. Stoma, 17:178, 1964.
Lewis, P. D.: Preorthodontic surgery in the treatment of
impacted canines. Am. ]. Orthodont., 57:543,1970.
Mathews, J. K: Translational movement of first deciduous
molars into second molar positions. Am. J, Orthodont.,
55:276, 1969.
o Mills, J. K E.: A long-term assessment of the mechanical
retroclinaticn of lower incisors. Angle Orthodontist, 37:165,
complement of permanent teeth with the exception of the left 1967,
mandibular lateral incisor. The maxillary first permanent Shehan, H. L., and Cheney, E. A.: Objectives and treatment in
premolars were extracted during orthodontic treatmen t. the mixed dentition. Am. J. Orthodont., 38:779, 1952.
Silla, M.: Uber die Bewertung des unteren frontalen Engstandes
im Wechselgebiss. Fortschr. Kieferorthop., 31 :3,1970.
Steiner, C. c.: Cephalometries in clinical practice. Angle
BIBLIOGRAPHY
---: The use of cephalometric" as an aid to planning and
Adolff, P.: Kritische Bemerkungen tiber die Frage der assessing orthodontic treatment. Am. J. Orthodont., 46:721,
Wachstumvorgange im Unterkiefer wahrend des Zahn- 1960.
wechsels und der Kinnbildung, Fort. Orthod. u. Kinder- Tweed, C. H: The Frankfort-mandibular plane angle in
zahnheilk. Deutsche Zahn-. Mund-, u. Kieferh., 2:No. 7, orthodontic diagnosis, classification, treatment planning, and
1939. prognosis. Am. J. Orthodont. & Oral Surg., 32:175, 1946.
Becker, R,: Results in the Treatment of Mandibular Pro- --_: Treatment planning and therapy in the mixed dentition. Am.
gnathism and Openbite with Tongue Reduction Deutsche J. Orthodont., 49:881, 1963.
Zahn. Ztsclin., 17:892-903,1962, Tulley, W. J.: A Critical appraisal of tongue-thrusting. Am.
Biederman, W,: Tooth ankylosis, Ann. Dent., 12:1, 1953. ---: J. Orthodont., 55:640, 1969.
Etiology and treatment of tooth ankylosis. Am. J.
Orthodont., 48:670, 1962.
Kerr, D. A.: Stomatitis and gingivitis in the adolescent and
preadolescent. J.A.D.A., 44:27, 1952.
24
Diagnosis and Treatment in the
Permanent Dentition
MALOCCLUSIONS Missing Lateral Incisors. When maxillary permanent
lateral incisors are missing, the age of the patient, the
The following dentofacial deviations should be treated
shape and size of the canines, the type of general interarch
in the permanent dentition:
occlusion, the size of the jaws, and the size and function
1. Mesiodistal arch deviations resulting in any one of
of the lips and tongue all influence the method of
the Angle classifications of malocclusion
treatment. It is advisable when the permanent canine teeth
2. Variations in length and width of the mandibular
are to be used for replacement of the missing permanent
dental arch in comparison to the maxillary dental arch
laterals to extract the deciduous lateral incisors when the
3. Positional deviations of teeth resulting in anterior or
permanent canines are nearing the eruption stage so that
posterior crossbite
they can erupt in a more mesial direction.
4. Crowding and rotation of teeth in the dental arch
Agenetic Premolars. Before deciding whether the
5. Positional abnormalities of the mandible caused by
deciduous molars without premolar successors should be
discrepancies between centric relation and centric
allowed to remain in the mouth, it should be determined
occlusion resulting in facial imbalance
by serial examinations at intervals whether the growth of
6. Malocclusion caused by abnormal dentofacial
the jaws will permit the deciduous molar retention in
pressure habits, also tongue biting and faulty tongue
regular alignment and in good occlusion without
posture
producing bimaxillary dental protrusion.
7. Moving teeth into abutment positions advantageous
for bridge and other prosthetic appliances.
ECTOPY AND IMPACTION

INCOMPLETE DENTITION Artificial Eruption of Malpositioned Teeth
The decision to close the space after loss of a It is frequently necessary to expose surgically
permanent tooth depends on the age of the patient, the
presence or absence of teeth in the opposing dental arch,
the usefulness of certain teeth for prosthetic restorations,
on the general character of the dentition, on the size and
shape of the dental arches, and on arch length adequacy.
Ankylosed Permanent Teeth. Since it is impossible to
move ankylosed permanent teeth by orthodontic means,
slight dislodgement may be attempted to break the
ankylosis. Before soreness disappears, orthodontic
movement is undertaken.
'Malformed Teeth. Developmentally or traumatically
Fig. 24-1. (Left) A deformed central in-
malformed teeth should be appraised from the standpoint
cisor tooth. The crown is at right angles to
of their potential for functional and esthetic restoration the root. (Right) After orthodontic
before the decision is made concerning their retention in treatment tooth presents a problem in es-
the dental arch. Malformed, unsightly teeth in the anterior thetics and restoration. Deformed teeth
part of the mouth on which jacket crowns cannot be con- should be diagnosed from the standpoint
structed should be extracted. of esthetics and function. The fact that a
tooth can be moved is not a sole reason
for undertaking orthodontic therapy.
335
336 . Diagnosis and Treatment in the Permanent Dentition
Fig. 24-2. (Top left) Fractured

maxillary central incisors, 1
month after the accident. (Top
right) Fractured maxillary
central incisors 4 years later, 2
years after orthodontic
treatment of Class II, Division
1 (Angle) malocclusion was
corrected. An edgewise
appliances were used in both
of the dental arches Edgewise
brackets were attached to the
canines and the premolars.
The molars were banded, and
buccal molar tubes were
attached to the molar bands.
An 0.016inch round arch wire
was used to align the
maxillary canines, the
premolars, and the molars. An
0.020-inch round arch wire
with sliding jigs and
intermaxillary elastics was
used to move distally the
maxillary canines, the
premolars, and the molars.
The upper central and lateral
incisors were not banded but
allowed to move lingually of
their own will. Lip pressure
and removal of interferences
by the tongue and lower lip
helped to bring the maxillary
incisors into normal align-
ment. (Center) Profile views
before and after treatment.
(Bottom) Anterior teeth before
and after treatment.
unerupted teeth and to move them into occlusion when they the crown should be packed with zinc oxide-eugenol
are in an ectopic eruption path and are past their compound for about 3 weeks. The tooth will usually begin to
developmental eruption age as judged by the state of the erupt and should be aided in doing so by orthodontic means
erupted teeth. When the axial position of a delayed if the patient is over 12 years old. In younger children the
unerupted canine is in line with its normal eruption path, the tooth may not need orthodontic intervention. Insufficient
bone surrounding the crown should be removed when the removal of bone around the crown of the ectopically
root is at least three-quarters formed and the space about erupting tooth will interfere with its eruption,
Ectopy and Impaction . 337
Fig. 24-4. (Left) The radiogram shows submergence of the

deciduous second molar which is now below the line of
occlusion of the deciduous canine and first molar. This can be
caused by mesial inclination of the erupting permanent first
Fig. 24-3. Canine teeth were shaped to resemble a lateral molar which depresses the deciduous second molar. (Right)
incisor. Radiogram shows appliance with coil spring opening space for
the deciduous second molar, which was subsequently removed
and the space retained for the eruption of the second premolar.
Fig. 24-5. (Left> Radiogram showing

ectopism of second premolar. (Center)
Radiogram showing appliance with coil
spring, moving first molar distally and
inducing eruption of the second
premolar. (Right) Second premolar,
now in position, has been banded in the
course of general orthodontic treatment.
Surgical interference to uncover ectopic
teeth is of other hard tissues. The change of position of a
not necessary when the overlying radiographed object must be judged in relation to a fixed
bone shows resorption, and treat-
object.
ment is started not long after the
physiologic eruption age of the tooth
One method of locating canine teeth is to make two
to be brought into occlusion. The radiographic exposures of the impacted tooth at different
insertion of hooks into ectopic teeth angles. One should be directed from the mesial side and
to bring them into occlusion is, as another from the distal side of the ectopic or impacted
a rule, unnecessary. tooth. If the tooth is located palatally, it moves in the
same direction as the radiographic exposure in relation to
Diagnosis of Ectopy the adjacent teeth in the dental arch. If it is located
buccally it moves in the opposite direction in relation to
In diagnosing ectopy of teeth, consider the following: the adjacent teeth in the arch. If the crown of an impacted
1. The degree of deviation of the unerupted tooth from canine lies in contact with the apex of a lateral incisor in
its normal position in relation to the general dental both radiograms, it means that the teeth actually are in
development of the patient contact with one another. Objects near the film will
2. The distance of the unerupted tooth from the site appear clearer than those at a distance.
into which it should normally erupt When two teeth are directly in back of one another
3. How long "overdue" the unerupted tooth is when the radiogram is made on a direct line, the tooth
4.The adequacy of the space into which the tooth is to farther away will be hidden by the nearer one. When the
erupt center of the x-ray head is moved to the right, the more
5., Presence of osteogenic or cystic disturbances; anomalies distant tooth (the palatally located one) will appear to
of the tooth itself or interference from roots of adjacent teeth. have moved in the same direction. When the position of
the impacted tooth does not change in the same direction
in which the radiogram was taken, it indicates that the
object is located buccally. When moving ectopic or
Locating Impactions impacted teeth into occlusion consideration should be
given to the involvement of adjacent teeth. Before one
Impacted canine teeth frequently can be located' by
palpation. The usual dental periapical radiograms are not
always sufficient because of superimposition
24.
Fig. 24-6. (Top left) before treatment. (Right) after treatment. (Center left) canine is being moved into position palatally past the
permanent lateral incisor tooth. (Right) Canine in position and central incisor is being brought into position. (Bottom left) Radiogram
shows impacted maxillary left central incisor with canine in ectopic eruption under it. (Right> Radiogram after treatment.
Fig. 24-7 A. (Left) The maxillary canines erupted on the palate. Orthodontic movement in such cases must use
extremely light pressure to prevent root displacement. (Center) The canines are in position after treatment. B. (Right)
This patient's maxillary canine is brought into position with a finger spring from an edgewise appliance.
attempts to bring an ectopic or impacted tooth into position

it should be ascertained that the tooth is not ankylosed.
Orthodontic Therapy
When the patient's age and dental development indicate
that a tooth is long past its physiologic eruption period and
the position of the apex of the tooth indicates that the tooth
will have to be moved through a considerable amount of
bone, the prognosis for bringing it into arch alignment is
poor. Otherwise, orthodontic therapy of impacted teeth is
recommended.
Buccal canine impactions, while less common than
palatal ones, present special problems. The eruptive path of
the canine is longer than that of any other tooth. The height
of the canine tooth germ and the forward and downward
path of eruption of the lateral incisor may cause the canine
to be deflected palatally. Delayed resorption of the deci-
duous canine root may also cause the permanent canine
tooth to become deflected.
When the prognosis of an impacted canine tooth is
questionable, or where other teeth may have to be
sacrificed in trying to bring it into alignment, the canine
may be allowed to remain im pacted or it may be removed
surgically.
Treatment of canine teeth in transversion with premolars
can be accomplished when the premolars are not on a
direct line with the canines by moving the premolars
distally and the canines mesially. If 'the canine is in labial
position, the labial plate
Fig. 24-8. This removable appliance is used for moving

ectopically erupting canines into position (top). The lateral
incisors were ageneticaIly absent. (Center) Appliance used,
in position. (Bottom) canines were moved into position, a
bridge supplied artificial lateral incisors.
Fig. 24-10. Locating impacted canines. (Top) The radiogram

on the left was taken with the central ray at the midline; that on
the right was taken with the central ray at the lateral incisor. The
canine moves in the opposite direction of the central ray.
Therefore it is labial. (Bottom) The position of the canine
changes in the opposite direction from that in which the film is
taken. Again, the canine is labial.
elude the removal of the bone slightly past the greatest

diameter of the crown. The opening over the crown
should be covered by a surgically packed crownform for
about a week or until the mucosa around the tooth shows
epithelization.
Strock presented the following method of exposing
unerupted maxillary incisors and canine teeth for the
Fig. 24-9. (Top) Spacing between maxillary incisor teeth. purpose of aiding their eruption:
(Cente1') Removable appliances used with :Yg" rubber dam 1. Localize the crown of the unerupted tooth by
elastic. (Bottom) Same dentition after orthodontic therapy. radiographic means.
2. Excise the overlying mucosa. (Do not make a flap.)
and overlying mucosa may be lost during rapid tooth An electrosurgical scalpel, ordinary scalpel,
movement. When the canine is between the first and mucoperiosteal elevator, chisel and mallet, hand chisels,
second premolars, or between the central 'and lateral or other instruments may be employed.
incisors, but on a straight line, the transversion should 3. Remove the bone overlying the crown of the tooth
be allowed to remain. Changes in the position of the to permit adequate direct access.
canines in transversion are difficult to accomplish. 4. Establish a trough around the entire crown by
removing the saclike portion of the tooth follicle, using
scalers and periodontal files until the cementoenamel
Surgical Exposure of Impacted Canines junction is reached.
5. Shape celluloid tooth crown form with heated band-
Surgery to expose impacted canines should in- stretching pliers until the neck of the celluloid
25. Ectopy and Impaction . 341
Fig. 24-11. Locating impacted canines.

(Top) The central ray was directed between
the central incisors for the radiogram on the
left and for that on the right, at canine region.
The canine tooth is palatal because it changed
its position in the same direction as the cen-
tral ray of the x-ray machine was moved.
(Bottom) The canines are in palatal impaction
for the same reason as above.
crownfonn is as wide as the greatest width of the tooth. Cut

the neck of the crownform to fit the contour of the tooth
crown.
6. Adapt the crownform to fit snugly over the crown of
the tooth; it need not fit over the full length of the crown.
7. Sterilize the crownform and fill it with an obtundent
ointment. Place it over the crown of the exposed tooth and
leave it in place for a week to 10 days.
It is advisable to provide space into which the tooth is to
be moved before exposing the impacted tooth crown. If the
impacted tooth is at some distance from the space into
which it is to be moved, it is advisable to expose the tooth-
crown before the space is fully opened.
Immediate Torsion of Teeth. Immediate torsion of teeth
to correct irregularities actuaUy is autogenous replantation
of teeth though the tooth never leaves the socket. Teeth so
treated later show varying degrees of root resorption in
most cases.
Under local or general anesthesia the crown of the tooth
on which a band has been placed is held by a forceps
designed to preven tit from leaving the socket. A rotary
movement is applied. When the tooth is loosened, it is
turned but not pressed, apically. The tooth is then splinted
to the ortho-
Fig. 24-12. A lateral cephalogram was used to locate an

impacted canine tooth. (Arrow points to impaction.)
Fig. 24-13. To locate an

impaction a radiogram is
taken from the position
shown at left. (Center) The
impacted canine is located
palatally. (Right) The
radiogram shows that a
canine is erupting ectopically.
26.
Fig. 24-14. (Top left) Loop of electro surgical

scalpel cutting into gum tissue. Dotted line
indicates location of tooth. (Top right) Needle
electrode coagulates the remnants of the dental
sac so that it can be removed readily. (Center left)
Tooth entirely exposed. (Center right) Neck of
celluloid crownforrn being stretched with
warmed pliers. (Bottom left) Crown being filled
with ointment. Note how edges of crownform are
festooned. (Bottom right) Crown applied to tooth.
(Courtesy M. S. Strock)
dontic bands on the adjacent teeth and on the turned tooth. of infection, and severity of the tooth rotation required.
The turned tooth should be positioned so that it is not Replantation of Teeth. Replantation of teeth with
traumatized in function. incompletely calcified apices may be performed without
, Successful surgical movement of teeth with incompletely pulp canal therapy, even though the nerve may be severed.
formed roots is attributed to the rich vascularity of the The nerve may recover or root development may be
atypical, and the pulp cavity may eventually be eliminated.
apical region and the presence of undifferentiated
Treatment of Mutilated Dentition. Patient S. B. (Fig.
mesenchymal tissue in the remnant of the dental papilla.
24-15) has congenital facial asymmetry and microtia. The
This can produce the vascular supply needed for repair of patient was born with stenosis of
stretched or torn tissues. Successful prognosis after this
technique depends on the degree of root maturation,
absence
27.
28.
S,B. --
Before
--- - After
I
I
--,.L
,\ :
,~
.;},
IN
rl
I'
<, <, vII
............... y
<, -, !
<, ~~-(:
L
"\.-
Fig. 24-15 S. B. (A, B, C, top) S. B. before treatment. (Center) After treatment. (Bottom) 3 years out of retention. (0)
Occlusal views. (Left) Before treatment. (Center) After treatment. (Right) Three years out of retention. (E) Removable
appliance used to correct maxillary incisor overbite. (F) Appliances used in treatment showing use on an anterior
intermaxillary elastic to improve inter-incisor alignment. (G) Dentition after 3 years out of retention. (H) Facial asymmetry
before treatment. (I) Facial appearance three years out of retention. (J) Lateral cephalogram before treatment. (K)
Posteroanterior cephalogram 3 years out of retention. (L) Lateral tracings superimposed on sella nasion line show favorable
development.
the right external auditory canal, which was later lary right and left permanent first molars were extracted
surgically reconstructed. Both temporomandibular because of severe caries before the patient was seen for
articulations are normal. The anterior teeth in crossbite orthodontic treatment.
were corrected with a modified activator worn on the In the mandible the right and left permanent central and
mandibular arch. After the incisors were moved labially, lateral incisor teeth are erupted and are spaced. The right
the patient was treated with an edgewise appliance. deciduous first molar is in position. The deciduous left first
molar had been exfoliated and the first premolar is erupted.
The mandibular right and left deciduous second molars
have been extracted, and the right and left permanent first
CASE REPORTS
molars are erupted.
Skeletal Classification. The facial skeletal pattern is
EXTREME MAXILLARY PROTRUSION Class 2. Although the facial angle is within normal range,
Clinical Description. K. C. (Fig. 24-17) an Angle Class the maxilla is decidedly forward to the an terior cranial
II, Division 1 malocclusion. There is a severe protrusion base (S- N).
of the maxillary incisor teeth. The maxillary permanent Treatment Summary. K.c. was treated by moving the
right and left central and lateral incisor teeth are erupted posterior mandibular teeth distally. Space was thus
and are spaced. The right and left maxillary deciduous provided for the second mandibular premolars. The
canines and first and second deciduous molars are in maxillary dental arch anterior to the molars
position. The maxil-
29.
Fig. 24-16. The top and

second rows show lateral and
anterior views of a Class II
malocclusion before and after
treatment. (Third row) Occlusal
views before (left) and after
treatment (right), Top
radiogram shows a cyst in-
volving the maxillary inci-
sors. The radiograms on the
right show the teeth and
alveolar process after the cyst
was eliminated and the oc-
clusion corrected. (Bottom)
Anterior views before treat-
ment (left) and after treatment
(right). The patient had been
advised to have all maxillary
incisor teeth extracted before
presenting for orthodontic
treatment.
Case Reports' 345
Patient K. C.
Age Age 13 Years

Downs Downs 8 Years, (l Yr. Qut of
Dimension Range. Mean 6 Months Retention)
(F.H. to N-Pg)
Angle of Convexity -8.5 to + 10 0 +190 +190
( -A-Pg)
A-B line to N-Pg -9 to 0 -4.8 -10 -10
Mand. Plane to F.H. 280 to 17 21. 9 29 30
Y-Axis 66 to 53 59.4 59 60
1 to Tangle 130 to 150S 135.4 115 134
T to Mandibular Plane 81S to 97 91.4 960 95
S-N-A 82 850 87"
5- -B 80 76 780
Tweed
Gonion Angle 116_1350 1260 1350 135
Fig. 24-17. (Top left) K. c.

front view before and (n:ght) front
view after treatment. (Bottom left)
Profile before and (right) profile
after treatment. Note the
constancy of profile convexity.
346 . Diagnosis and Treatment in the Permanent Dentition 30.
Fig. 24-17 (Continued). (Top, A)

Before treatment. (Center) After
retention. (Bottom) Occlusal views
before (left) and after (right)
treatment. The dental casts are
oriented along the F~ankfort
plane. (B) Lateral jaw radiograms
before (top) and after (bottom)
treatment. (C) Lateral
cephalograrns tracings show
continuing enlargement of the
face with mandibular translation
in a retrognathic direction.
K.c.
-- age8yrs.,6 mos.
- - - age 13 yrs.
c
Case Reports . 347
Fig. 24-18. (Top left) M. c., anterior view before, and (right) after treatment. (Center left) Profile view before, and
(right) after treatment. (Bottom left) Anterior view of dentition before and (right) after treatment. (Continued on overleaf)
31.
Fig. 24-18. Continued. (Top row) M. C's casts before treatment.
(Second row) Casts after retention. The maxillary and
, mandibular first premolars were extracted. (Bottom left) Occlusal
M.e. - view before premolar extraction. (Right) Occlusal view after
- age 12 yrs. retention was completed. The casts are oriented along the
- - -age 14yrs
Frankfort plane. (Bottom) Super-imposed tracings before and after
treatment. The face continued to grow downward while nasion
and pogonion grew forward at the same rate,
Case Reports' 349
Patient M. C.
Downs Downs Age Age

Dimension Range Mean 12 Years 14 Years
Facial Angle 82 to 95 87.8 77 7So
(F.H. to -Pg)
Angle of Convexity -SS to +10 0 +170 +9
( -A-Pg)
A-B line to N-Pg -9 to 00 -4.8 -120 _9
Y-Axis 66 to 530 59.4 67" 68
1 to "1 angle 130 to 150S 135.4 109 1350
I to Mandibular Plane 81.5 to 970 91.4 105 96
s- -A 82 83 81,
S-N-B 800 76 76
Tweed
Gonion Angle 116-135 126 132 132"
Fig. 24-19. (Top left) B. J., front

view before treatment. (Rig/It! Front
view after treatment. (Bottom left!
Profile view before treatment. (Right!
Profile view after treatment.
(Continued on next page)
Fig. 24-19. Continued. (Top

row) B. J- 's casts before treat-
ment. (Center) Casts after
treatment. (Bottom left) Occlusal
Occlusal view after treatment.
Casts are oriented along
Frankfort plane. (Bottom)
Profile tracings before and after
treatment show little growth
change. Changes in the dentition
were brought about by
orthodontic therapy.
32.
was moved distally with an extraoral appliance, and the

maxillary permanent second molars were allowed to erupt
in a mesial direction and moved to occlude with the
B.J. - mandibular first molars. The erupting third molars were
ag"l3yrs.
- - -age 18y r-s.
then brought forward to occlude with the mandibular
second molars and with the mandibular third molars, when
they erupt.
,,
,, , BIMAXIllARY PROGNATHISM
I
(Patient M.C.)
Clinical Description. M.e. (Fig. 24-18) has a Class II,

Division 1 malocclusion in the permanent dentition. There
is an abnormal overbite and an overjet of 13 mrn, The
mandibular incisor teeth occlude on the palatal gingivae of
the maxillary incisors. The maxillary right first and second
pre-
Case Reports . 351
molars are in buccal crossbite. The maxillary permanent (1M A is 140);' they occlude on the palatal mucosa of the
teeth, including the second molars, are erupted. The maxillary incisor teeth. There is a crossbite of the first
mandibular permanent teeth up to the second molars are premolar teeth.
fully erupted. The teeth are not crowded. Skeletal Classification. The facial skeletal pattern is
Skeletal Classification. This is a Class 2 facial skeletal Class 1.
pattern. Treatment Plan. The procumbency of the mandibular
Treatment Summary. The four first premolars were incisors was reduced and their overeruption was corrected
extracted. The facial angle increased from 77 to 78. using 0.018- and 0.020-inch round wire arches. The
There was only limited forward translation of the mesiodistal relation was corrected with an extraoral
mandible. Most of the mandibular rotation was downward appliance. The maxillary incisors were inclined forward
and rearward. The face increased in length. The maxillary- and the interincisor angle was reduced. If the maxillary
mandibular incisor angle was increased 26, from 109 to incisors are left in their original vertical axial position they
135. Because of the Class 2 facial skeletal pattern and the are apt to elongate again after treatment.
heavy soft tissue covering, the profile will continue to The dentition is stable 3 years and 4 months out of reten
show some convexity, regardless of the premolar extraction.
tions. The soft tissues do not necessarily follow the teeth
after space closure. In these cases the face does not
become more orthognathic. The patient cannot always be
assured that an orthognathic facial profile will be achieved INFLUENCE ON TREATMENT OF
through extraction and dental incisor respositioning. ADOLESCENT DENTOFACIAL
GROWTH CHANGES
Patient R.Z.
Clinical Description. R.Z. (Fig. 24-20) has Class I
CLASS II, DIVISION 2 MALOCCLUSION malocclusion with deep overbite. The facial skeletal pattern
Patient B.J. is Class 1. The A-Point and B-Point indicate a retrognathic
profile. The maxillary right and left permanent central and
Clinical Description. B.J. (Fig. 24-19) has Class II, lateral incisors have erupted. The right and left deciduous
Division 2 malocclusion in the permanent dentition. The canines are in position. The right and left first and second
maxillary central incisors are in lingual axial inclination. premolars have erupted. The right second premolar is in
The dentition as a whole is in Class II relation. There is an torsi.version, and the right and left permanent first molars
abnormal overbite. The mandibular incisors are have erupted.
overerupted and procumbent
Patient B. l-
Age Age 18 Years,
13 Years 4 Months
Downs Downs (Began (3 Yrs., 4 Mos.
Dimension Range Mean Treatment) Past Retention)
(F.H. to N-Pg)
Angle of Convexity -8S to +) 00 0 +160 +70
(N-A-Pg)
A-B line to N-Pg -90 to 0 -4.80 -]50 -7
Y-Axis 66 to 530 59.40 58 60
l to 1 angle 1300 to 150S 135.40 1420 1380
] to Mandibular Plane 81S to 97 91.4 1040 1000
S-N-A 820 82 79
S-N-B 800 740 74
Tweed
Gonion Angle 116-135 1260 113 113
Fig. 24-20. (Top left) R. Z., anterior view before, and (right) after treatment. (Bottom left)
Profile view before, and (right) after treatment. (Opposite, top) Before treatment. (Center)
After treatment. (Bottom left) Before, and (right) after treatment. Casts are oriented along
the Frankfort plane. (Bottom) Superimposed tracing shows unusual changes in base of-
mandible.
In the mandible the right and left permanent central were changes also at the mandibular base, which had
and lateral incisors and right and left canines are erupted. grown decidedly downward and outward. The profile
The right first premolar is erupting, and the left first became more concave. The interincisor angle had
premolar has erupted. The right and left second premolars increased from 1360 to 1440 at age 16 years and 8 months.
and permanent first molars are erupted, and the second The relation of the mandibular incisors to the man-
permanent molars are erupting. At age 16 years, 3 years dibular plane was 64 at the beginning of treatment. The
and 4 months out of retention, the mandible showed angle had increased to 81. This was 78 at 3 years and 4
decided forward growth at the chin, and the facial angle, months out of retention. The gonion angle showed an
which was 88 at completion of active treatment, is 90. unusual change. It was 1330 before
There
33. Case Reports . 353
Fig. 24-20. Continued. }

RZ.
-age llyrs.,6mos.
.,
I
l
---age 13 yrs,4rros.
treatment and 1370 at age 16 years and 8 months. This was _.- . age 13 yrs.
caused by the changes at the mandibular base.
DIFFERE TIAL DrAG 0515 AND TREATMENT OF

PROGNATHISM
The following four patients (Figs. 24-21 to 24-23) show
many dentofacial similarities. On cephalometric analyses we
find each of these patients to present different problems in
dentofacial development, diagnosis, and plan of treatment.
Differences are shown between skeletal and denture
classification and between actual Class III prognathism and
Patient R. Z.
Age 16 Years
Age Age (2 Yrs., 8 Mos.
Downs Downs 11 Years, 13 Years, Out of
Dimension Range Mean 6 Months 4 Months Retention)
Facial Angle 8r to 95 87.8 88 88 900
(F.H.to -Pg)
Angle of Convexity -8.5 to +10 0 -90 -50 -flo
(N-A-
A-B line to N-Pg -90 to 0 -4.8 +2 _2 -40
Mand. Plane to F.H. 28 to 17 21.9 30 32 32
Y-Axis 66 to 53 59.4 56 58 57
Occlusal Plane to F.H. 1.5 to 14 9.3 17 15 1'20
1 to 1 1300 to 150S 135.4 161 136 144
1 to Mandibular 81.5 to 97 91.40 64 810 78
s- -A 820 780 79 79
s- -B 800 790 79 780
Tweed
Gonion Angle 1160 -1350 126 133 136 1370
Fig. 24-21. An apparent Class III malocclusion at

three stages: (Left) at the beginning of treatment; (center)
at the completion; and (right) 3 years after treatment was
complete.
Case Reports . 355
Fig. 24-22. E. s. (Top left) Profile before treatment; (right) profile after treatment. (Bottom left) Front view
before treatment; (right) front view after treatment. (Continued on overleaf)
anterior cross bite and also deficient growth of the middle tient came for orthodontic treatment. The maxillary teeth
one-third of the face. had shifted to the right, partly closing the space of the
Patient .5. extracted maxillary right first molar. The mandibular teeth
shifted to the left after the first molar was extracted,
Clinical Description. .5. (Fig. 24-21) originally had an partially closing the extraction space. The patient was a
Angle Class I malocclusion in the permanent dentition. tongue thruster, and the tongue habitually rested between
The facial skeletal pattern is Class 1. The maxillary right the maxillary and mandibular teeth. The incisal edges of
first molar and mandibular left first molar had been the maxillary incisor teeth were on the same vertical plane
extracted before the pa- as
356" . Diagnosis and Treatment in the Permanent Dentition
Fig. 24-22. Continued. (Top, left) E S.,

anterior view before treatment. (Right)
Anterior view after treatment. (Bottom
left) Occlusal view before treatment.
(Right) Occlusal view after treatment.
the mandibular incisor teeth. There was an incisor tivator appliance was used as a retainer to confine the
openbite and slight mandibular incisor irregularity. tongue and overcome the tongue thrusting. The patient
Outline of Treatment. The mandibular right first premolar was taught to swallow properly. The occlusion was
was extracted. Maxillary and mandibular edgewise bracket equilibrated. After the first 3 months, the patient refused to
bands were used with round O.OIB-inch archwires followed wear the retainer as instructed. The completion casts and
by 0.020-inch ones. Intermaxillary elastics were used on the photographs were taken 1 year after treatment. Growth
archwire from hooks in front of the maxillary molar tubes to during treatment was equal in amount for both the maxilla
hooks mesial to the canines on the mandibular 0.021 X 0.025- and the mandible.
inch rectangular archwire. The first molars were then moved
mesially by means of intramaxillary elastics to close the
spaces mesial to the first molars, and establish normal
Patient B.B.
mesiodistal dental arch relation. Vertical elastics were used on
the anterior segments to close the openbite. An ac- Clinical Description. B.B. (Fig. 24-22) had a Class III
(Angle) malocclusion in the permanent dentition. The
maxillary right second premolar is crowded
34. Case Reports' 357
Fig. 24-22 (Cont.). (Top) Right

and left sides of casts of patient E.
S. before treatment. (Center) Right
and left sides after treatment.
(Bottom left) anterior view before
treatment. (Right> anterior view
after treatment.
(Bottom) Tracings before (solid
line) and after (dashed line) treatment.
Growth between the ages of 12 and
15 years shows the mandible to have
continued forward growth. The
mandibular incisors are changed
into a more acute angulation to the
mandibular plane. The maxillary
incisor teeth were brought
downward and forward when the
bite was closed.
lingually out of the arch. There is an openbite beginning with

the maxillary first molars which occlude distal to the
mandibular first molars. In the mandible, all permanent teeth
including the third molars are erupted and the mandibular
incisors are crowded. The maxillary incisor teeth occlude lin-
gually to the mandibular incisor teeth.
Skeletal Classification. The facial skeletal pattern is Class E.S. --
age12yrs.
1, and the dental malocclusion is Class III. There is a ---age15yrs.
deficiency in the middle third of the face. The maxilla is
retrognathic in relation to the anterior cranial base. The facial
skeletal classification is different from the dental
malocclusion classification.
Fig. 24-23. B. B. (Top left) profile before treatment. (Right) Profile after treatment.
(Bottom left) front view before treatment. (Right) Front view after treatment. (Opposite,
top) Before treatment; (center) after treatment. (Bottom) before (left) and after (right).
Outline of Treatment. The mandibular first premolar Patient T.L.

teeth were extracted. An edgewise appliance was used
with intermaxillary elastics from hooks on the 0.020-inch Clinical Description. T.L. (Fig. 24-23) has Class I
round arch wire in front of the maxillary molar teeth to malocclusion in the permanent dentition. All of the
hooks mesial to the canines on the mandibular 0.021 X maxillary permanent teeth are erupted; there is crowding
0.25-inch rectangular arch wire. The mandibular incisor on the right side. The maxillary left first molars and second
teeth were moved lingually, and the maxillary incisor teeth premolars and left canine are in lingual occlusion in
were moved labially into normal interarch relation. crossbite. The mandible shows crowding of the mandibular
Vertical elastics were used to correct the openbite. An incisor. The mandibular canine and first molar on the left
activator appliance was used as a retainer to confine the side are in buccal crossbite. The entire mandibular arch
tongue, and the patient was instructed in swallowing and the mandible itself have shifted to the left.
normally. The occlusion was equilibrated. There were no Skeletal Classification. The facial skeletal pattern is
over-all growth changes. Class 1. The maxilla is retrognathic. The maxillary
Case Reports' 359
Fig. 24-23.
Continued.
deficiency is evidenced by the anterior limit of the from the maxillary round O.020-inch arch wire distal to
maxillary basal arch, S-N-A angle is 68. the molar tubes to hooks mesial to the mandibular
Outline of Treatment. The cross bite was corrected canines on the mandibular archwire to obtain normal
with No. 3 cross elastics. The mandibular incisor mesiodistal relation of the dental arches.
procumbency was reduced after the mandibular first
premolars were extracted. The maxillary-mandibular
Patient A.K.
incisor angle was decreased when the incisors were
inclined labially. The maxillary incisor teeth were made Clinical Description. A.K (Fig. 24-25) has Class III
somewhat more procumbent as they were brought malocclusion in the permanent dentition. All teeth,
downward. Most of the maxillary-mandibular incisor including the second molars, are erupted. The bite is
increase was caused by the change in axial relation of open beginning with the second molar on the left side to
the mandibular incisor teeth to the mandibular base. the second molar on the right side. There is crowding of
Intermaxillary elastics were used the mandibular second premolar teeth.
. Fig. 24-23. (Cont.). (Top left) B. B. before, and

(right) after treatment. (Center left) before, and
(right) after treatment.
(Bottom) Tracings of patient B. B. before (solid line)
and after (dashed line) treatment. Growth between age
17 years and 20 years was not significant. The
mandibular incisors were moved lingually and at a
more acute angle to the mandibular plane. The maxil-
lary incisors were brought forward and downward.
The maxillary and mandibular dental arches are con-

tracted in the premolar region. The maxillary teeth a.re
lingual to the mandibular teeth. The patient had been
advised by an oral surgeon to have mandibular resection
before she requested orthodontic therapy.
Skeletal Classification. The facial skeletal pattern is Class
3. The face is deep and long anteroposteriorly, with the
mandible beyond the normal range 'in relation to the
BB. - anterior cranial base (S-N). The anterior limit of the
age17yrs.
-- - mandibular basal arch (B-Point) also is above the normal
age20yrs.
range.
Outline of Treatment. This patient had a Class III
malocclusion with an anterioposteriorly long maxilla. The
body of the mandible was long and prognathic. The
mandibular first premolars were extracted and the
mandibular incisor crowns were moved lingually. The
inclination of the mandibular incisor teeth to the base of
the mandible was reduced from 76 to 65 in relation to
the base of the mandible, and the angle of the maxillary to
the mandibular incisors was increased from 130 to 136.
Edgewise bracket bands were used with o.oIB-inch
followed by 0.020inch round wires. Intermaxillary
elastics were used on the archwires from the distal of the
maxillary
Case Reports . 361
Fig. 24-24. T. L. (Top left) profile before, and (right) after treatment. (Bottom left) front
view before, and (right) after treatment. (Continued on overleaf)
molars to the mesial of the mandibular canines. Vertical limit of their maxillary basal arch (A-Point) distal to the
elastics were used to close the open bite. An activator anterior limit of the mandibular basal arch (B-Point). All
appliance was inserted as a retainer and to prevent the have the angle of convexity on the minus side, i.e.,
tongue from resting in the interarch space. concave profile. A.K. has a Class 3 facial skeletal pattern;
Closure of the mesiodistal deficiency of the maxillary the rest have a Class 1 facial skeletal pattern with middle
and mandibular dental arches was effected mostly by face deficiency. The maxillas are retrognathic. The
lingual movement of the mandibular incisors and by Yvaxes. with the exception of A.K. 's. are on the wider side
change in axial relation of the mandibular incisor teeth, of normal range. All have long faces, which tend to
and the distal repositioning of the mandible as the increase the angulation of the Y-axis. In addition, A.K. has
malocclusion was corrected. There was little increase in an extremely deep face and a long prognathic mandible.
maxillary incisor procumbency. Therefore, her Y-axis is more acute than the others', since
Summary. These four patients have the anterior the chin is in a more forward relation to sella.
Fig. 24-24. Continued. (Top row) T. L. Before treatment; (second row) after
treatment. (Third row) Front view before treatment. ote crossbite in left buccal
segment. (Bottom) Front view after treatment.
35. Case Reports . 363
Fig. 24-24 iCont.). (Top left) T. L., front view

before, and (right) front view after treatment.
(Center left) occlusal view before, and (right)
occlusal view after treatment. (Bottom)
Tracings of patient's radiograms before (solid
line) and after (dashed line) treatment. Growth
between age 15 years and 17 years was not
significant. Changes were in incisor teeth rela-
tion. As vertical height was increased the
mandible assumed a slightly more distal
position.
T.L. -
age15yrs.
- - - age 17 yrs.
Fig. 24-25. A. K. (Top left> profile before, and (right> profile after treatment. (Bottom
left) front view before and (right) front view after treatment. (Opposite top) Before
treatment. (Second row) After treatment. (Third row) Before treatment. (Bottom) After
treatment.
Dental Arch Relation She has a large and deep face, with the mandibular basal arch
beyond normal range.
E.S. has her maxillary basal arch (A-Point) retrusive, and
the mandibular basal arch (B-Point) is within normal range.
Patient B.B. shows the maxillary basal arch (A-Point)
extremely retrusive and the mandibular basal arch (B-Point) ORTHODONTICS IN MANDIBULAR
also extremely retrusive. T.L. shows a retrusive maxillary RESECTION
basal arch (A-Point) and a retrusive mandibular basal arch (B- In surgical resection of mandibular prognathism
Point). Some of the apparent retrusion as indicated by S- -A the orthodontic procedure is as follows:
and S- -B is caused by the cranial inclination of the S-N line 1. Dental impressions are taken and casts made.
at nasion in relation to the Frankfort horizontal. A.K. shows 2. The mandibular arch is set into a template.
the maxillary basal arch (A-Point) forward, above normal. and 3.Sections are cut on the mandibular cast to the least amount
the mandibular basal arch (B-Point) extremely protrusive. that will allow the mandibular incisors to occlude in normal
relation with the maxillary incisors.
36. Surgical Orthodontics . 365
"
Fig. 24-25.
Continued.
4. The mandibular segments are aligned in the template, is sterilized and is used to measure the amount of bone to
and the amount of bone to be removed from the mandible be excised.
is measured on the aligned cast. q. The maxillary splint is
constructed with bands and an O.040-inch archwire.
SURGICAL ORTHODONTICS
6. The archwire is made in three sections and soldered
to the bands. The ends of the arch wire are turned to There is a difference between purely surgical pro-
permit tying them together. cedures which completely replace orthodontic treatment
7. A mandibular splint is constructed in the same and those that are an adjunct to orthodontic treatment.
manner as the maxillary splint. Surgical operations of the jaws for the correction of the
8. An aluminum template is constructed to fit into the usual classifications of malocclusion as designated by
space cut from the mandibular casts. This Angle are not required when the alveolar process only is
involved. Specific cri-
37.
38.
Fig. 24-25 (Cont.). (Top left) A K.

before, and (right) after treatment. (Center
left) occlusal view before, and (right)
occlusal view after treatment. (Bottom)
Tracings of patient's radiograms before
(solid line) and after (dashed line)
treatment.
AK.
__ age 14 yr 56 mo. ---
age17yr561nJ. )
l
Interception of Malocclusion in Scoliosis Patients' 367
TABLE 24-1 Analyses of Four Cases of Prognathism.

E,S, B.B, T.L. A.K.
1 Year 1 Year 1 Year
D'imension Downs Range Age 12 Past Age 17 Past Age 15 Age 17 Age 14.6 Past
Years Ret. Years Ret, t Years No Ret. t Years Ret.t
Before' After# Before After Before After 9 Before After
Facial Angle 82 to 95 85 87 84 84 86 86 960 94

(F.H. to N-Pg)
Angle of Convexity -8.50 to +10 _7 -60 -190 -15 -14 -12 -80 -40
( -A-Pg)
A-B line to N-Pg -90 to 0 +3 +3 +9 +7 -HJ0 +40 +4 0
Mand. PI. to F.H. 28 to 17 40 40 30 30 27 280 34 38
Y-Axis 66 to 53 64 63 64 64 60 62 57" 60
Occlusal Plane 1.5 to 14 16 15 6 6 10 12 9 9
to F.H.
1 to 1 130 to 124 147 132 138 101 0 120 130 136
- (Mean) 90
1 to Mand. PI. 81.5 to 97 83 64 84 73 98 90 76 65
78 80 65 67 68 70 87 88
. West. Mean)
( and and and and and and and and
S-N-A and 5- -8 82 and 800 80 82 73 73 74 73 90 880
(Tweed)
Gonion Angle 116-135 145 145 127 1270 130 130 137 137
, Before = before treatment t Treated for 2 years.
# After retention
teria for surgical intervention in the dento-oro-facial tous surgical insult when other factors do not contraindicate
complex are at present highly subjective. The substantive orthodontic procedure (See Chap. 25).
knowledge of the orthodontist is of utmost importance in Significant differences may be found in autografted
deciding on the need for surgery, especially when transplanted teeth as follows: disturbed interarch tooth
dentofacial growth is continuing. contacts, absence of occlusal contact in terminal occlusion,
Surgical procedures are contraindicated when the mobility of the transplanted teeth: disturbed crown-root;
malocclusion or dentofacial deviation can be treated by and shortened roots.
orthodontic means for the following reasons: The need for a surgical operation where the bodies of the
1. The danger of interfering with growth of the jaws if jaws are involved is understandable but not when the
the operation is performed when growth is continuing. alveolar process alone is involved or where the involvement
2. The dangers of tooth devitalization when certain of the body of the mandible or maxilla does not adversely
severed dental nerves fail to regenerate. affect facial esthetics. Present methods in orthodontics can
3. The abrupt oral changes and reduction of tongue obtain satisfactory results without subjecting the patient to
space, which can interfere with oral kinesthetics and surgical operations in these cases.
function.
4. The interference with muscle attachment and muscle
function which may require a prolonged period of
retraining. I TERCEPTIO OF MALOCCLUSION IN
SCOLIOSIS PATIENTS
5. The discomfort and untoward sequelae that may
attend surgical operations. Riser jackets, body casts, and Milwaukee jackets are
6. The attitude of the patient and the parents to surgery. placed by orthopedic surgeons to oppose spinal
If the morphologic changes required in treating contractions which result from scoliosis. A body cast
dentofacial condi lions are confined to the alveolar process covers the trunk and may cover parts or all of the legs,
and do not involve the basic parts of the jaws themselves, arms, and the back of the head. The chin pad of the body
surgical intervention is a gratui- cast contacts the inferior border of the body of the
mandible, These orthopedic appliances bring pressure
against the inferior border of
Fig. 24-26. Lateral views

at age 11 (A) and at age 18. (B)
Superimposed tracings of
cephalograms taken at age 18
years (C) show extreme
change in mandibular rota-
tion which continued for 3
years after full retention. Pa-
tient was advised to continue
wearing a passive activator at
night as a retaining appli-
ance.
He - tical changes when body casts were worn for 40 days by

AGE 11 children being treated for scoliosis. He found infraclusion
---AGE 18 of the posterior teeth within 3 weeks. Howard used a
removable splint to maintain maxillary-mandibular dental
relationship while the children were in casts. This
appliance did not prevent depression of teeth or a
reduction in dimension of the lower third of the face.
Bunch used one-piece slightly modified rubber
positioners to maintain or improve dental stabilization
while maintaining or improving dental occlusion. The
patient is informed that there will be some soreness of the
mouth when the positioner is placed, especially when he
attempts to move the teeth with the positioner in place.
The positioner is usually placed about 5 to 7 days prior to
placement of the body cast.
c TEETH PROTECTORS
Fixed orthodontic appliances need not be removed in
the mandible, as the chin is elevated and the head is order to construct a teeth protector. The impression is
tipped backwards. Mandibular-maxillary dental arch made with the fixed orthodontic appliance in place and the
relation and malocclusion can follow close bilateral teeth protector is constructed to fit over the appliance. To
adaptation of the body casts. Increased dental protrusion construct a teeth protector, alginate impressions of the
is usually observed in these patients. dental arches and a wax bite with the teeth in occlusion are
Improvement in the alignment of the teeth can occur taken, and the casts are poured.
when the use of the Milwaukee jacket is discontinued. An Teeth protectors should meet the following re-
activator appliance may be used on children who are in quirements: occupy as little space in the mouth as
the Milwaukee jacket, since the appliance gives skeletal possible; be light and easily placed in position and
support and so prevents intrusion of the buccal series of removed from the teeth; not impinge on the soft tissues;
teeth and protrusion of the incisor teeth. and not distort the muscles of the face to any great degree.
Treatment. Howard (1926) observed the rapid ver- Teeth protectors may be made of prefabricated rubber with
a thermoplastic lining,
Fig. 24-27. (Top) Cast of a

prognathic mandible in a
template constructed of dental
stone. (Second row) Cast is cut
and replaced in stone template.
The size of the part of the
mandible to be excised is
shown. (Third row) Occlusion
after mandibular cast is
assembled in template. (Fourth
row, left) View of sectional casts
showing size of bone to be
excised. A metal template may
be constructed to indicate the
size of the segment to be
excised. (Right) The parts of the
cast are approximated to deter-
mine whether the parts to be
excised are the proper amount.
(Bottom) View of template.
'.
Fig. 24-28. (Top left) Anterior view of casts before jacket was
worn. (Bottom left) Increase in overbite and overjet after wearing a
jacket. (Center) Views of patient in Milwaukee jacket. (Above)
Anterior views before (left), and after (right) wearing the
Milwaukee jacket.
Fig. 24-29. This patient wore

a Milwaukee jacket while under
treatment for scoliosis. Her
previously normal overbite
(bottom left) increased in incisor
overbite and procumbence
(bottom right) while she wore the
jacket.
Fig. 24-30. Patient under treatment for scoliosis

in Milwaukee jacket. Chin rests on rigid collar of
the jacket. C and D. Activator type appliance
worn to prevent intrusion of mandibular teeth and
increase in maxillary incisor overjet. (E) Side view
of casts showing (top) before treatment, (center)
during treatment, and (bottom) improvement after
wearing activator-type appliance for 6 months. He
still continues to wear it. (F) Anterior view
showing (left) before wearing the Milwaukee brace.
(Center) Before wearing activator type appliance.
(Right) Improvement while wearing activator type
appliance. (G) Occlusal views in same order as in
F.
latex, clear acrylic, or sernihard acrylic shell with a soft inch thick is available in sheets of 3" x 6". The material is
acrylic insert. soft and flexible and is readily formed by softening in heat
A material of silicon vinyl in clear plastic 0.125 and molding on a dental cast. The
teeth protector is trimmed to about the middle of the Ketcham, A. H.: The treatment of openbite cases. Int. ].
crowns of the teeth. A second layer can be added to the Orthodontics & Dent. Children, 17:807, 1931.
first by heating the surface of the layers. Lewis, P. D.: Canine retraction. Am. J. Orthodontics, 57:543,
1970.
Lund, B. A, Sather, A., and Nelson, D. H.: Compound corrective
surgical procedures on the mandible. Am. J. Orthodontics,
BIBLIOGRAPHY 60:398, 1971.
Alexander, R. G.: The effects on tooth position and maxillofacial MacCouley, F. J.: Ectopic Incisors. D. Practitioner, 20:145,
vertical growth during treatment of scoliosis with the 1969. .
milwaukee brace. Am. ]. Orthodontics, 52:161, 1966. Meklas, J. F.: Bruxism ... diagnosis and treatment. J.
Angell, E. c.: Treatment of irregularities of the permanent teeth. Acad. Gen. Dent., p. 192, 1971.
D. Cosmos p. 440, 1860. Mershon, J. V.: Possibilities and limitations in the treatment of
Biederman, W.: The orthodontist's role in resecting the closed bites. New York J. Dent., 7:185,1937.
prognathic mandible. Am. J. Orthodontics, 53:356, 1967. Miller, H. M.: Transplantation and reernplantation of teeth. Oral
Bolton, W. A.: The clinical application of a tooth-size analysis. Surg., 9:84, 1956.
Am. J. Orthodontics, 48:504, 1962. Moore, A. W.: Orthodontic treatment factors in Class II
Bunch, W. 5.: Orthodontic positioner treatment during malocclusion. Am. J. Orthodontics, 45:323, 1959. awrath, K.:
orthopedic treatment of scoliosis. Am. J. Orthodontics, 47:174, Kasuistischer Beitrag zur Prognose der transversalen und
1961. sagittalen Erweiterung. Fortschr. Kieferorthopadie. 23:320,
Caldwell, 1- B.: Preoperative roentgenographic localization of the 1962.
Ohler, D., and Skotnicky, F.: Die Gaumennahterweiterung.
impacted maxiIJary canine. Oral Surg., Oral Med. & Oral
Deutsche. Zahnarzt. Zeitsch., 13:783, 1958.
Path., 7:499, 1954.
Oppenheim, A.: The crisis in orthodontia, Int. J. Orthodont. &
Costich, E. R., Haley, E. W., and Hoek, R. B.: Plantation of
Dent. Child., 19:1201, 1933; 20:18, 137,250,331,
teeth: a review of the literature. New York State D. J.,
461,542,639,759,964, 1072, 1178, 1934; 21:50, 153,531, 621,
29:3,1963.
731, 1935.
Derichsweiler, H.: Caumennahterweiterung: Methode, Indikation
Paskow, H: Self-alignment following interproximal stripping.
und Klinische Bedeutung. Munich, Carl Hanser, 1956.
Eastham, R. M.: An Evaluation of Stabilizing Appliances for
Pottier, M.: Un cas d'affaisement de la voute palatine pendant Ie
Milwaukee Brace Patients. Am. J. Orthodontics, 60:445,1971.
traitment d'une scoliose consecutive a la poliomyelite. Orthod.
Haas, A J.: Rapid expansion of the maxillary dental arch and
Francaise, 33:165, 1962.
nasal cavity by opening the midpalatal suture. Angle
Reidel, R. A: Esthetics and its relation to orthodontic therapy.
Angle Orthodontist, 20:168,1950.
Hausser, E., and Lieb, G.: Zur Frage der Auswirkung
Salzmann, J. A.: Surgical orthodontics. Am. J. Orthodontics,
kieferorthopadischer Hilfsmittel bei der Progeniebehandlung.
56:196, 1969.
Deutsche Zahn. Zeitschr., 19:65, 1964.
Stilwell, F. 5.: The correlation of malocclusion in scoliosis to
Holdaway, R. A.: Changes in relationship of Points A and B
posture and its effect upon the teeth and spine. D. Cosmos,
during orthodontic treatment. Am. J. Orthodontics, 42:176,
69:154, 1927.
1956.
Stoner, M. M.: Past and present concepts of anchorage
Howard, C. c.: A preliminary report in intraocclusion of the
preparation. Angle Orthodontist, 28:176, 1958.
molars and premolars produced by orthopedic treatment of
Thilander, B. and [akobsson, S. 0.: Local factors in impaction of
scoliosis. Int. ]. Orthodontics, 12:434, 1926.
maxillary canines. Acta odont. scaridinav., 26:145, 1968.
___ : The physiological progress of the bone centers of the hands
Thorne, H.: Experiences on widening the median maxillary
of normal children between the ages of five and 16 inclusive;
suture. Report of the 32 Congress, European Orth. Soc.,
also a comparative study of both retarded and accelerated hand
Annual, 1956.
growth in children whose general skeletal growth is similarly
Thorne, . A: Expansion of maxilla. Spreading the midpalatal
affected, Int. J. Orthodont. & Oral Surg., 14:948-997; 1041-
suture; measuring the widening of the apical base and the nasal
1066,1928.
cavity on serial roentgenograms [Abstract]. Am. J.
___ : Growth; ossification of the bone centers of the hand as
correlated with general growth stages. Int. J. Orthodont. &
Tuverson, D. L.: Orthodontic treatment using canines in place of
Oral Surg., 22:888, 1936.
missing maxillary lateral incisors. Am. J. Orthodontics, 58:109,
___ : Acromegaloid growth and dwarfism. Int. ]. Orthodont. &
1970.
Oral Surg., 22:992, 1937.
Wylie, W. L.: The mandibular incisor-its role in facial esthetics.
Howes, A. E.: Expansion as a treatment procedure- where does it
Angle Orthodontist, 25:32, 1955.
stand today? Am. J. Orthodontics, 46:515, 1960.
___ : Discussion of "The lower incisor-its influence on treatment
Kesling, H. D.: Coordinating the predetermined pattern and tooth
and esthetics." Am. J. Orthodontics, 45:50, 1959.
positioner with conventional treatment, Am. J. Orthodont.,
___ : The philosophy of orthodontic diagnosis. Am. J.
32:285-293, 1946. Orthodontics, 45:655, 1959.
25
Orthodontic Treatment of Adults
PSYCHODYNAMICS OF THE ADULT PATIENT sirability of going through with the treatment, and may reject
the repeated manipulation of his oral cavity by the
It is important to ascertain the motivation of the adult
orthodontist. The adult usually is impatient to see
patient who seeks orthodontic therapy to prevent conflict in
improvement. If the malocclusion occupies a prominent place
patient-doctor relations. Psychologic factors that motivate the
in the consciousness of the patient, he is apt to be cooperative.
patient must be ascertained in advance. There are patients who
Above all, one should make certain that he is dealing with an
have an oral fixation. They are not satisfied with their present
adult personality.
dental condition, do not basically wish to be satisfied with it,
and continue to go from one orthodontist or general dental
practitioner to the next until these rounds become part of their
life style. Adult patients should not be urged to accept treat- TISSUE TOLERANCE I ADULT THERAPY
ment. They must decide for themselves.
Do not take for granted that the adult patient is always Bone Changes
cooperative. Lack of cooperation can stem from Bone growth and phosphatase activity that accompany bone
psychodynamic as well as functional causes. The adult may change are less pronounced in the adult than in the child.
have second thoughts about the de- Rapid bone change does not occur in the adult and osteoclastic
activity on the application of orthodontic force to the teeth
Fig. 25-1. (Top left) Mutilated

dentition with severe overbite.
(Right) Radiogram showing
missing maxillary right lateral
incisor, infected area at apex
of left central incisor tooth and
loss of apical root substance.
(Bottom left) After the maxillary
incisor teeth were extracted a
partial denture with bite plane
was inserted to depress the
mandibular incisor teeth which
occluded on the maxillary
alveolar process. (Center) The
denture with bite plane in
position. (Right) Space opened
between maxillary alveolar
process and mandibular incisor
teeth for insertion of a
stationary bridge.
373
374 . Orthodontic Treatment of Adults
Fig. 25-2. (Left) Before treat-

ment. (Right! Treatment com-
pleted. The maxillary right and
left first premolar teeth were
extracted and maxillary incisors
and canines were moved
lingually. This patient is 24 years
of age.
Fig. 25-3. Treatment of adult. (Left)

Anterior view showing midline diastema
and loss of the maxillary left lateral
incisor. (Right) Anterior view after
treatment.
may exceed osteoblastic activity, diminishing the

thickness of the labial and buccal cortical alveolar bone.
"Rapid orthodontics" can harm adult tissues.
Soft Tissues
Light forces should be applied and as few teeth as
possible should be moved to obtain the desired result.
The patient should be informed in advance that ideal
results are not possible, if that is the case.
Low resistance of soft tissues surrounding the teeth of
Fig. 25-4. (Left) Large diastema between maxillary central adults can result in irritations, chronic gingivitis, and
incisors in an adult. (Right) Diastema closed by orthodontic gingival pocket formation. Some adults may show less
therapy. Spaces distal to the patient's lateral incisors have been tooth mobility after a period of treatment and retention
eliminated by bridgework. than before the teeth were
Tissue Tolerance in Adult Therapy . 375
Fig. 25-5. (Left) Adult for-

merly treated by closing spaces
of agenetically missing
maxillary lateral incisor teeth.
The incisor teeth are spaced.
(Center) Canine teeth moved into
normal occlusion. Round face
and round dental arch. This type
of facial pattern requires full
complement of incisor teeth.
(Right) Bridge in position.
moved to new positions. Slight alveolar bone loss does not present and caution is exercised in the application of force.
contraindicate treatment, provided active inflammation or Functional adaptation to the new occlusion ob-
other pathologic conditions are not
Fig. 25-6. (Top left) Profile view of an adult

with a mutilated dentition and Class 1 (Angle)
malocclusion. (Top right) Profile after
treatment. (Bottom left) Casts before and after
treatment. Increase in vertical space for
insertion of partial denture in mandibular den
tal arch. (Bottom right, above) The biteblock
used in raising the extruded maxillary
posterior teeth during treatment and re-
positioning the mandible. (Bottom right, below)
Prosthetic appliance worn after treatment.
376 . Orthodontic Treatment of Adults 39.
Fig. 25-7. Orthodontic treatment of an adult. (Top and center

rows: left) Before treatment, there is protrusion of the maxillary
incisors which rested on the lower lip when the mouth was in
repose. The mandibular incisors are spaced and there is distal
shifting of the premolars, following loss of the permanent first
molars. (Center) After treatment. (Right) Three years after
treatment. A partial denture with a continuous bar clasp has
been worn on the mandibular arch since completion of
treatment. At left is the type of partial denture worn by patient.
tained in treatment is usually slower in the adult than in the 4. Reestablish vertical height of the teeth and face
child. Equilibration of the occlusion, while important, may 5. Improve facial esthetics
not be the entire answer to interference with functional 6.Correct temporomandibular articulation abnormalities
excursions of the mandible. 7. Correct extreme variations in centric occlusion and
Functional and postural jaw pattern changes resulting from centric relation.
occlusal change and rapid tooth movement are not as readily Limitations in treatment of adults can be mini-
tolerated by the adult as by the child patient. The adult patient .rnized if attention is given to the following:
is more apt to follow long-established functional patterns that 1. General health of the oral tissues
were originally responsible for the malocclusion and thus 2. Abnormal tooth mobility and root resorption
provoke relapse. 3.At least half of the root should be surrounded by alveolar
bone
4. Condition of the periodontium should be satis-
factory
SCOPE OF ORTHODONTICS FOR ADULTS 5. Gingival infection should be eliminated
The scope of orthodontic therapy in adults includes the 6. Oral hygiene should be satisfactory
following: The age of the orthodontic patient is not as important as the
1. To move teeth to advantageous positions for use as soundness of the teeth and surrounding tissues, the height of
bridge abutments the alveolar process, and the amount of tooth movement
2. For establishing a more orthognathic profile required.
3.To improve the occlusion of the teeth by eliminating Treatment of Nonvital Teeth
spacing, crowding, crossb ite, abnormal overbite and overjet,
anteroposterior deviations of individual teeth and of the dental
arches Nonvital teeth can be moved orthodontically as
Case Report 377
Fig. 25-8. (Top left) Profile of

adult patient before treatment.
(Right) Profile after retention.
(Bottom left) Front view of dentition
before treatment. The maxillary
central incisor teeth were mutilated,
and crowded out of the arch. (Right)
After treatment. The canine teeth
were moved distally and jacket
crowns were constructed on the
centrals. Note the improvement in
the facial profile.
well as vital teeth. Tissue repair is slower in adults than through bridgework that replaces missing teeth.
in growing children. Care should be taken not to damage Retainers may be worn at night only, if they are
supporting tissues. The teeth should be reexamined at otherwise objectionable to the patient.
short intervals to detect root resorption. Anchorage is
frequently difficult to obtain and removable appliances
should be used whenever possible. CASE REPORT
Patient ]. G. (Fig. 25-11). This adult patient practlced

an occlusal mannerism of placing her incisor teeth in
Relapse and Retention edge-to-edge occlusion. She also suffered from bruxism
during the day and at night. The treatment changes were
Individual tooth movement in a labial or lingual confined to change in the intermaxillary-mandibular
direction presents less danger of relapse, especially incisor relation, which was decreased from 152 to 137.
when the change in position brings the teeth into a more The procumbency of the mandibular incisor angle to the
favorable functional position. Mesial or distal movement mandibular plane was increased from 90 to 93. The
of shifted posterior teeth can also be accomplished change in incisor axial relation is necessary to avoid
successfully. It is not always possible to obtain ideal relapse to the abnormal overbite which occurs when the
results in adult orthodontic treatment. Therefore, incisor teeth are permitted to remain in a relatively
compromises must be considered, and the appliances vertical relation with the maxillary-mandibular incisor
used should be acceptable to the adult patient. angle beyond normal range. (Normal range is 130 to
Adequate posttreatment retention is required and may 150S.) The reduction in the angle of convexity from +7
have to be used for longer periods than is usual with to +5 is shown in the change in the axial relation of the
children. Stationary retention is obtained maxillary incisor teeth which
Fig. 25-9. (A) dentition before

treatment, (B) abnormal overjet
corrected, (e) anterior facial
view before treatment, (D) after
treatment, (E) lateral view
before treatment, (F) lateral view
posttreatment.
were moved upward and distally. The slight occlusal lowed the change in A-Point when the angle of con-
plane change can be attributed also to the change in vexity and the maxillary-mandibular incisor angle were
incisor relation. The S-N-A dimensional change fol- reduced.
40. Treatment of Abnormal Overbite' 379
Fig. 25-]0. (A) anterior view

before treatment, (B) crowding
of mandibular incisor teeth, (C)
measurement revealed
sufficient space for aligning
three mandibular incisor teeth
without extensive tooth
movement of the mandibular
dental arch. The left lateral
mandibular incisor was
extracted and the occlusion of
the maxillary dental arch was
corrected with an extraoral
appliance. (0) anterior view of
dentition after treatment was
completed.
Fig. 25-11. Patient J. G. (Top

left) before treatment, severe
overbite, spacing and
periodontal inflammation.
(Right) Patient practiced an
occlusal mannerism in which
she brought her maxillary
central incisor teeth into edge-
to-edge relation under
pressure. The habit was prac-
ticed during waking hours and
while sleeping. (Center left)
abraded incisal edges of the
mandibular incisor teeth. (Right!
After treatment. Improvement
of periodontal condition.
(Bottom) Note the change in
axial relation of maxillary-
mandibular incisor teeth in the
tracings. Change in mandible
is due to increased vertical
dimension when overclosure
was corrected.
JG. -
Before
-- -After
'TREA TMENT OF ABNORMAL OVERBITE

In abnormal overbite when the angle between the maxillary
and mandibular incisors in occlusion is obtuse, there is a
gliding contact which tends to eliminate axial stress on the
incisor teeth and permits them to continue erupting, to show
an excessive amount of alveolar process, and to reach
excessive vertical levels that characterize deep overbite.
41.
Fig. 25-12. (Top left) Profile of S. A. before treatment. (Right)

Profile of patient after treatment. tBonom left) Anterior view of
dentition in occlusion showing severe overbite. (Right) anterior
view of dentition after treatment. Note chance in vertical relation
of incisor teeth. Tracing of lateral cephalogram showing change
SA. --
Before in axial relation of maxillary to mandibular incisor teeth. The
---After maxillary-
, mandibular interincisor angle was reduced. This is an aid in
preventing relapse of the corrected overbite.
rary relief only, since these teeth again show elongation.

Changes in the axial relation of the incisors is required.
Patient S. A. was treated for abnormal incisor overbite.
Approximately 6 years after retention was discontinued,
the cephalogram shows that there were no facial skeletal
changes during or after treatment. Changes were produced
in the maxillary-mandibular relation by orthodontic
therapy. There was an abnormally deep overbite before
Eruption of the incisor teeth continues until they meet treatment. Treatment required moving the maxillary and
resistance offered by the soft tissues on which they mandibular incisors into more procumbent relation by
impinge. Grinding of the incisors to relieve the changing
impingement on the soft tissues is a tempo-
42. Orthodontics in Occlusal Rehabilitation' 381
Fig. 25-13. C. L., 25 years of

age. (A) Lateral view before
treatment. (8) Lateral view after
treatment. C (top) Anterior view
of casts before treatment; (bot-
10m) anterior view of casts after
treatment by orthodontic means.
(Bottom) Cephalogram tracing
shows that the bite was opened
and the maxillary incisor teeth
were moved palatally while the
mandibular incisor procum-
bency was slightly increased to
overcome the extreme maxillary
incisor overjet without produc-
ing linguoaxial inclination,
"rabbiting" of the maxillary in-
cisors.
C.L -Age
21
their axial inclination to their basal arches in their
respective jaws and to one another. The maxillary- ----Age 26
mandibular incisor angle was reduced from 1560 before
treatment to 1400 after retention. This is required to
eliminate the "chopbite" and avoid relapse. The mandibular
incisor-to-mandibular plane angle was increased from 900
before to 960 after retention. Increase in procumbency of
the teeth is required in these cases (Fig. 25-12).
BRUXISM
The orthodontist should look for bruxism in his patients,
whether children or adults. Bruxism should be suspected
when severe wear is present in the teeth of a child or
adolescent or when there is unaccountable loss of alveolar
bone. Bruxism can cause periodon tal disease.
Variations of bruxism are teeth clenching, in which before any other reconstruction is undertaken. Functional
pressure is brought upon the periodontal structures by disturbances can follow lack of coordination between the
repeated clenching of the teeth and the teeth clicking habit, teeth, muscles, and temporomandibular articulation. Centric
which consists of repeated, rhythmic clicking of the teeth. relation can vary greatly from centric occlusion. While
Discovery by the patient of his own unconscious biting or radiographic examination is important in these cases, the
teeth clenching habits during waking hours is of diagnostic correction of the condition actually depends on trial and
value and is often the first step toward correction. The error, which is reduced by the clinical experience of the
patient then becomes more willing to cooperate. Treatment dentist and the changes in the pattern of occlusion
includes occlusal equilibration and an appliance similar to experienced by the patient.
a tooth guard or an activator. The appliance should be If occlusal rehabilitation, or so-called "bite-raising," does
made to fit over the mandibular dental arch. not take into consideration centric relation and centric
occlusion, the result is an unbalanced face, although the
teeth in the dental arch may be in good appositive relation
in terminal occlusion. This is true of orthodontic treatment
in general. Relocation of the mandible by orthodontics
actually is the result of the relocation of the teeth, which al-
ORTHODONTICS I OCCLUSAL lows the mandible to come into, or to maintain, centric
REHABILITATION relation when the teeth are in full occlusion.
Occlusal rehabilitation depends on the establishment of
correct centric relation and centric occlusion
43.
H
"I,
Fig. 25-14. (A) Anterior view before treatment. (B) Anterior view after completion of treatment. (C left) Occlusal view before treatment.
ote the loss of the mandibular permanent first molars. (D) Anterior view before treatment. (E) Anterior view after treatment. (F) Profile
before treatment. (G) Profile after treatment. (H) Cephalogram tracing shows maxillary and mandibular incisors have been lingually
repositioned.
However, where readjustment of the mandible is at- original off-center relation when the teeth are in full
tempted arbitrarily, necessitating stretching the occlusion.
masticatory muscles, the effort usually is attended by Occlusal rehabilitation cannot ignore functional
failure, and the mandible tends to return to its requirements. If arbitrary principles are followed in
44. Orthodontics in Occlusal Rehabilitation' 383
Fig. 25-15. (A) Edge-toedge

bite. (B) After treatment. (C;
Modified activator appliance
used, allowed the maxillary
arch to expand and assume
intermaxillary occlusion
shown in 16B, (0) View of
appliance. (E) Lateral view
before treatment. (F) Lateral
view after treatment. (G)
Cephalogram tracing shows
change took place in the oc-
clusion only.
KR
Before
Afte r
o
SNA
SNB Y- 77
0
AXIS N-
PgFH 8
IMPA 0
1
6
0
1 870
88
0
124
bite-raising, interferences are developed with the movements centric relation in rest position to full occlusion.
of the mandible, which seeks to function as it did before bite- Measurements of the profile from the hairline to the gnathion
raising was undertaken. or the menton point are not reliable. Profile roentgenographic
The patient must establish his own optimum vertical cephalograms can be helpful in establishing vertical height.
dimension. Measurement of the skin is inaccurate because of Mandibular repositioning can be accomplished by means of
muscular contraction, grimacing, and the manner in which the grinding away interfering cusps of teeth, by onlays to permit
patient will position his lips when requested to do so the mandible to assume a new centric occlusion. When the
purposefully. Repeating the word mama, m, or Mississippi is a mandible is forced into lateral, protrusive or retrusive relation
useful exercise for establishing centric relation. It can then be to the maxilla due to local dental interferences and tooth loss,
observed if there is a median line shift of the central incisors repositioning is a useful method of cor-
when the teeth are brought from
45.
AT
-- Before
---- After
Fig. 25-16. (A) Anterior view of dentition in an adult age 25 years. Patient had received orthodontic treatment which was completed
when he was age 13 years. (B) Dentition after retreatment. (C) Photograph showing profile before treatment. (0) Profile after retreatment,
(E) Tracing of cephalograms before and after retreatment.
recting the discrepancy. "Jumping the bite" is an old and

usually unsatisfactory method of mandibular
repositioning. When growth occurs at the tempore-
Fig. 25-17. Appliance used for bruxism. (Left) Inside view of

appliance. (Right) Outer view of appliance. (Bottom) Appliance in
position on mandibular dental arch.
Orthodontics in Occlusal Rehabilitation 385
46.
M,R. -
Before
---- After
Fig. 25-18. Adult patient who had refused mandibular resection 35 years earlier. Examination revealed a forced-forward
position of the mandible to achieve full occlusion, Rest position showed lingual surfaces of the mandibular incisors to be in
contact with the labial surfaces of the maxillary incisor teeth. (A) Lateral view before orthodontic treatment. (B) Lateral view
after orthodontic treatment. (e) Anterior view of occlusion before treatment. (D) Occlusion after treatment wi th orthodontic
appliances only. (E) Tracing of cephalogram before and after treatment.
mandibular articulation, bite jumping can be successful. are must be determined for the individual patient. When the
Vertical height should be established with a temporary variation between centric relation and centric occlusion
overlay splint which the patient uses for some time before goes beyond the range of individual tolerance or adaptation,
permanent reconstruction is attempted. This permits the traumatic conditions develop in the dentition, and
patient to become accustomed to the new occlusal temporomandibular articulation disturbances can manifest
relationship.
themselves,
An activator can be used to establish the vertical position
The innervation and musculature are adjusted to the
of the mandible and to bring centric relation of the
functional pattern before bite-raising is undertaken. This
mandible into close relation with centric occlusion. The
pattern develops gradually. The sudden change in the
appliance is worn by the patient until he feels comfortable
functional pattern when the occlusion is changed is
with the new mandibular position. Then splints are made to
responsible for the loss of the kinesthetic sense on the part
maintain the vertical height and the new position of the
of the patient, who now must learn to use his jaws
mandible. When the patient finds the new position
according to the reconstructed occlusion. This is difficult to
comfortable, permanent restorations are constructed.
accomplish for most patients, and some never master it. It
The human dentition can adjust itself, within limits, to
is necessary to make occlusal changes gradually and to
differences in centric relation of the mandible when the jaw
determine provisionally the patient's reaction to occlusal
is in physiologic rest position, or in centric occlusion of the
changes induced by bite-raising. The patient must be
teeth. What these limits
prepared for the changes he will experience in the
kinesthetics in his mouth.
The activator appliance is a means of determining the reconstruction of adult dentition. Tr. European Orthodorit.
adequacy of the mandibular relocation, the amount of Soc.. Annual, 1956.
optimal increase in a vertical dimension, and the patient's ___ : An orthodontic approach to therapy in cases of deep
tolerance of these changes. overbite in adults. Trans. European Orthodont. Soc. Annual,
1960.
Reitan, K.: Orthodontic treatment of adult patients. Den Norske
Tandlaegeforenings Tidende, 51:41, 1941.
Salzmann, J. A.: Problems of the adult as an orthodontic patient.
BIBLIOGRAPHY
Am. J. Orthodont., 57:84, 1970.
Beyron, H. L.: Occlusal changes in adult dentition. Schonherr, E.: Das Rez idiv und seine Verhiitung bei der
J.A.D.A., 48:674,1954. Kieferorthopadischen Behandlung Erwachsener (The relapse
Ford, J. W., and Ford, W. F.: Cephalometric appraisal of treated and its avoidance in orthodontic treatment of adults). Fortschr.
manibular displacement in an adult patient. Am. J. Orthodont., Kieferorth., 23:366, 1962.
36:222, 1950. Schwarz, A. M.: Orthodontic treatment of adults. Internat.
Goldstein, M.S.: Adult orthodontics. Am. J. Orthodont., D. J., 13:372, 1963 .
39:400, 1953. Wilson, J. H.: Some aspects of occlusion and restoration of the
Cranerus, R.: Orthodontics as a therapeutic measure in the mouth. Australian D. J., 5:185, 1960.
26
Orthodontics in Cleft Palate Therapy
ETIOLOGIC FACTORS Chromosomal Aberrations and Clefts. Cleft lip and

There are no clear-cut etiologic factors in clefts of the palate patients may show other malformations in the
lip and palate that are recognizable in the individual skull, fingers, or toes. The patient in Figure 26-5 shows
patient. Cleft lip and cleft palate formation can be chromosome aberrations usually associated with trisomy
attributed directly to failure of the lateral maxillary 18. Trisomy 18 is often accompanied by the following
processes to meet the medial frontal process at the proper malformations: prominent occiput and elongated skull,
developmental period. The cleft than occurs as a low-set ears, micrognathia, receding chin, Franceschetti's
manifestation of arrested development. One of the disease, hip dislocation, web bed neck, cleft lip, cleft
processes may have developed too slowly. Furthermore, palate, palpebral ptosis, club foot, small stature,
the processes may fail to fuse or they may fuse and then syndactyly, renal and cardiac deformities.
separate (see Chap. 2~. Cleft palate occurs once in about
700 births in the United States.
Stages of Cleft Formation. At about the sixth week, the
TYPES OF CLEFT LIP AND PALATE
ends of the medial nasal process and the maxillary
process have not yet met, and there is a gap or groove The major types of clefts are as follows:
running between them from the mouth to what eventually Class I-cleft of the soft palate only.
will be the nostrils. If the two processes do not fuse, the Class II-cleft of the soft palate and some part of the
gap will remain and the child will be born with a cleft. hard palate, up to the incisive foramen. These types show
Various degrees of incomplete fusion lead to different palatal tissue deficiency.
degrees of clefts from the barely noticeable subcutaneous Class III-clefts through the hard and soft palates plus a
scar on the lip, a complete gap in the lip, to a cleft or complete or incomplete fissure through the alveolar
clefts that extend into the nostrils. Simple cleft lip is process either to the left or the right side of the frontal
characterized by integrity of the alveolar process. (premaxillary) section of the maxilla. This is the most
Malocclusion in the surgically corrected cleft lip child, frequent type. Complete unilateral clefts usually show the
when the alveolar process is intact, is not related to the least deficiency of tissues.
cleft. In unoperated clefts of the lip only the incisors Class IV -clefts involving all of the hard and soft
show irregulari ty. palate. These show a fissure at the right and left sides of
Clefts without genetic reference include cleft lip the frontal section of the maxilla. The frontal ~ection
without associated cleft palate, which occurs mostly in (premaxilla) is isolated. It may be underdeveloped and is
males, and cleft palate without cleft lip, which is more usually malpositioned.
frequently found in females. Clefts occur more frequently Class III and Class IV-clefts accompanied, as a rule, by
on the left side. a cleft of the lip on the side of the alveolar cleft. Lip clefts
Parents who may not themselves have cleft lip or cleft may be complete or incomplete and occur on the right or
palate but who have had one child with a cleft, have one left side of the upper lip.
chance in 25 that another child will have the same defect.
There is 1 chance in 50 in nephews and nieces, 1 in every
200 in uncles and aunts and first cousins. In heterozygous DENTAL ABNORMALITIES
twins, about 5 per cent of twins show the cleft in both
twins. Of monozygous twins with clefts, about 40 per There usually are dental abnormalities in number, size,
cent will both have the cleft, and in 60 per cent only one and arrangement of teeth in all types of cleft palate. Clefts
has it. can occur in children who would have had different types
of malocclusion even if they did not have the cleft. The
malocclusion is modified by the presence of the cleft. In
extreme Angle Class II malocclusion the presence of a
cleft may reduce the
387
388 . Orthodontics in Cleft Palate Therapy 47.
~ c ~ o
H
r[f~ 0 01
J M N
K L o p
Fig. 26-1. Common types of cleft of lip: (A) Submucous cleft of lip. The epithelium is intact but the
orbicularis oris muscle is cleft. (B) Complete cleft of lip. (C) Partial bilateral cleft of lip. (0) Complete
bilateral cleft of lip. The prolabial part of the lip (shaded) contains no muscle tissue. Unilateral clefts of
lip, alveolus, and palate: (E) Cleft lip and alveolus. (F) Cleft alveolus, lip and palate intact. (C) Cleft of
lip, alveolus, and anterior part of hard palate. (H) Complete unilateral cleft of lip, alveolus, hard, and
soft palate. The absence of any muscle tissue in the prolabium (shaded) is a constant feature of bilateral
clefts: (l) Bilateral cleft of lip, alveolus, and anterior part of hard palate. The hard palate is intact but the
cleft follows the frontal process pattern. (j) Bilateral cleft of lip with unilateral cleft of lip, alveolus, and
palate. (K) Bilateral cleft of lip and alveolus. Unilateral cleft of palate. (L) Bilateral cleft of lip, alveolus,
and palate frontal segment is supported by the vomer, and the two lateral halves of the maxilla are
completely separated. Isolated cleft palate: (M) Submucous cleft of soft palate; epithelium is intact but
there is lack of midline continuity in the muscle of the soft palate. (N) Cleft of soft palate. (0) V-shaped
cleft of hard and soft palate. (P) U-shaped cleft of hard and soft palate. (Courtesy D. Glass)
maxillary prognathium. The nose may be deformed adjustment to life and has accepted a feeding formula and
when the lip is cleft into the floor of the nose. shows a steady, progressive gain in weight. Cleft palate is
usually closed at between 24 to 36 months of age. Lip or
nostril surgical revisions are performed at later ages.
Dentofacial Growth
Malocclusion in cleft palate and cleft lip patients can
Cleft lip is usually surgically closed several weeks be caused by deficiencies in the bone, the soft
after birth when the infant has made a satisfactory
Orthodontic Intervention 389
Fig. 26-2. Facial and palatal views of a father and two children. The father has a cleft of the soft and part of the hard
palate. (Center) Child, age 2V2 years, has a cleft of the soft palate extending only partially into the hard palate. (Right)
The girl, 1 year old, has cleft of the soft palate only. Tl;e trait seems to be transmitted as a recessive one.
tissues, supernumerary teeth, and missing tooth germs. labial or premaxillary segment in a protrusive position.
Malocclusion can be caused also by excessive scar tissue Tightness of the repaired cleft lip can cause palatal
resulting from extensive surgery in the growing child. inclination of the maxillary incisors and anterior cross
Incomplete clefts of the lips only are not a direct cause bite.
of malocclusion. When the cleft affects the alveolar
process there is a malocclusion of the teeth. Clefts of the
ORTHODONTIC INTERVENTION
soft palate only and submucous palatal clefts do not
affect the occlusion although they are a cause of speech Orthodontic therapy is required to prevent or correct
nasality. Clefts of the hard palate only may cause a collapse of the maxillary dental arch before and after
narrowing of the maxillary arch with a tendency to surgical lip closure. Orthodontic treatment in the
crossbite, but severe malocclusiens in these cases can be deciduous dentition when the roots show advanced
attributed to other etiologic factors. Accompanying resorption is of no value. Removable appliances should
abnormalities of clefts of the lip, alveolar process, and be used where possible in the deciduous and early mixed
palate are difficulties in feeding and swallowing, speech dentitions.
defects, syndactyly, hypertelorism, and other somatic and The orthodontist in the cleft palate team is concerned
psychic disturbances. with the following:
In bilateral clefts of the lips there usually is lateral 1. Consult and advise on dentofacial growth.
collapse of the maxillary buccal segments with the 2.Prepare diagnostic aids and records including dental
impressions and casts, photographs, and face casts.
390 . Orthodontics in Cleft Palate Therapy
Fig. 26-3. (A, B) Both of these

monozygous 8-year-old twins have
clefts of the lip and palate which
have been closed. The dentition is
disturbed in these twins, as is
usually the case in persons with
clefts (C, D). The maxillary left
central incisor tooth in the child on
the left has erupted, but not the
adjacent lateral incisor. The child
on the right shows lack of eruption
of the upper left central incisor,
although the lateral incisor on this
side has erupted.
Fig. 26-4. (A) One of these

heterozygous twins has cleft lip
and palate. (B) A thumbsucking
habit has affected her dentition,
too. The twin with the clefts
also had webbed fingers and
clubfoot- both on the left side -
which have been operated on (C,
D). The girl's syndrome has been
correlated with trisomy ]8
(triplication of the 18th chro-
mosome of group E). Abnor-
malities of the extremities are
frequently found in cleft palate
patients. (Salzmann, J. A.: Am. J.
Orthodontics, 61: 453, 1972)
48. Orthodontic Intervention . 391
Fig, 26-5. (AJ This boy has

hypertelorism and a flat nose,
His cleft lip and palate were
closed surgically (8), but he has
anterior and right lateral cross
bite (C). He had malformed
hands with syndactyly and
webbed fingers which have
been operated on. This type of
malformation is typical of
patients with trisomy 13,
(Salzmann, ], A.: Am. ].
Orthodontics, 61:445,1972)
3. Make radiograms - periapical dental films; lateral One exposure is made with the mandible in rest
jaw, cephalometric, and posteroanterior films, and position. The patient makes the sustained sound, eee, and
tracings of cephalograms. is told to pronounce kaa and to hold the k sound as long as
4. Make stents to maintain lip contour and prevent possible. These sounds are representative vowel and
postoperative lip tightening. consonant sounds.
5. Provide orthodontic treatment preoperatively, In the normal palate the soft palate extends downward
postoperatively, and before the construction of prosthetic and curves gently from the posterior margin of the hard
appliances. palate at a thickness of 0.5 to 1.0 em., as measured on the
6. Advise on the patient's dentofacial growth status and radiogram. The lower portion of the soft palate terminates
potential in relation to optimum timing of plastic surgery, in the uvula which appears bulbous on the radiogram.
orthodontic treatment, and prosthetics. The soft palate moves upward and backward during
7. Correct malocclusion. speech, touching the posterior pharyngeal wall. In cleft
palate the two halves retract laterally against the fauces
and produce a hazy, unrecognizable shadow on the
radiogram, making it appear that the soft palate is
Radiography
missing entirely. The repaired cleft may show the palate
Contrast material is applied in the following manner to to have a normal appearance or to be short to varying
obtain a profile radiograph of the pharynx. The patient is extents. The palate may appear to be thicker or thinner
put in a reclining position, and 1 to 2 mg. of a thin than normal on the radiogram.
barium mixture is placed in each nostril, If the patient
does not sneeze, he is asked to cough with the mouth
closed in order to distribute the barium through the
pharyngeal area. A small amount of the mixture is then
given by mouth to coat the tongue. The radiogram is now Timing of Orthodontic Treatment
made, using an 8 x lO-inch film in a cassette. The central Orthodontic therapy in cleft palate patients does not
ray is directed to a point about 1 inch anterior to, and 1 follow the usual pattern that applies to children with
inch below, the external auditory meatus. sound lips and palates. Treatment is on a periodic basis.
It may be for as little as a few months to
Fig. 26-6. (A) In this case of

bilateral cleft lip, alveolar
process, and palate, the max-
illary oversized permanent
central incisor and the right
permanent lateral incisor and
deciduous central incisor are
in position. (B) A deciduous
canine extends into the cleft
and should be extracted along
with the first premolar, to
allow the permanent canine to
erupt. (C) The lateral incisor
on the right shows a lack of
alveolar bone. These teeth
cannot be stabilized without
permanent retention. A
supernumerary tooth extends
into the cleft and should be
extracted. (D) There is a
deciduous canine at the edge
of the bone at the cleft.
correct what is required at a given time. There may be a period of treatment in a cleft palate child, while in the child
number of periods of supervision necessary when further with a normal palate it would be better to wait until more
orthodontic treatment has to be held in abeyance for the development has taken place. Crossbite should be corrected
dentition to gain further development. It frequently is as early as possible, as is true also for the child with a
necessary to initiate a short normal palate.
Fig. 26-7. (Left) Frontonasal

process extends outward.
Surgical excision of the fron-
tonasal process results in
collapse of the alveolar arch
and loss of the anterior teeth
(Center). (Right) Area from
which the frontonasal process
was excised.
49.
Orthodontic Intervention . 393
Fig. 26-8. (Left) The central in-

cisor next to the cleft is deficien t
in enamel. Alveolar bone sur-
rounding this tooth is deficient,
making it necessary to retain it
with a permanent bridge. At-
tempts to bring this tooth to the
same level as the right central
incisor failed because of the
deficiency of alveolar bone. (Right)
The position of the tooth in
supraclusion was corrected with a
stationary bridge.
Contraindications bone available in the area in which teeth are to be moved,

the presence of deformed teeth that cannot be moved and
Contraindications to orthodontic therapy are the general made serviceable, presence of a large number of missing
physical condition of the patient, lack of teeth, and the fact that extensive
Fig. 26-9. Radiograms of a

patient with a cleft on the left
side of the palate and alveolar
process. In the maxilla there
is agenesis of the lateral
incisors, permanent canines,
and permanent central
incisors. The second
premolars and the first pre-
molar on the maxillary right
side also are missing. In the
mandible the first premolars
are present but the second
premolars are missing as are
the mandibular central inci-
sors and permanent canines
and second and third molars.
Oligodontia frequently is
found in cleft palate patients.
394 . Orthodontics in Cleft Palate Therapy 50.
Fig. 26-10. A schematic

drawing of patient-centered
. cleft palate rehabilitation as
devised by Dr. Aaron Bleiberg.
(Mount Sinai Hospital Cleft
Palate Center)
prosthetic appliances would be required which would not by prosthetic appliances. The deficiency in bone and soft
be aided by orthodontic treatment. tissues as a result of the cleft present certain limitations to
the extent and direction of tooth movement.
Results
Advantages of orthodontic treatment are the improved
Indications for Prosthesis
function and esthetics, more secure retention of prosthetic
appliances, the teeth remain longer in the jaws if not A denture should be constructed when prognosis for
covered by the prosthetic appliance, and speech therapy surgical correction is poor or when it has proved
is facilitated. unsuccessful, when many teeth need replacement, and
When teeth are absent the plan of treatment must take where teeth needed for abutments of bridgework are
into consideration the positioning of the teeth in the missing or unsuitable. Bridges should be used wherever
mouth to aid in restoring the missing teeth possible to replace missing teeth
Orthodontic Intervention . 395
so the patient need not wear a denture throughout life. A

denture or a bridge can serve as a permanent retention
appliance after orthodontic therapy.
Supernumerary Teeth
Supernumerary teeth in cleft palate patients should be
allowed to remain in the mouth if they are erupted and can
be made useful. They should be extracted if they are
impacted and interfere with the eruption of adjacent teeth.
Malformed teeth should be allowed to remain if they can
be brought into occlusion and restored by jacket crowns.
Teeth in supraclusion should be brought into occlusion by
orthodontic means.
When the maxillary dental arch is expanded in cleft
palate patients, permanent retention by means of a plate or
Fig. 26-11. This alginate impression was taken on an
bridgework may be required. In dental arches where the
infant with bilateral clefts of the lip and alveolar process
teeth are inclined palatally they should be uprighted.
and cleft of the palate.
Orthodontic treatment in cleft palate may be performed
with fixed or removable appliances. Interjaw traction may
be used to correct maxillary collapse.
Delay is not always necessary in constructing obturators,
speech aids, and other prosthetic appliances
Fig. 26-12. This child had deft

lip with a protruding frontonasal
portion. A split-plate with
extensions and a bar across the
lip was used to bring it inward
and reduce the protrusion of the
frontonasal portion.
Fig. 26-13. (Left) The maxillary arch had collapsed.

Orthodontic therapy restored the arch (right) before a stationary
bridge was inserted.
1. Resection of the frontal portion. This results in

collapse of the alveolar arches and severe malocclusion.
2. The frontal portion may be allowed to remain in place
until after eruption of the permanent teeth at which time
until orthodontic treatment is completed. Orthodontic aids the course of treatment of the so-called floating premaxilla
can frequently be incorporated into prosthetic appliances. is determined.
3. Dental orthopedics provides a satisfactory solution
when the space for the protruding premaxilla is too small.
After initial lip closure, the pressure of the lip against the
Postoperative Anomalies
frontal process has a tendency to reposition this segment
Postoperative dentofacial abnormalities in children into a more functionally stable position.
with cleft palate include: 4. Expansion of the collapsed lateral maxillary seg-
1. Anterior and posterior crossbite ments, shortly after birth, either before or after lip closure
2.Collapse or underdevelopment of the anterior and is accomplished by the insertion of a splitplate and the use
buccal maxillary segments of adhesive tape across the upper lip and cheeks. This type
3. Openbite or dental arch collapse in association with of repositioning of the frontal segment is less effective
maxillary underdevelopment and bone deficiency. after the age of 3 months, when the prevomerine segment
of the nasal septum begins to show cartilage formation.
McNeil (1954) pointed out that undesirable changes
begin to occur in children with cleft palate immediately
CLEFT PALATE ORTHOPEDICS after birth, and that these are accentuated by early surgical
The frontal portion of the maxilla (the floating pre- closure of the lip and palate.
maxilla) in bilateral clefts of the lip, alveolar process, and
palate can be treated in one of the following ways.
Fig. 26-14. (Left) Collapsed dental arch with frontonasal process out of the line of occlusion. (Center) Widening of the dental arch permits
the frontal portion to come into position. (Right) The arch is expanded. The frontonasal process, which was included in the mucosa when
the lip was closed, can now be freed and permitted to come into position. Thus, the patient will eventually have the advantage of the teeth
in the frontonasal process.
Cleft Palate Orthopedics' 397
Fig. 26-15(AJ. This infant had a double cleft. The frontonasal portion protrudes and is horizontal
to the lateral segments. Adhesive tapes exert light pressure on the frontonasal process. A split plate
is used intraorally; dental floss is attached to prevent it from being swallowed or otherwise
misplaced. Notice how the process approximates the lateral segments and how the clefts
approximate. (8, Below) Two views of the split plate; the lingual surface shows the expansion screw
and the dental floss to hold the plate. An applicator was necessary to feed the baby soon after birth.
Fig. 26-15 (Cont.) (C) Compare casts of the palate and protruding frontal process before and after
treatment. The photograph shows the beginning of deciduous tooth eruption. (D) The appearance of
the infant before and after cleft lip closure. (Courtesy Mount Sinai Hospital Cleft Palate Center)
Cleft Palate Orthopedics . 399
McNeil's technique for treating collapsed cleft palates is after they are' repositioned. A new impression is taken and
as follows: a cast is poured.
1. An impression is taken of the palate and a dental cast 4. An acrylic plate is constructed on the new cast.
is made to be used as a master cast. Three or four plates may have to be made if the collapse is
2. An impression is taken of the master cast and a severe.
working cast is made. 5. Looped retaining wires are inserted to extend forward
3. The working cast is sectioned through the cleft or from each side of the anterior part of the acrylic plate.
clefts, and the maxillary segments are repositioned to ideal The appliance floats freely in the mouth but is upheld by
arch width anteriorly while the original width at the molar the tongue, which is kept out of the cleft. This helps the
region is maintained. Wax is filled into the spaces between child to bottle feed. Lip surgery is
the sectioned parts
Fig. 26-16A. Lateral casts of dentition before (left) and after (right)
treatment to correct crossbite and change the axial position of the
central incisor teeth. Anterior and occlusal casts made were before
and after treatment and with a partial denture inserted. (Continued on
overleaf)
400 Orthodontics in Cleft Palate Therapy
Fig. 26-16B. Radiograms

were made before and after
treatment. The appliance used
was a split plate with extensions
to widen the arch, (Courtesy
Mount Sinai Hospital Cleft
Palate Center)
postponed until the bony segments have been moved brought into apposition before faulty speech patterns
into favorable position. Repair of the soft palate then are formed.
is performed, and the functioning muscles are Treatment is begun about 6 weeks prior to lip re-
Fig. 26-17, This patient had

clefts of the hard and soft palates
which did not involve the
alveolar process:
She had never received or-
thodontic treatment. (Top) At
right are an occlusal view of the
operated palate and a frontal
view of the dentition after
treatment When the alv.eolar
process is not involved in a cleft
of the palate, the occlusion is not
subject to the effects of the cleft.
Malocclusions present are
coincidental to the cleft palate.
Cleft Palate Orthopedics . 401
Fig. 26-18. This child with

cleft lip and palate sucks her
thumb. The alveolar process is
disturbed by thumb-sucking.
pair. The appliance usually is tolerated well by the McNeil constructs a plate after the. soft palate only is
patient. Alignment of the palate in the cleft palate patient surgically closed. This he calls a stimulation plate. It is
eliminates many of the problems that orthodontists, intended to bring about a reduction in the width of the
dental prosthetists, and speech therapists face when cleft during maxillary growth while the deciduous
treating the cleft palate patient at a later age. dentition is developing.
Bone grafting to supply missing tissues in oral
Fig. 26-19. (Top) Occlusal views before

(left) and after (right) treatment. The deficiency
of palatal tissues was supplied by a partial
denture (bottom).
Fig. 26-20. (Left) An incomplete cleft

of the soft palate extending into the
hard palate. A speech appliance (an
obturator, shown below) that had an
extension through which an auxiliary
wire spring was attached to obtain
movement of teeth into alignment is
shown in place of the mouth (right),
Fig. 26-21. This boy had a col-

lapsed maxillary arch, oligodontia,
and crossbite. Compare the profile
and occlusal views before (left) and
after (right) treatment. (Continued
on next page)
Cleft Palate Speech . 403
Fig. 26-21. Continued. The

patient had round, misshapen,
short-rooted central incisors
which were extracted. The
appliance used for orthodontic
correction is shown on a cast
(bottom). A bridge was
constructed to supply the
extracted teeth.
clefts is now practiced widely. Rosenstein advocates CLEFT PALATE SPEECH

bone grafting after the alveolar ridges are aligned. The
graft, usually an inch long, is taken from the sixth, Normal speech depends on intermittent closure
seventh, or eighth rib. between the nasopharynx and the oropharynx. Cleft
Fig. 26-22. This lO-year-old girl had

muscular incoordination, retarded growth,
facial asymmetry, webbed and deformed
fingers and toes. The maxillary arch was
collapsed, and the premaxilla had been excised
(bottom left>. The appliance used to widen the
arch is shown at bottom right and in place in
the mouth (overleaf, top left). A partial denture
with four incisors was made (overleaf, top right>.
The clasps used to retain the partial denture are
fashioned around the first premolars. The
patient still has no incisor occlusion, and she
now needs a partial lower denture. Compare her
profile with the denture out (overleaf, bottom left>
and with the denture in place (right> at age 17.
Fig. 26-22. Continued. (Top left) Appliance in position. (Top right) A partial denture with 4 incisor teeth inserted in the
mouth. Deciduous canines seen in 26-27 (A) (bottom left) were extracted. The clasps used to retain the partial denture are
fashioned around the first premolars. The patient still has no incisor occlusion. She now requires a partial lower denture.
(Bottom left) Profile view at age 17 years taken with the denture out of the mouth. (Bottom right) Lateral view with denture in
position,
Fig. 26-23. (Left) Schematic

drawing of maxillary arch
alignment which usually results
after lip closure without early
segment guidance. (Right) Actual
cast of patient in whom an early
maxillary orthopedic appliance
was not placed. Note medial
collapse of the lesser segment.
(Rosenstein, S.: Am. J.
Cleft Palate Speech 405
Fig. 26-24. (Top, left) A

schematic drawing of the arch
relation of one patient with
unilateral cleft shows the outline
(broken line) of the passive
appliance that maintains relation
of the segments as the larger one
responds to molding pressure of
the surgically closed lip. A cast
was made with the appliance in
place (right). (Second row) Three
months' use of a passive
appliance and lip closure
brought the patient's arches into
good alignment for bone
grafting for stabilization. The
schematic represents the ideal
arch alignment for a complete
unilateral cleft before grafting.
(Bottom row, left) Compare the
cast of this patient taken on the
initial visit (below) with one
made after the deciduous
dentition had erupted (above).
Note how segment rotation had
been reduced. (Bottom row, right)
The occlusal radiograph on the
top was taken immediately after
the bone graft; approximately 2
years later (bottom), a tooth can
be seen erupting in the graft
area. (Rosenstein, S.: Am. J.
palate causes more speech defects than any other oral Cleft palate speech is a term used to describe the
deformity. A speaker with cleft palate may omit every characteristic speech disorder of a person with cleft or
consonant except 111, n, and ng; his speech is characterized nonfunctioning palate. The abnormalities of the teeth, the
by many vowel distortions and a nasal vocal tone. Anatomic nasal structures, and the tongue contribute to speech
or physiologic abnormalities produce nasal escape of air and difficulties in articulation which are usually accompanied
the familiar errors in articulation which make up the so-called by hypernasality,
cleft palate speech. A severe dyslalia can occur, as well as an excessive
hyperrhinolalia and/or hyporhinolalia, if the soft
palate is tight, scarred, short, or cleft, if the hard palate is Fogh-Andersen, P.: Significance of a centralized treatment of cleft
too high or too flat, if there are certain types of lip and cleft palate. Acta Chir. Traum. Surg., 24:448, 1958.
malocclusion and obstruction or irregularity in the nasal ___ : Inheritance patterns for cleft lip and cleft palate.
cavity, or the upper lip is tight and scarred. In Pruzansky, S. (ed.): Congenital Anomalies of the Face and
Associated Structures. Springfield, Ill., Charles C Thomas, 1961.
Surgical operations are best performed before the
Fraser, F. C: Some experimental and clinical studies on the cause
optimum age for development of speech is passed and
of congenital clefts of the lip. Arch. Pediat., 77:151, 1960.
before defective speech patterns are fully established. Fraser, F. C, and Baxter, H.: The familial distribution of
Since the majority of consonant sounds is used before congenital clefts of the lip and palate. Am. J. Surg., 87:656,
the end of the first year, early cleft palate closure 1954.
operation actually can be effective in aiding speech. ___ : Harelip and cleft palate. In Fishbein, M., (ed.):
Problems of speech may originate from imitative Birth Defects. Philadelphia, J. B. Lippincott, 1963.
psychological and neurologic causes as well as from Fukuhara. T" and Saito, S.: Possible carrier status of hereditary
disturbed anatomy and physiology. Consideration should cleft palate with cleft lip. Bull. Tokyo M. & D. Univ., 10:333,
be given to the complete biosociopsychic dynamics of 1963.
the patient. Glass, D. F.: The orthodontic treatment of cleft lip and palate
patients. Ann. R. ColI. Surg. Engl.. 239:25, 1959.
Goddard, C. L.: Separation of the superior maxilla at the
symphysis. Tr. World's Columbian Dent. Cong., 2:89, 1894.
Counselling Parents Crabb, W. C, Rosenstein, S. W., and Bzoch, K R.: Cleft Lip and
Palate: Surgical, Dental and Speech Aspects. 619 Illus., pp.
During the interview with the parents an attempt is 952.
made to alleviate their many fears and anxieties. Parents Hagerty, R. F., et al.: Dental arch collapse in cleft palate.
are informed that they are exempt from any guilt or Angle Orthodontist, 34:25, 1964.
contribution to their child's physical defect. They are Harkins, C. S., Harkins, W. R, and Harkins, J. F.: Principles of
advised that the patient should be thought of and treated Cleft Palate Prosthesis: Aspects in the Rehabilitation of the
as a normal child. Under supervision and treatment, they Cleft Plate Individual. New York, Temple University, 1960.
should be assured, and precluding unforseen Harvold, E.: Cleft lip and palate: morphologic studies of the facial
disturbances, the child will develop into a healthy adult skeleton. Am. J. Orthodontics, 40:493, 1954.
with a normal appearance. Haupl, K: Die funktionelle Kieferorthopadie im Dienste der
Behandlung der Kiefer-und Caumenspalten. Fortschr. Kiefer
Cesichtschir., 1:161, 1955.
BIBLIOGRAPHY Law, F. E., and Fulton, J. T.: Unoperated oral clefts at maturation.
Am. J. Pub. Health, 49:1507, 1959.
Bolin, A.: Dental anomalies in harelip and cleft palate. indquist, A. F.: The team approach to the cleft palate problem.
Acta Odont, Scandinav., 21 :38, 1963. Am. J. Orthodontics, 47:171,1961.
Bzoch, K R.: Clinical appraisal of cleft palate rehabilitation Mazaheri, M., et al.: Changes in arch form and dimensions of cleft
problems. J.A.D.A., 60:696, 1960. patients. Am. J. Orthodontics, 60:19, 1971.
Cadenat. E.: Le Bec-De-Lievre Quelques Aspects Actuels de la McKee, F. L.: A cephalometric radiographic study of tongue
Question. Ann. Odonto-Stomatol., 3:99, 1960. position in individuals with cleft palate deformity. Angle
Charnbiras, P. G.: Reduction of prominent premaxilla in bilateral Orthodontist, 26:99, 1956.
cleft palate. Australian D. J., 6:29, 1961. McKenzie, J.: The first arch syndrome. Arch. Dis. Child., 33:477,
Cooper, H. K: Cinefluorography with image intensification as an 1958.
aid in treatment planning for some cleft lip and/or cleft palate Mc eil, C. K.: Oral and Facial Deformity. New York, Pittman,
cases. Am. J. Orthodontics, 42:815, 1956. 1954.
Crikelair, G. F., Born, A. F., Luban, L and Moss, M.: Early ___ : Congenital oral deformities. Brit. D. J., 101:191, 1956.
orthodontic movement of cleft maxillary segments prior to cleft Mestre, J. c.. Dejesus, j.. and SubteLny, J. D.: Unoperated oral
lip repair. Plast. Reconstr. Surg., 30:426, 1962. clefts at maturation. Angle Orthodontist, 30:78, 1960.
Curtis, E. L Fraser, F. C, and Warburton, D.: Congenital cleft lip Morley, M. E.: Cleft Palate and Speech. Baltimore, Williams &
and palate. Am. J. Dis. Children, 102:105, 1961. Wilkins, 1962.
Derichsweiler, H.: Orthodontic particularities in the treatment of Moss, J. P.: Cephalometric changes during functional appliance
harelip and cleft palate and their anatomical explanation. Zbl. therapy. Tr. European Orthodont. Soc.. Annual, p. 327, 1962.
Chir., 84:1799, 1959. Pielou, W. D. and Allen, A.: The use of An Obturator in
Deuschle, F. M., and Kalter, H.: Observations on the mandible in
association with clefts of the lip and palate. J. D. Res., 41:1085,
1962.
Dorrance, C. M.: The Operative Story of Cleft Palate.
Philadelphia, W. B. Saunders, 1933.
Eby, J. D.: Maximum improvements in congenital orofacial clefts.
Am. J, Orthodontics, 42:867, 1956.
Bibliography . 407
the Management of the Pierre Robin Syndrome. D. clefts of the 'lip and palate, Public Health Reports, 78:589-602,
Practitioner, 18:169, 1968. 1963.
Ridley, D. R.: Some difficulties experienced in the orthodontic Schweckendieck, H.: Ergebnisse bei Lippert-Kiefer-
treatment of patients with cleft lip and palate. Dent. Guamenspaltoperationen mit der primaren Veloplastik,
Practioner, 8:166, 1962. Fortschr. Kiefer Gesichts, 4:167, 1958.
Rosenstein, S. W.: A new concept in the early orthopedic Services for Children with Cleft Lip and Cleft Palate. A Guide for
treatment of cleft lip and palate. Am. J. Orthodontics, 55:765, Public Health Personnel, N. Y., Am. Pub. Health Ass., 1955.
1969. Smith, J. L., and Stowe, E. R.: The Pierre Robin syndrome
Ross, R. B. and Johnston, M. c.: The effects of early ortho- (glossoptosis, micrognathia, cleft palate). Pediatrics, 27:128,
dontic treatment on facial growth in cleft lip and palate. Cleft 1961.
Palate J., 4:157, 1967. Veau, V.: Division Palatine. Paris, Masson & Cie, 1931. ___ :
Salzmann, J. A.: Personality problems in cleft palate and Hasenscharten menschlicher Keimlinge auf der Stufe 21-23 mm.
orthodontic patients. In Cantor, A. J. and Foxe, A. (eds.): Anal. Entwckl., 108:459,1938.
Psychosomatic Aspects of Surgery. New York, Crune & Wildman, A. J.: The role of the soft palate in cleft palate speech.
Stratton, 1956. Angle Orthodontist, 28:79, 1958.
-_: The reprieve of the premaxilla. Am. J. Orthodont., 57:411, Wood, B. G.: Maxillary arch correction in cleft lip and palate
1970. cases. Am. J. Orthodontics, 58:135, 1970.
San Francisco, California, Epidemiology of congenital
27
The Edgewise Appliance
R. WILLIAM McNEILL, D.D.S., M.S.
The edgewise appliance, as it is used in presentday principles is a necessary prerequisite to application of the
orthodontic practice, is applicable to the treatment of any details of appliance manipulation.
type of malocclusion from the most simple to the most
complex. The unique capability of the edgewise bracket DEVELOPMENT
wire combination to produce bodily tooth movement
simultaneously or separately in all three planes of space The universal applicability of the edgewise appliance
permits correction of the most extreme tooth malpositions has been achieved by a long process of evolution that
without the necessary addition of specialized intraoral began in the late 19th century with the innovative efforts
auxiliaries. However, the generalized nature of the of Edward H. Angle and continues to the present day. The
edgewise appliance permits the addition of auxilliaries original edgewise appliance represented the culmination
where desired for adaptation to specific tooth movement of Angle's efforts to design a system that would provide
tasks. intimate control of tooth position in all three dimensions.
Thus, in contrast to specialized appliance systems that Each of Angle's treatment systems beginning with the E
have been developed for and are limited to treatment of arch and extending through the pin and tube appliance and
particular types of malocclusions, the modern edgewise ribbon arch to the edgewise bracketwire combination was
appliance can be manipulated to correct the entire designed in keeping with his contention that maintenance
spectrum of tooth malpositions and dentoalveolar of a full complement of teeth and development of alveolar
disharmonies. This chapter is a presentation of the bone through dental arch expansion were the sine qua non
methods of construction and application of only one of of orthodontic correction.
the many variations of the edgewise appliance. However, At each phase in appliance evolution, Angle recognized
the mechanical principles employed in the appliance limitations in design and ingeniously devised means to
system shown here are central to the functions of al1 the circumvent them thus giving rise to the next
edgewise modifications. An understanding of these developmental step. With the E arch appliance (Fig. 27-1)
mechanical principles and their relationship to hard tissue direct ligation from the base arch to anterior teeth limited
physiology, as well as a grasp of orthodontic treatment tooth movement to rotation and tipping in a labiolingual
planning and mesiodistal direction. The subsequent addition of
vertical pins to the archwire and tubes to the labial band
surfaces (Fig. 27-2) introduced the capability for bodily
axial tooth movement in both labiolingual and mesiodistal
directions. Dental arch expansion and correction of
crowding was accomplished by periodic mesial ad-
vancement of the base arch and successive adjustment of
pin position and inclination. Rigidity of the base arch and
the critical nature of pin positioning made manipulation of
this pin and tube appliance very difficult.
Introduction of the ribbon arch appliance in 1916 (Fig.
27-3) resulted in considerable simplification of appliance
adjustment and gained direct rotation control without the
use of staples or auxiliary springs such as were necessary
with the pin and tube ap-
Fig. 27-1. Tooth movement was accomplished with
Angle's E arch appliance by direct ligation from malposed
teeth to a heavy labial archwire anchored to molar bands.
Only tipping movements were possible with this mecha-
nism.
40
8
Development . 409
Fig. 27-2. With the pin and tube appliance, progressive Fig. 27-3. With the ribbon arch appliance a base arch with
adjustment of the base archwire and alteration of pin rectangular cross section and a rectangular slotted bracket
position and inclination produced expansion of dental are provided for excellent labiolingual bodily tooth
arches by bodily movement of teeth in mesiodistal and movement (root and crown torque). Mesiodistal axial
labiolingual directions. Rotational correction was achieved control was compromised because of the loose attachment
by the addition of mesial or distal staples and direct ligation between archwire and bracket afforded by the locking pin.
to the base arch.
pliance. At the same time, because of the vertical slot

opening of the ribbon arch bracket, its use sacrificed
definitive control of mesiodistal axial tooth position. Since
in both the pin and tube and ribbon arch appliances the
base archwire was inserted from mesial to distal into
buccal molar tubes and from incisal to gingival into labial
brackets, direct premolar engagement was not possible.
Premolar position was controlled indirectly by ligature ties
to the tooth or to staples soldered to bicuspid bands.
Angle next designed the edgewise bracket (Fig. 27-4)
with its slot opening to the facial so that a base arch could
be engaged simultaneously into both buccal molar tubes Fig. 27-4. The facial bracket slot opening in the edgewise
and premolar brackets. While gaining bodily control of appliance permitted engagement of bicuspids and improved
premolar position, this design compromised rotation mesiodistal axial control with no sacrifice of capability for
control and necessitated the employment of staples and labiolingual torque control. Ligatures around the bracket
ligatures in addition to the bracket itself. wings facilitated archwire seating and retention and
The original edgewise appliance design has undergone provided for some rotational correction. Additional
considerable modification since its introduction in 1929 rotational control was achieved with mesial or distal staples
and its "perfection" in succeeding years by Angle and his (see Fig. 27-6A).
students. The use of the appliance as originally intended is
almost nonexistent today.
An increasing body of evidence has questioned the
tal and vertical slots for multiple and segmental archwire
validity of Angle's premise that dental arch expansion
would result in bone growth and that establishment of ideal use (multiphase, Broussard, Burstorie), and by the addition
functional relationships of cusps and inclined planes would of bracket width or mesial and distal extensions for
guarantee stability of the malocclusion correction. The rotational control (Siamese brackets, Lewis, Steiner).
efforts of Case.s Tweed 11 and Lundstrorn'" were The use of arch wires of small diameter as advocated by
particularly important to the increased acceptance of Johnson and the incorporation of loops for increased
extraction therapy for correction of arch length deficiency resiliency and range of movement as advocated by Begg
malocclusions. gradually eliminated the exclusive use of heavy rectangular
As the philosophical climate changed there were archwires for initial tooth alignment. In addition, extraoral
concomitant mechanical adaptations of the edgewise appliances and intraoral auxiliaries such as elastics,
appliance to solution of the bodily tooth movement removable canine retractors, lingual arches and palatal
problems characteristic of extraction therapy. Brackets expansion devices, were applied variously for control of
were modified by the addition of horizon- anchorage, individual tooth movement, modification of
facial growth pattern and correction of skeletal
disharmonies.
410 . The Edgewise Appliance
the teeth and their supporting structures. Bands and

brackets can be considered passive in the sense that no
tooth moving forces are stored in them or generated by
them. Archwires, on the other hand, are the active
components of the fixed appliance system.
A. In most cases, tooth moving forces are stored in arch
wires and delivered through brackets to the tooth and
periodontium by deflection of the archwire from a passive
to an active state. In other situations, tooth moving forces
are generated by auxiliaries such as springs or elastics and
are transmitted through the arch wire to the fixed portions
of the appliance and hence to the periodontium.
The early use of gold alloys for archwire material has
been largely supplanted by the development of stainless
steel alloys. Steel archwire material is commercially
available in many degrees of resiliency and hardness, in
c both multistrand and single strand configurations, and in
round and rectangular crosss ctional shapes. By selection
and modification of archwire resiliency, size, cross-
sectional shape, and spatial configuration, the clinician can
deliver forces of varying degrees and in varying
directions.
The development of preformed, seamless stainless steel
bands has virtually eliminated the timeconsuming
procedure of custom orthodontic band fabrication. Bands
are manufactured in both generalized shapes for each
Fig. 27-5. Three-dimensional bodily tooth movement can be group of teeth (i.e., maxillary central incisors, mandibular
effected with the edgewise bracket. Axial tooth movement in a molars, bicuspids) or in specialized configurations
mesiodistal direction is achieved by longitudinal deflection of designed separately for individual teeth (i.e., right and left
an archwire into the bracket slot and by the mechanical couple maxillary central incisors, right and left mandibular first
produced by the energy stored in the archwire (A). Torsional molars, and right and left mandibular second molars,
(torque) deflection of the base arch produces labiolingual axial maxillary bicuspids, and mandibular bicuspids). Because
movement (B), while deflection in a vertical direction results in of their individual contours, specialized bands require
intrusion or extrusion depending on the position of the archwire minimal modification during placement provided the teeth
segment in its passive state (C). are of reasonably normal morphology. However,
specialized bands are frequently less adaptable to teeth
which vary markedly from normal
'shape. The use of general purpose bands is particularly
In practice, the edgewise appliance is at times em-
advantageous to the nonspecialist since it permits a greater
ployed independently but more often is combined with
degree of flexibility in adapting to unusual situations
these other devices for correction of complex
while requiring significantly less inventory.
malocclusions. Thus usage of the modern edgewise
For optimum use orthodontic band materials should
appliance is based on an amalgamation of mechanical
possess the following physical characteristics:
principles derived from many sources but retaining the
central capability of three-dimensional tooth control 1. Strong enough to resist deformation or breakage
through the action of a rectangular wire in a rectangular under stresses of occlusion and appliance function
bracket slot (Fig. 27-5). 2. Malleable enough to permit ready adaptation to tooth
surfaces
3. Resilient enough to provide good frictional retention
APPUA CE COMPONENTS 4. Thin enough so that arch length will not be
Fixed orthodontic appliances have three basic com-
ponents: bands, brackets and archwires, Bands serve the
primary function of providing the means of attachment of
brackets to the crowns. Brackets are deSigned for
attachment of arch wires and for the transmission of
forces from arch wires through bands to
Appliance Components 411
affected by presence of excessive interproximal band tion of bands with physical properties and configuration
material that best suit his individual needs.
5. Surface characteristics should permit polishing by The original edgewise bracket as designed by Angle
conventional methods and welding or soldering of consisted of a rectangular slot for ai chwire engagement
attachments. and occlusal and gingival flanges for reception of wire
Optimum band fit and placement will be achieved if ligature ties. Because of the relatively narrow mesiodistal
bands are contoured so that bracket width and the facial bracket slot opening, rotational
1. Gingival edge is festooned to avoid impingement on control was exercised either by ligature tension across the
the periodontal attachment and displacement of the base arch and under the ligation flanges or by ligature ties
gingival cuff. to staples soldered to the bands at some distance from the
2. Occlusal edge is festooned to avoid occlusal bracket (Fig. 27-6A). In either case, the ligature resulted in
interference and is beveled slightly to resist little deflection of the heavy rectangular archwire being
deformation in seating. used at the time and considerable discomfort to the patient
3. Proximal surfaces are relatively flat, incisogingivally as a result of direct compression of periodontal structures.
or occlusogingivally to preclude excessive cement Many
thickness at interproximal contact areas.
4. Maximum contact is achieved between inside surface
of bands and coronal surfaces of the teeth.
Clinical usage by each operator will permit selec- I
~
I I
c:=J A.
A.
enCD
I
I
I
I I
I
I
D
I
I I
D I
I
B. I
I
D B
I
I
D
I
I I
[ I I
I
r
I I
) c. I
Fig. 27-7. The degreeI of mesiodistal
Fig. 27-6. Modifications of the edgewise

C
axial control afforded by an edgewise
bracket is a function of the distance from
the central tooth axis to I the bracket ex-
bracket for rotational movement include tremity. Modifications designed to increase
staples and ligation (A), twin brackets (B)
and mesial and distal rotating arms. (C).
D
this distance include twin brackets (B) and
] (C).
anti-tip slots in rotation arms
C.
0 --,
Fig. 27-8. Maxillary (A) and mandibular (8)

edgewise bracket and tube set-ups.
of the subsequent bracket modifications have been directed lumens are 0.022" X 0.028" permitting maximum wire size
at overcoming this lack of definitive rotational control. The of 0.0215" x 0.027". *
use of two single width edgewise brackets with slots
aligned horizontally and positioned some distance apart on BAND FITTING AND BRACKET PLACEMENT
the facial band surface (Siamese or twin brackets)
permitted the application of a longer lever arm for Accurate bracket positioning on the teeth is one of the
rotational movement (Fig. 27-6B). The addition of rotation most critical requirements in fabrication of a fixed
arms mesial and distal to a centrally placed bracket (Lewis, orthodontic appliance. If brackets are positioned properly,
Steiner) was another modification designed to improve the archwire fabrication is greatly simplified, the need for
capability for rotational correction (Fig. 27 -6C). compensating arch wire bends is minimized, and final
Narrow mesiodistal width of the original single interarch and intraarch tooth relationships are achieved with
edgewise bracket required the use of archwires of relative ease.
maximum dimension for optimum mesiodistal axial Since bands and brackets are purchased as preassembled
movement (Fig. 27-7 A). The additional distance from the units, bracket position is dependent upon proper band fitting
central tooth axis to the bracket extremity afforded by and placement. Brackets are welded to bands with the slot
development of twin brackets (Fig. 27-7B) and by the centrally located mesiodistally (except for molars) and at a
incorporation of anti-tip slots into mesial and distal rotation uniform 'distance from and parallel to the occlusal and
arms resulted in improvement of mesiodistal axial control incisal band edge (with the exception of cuspids and maxil-
capability (Fig. 27-7C) and permitted the use of wires of lary lateral incisors). Molar brackets and tubes are placed so
smaller dimension and higher resiliency for active tooth that the mesial edge of the bracket slot is at the height of
movement. facial contour of the mesiobuccal cusp in order to effect
In the treatment method described here, a combination of better rotation control. Cuspid brackets are positioned closer
single width edgewise brackets with anti-tip rotating arms to the occlusal edge to obtain better band retention by more
(Fig. 27-8A) and twin edgewise brackets are used (Fig. 27- gingival seating, and maxillary lateral incisor brackets are
8B). The former have proven to be most efficacious in inclined mesiodistally to produce distal root inclination.
controlling rotation and axial inclination of teeth adjacent Thus, if bands are placed with occlusal edges and
to extraction sites; the latter are most efficient in
controlling axial inclination of teeth with great mesiodistal
dimension (first molars when second molars carry buccal
tubes) and in correcting position of teeth with extreme root
convergence. All bracket slots and tube
Bracket slot and wire siz-es are designated in thousandths of an inch.
Band Fitting and Bracket Placement 413
bracket slots in uniform relation to chosen anatomical Cuspids

contours and tooth axes, a predictable brackettooth Bracket height is established by seating the bands so that
relationship will result. Marginal ridges and incisal edges the distance from bracket slot to cusp tip is the same as on
are used as determinates of posterior and anterior bracket first bicuspids (second bicuspids in first bicuspid extraction
height respectively. Long axes and buccal contours of cases). Because brackets are positioned closer
teeth are used to determine mesiodistal bracket position (approximately 1 mm.) to the occlusal band edge, cuspid
and inclination. Faciolingual bracket position and bands are seated further towards the gingival margin to
inclination is determined by labial and buccal tooth obtain proper bracket height. This provides for better band
contour. retention, removes the lingual surface of the maxillary band
from occlusal function, and compensates for the gingivally
Maxillary and Mandibular Bicuspid placed distal contact point of the mandibular cuspid (Fig.
27-11).
Bicuspid bands are usually fitted first and the bracket
height so established is used as a guide to band position on
the other teeth. Bands are seated with their mesial and
distal occlusal edges at the junction of marginal ridges and
proximal surfaces. Brackets are bisected mesiodistaUy by
Fig. 27-11. Cuspid bracket posi-
the long axes of the teeth and positioned over the height of
buccal contour (Fig. 27-9).
I tion. Note the gingival position of
the bands compared to the
bicuspids and the compensatory
incisal placement of brackets on
~ the bands.
Maxillary and Mandibular Molars
Bracket height is established in the same fashion as with
bicuspids, i.e., with occlusal band edges at the junction of
marginal ridge contours and proximal surfaces. Mesial
edges of brackets and tubes are aligned with the height of
facial contour of mesiobuccal cusps (Fig. 27-10).
@ I
ffi
I
I
I
Fig. 27-12. Incisor bracket posi-

~ tion. The lateral incisor bracket is
angulated on the band to com-
~ pensate for distal root inclination.
I It is also placed closer to the
I incisal band edge to produce the
normal vertical difference in
Fig. 27-9. Bicuspid Fig. 27-10. Molar bracket and central and lateral incisal edge
bracket position. buccal tube position. relationship.
buccal side while maxillary posterior bands seat readily on

the buccal side requiring final seating pressure to be
exerted on the lingual band margins. Maxillary and
mandibular cuspids and incisors are swaged to place with
malleting on seating lugs welded to the lingual band
surfaces (Fig. 27-14). Bracket heigh is marked and
confirmed with a preset adjustable divider or bracket
height gauge (Fig. 27-15). Marginal adaptation is
accomplished py burnishing (Fig. 27-14D) all accessible
band edges and by slight inward crimping of unexposed
(particularly gingiva-proximal) margins. Extensive crimp-
A. B, ing of gingival margins serves to improve band retention
in cases of unusual tooth morphology.
Fig. 27-13. Bands are fitted so that bracket slots parallel a Iine
Band placement should be such that there is no direct
tangent to facial tooth surfaces (A). Distortion of the facial of band
precludes achievement of proper bracket-. slot tooth relationship contact between teeth and appliances when the jaws are in
(B). centric occlusion. Where occlusal contact is unavoidable
(e.g., lingual of maxillary central incisors in deep overbite
malocclusions) the band sqrface can be strengthened by a
Maxillary Central and Mandibular Central and thin layer of solder prior to cementation in order to
Lateral Incisors preclude breakdown of the cement film.
Bracket height is the same as for cuspids. Bracket slots
are centrally located on facial surfaces and bisected by the
long axes of the teeth (Fig. 27-12). ARCHWIRE FORMATION
Maxillary Lateral Incisors Orthodontic tooth movement occurs as a result of

alveolar bone resorption and deposition in response to
Bands are seated with bracket slots one-half to 1 mm. forces delivered by resilient archwires, Progressive tooth
closer to incisal edge than on central incisors. Incisal movement from the position of malocclusion to normal
edges of bands parallel tooth incisal edges so that bracket interarch and intraarch relationships is achieved by
inclination will allow distal root inclination (Fig. 27-13). sequential placement of archwires of varying cross
It is of critical importance that all bands be placed so sectional size and shape. In order to realize coordinated
that the base of the bracket slot is parallel to and as close tooth movement in all three planes of space, it is essential
as possible to a line tangent to the facial tooth surface at a that the final treatment result be visualized by the clinician
point opposite the bracket position. Failure to do this will and that each arch wire be designed to perform specific
result in improper bracket slot-archwire relationship and tooth movement tasks toward accomplishment of the
will make ideal faciolingual axial tooth position difficult established treatment objectives. Archwires are designed
to achieve. within the limitations of and in conformity with the follow:
Properly fitted orthodontic bands are in sufficiently ing principles:
close contact with the tooth surface that retention is , 1. The resiliency of an archwire must vary directly with the
achieved primarily by friction and is not dependent upon distance through which the wire is deflected from a passive to
the adhesive properties of the cementing agent. Band size an active state. The further removed a tooth is from its
is selected so that the band can be seated initially by projected posttreatment position, the greater the deflection
finger pressure to, but not beyond, the height of tooth required to engage archwire to bracket and thus the greater
contour (Fig. 27-14A). Pressure is then exerted in a the required initial archwire resiliency. As tooth position
gingival direction with a rectangular amalgam plugger approaches normal alignment, less archwire deflection is
(Fig. 27-14B) or with a pneumatic condenser placed on necessary, thereby permitting the use of wires with less
mesial and distal band margins. This results in band resiliency ' (Fig. 27-6).
stretching over the maximum circumference of the tooth. Since archwire resiliency varies inversely with
Final swageing and seating of the band to position is thickness, it follows that wires of small diameter are best
accomplished by occlusal biting pressure on a band driver applied in the early stages of treatment when tooth
or by a hand or spring loaded mallet (Fig. 27-14C). malposition is greatest (Fig. 27-16) and that wires of larger
Tooth morphology is such that seamless mandibular diameter are appropriate to the later stages of correction.
posterior bands seat easily on the lingual surface and final Properly designed smalldiameter archwires deliver forces
seating pressure is best exerted from the of low magnitude
Archwire Formation' 415
Fig. 27-14. Seamless bands are

placed by initial seating with finger
pressure (A), stretching over the height
of contour by hand instrument pressure
(B), and final swageing with occlusal
pressure on a band driver (C). Marginal
adaptation is accomplished by
burnishing with a hand instrument (0).
Incisor and cuspid bands are swaged to
place by malleting on lingual seating
lugs (E).
within the limits of patient tolerance and act over a long force per unit deflection and act over a shorter distance.
distance and an extended time period. Archwires of larger Archwire resiliency also varies directly with the
diameter deliver higher levels of
Fig. 27-15. Bracket height is marked and confirmed with

dividers or a bracket height gauge.
Fig. 27-17. Archwire loops increase resiliency for initial

Fig. 27-16. A highly resilient small diameter round arch wire stages of tooth movement. (A) The archwire is in passive
is used for initial stages of tooth movement. (A) The archwire is position before ligation to brackets. (B) It is deflected into active
in passive position before ligation to brackets. (B) It is deflected position by ligation to brackets. Note distortion of original loop
into active position by ligation to brackets. (e) Corrected tooth shape by bracket engagement. (C) The archwire is returned to its
position after 8 weeks of force application. original form in keeping with improving tooth position.
51.
52.
Archwire Formation' 417
length of wire included between points of bracket ------Lateraloffset

engagement. Thus resiliency can be increased by the
Cuspid offset
inclusion of loops in areas requiring great amounts of
archwire deflection (Fig. 27-17).
2. Archwires must be designed to maintain pretreatment arch
width and arch form. Retrospective studies have indicated that
increase of mandibular arch width by appliance therapy
cannot be maintained over an extended time period and that
the most stable treatment results are realized when no modi-
fication of mandibular arch width and arch form has taken
placeJ,2,9 (Maxillary arch width is somewhat more labile,
particularly in correction of malocclusions with marked
maxillary constriction.) During their fabrication, archwires are
compared with casts of the original malocclusion so that arch
width and form can be adapted accordingly. This will pre-
clude inadvertent modification of dental arch dimension
during corrective tooth movement.t-v"
Compensatory adjustment of archwire width may be
necessary to counteract the secondary constriction or
expansion produced by certain intraoral and extraoral -- Molar offset
auxiliaries. For instance, cervical headgear application to the
maxiIlary arch tends to produce increase in posterior arch
width. This can be compensated for by the design of Bicuspid
maxillary archwires with constricted intermolar width. offset
Cuspid offset
Similarly, the tendency for Class II intermaxillary elastics to
increase mandibular intermolar width can be overcome by
mandibular archwire constriction in the molar area. Fig. 27-18. Ideal i nterarch occlusion is dependent on
3. Archwire configuration must account for the variation in establishment of ideal intraarch tooth relationship. Variation in
labial tooth surface position and contour when the teeth are in faciolingual tooth contour and facial surface prominence
ideal occlusal relationship. Because of differences in dictates the need for compensating arch wire bends at specific
faciolingual tooth thickness locations to properly position teeth within each dental arch.
and in contours of facial tooth surfaces, properly positioned

brackets do not lie on a smooth arc even with the teeth in ideal
alignment (Fig. 27-18). For
Fig. 27-19. Mandibular incisors require

no torque modification of rectangular
arch wires, while proper faciolingual
axial alignment of mandibular cuspids
and posterior teeth requires progressive
lingual crown (buccal root) torque.
example, with the lingual surfaces of maxillary central and sate for variations in incisogingival facial surface contour.
lateral incisors describing an even arc of occlusion with In position of normal occlusion the facial surfaces
ideally aligned mandibular incisors, the maxillary lateral underlying the points of bracket placement are at varying
incisor labial surface at the point of bracket placement lies angles relative to the plane of occlusion. Establishment of
slightly lingual to the central incisor labial surface. Thus in proper faciolingual axial relationship of teeth during
order to achieve the ideal lingual surface alignment, correction of malocclusion is accomplished by longitudinal
maxillary archwires must have a compensating bend torquing of rectangular arch wires to conform to the desired
toward the lingual just mesial to each lateral incisor. angular relationship. These compensating bends are
Similarly, prominence of maxillary and mandibular cuspid described in terms of the direction of root or crown
facial surfaces dictates the need for compensating bends in displacement from a position perpendicular to the plane of
a labial direction mesial to each cuspid. Compensating occlusion i.e., lingual crown torque, labial (buccal) crown
bends are also necessary mesial to mandibular first torque, lingual root torque, labial (buccal) root torque. Ideal
bicuspids, as well as mesial to maxillary and mandibular mandibular tooth relationships are characterized by neutral
first and second molars. Evaluation of individual tooth torque on incisors and progressive lingual crown (buccal
morphology and visualization of final tooth position serve root) torque on cuspids, bicuspids, and molars (Fig. 27-19).
as guides to shape and depth of compensating bends. Ideal maxillary axial alignment is characterized by
Faciolingual compensating bends are placed in both round moderate labial crown (lingual root) torque on central
and rectangular arch wires with the exception of wires of incisors, slight labial crown (lingual root) torque on lateral
small diameter where the loose fitting archwires make the incisors and progressive lingual crown (buccal root) torque
bends unnecess.ary. on cuspids, bicuspids, and molars (Fig. 27-20).
Archwires of rectangular cross-section must be further While the direction of torque placed in rectangular
modified in the horizontal plane to compen-
Fig. 27-20. Maxillary cen-

tral and lateral incisor posi-
tion is established by in-
corporation of labial crown
(lingual root) torque. Proper
cuspid, bicuspid, and molar
axial positioning requires
progressive lingual crown
(buccal root) torque.
Fig. 27-21. Ideal maxillary

(A) and mandibular (B) arch
wires incorporating fa-
cioIingual offsets and torque.
A B
Reciprocal Tooth Movement and Anchorage' 419
Fig. 27-22. (A) A hypo-

thetical anchorage problem
in which the space made
available by first bicuspid
extraction is exactly equal to
the space required for ac-
commodation of the cuspids
in normal alignment. (B) Use
of molars and second bicus-
pids for anchorage results in
reciprocal mesial movement
of the "anchor" teeth and distal
cuspid movement partially into the
now made- A C
quate bicuspid space. The
distal cuspid movement is
primary and desirable; the
mesial movement of poste
rior . teeth is secondary and
undesirable. (C) An appliance
design that utilizes anchorage
offered by incisors
as well as posterior teeth
reduces mesial movement of
the latter at the expense of
labial incisor movement. Since
this provides adequate space
for cuspid accommodation, it
is a satisfactory solu
tion provided labial incisor D
position is esthetically and B
functionally acceptable. (0)
Augmentation of dental an-
chorage by auxiliary appliance components (e.g., inter-
maxillary elastics, cervical headgear) resists mesial movement
of posterior teeth, thus allowing cuspid accommodation
without labial incisor movement. (E) Use of auxiliary extraoral
anchorage alone eliminates potential for undesirable
reciprocal tooth movement and results in satisfactory cuspid
accommodation.
archwires is uniform, the degree of torque varies depending on

the anatomical configuration of the individual dentition and
upon the desire for passive or active archwire-bracket
engagement. Where active tooth movement is being
undertaken, the degree of torque is generally greater than the
E
final axial relationship desired, whereas nonactive archwires
are formed with passive torque equivalent to the existing
faciolingual axial tooth position.
Similarly, active tooth movement faciolingually and/or RECIPROCAL TOOTH MOVEMENT AND
incisogingivally requires an archwire whose design deviates ANCHORAGE
markedly from the ideal configuration described above. In
fact, it is seldom that an ideal arch wire is used in clinical Fixed orthodontic appliances function as mechanical
practice. However, an understanding of ideal archwire systems in which primary tooth moving force vectors can be
formation is a necessary conceptual prerequisite to the design generated only in conjunction with secondary force vectors of
of active treatment archwires (Fig. 27-21). equal magnitude that operate in the opposite direction. Thus, if
force is applied between two teeth or two groups of teeth, both
will move in response to that force. Appliances
Fig. 27-23 A Class II, Di-

vision 1 malocclusion after
extraction of maxillary first
and mandibular second bi-
cuspids and initial tooth
alignment (A). Treatment ob-
jectives included: correction to
Class I molar and cuspid
relationship by mesial move-
ment of mandibular molars and
stabilization of maxillary
molars; minor reduction in
mandibular incisor protrusion;
major reduction in maxillary
incisor protrusion. Reciprocal
mandibular space closure was
achieved by intraarch elastic
traction (plastic chain module).
Mandibular incisor retraction
was augmented by Class III
intermaxillary elastics (B). The
secondary mesial vector of
force on the maxillary first
molar was dissipated
throughout the maxillary arch
via a continuous stopped
maxillary arch wire. (0 Further
resistance to mesial maxillary
molar movement was provided
by intermittent extra-
oral traction (cervical head-
gear. After completion of
mandibular space closure,
intraarch elastic traction was
are designed to counteract or dissipate undesirable secondary
applied for maxillary space
force vectors and to take advantage of desirable ones in order closure (D) and incisor re-
that established treatment goals can be met. Pretreatment traction augmented by Class II
visualization of final tooth positions which will be intermaxillary elastics from the
functionally and esthetically compatible is basic to rational stabilized mandibular arch (E).
control of this reciprocal movement. Extraoral traction was
The term anchorage is used to describe the resistance to continued to preclude
these secondary force vectors offered by the periodontal reciprocal mesial movement of
structures surrounding the "anchor" teeth, or a combination of maxillary molars (F).
this periodontal resistance and opposing forces generated by
auxiliary appliance components. It is generally considered
that the resistance to movement of teeth is equivalent to their
relative root surface areas and that the resistance is additive if lary elastics serve to control the relative rate of movement of
teeth are moved in groups rather than singly. Thus, the tooth groups by supplementing or negating forces delivered
distance and direction over which teeth are moved by the fixed appliance. It is necessary in treatment planning
reciprocally is dependent upon careful balance of the and appliance selection to consider the primary and secondary
anchorage offered by the periodontal structures and the ortho- effects of auxiliary anchorage appliances both antero-
dontic appliance (Fig. 27-22). posteriorly (Fig. 27-23) and vertically (Fig. 27-24).
The most complex anchorage balance problems are Since periodontal structures respond to tooth moving forces
encountered when interarch and intra-arch tooth movements with such great variability in different patients and even in
are taking place simultaneously. Various combinations of different quadrants of the same patient, it is not possible to
extraoral traction and intermaxil- generalize about the balance of appliance forces that will
produce a given effect. Some of the variables that contribute
to the
Case Reports' 421
A B
Fig. 27-24. Auxiliary appliance selection for anchorage
control in Class II correction: (A) Use of intermaxillary elastics
from mandibular posterior to maxillary anterior (Class II)
produces distal maxillary dentition movement and mesial
mandibular dentition movement. The former is desirable; the
latter is undesirable. Secondary vertical components of force
produce occlusal plane tipping by maxillary incisor extrusion
and anteroinferior tipping of mandibular incisors. Such a
combination of movements is usually unstable and esthetically
unacceptable. (B) Preliminary use of intermaxillary elastics
hom maxillary posterior to mandibular anterior segments
results in mandibular dentition retraction and occlusal plane
tipping in the opposite direction. Simultaneous use of extraoral
traction (cervical headgear) to maxillary molars prevents
mesial maxillary tooth movement, or produces distal tooth
movement. (C) Subsequent Class II elastic application
continues distal maxillary tooth movement and mesial
mandibular tooth movement toward, but not beyond, the
pretreatment position and return of the occlusal plane to its
original inclination. Excessive maxillary incisor extrusion is
precluded by vertical extraoral force to the maxillary anterior
segment.
c
complexity of this biomechanical system are the duration and adherence to, the broad biological and mechanical principles
constancy of force delivery, the root surface and shape, the that govern appliance function, in conjunction with individual
pattern of force distribution through the periodontal ligament, observation and appliance adjustment are necessary in order to
and the reactivity of .bone-rnobilizing cells. It has become assure that tooth movement progresses satisfactorily toward
evident in recent years that optimum tooth movement can be attainment of treatment objectives.
produced over a broad range of force Ievelss-? and that
detailed measurement of appliance forces is not necessary
provided the forces (1) exceed the tissue threshold governing
CASE REPORTS
cell conversion, (2) do not exceed the patient's pain threshold,
and (3) are distributed in such a fashion that periodontal The following case reports illustrate the correction of
membrane vitality is maintained. An understanding of, and complex malocclusions with the edgewise appliance. The first
patient, L.B., had a dental malocclusion with normal
anteroposterior skeletal relation-
Fig. 27-25. Pretreatment

casts, facial photographs, and
cephalometric tracing of L.
B., 12 years and 7 months.
ships. Orthodontic therapy was instituted after all factory upper and lower lip relationship, and acceptable
permanent teeth had erupted and some had been extracted prominence of the mentalis area. There was no evidence of
to make up for arch length deficiency. The second patient, facial asymmetry (Fig. 27-25). Dental
CM., had a dentoskeletal malocclusion; extraction was not 'examination disclosed generally satisfactory oral hygiene
required for correction. Treatment was carried out in two and a low caries rate. The maxillary left central incisor had
phases with the first phase beginning in the mixed a mesial angular fracture. Slight marginal gingivitis was
dentition period and the second commencing after noted in the maxillary and mandibular incisor regions,
completion of succedaneous tooth eruption. In both cases probably related to the dental crowding. Labial and lingual
active tooth movement was accomplished with archwires muscle function appeared to be within normal range. Arch
utilized in the sequence illustrated in combination with length analysis indicated the presence of a 6-mm. de-
auxiliary appliances for anchorage control. ficiency. Pretreatment cephalometric evaluation showed
that maxilla and mandible were both well related
anteroposteriorly to the cranial base. Slight protrusion of
the maxillary denture base and slight retrusion of the
Patient L.B.
mandibular denture base yielded an ANB angle at the
The patient was a Caucasian female, 12 years 7 months old upper end of the normal range. The interincisal angle was
with a Class I arch length deficiency malocclusion. Facial more obtuse than normal, primarily owing to vertical
examination revealed an orthognathic profile with slight orientation of the maxil-
subnasal maxillary lip protrusion, satis-
53. Case Reports' 423
lary incisors. All of the other cephalometric values were TABLE 27-1. PRETREATMENT A 0 POST-
within the limits of normality (Table 27-1). TREATMENT CEPHALOMETRIC VALUES, CASE
Treatment objectives were established as follows: (1) L. B.
reduction of maxillary and mandibular arch length
deficiencies; (2) reduction of vertical overbite; (3) AGE 12:7 15:3
overcorrection of end-to-end buccal occlusion; and (4)
reduction of maxillary subnasal protrusion. The treatment SNA 85 83
plan was outlined as follows:
1. Maxillary and mandibular dental arch length SNB 81 800
deficiencies dictated the need for extraction. Maxillary
A B 4 3
first bicuspid extractions were planned to provide
sufficient space for maxillary cuspid retraction and incisor
1 to A 70 25
alignment. Mandibular second bicuspid extractions were
planned to permit incisor alignment without adversely
affecting facial profile by excessive mandibular incisor
1 to Amm 2 3
retraction. 170
I to 16
2. Maxillary and mandibular edgewise appliances were
to be used with intermaxillary elastics during space 1 to 3 4
closure. Maxillary extraoral traction would be used as
4.
necessary to reinforce maxillary molar anchorage. B 2
5
3. It was anticipated that 24 months of active treatment
would be required. 32 32
Following the extractions, treatment progressed as
follows: Maxillary and mandibular bands with edgewise
attachments were placed with light round archwires used dibular superpositioning indicated minimal retraction of
progressively to correct maxillary and mandibular incisor mandibular incisors and considerable forward movement
rotations and to achieve bracket engagement (Fig. 27-26). of mandibular buccal segments. Approximate equal
Maxillary cervical headgear to the first molars was placed amounts of vertical eruption in both anterior and posterior
to be worn 12 hours per day. During initial mandibular areas was observed (Fig. 27-28). Total active treatment
space closure the maxillary archwire was stopped, and time was 23 months.
Class III elastics were worn with the cervical headgear.
Maxillary space closure was initiated in conjunction with
final mandibular arch closure and leveling. Class II Patient CM.
elastics with cervical headgear were used for anchorage The patient was an ll-year-old Caucasiori male with Class
control. During the finishing stages major efforts were II, Division 1 malocclusion. The patient exhibited
directed towards correction of mesial axial inclination of protrusive profile of the convex type with eversion and
the maxillary left cuspid, correction of the deep overbite, entrapment of the lower lip. Nasal development appeared
and overtorquing of the maxillary central and lateral to be well advanced; the nose being rather prominent. The
incisors (Fig. 27-27). A maxillary Hawley retainer and a face was not noticeably asymmetric (Fig. 27-29). Dental
mandibular faciallingual splint were placed for full-time examination showed that the patient had mixed dentition
wear during the retention period. with premature loss of the mandibular left first primary
Before and after cephalometric tracings superimposed molar due to caries. A 6-mm. arch length deficiency was
on the cranial base indicate that the patient's face grew present. Oral hygiene was generally good and potential
primarily in a downward direction. Facial profile appeared caries rate was low. The maxillary dental midline
to be in satisfactory balance following treatment. coincided with the facial midline; the mandibular dental
Maxillary superimposition indicated that maxillary midline deviated 3 mm. to the left. Lingual muscle
incisors were maintained in approximately the function appeared to be normal. The lower lip was
pretreatment anteroposterior position and that postured lingual to the maxillary incisors during rest and
considerable axial change resulted from efforts to torque swallowing. In centric occlusion the mandibular incisors
the maxillary incisor root palatally. Distal bodily occluded with the palatal gingiva approximately 4 mm.
movement of the maxillary left cuspid was accomplished lingual to the maxillary incisors' cingulum. Pretreatment
in a satisfactory fashion. Man- cephalometric evaluation revealed that the maxilla was
slightly protrusive and the mandible slightly retru-
Case Reports . 423
lary incisors. All of the other cephalometric values were TABLE 27-1. PRETREATMENT A D POSTTREATMENT
within the limits of normality (Table 27-1). CEPHALOMETRIC V ALVES, CASE L. B.
Treatment objectives were established as follows: (1)
reduction of maxillary and mandibular arch length
deficiencies; (2) reduction of vertical overbi te; (3) AGE 12:7 15:3
overcorrection of end-to-end buccal occlusion; and (4)
reduction of maxillary subnasal protrusion. The treatment plan SNA 85 83
was outlined as follows:
1. Maxillary and mandibular dental arch length deficiencies 5 B 81 80
dictated the need for extraction. Maxillary first bicuspid
ANB 4 3
extractions were planned to provide sufficient space for
maxillary cuspid retraction and incisor alignment. Mandibular
1 to A 7 25
second bicuspid extractions were planned to permit incisor
alignment without adversely affecting facial profile by
excessive mandibular incisor retraction.
1 to NA mm 2 3
2. Maxillary and mandibular edgewise appliances were to
I to NBo 16 17
be used with intermaxillary elastics during space closure.
Maxillary extraoral traction would be used as necessary to I to NB mm 3 4
reinforce maxillary molar anchorage.
3. It was anticipated that 24 months of active treatment 4.
Po to NB 2
5
would be required.
Following the extractions, treatment progressed as follows: Go-GN-SN 32 32
Maxillary and mandibular bands with edgewise attachments
were placed with light round archwires used progressively to
correct maxillary and mandibular incisor rotations and to dibular superpositioning indicated minimal retraction of
achieve bracket engagement (Fig. 27-26). Maxillary cervical mandibular incisors and considerable forward movement of
headgear to the first molars was placed to be worn 12 hours mandibular buccal segments. Approximate equal amounts of
per day. During initial mandibular space closure the maxillary vertical eruption in both anterior and posterior areas was
arch wire was stopped, and Class III elastics were worn with observed (Fig. 27-28). Total active treatment time was 23
the cervical headgear. Maxillary space closure was initiated in months.
conjunction with final mandibular arch closure and leveling.
Class II elastics with cervical headgear were used for
anchorage control. During the finishing stages major efforts Patient CM.
were directed towards correction of mesial axial inclination of
The patient was an ll-year-old Caucasion male with Class II,
the maxillary left cuspid, correction of the deep overbite, and
Division 1 malocclusion. The patient exhibited protrusive
overtorquing of the maxillary central and lateral incisors (Fig.
profile of the convex type with eversion and entrapment of the
27-27). A maxillary Hawley retainer and a mandibular facial-
lower lip. asal development appeared to be well advanced; the
lingual splint were placed for full-time wear during the
nose being rather prominent. The face was not noticeably
retention period.
asymmetric (Fig. 27-29). Dental examination showed that the
Before and after cephalometric tracings superimposed on patient had mixed dentition with premature loss of the
the cranial base indicate that the patient's face grew primarily mandibular left first primary molar due to caries. A 6-mm.
in a downward direction. Facial profile appeared to be in arch length deficiency was present. Oral hygiene was generally
satisfactory balance following treatment. Maxillary good and potential caries rate was low. The maxillary dental
superimposition indicated that maxillary incisors were midline coincided with the facial midline; the mandibular
maintained in approximately the pretreatment anteroposterior dental midline deviated 3 mm. to the left. Lingual muscle
position and that considerable axial change resulted from function appeared to be normal. The lower lip was postured
efforts to torque the maxillary incisor root palatally. Distal lingual to the maxillary incisors during rest and swallowing. In
bodily movement of the maxillary left cuspid was centric occlusion the mandibular incisors occluded with the
accomplished in a satisfactory fashion. Man- palatal gingiva approximately 4 mm. lingual to the maxillary
incisors' cingulum. Pretreatment cephalometric evaluation
revealed that the maxilla was slightly protrusive and the
mandible slightly retru-
424 . The Edgewise Appliance 54.
METHOD OF
MAXILLARY MANDIBULAR ARCHWIRE ACTIVATION AUXILIARIES OBJECTIVES
TYPE USED
.I
Fig. 27-26. These archwires were used in active treatment with a full banded edgewise appliance, for L. B.
Case Reports' 425
ARCHWIRE METHOD OF AUXI L1ARIES OBJECTIVES
TYPE ACTIVATION USED
0,0175 BRAIDED ENGAGED TO BRACKETS INITIAL

'
\
0.0195 BRAIDED WITH PLASTIC MODULES ROTATION
NONE
OR AND/OR STEEL L1GA- CORRECTION AND
0,016 SINGLE TURES. PLASTIC CHAI N LOWER ARCH
STRAND MODULE FROMQTO LEVEll NG
MULTILOOP /56
0.Q18 MAXILLARY ENGAGED TO BRACKETS CERVICAL HEADGEAR FINAL ROTATION

MULTILOOP WITH PLASTIC MODULES AND CLASS III CORRECTION, /3
0.Q18 MANDIBULAR THEN STEEL L1GA ELASTICS TWELVE BRACKET ENGAGE
SINGLE TURES. ACTIVELY TIED HOURS PER DAY MENT. CONTINUED
STRAND BACK TO FIRST MOLARS LEVE LI NG. AND
INITIAL EXTRACTION
. SPACE CLOSURE
0.019 x 0.025 TIED TO BRACKETS CERVICAL HEADGEAR EXTRACTION SPACE
RECTANGULAR WITH WITH STEEL L1GATU RES. WITH CLASS III CLOSURE WITH
HELICAL CLOSING HELICAL CLOSI NG LOOP ELASTICS UNTIL 5/5 LEVELING AND
LOOP TIED BACK TO 65/56 SPACES ARE CLOSED. INCISOR ROOT
AND 76/67. CLASS II ELASTICS TORQUE CONTROL
MAXI LLARY STOPPED DURING FINAL 4/4
WITH REMOVABLE LOCK SPACE CLOSURE
MESIAL TO 5/5 DURING
INITIAL MANDIBULAR
CLOSURE
0,019 x 0.025 TIED TO BRACKETS CLASS II ELASTICS ROOT PARALLE LI NG
RECTANGULAR WITH STEEL L1GA- UNOER MANDIBULAR AND LEVELING.

FINISHING ARCH TURES, ADJUSTED DELTA LOOP FINAL TOOTH
PROGRESSIVELY FOR POSITIONING
INCISOR TORQUE AND
ROOT PARALLELI NG
Fig, 27-26. Continued.

Fig. 27-27. Posttreatment

casts, facial photographs, and
cephalometric tracings of L. S.,
at 15 years and 3 months.
sive, relative to cranial base, although the cephalometric
1l~'
values for both were within the normal range of variation.
1
The maxillary incisors were proelined excessively relative
to the cranial base yielding an acute interincisal angle.
The mandibular dentition was positioned satisfactorily
relative to the mandibular base and symphysis. All other
. cephalometric values were within the limits of normality
~ . (Table 27-2).
\.
: "
..
,,) " ",

Treatment objectives were to (1) reestablish man-
dibular arch length by regaining space loss due to drift
into primary molar area; (2) reduce Class II molar
relationship and horizontal overjet; (3) reduce vertical
overbite and (4) establish acceptable functional occlusion.
The treatment plan was outlined as follows:
1. Nasal and chin prominence coupled with borderline
arch length deficiency indicated treatment without
Fig. 27-28. Composite cephalometric tracing of pre(---) and
posttreatment (-----) skeletal and dental relationships. Cranial
removal of permanent teeth.
base superpositioning indicates facial growth changes; separate 2. An initial phase of treatment was planned in order to
maxillary and mandibular tracings depict tooth movement and regain the lost arch length on the mandibular left and to
eruption. Note bodily distal movement of maxillary left cuspid achieve a Class I molar relationship
and axial control of incisors.
Case Reports . 427
Fig. 27-29. Pretreatment

casts, facial photographs and
cephalometric tracing of C.
M. at 11 years,
with reduction of overbite and overjet. This was to be TABLE 27-2. PRETREATMENT PROGRESS AND
achieved with mandibular adjustable lingual arch and POST-TREATMENT CEPHALOMETRIC
maxillary cervical headgear and incisor bands. V ALVES, CASE C. M.
3. Final occlusal relationships were to be obtained by full
banding with edgewise appliance following completion of AGE 11:0 13:4 14:1
eruption of the permanent dentition. 4. Thirty months
treatment time would be required for the active phase of S A 86 85 85
correction.
Treatment was initiated with maxillary and mandibular 5 B 8P 82 83
first molar bands and an active mandibular lingual arch for
regaining mandibular arch length (Fig. 27-30). Cervical ANB 5 3 20
headgear was placed to the maxillary first molars and worn
14 hours per day. Headgear and lingual arch were adjusted 1 to NN 32 37' 32
progressively at 6-week intervals until sufficient space had
been gained for accommodation of mandibular suc- 1 to NA mm 9 6 6
cedaneous teeth. At this time the mandibular lingual arch
was deactivated and used as a space maintainer. Correction 1" to NBo 21 20 20
of the mandibular midline shift had been achieved at this
time. After 9 months of treatment, maxillary lateral and 1" to NB mm 5 5 6
central incisor bands were placed and light round arch
wires were used to cor- Po to NB 5 6 7
Go-GN-SN 25 25 27
METHOD OF
MAXILLARY MANDIBULAR ARCHWIRE AUXI LIAR IES
ACTIVATION OBJECTIVE
TYPE USED S
.
'
c
Fig. 27-30. Archwires and cervical headgear were used in the first phase of C. M.'s treatment with a partial edgewise appliance.
.-
,
Fig. 27-31. Progress casts and cephalometric tracings were made at the conclusion of the first treatment phase, when C.
M. was 12 years and 7 months old.
56.
Case Reports . 429
ARCHWIRE METHOD OF AUXILIARIES OBJECTIVES
0.0175-0.0195 MAXI LLARY INCISOR CERVICAL HEADGEAR MAXILLARY MOLAR
MAXILLARY PLASTIC CHAIN MOD- FOURTEEN HOURS ROTATION. CLASS

BRAIDED ULE AND STEEL PER DAY II CORRECTION
MANDIBULAR LIGATURES THRU MAXILLARY
LINGUAL ARCH PROG RESSIVE LINGUAL GROWTH MODIFICA-
LOOP OPENING TION. MANDIBULAR
MANDIBULAR LEFT ARCH LENGTH GAIN.
OVERBITE
REDUCTION
0.020 MAXILLARY ENGAGED TO BRACKETS CE RVICAL HEADGEAR CONTINUATION OF
SINGLE WITH STEEL LIGATURES WITH INCISOR SPUR ABOVE

STRAND
MANDIBULAR
LINGUAL ARCH
0,019 x 0.025 MAXILLARY ARCH CERVICAL HEADGEAR CONTINUATION
MAXILLARY ADJUSTED PRO WITH INCISOR SPUR OF ABOVE

RECTANGULAR GRESSIVE L Y FOR
MANDIBULAR INCISOR LEVELING
LINGUAL ARCH AND MOLAR
ROTATION
Fig. 27-30 Continued, ,

METHOD OF
MAXILLARY MANDIBULAR ARCHWIR ACTIVATION AUXILIARIES
OBJECTIVE
E TYPE USED S
Fig. 27-32. These archwires were used in the second phase of C. M.'s treatment with the full edgewise appliance.
Case Reports . 431
ARCHWIRE METHOD OF AUXILIARIES

OBJECTIVES
0.0175-0.0195 ENGAGED TO BRACKETS CERVICAL HEADGEAR CONTINUED CLASS
BRAIDED WITH PLASTIC CHAIN WITH INCISOR SPUR II CORRECTION,

, MOOULES THEN TIED FOURTEEN HOURS OVERBITE RE
WITH STEEL LIGATURES PER DAY DUCTION AND
CUSP I D-BI CUSPI D
ROTATION
CORRECTION
0.020 SINGLE ENGAGED WITH PLASTIC CE RVICAL HEADGEAR MANDIBULAR ARCH
STRAND CHAIN MODULES THEN WITH SPUR CLASS LEVELING AND

STEEL LIGATURES III ELASTICS OCCLUSAL PLANE
STOPPED AGAINST UNDER 43/3-4 TIPPING IN
6/6 and 6/6 LOOPS WITH PREPARATION FOR
HEADGEAR CLASS II
ELASTIC WEAR
0.019 x 0.025 TIED WITH STEEL CLASS CONTINUATION
RECTANGULAR LIGATURES. AD III ELASTICS OF ABOVE

JUSTED PROGRES UNDER 4-3/34
SIVELY FOR SPURS WITH CE RVICAL
TORQUE, MARGINAL HEADGEAR
RiDGE RELATION
SH IP AND LEVELING
0.021 x 0.025 TlEDWITHSTEEL CERVICAL HEADGEAR FINAL CLASS II
LIGATURES WITH SPU R, CLASS COR RECTION,

MANDIBULAR INCISOR II ELASTICS FULLTIME DETAILED TOOTH
LABIAL ROOT TORQUE POSITIONING
TO RESIST CLASS II
ELASTIC PULL

58.
Fig. 27-33. Posttreatment

casts, facial photographs and
cephalometric tracing of C. M.
at 14 years, 1 month.
reet rotations and achieve bracket engagement. Progressive

maxillary round archwires with a reverse curve of Spee
were used for vertical overbite reduction in conjunction
with an incisor spur to place intrusive force against the
maxillary incisors with the cervical headgear. The initial
phase of treatment lasted 16 months and was completed at
the time of eruption of the succedaneous teeth and the
achievement of a full Class I molar and cuspid relationship
(Fig. 27-31).
At that time maxillary and mandibular banding was
completed for the second phase of treatment. Progressive
maxillary and mandibular light round arch wires wi th
reverse curves were used for continued vertical overbite
correction (Fig. 27-32). Class III intermaxillary elastics
Fig. 27-34. Composite cephalometric tracing of pretreatment were used with the cervical headgear to aid in mandibular
(---) , progress (-----), and posttreatment (- - - - -) skeletal and arch leveling and to
dental relationships for C. M,
References . 433
insure reduction of the mandibular denture protrusion. orthodontic treatment and following a post retention
Rectangular archwires were placed for continued overbite period of five or more years. Master's Thesis, Univ. of
reduction and torque control. During the last 3 months of Washington, Seattle, 1963.
correction Class II intermaxillary elastics were used for 3. Begg, P, R: Light arch technique employing the principle
final overjet reduction and establishment of Class I cuspid of differential force. Am. J. Orthodontics, 47:30, 1961.
4. Burstorie, C,: Biomechanics of the orthodontic appli-
relationship (Fig. 27-33). Total treatment time was 30
ance. In Graber, T. M. (ed.): Current Orthodontic
months. Posttreatment cephalometric evaluation indicated
Concepts and Technics. Philadelphia, W. B. Saunders,
downward and forward mandibular growth and downward 1969.
maxillary growth with considerable increase in nasal 5. Case, C. S.: The question of extraction in orthodontia.
prominence. Maxillary 'superpositioning indica ted Tr. at. Dent. Ass., 1, 1911.
moderate maxillary incisor and molar vertical eruption and 6. Hixon, E. H., et al.: On force and tooth movement.
forward movement of maxillary molars. Mandibular Am. J. Orthodontics, 57:476, 1970.
superpositioning indicated that minimal incisor retraction 7. _____ : Optimal force, differential force, and anchor-
had taken place while a significant amount of vertical age. Am. J. Orthodontics, 55:433, 1969.
incisor and molar eruption had occurred (Fig. 27-34). 8. Johnson, J. E.: A new orthodontic mechanism: the
twinwire automatic appliance. J.A.D.A., 19:997, 1932.
9. [oondeph, D. R., et al.: Use of pont's index in ortho-
dontic diagnosis. J.A.D.A., 85:341,1972.
10. Lundstrom, A.: Malocclusion of the teeth regarded as a
REFERENCES
problem in connection with the apical base. Tandl.
1. Arnatt, R. D.: A serial study of dental arch measure- Festskrift, II:149, 1923.
ments on orthodontic subjects. Masters thesis, North- 11. Tweed, C. H.: Indications for extraction of teeth in
western University, Chicago, 1962. orthodontic procedure. Am. Assoc. Orthodontists Tr.
2. Arnold, M. L.: A study of the changes of the man- 30:22, 1944.
dibular intercanine and intermolar widths during
28
Direct Bracket Attachment to Enamel
Without Banding Teeth
FUJIO MIURA, D.D.S., PH.D.
A technique of direct attachment of brackets, tu bes, and Depending on the type of case involved, one technique
other auxiliaries to the enamel surface of teeth and the may be more practical than another. In this respect, one
elimination of stainless steel bands has long been needed disadvantage of the direct bonding system is that the
in orthodontics. This chapter presents a practical method preformed plastic brackets may not withstand severe
of bonding plastic brackets directly to the enamel surface occlusal stress. Should severe torque forces be needed, a
of teeth without the need to construct bracket bands for round archwire with auxiliary torque springs is
each tooth. This Direct Bonding System (DBS) has proven recommended in place of heavy rectangular arch wires, in
itself to be successful in the treatment of patients at the order to avoid deforming the plastic brackets. Because the
Department of Orthodontics of Tokyo Medical and Dental principle of DBS is based on the use of polycarbonate
University. More than 3 years of clinical research at the attachments, it should be kept in mind that not all of the
University on this new method has confirmed its techniques used with stainless steel bands can be applied to
reliability. plastic brackets. Slight improvisations should be made
Among the advantages of using this bonding svstern are accordingly.
the elimination of tissue irritation and spacing of the teeth
which result with the use of stainless steel bands.
Moreover, the pain and inconvenience to the patient
caused by tooth separation and band fitting is eliminated. BO DING TECHNIQUE
The elimination of the possibility of decalcification due to
Preparation of enamel surface. The enamel surface is
poorly fitting or loose bands is an even greater advantage,
cleaned thoroughly with a brush cone and isolated with
not to mention the esthetic factor, which also plays an
cotton rolls, dried with alcohol, and compressed air. The
important part in the acceptance of orthodontic treatment.
first pretreatment agent, 65 per cent phosphoric acid, is
then applied for 30 seconds for the purpose of etching the
enamel sur-
Fig. 28-2. A press is placed on the container, and pressure is

Fig. 28-1. The pretreatment agent, silane, is applied. applied to release the catalyst.
43
4
Clinical Use of Brackets' 435
Fig. 28-3. The brush-on technique: a bead is formed at the tip Fig. 28-4. The beaded adhesive is applied to the tooth surface.
of the brush.
face. The acid is then washed away thoroughly with

water, and the enamel surface is dried again with alcohol
and air. Thereafter, the second pretreatment agent, silane,
is applied and air-dried completely (Fig. 28-1).
Preparation of adhesive. A press is placed on the
container that holds the monomer and pressed firmly to
release the catalyst, a tri-a-butyl borane derivative from
the capsule on the underside of the container cover (Fig.
28.2). Then a small amount of polymer is put into a
dappen dish.
Bonding preformed plastic brackets - the brushon
technique. The fine brush is dipped into the solution and
then into the polymer until a bead is formed at the tip
(Fig. 28-3). The beaded adhesive is applied to the tooth
surface and repeated if necessary in order to spread it
slightly larger than the bracket base (Fig. 28-4). The fitted
bracket is now positioned onto the prepared tooth surface
with a DBS (Masunaga) tweezer or with a bracket
positioning gauge (Fig. 28-5). The area should be kept
dry for 10 to 15 minutes while the adhesive hardens after Fig. 28-5. A plastic bracket is positioned with a DBS
which time an initial leveling archwire can be inserted. (Masunaga) tweezer.
CLINICAL USE OF BRACKETS
REMOVAL OF BRACKET Figure 28-6 illustrates a typical bimaxillary protrusion

with moderate upper arch length discrepancy. A complete
The removal of the bracket is accomplished with a diagnostic analysis indicated that the four first premolars
conventional pin and ligature cutter. The remaining should be extracted. Plastic brackets were bonded on all
adhesive is softened with the application of chloroform teeth except the molars which used conventional metal
and removed with a scaler. Finish by polishing with a bands with buccal tubes.
rubber cup or a brush cone and prophylactic paste to At the beginning of treatment O.016-inch standard
restore the original luster of the enamel. round archwires with sliding hooks were placed on
436 . Direct Bracket Attachment to Enamel Without Banding Teeth
Fig. 28-6. (A) Before treat-

ment. (B) Bonded plastic
brackets with initial leveling
archwires are inserted. (C)
O.016-inch consolidation arch
wire is placed on the lower arch.
(0) O.016-inch square ideal arch
wire is inserted on the lower
arch and an O.016-inch square
contraction archwire is placed
on the upper. (E) After the
removal of the bonded brackets
and polishing, no discoloration
or decalcification is observed.
Fig. 28-7. (A) An impacted canine is exposed surgically, and a

plastic bracket is bonded to the labial surface. (B) The canine is
ligated with elastic thread to a spur of the lingual arch. (C) 10
months later, the bracket was removed. The canine was moved
into its normal position.
Clinical Use of Brackets . 437
the upper and lower dental arches. Class II elastics and tooth surfaces after the removal of the brackets at the end
lower horizontal elastics were also applied. In 5 months, of treatment.
after the crowding had been reduced and the canines Figure 28-7 illustrates treatment of an impacted upper
moved distally, an O.016-inch consolidation arch wire left canine using a plastic bracket. The direct bonding
was placed on the lower arch. Twelve months after the technique is especially effective in a case such as this,
start of treatment, an O.016-inch square contraction where excessive soft tissue coverage interferes with
archwire was inserted on the upper arch and an O.016- placement of a stainless steel band. After the crown of
inch square ideal archwire was placed on the lower. the canine was surgically exposed, a plastic bracket was
During the 16 months of active treatment, there was bonded directly to the tooth surface. This tooth was
no problem with loose plastic brackets. Nor was there moved into its normal position by means of auxiliary
any change in color or decalcification of the springs soldered to a lingual arch appliance.
29
The Begg Technique
RALEIGH WILLIAMS, D.D.S.
The Begg technique of treating malocclusions is based spaces. Accomplishing this objective results in lingual
on three concepts. When these are understood and tipping of the incisors on their apices. The amount of
properly employed, the operator will soon make rapid lingual incisor tipping at the end of the second stage will
strides in the proficient execution of the Begg technique vary with the severity of the case. The greater the
in the treatment of malocclusions. magnitude of the original problem, the greater the severity
of the lingual incisor tipping at the end of this stage. Space
closure tipping is undertaken while maintaining the
THREE FUNDAMENTAL CONCEPTS
overcorrected molar and edge-to-edge incisor
The first concept is the ever present phenomenon of relationships. As in the first stage, all movements of
continual mesial and vertical migration of the teeth anterior teeth are tipping movements, and only a small
through the alveolar process toward the midline amount of lower molar anchorage is expended in
throughout the lifetime of the individual. accomplishing the objectives of the second stage. The
The second concept is the Begg method of moving amount is customarily the least of any of the three stages.
teeth. This consists of two movements: tipping the teeth to In the third stage (Fig. 29-1D) there is one objective:
a proper position over the supporting bone and then correcting the axial inclinations of all teeth. This
uprighting them. customarily involves paralleling the roots of the teeth
The third concept is the employment of light, con- adjacent to extraction sites, torquing the roots of the upper
tinuous, physiological forces to achieve rapid tooth incisors lingually, and uprighting the mesiodistal
movement. inclinations of the upper and lower lateral incisors.
Paralleling of the roots adjacent to the extraction sites is
essentially of a reciprocal nature and consumes relatively
ST AGES OF BEGG TREATMENT little anchorage. However, torquing of upper incisors is a
Treatment with the Begg technique is divided into three bodily root movement with no reciprocals and if not
distinct stages. Experience has taught the necessity of controlled, tends to pull the entire upper dentition forward
following these stages in strict sequence if the treatment is off the supporting basal bone. To prevent this, lingual root
to be efficient, effective, and rapid (Fig. 29-1A). torquing of upper incisors is controlled with Class II
In the first stage of treatment there are three major elastics. As a result, lower molar anchorage is consumed
objectives: to overcorrect the molar relationship, to , in executing the third stage, and the third stage is the most
eliminate the overbite, and to tip the upper incisors back costly of the three in terms of anchorage expended. The
to an edge-to-edge relationship with the lower incisors amount of anchorage expended is directly related to the
(Fig. 29-1 B). Secondary objectives that must be achieved magnitude of the original malocclusion and the degree of
are to eliminate the crowding, spacing, or rotations in the incisor torquing required in this stage.
anterior segments and rotations in the premolar segments.
Since all of these movements are tipping movements,
usually only a small amount of anchorage is expended in
achieving these ob[ectives, The amount expended in this
stage varies directly with the magnitude of the correction
required. Rotation of molars is not easily performed EFFECTIVENESS OF BEGG TREATMENT
during the first stage and is better done at the end of the The Begg technique can correct all varieties of
second stage, when it can be accomplished effectively. malocclusions. It does so by matching tipping movements
In the second stage of treatment (Fig. 29-1C) there is against bodily movements. By manipulating tipping or
one objective: closure of extraction or .posterior bodily tooth movements, anchorage control is most
effective, and headgears to augment anchorage are neither
needed nor desirable in the Begg technique. Because
favorable axial inclinations
438
Fig. 29-1. Stages of Begg treatment- typical responses. (A) Original malocclusion;
(B) StageJ completed; (e) Stage 2 completed; (0) Stage 3 completed.
440 . The Begg Technique 59.
can be established consistently, the Begg treatment gates the forces and reduces the bite-opening ef-
promotes a high degree of denture stability. fectiveness of the tip-back bends. Archwires have tip-back
Patients treated in accordance with the Begg theory are bends in both the first and second stages; they are placed
able to sustain minimum posttreatment overbites. This is in both upper and lower archwires opposite the bracket of
because of the consistency with which optimum the second premolar. The amount of tip back is sufficient
interincisal angles can be achieved. This, in turn, is due to cause the anterior part of the archwire to lie in the
to a highly effective torquing procedure. While treatment fornix of the alveolar vestibule when in the tubes but not
time with the Begg technique for any given type of engaged in the brackets. The amount of tip-back will vary
malocclusion is about the same as with any other with the degree of overbite, never more than 40 in a very
technique, actual chair time is probably less, since deep bite nor less than 10 in an openbite.
adjustment intervals are usually 6 weeks or more and the Upper arch form in all stages is usually ideal and
time expended in making adjustments is frequently quite passive as to molar width. Lower arch form is expansive
minimal. These longer intervals between adjustments are in the molar region in the first and second stages to
possible because light, continuous physiologic forces are compensate for the lingual force vector of the Class 11
delivered by light, continuously acting resilient wires and elastics on the buccal surface of the lower molar.
light elastics. Intermaxillary circle hooks are bent into all archwires
used in any stage of treatment. They are positioned just
mesial to the cuspid brackets but need never be directly up
against them. For the most part, 0.016 wire is utilized in
APPLIANCES
the first and second stages. In the third stage 0.018 flat
archwires of ideal arch form without tip-backs are used.
Archwires Intermaxillary circle hooks and molar offsets are
incorporated in them. The circle hooks in all archwires are
To start treatment, 0.016 stainless steel resilient constructed so that the anterior portion of the archwire lies
archwires are customarily employed. A lighter archwire gingivally to the posterior sections.
of 0.014 diameter may be used to start treatment for the
initial adjustment interval if there is a need or desire to
avoid any possible tooth discomfort, but this is
infrequent. If there is crowding or rotation in the anterior
segments, the archwires are formed with loops to permit
the arch to be engaged in the brackets without distortion.
Attachments and Auxiliaries
As soon as the anterior crowding or rotations are
eliminated, usually within 6 weeks, rarely, more than 12, Attachment height on the teeth is a very important
the 0.016 archwire with loops is replaced by a plain one factor in successful treatment. The recommended
without loops. placement heights for the tubes and brackets are shown in
It is advantageous, for rapid bite opening, to discard Figure 29-2. When measuring proper heights on molars
the looped arch wire as soon as possible. The extra and premolars, it is essential to measure relative to the
amount of wire incorporated in the loops miti- long axis of the tooth, not against the buccal surface.
Attention to this suggested positioning will minimize
archwire distortion during the first and second stages. It
will also help open the bite more rapidly and completely.
This is vital for rapid and successful treatment. The ob-
jectives of the first and second stages of treatment may be
secured even in spite of inappropriate attachment
placement, but the toll will be taken in the third stage if
this error is allowed to go uncorrected.
Use of the recommended attachment heights will
prevent the bite from closing during the third stage. If the
5 4 4 attachments are placed correctly, flat archwires can be
placed in the third stage. Tip-ups or tip-downs will not be
necessary to maintain the bite open during the third stage.
If the attachments are placed incorrectly, any or all of
the following sequelae are apt to occur during the third
stage: deepening of overbite, flaring of
Fig. 29-2. Recommended heights for attaclTments.

60.
61. Appliances 441
42 MONTHS PRETREATMENT
Case P.R. 0 to 42nd mo.
ANB 7' 6'
FMA 30' 27' ~; \
FMIA 80' 68' i\
l-NS 102' 91' ;:
T"AP -; -6mmdi\"
Fig. 29-3. Original malocclusion of P. R.
molars, lingual and mesial tipping of lower molars,

delayed or inhibited root paralleling, degeneration of
normal molar relationship toward Class II.
Auxiliaries are used, for the most part, to correct the
axial inclincations of the teeth in the third stage of ....
......
treatment. When a two-finger-incisor torquing wire is ...
. ....
indicated, 0.014 wire is best, and the torquing auxiliary
can be constructed so as to deliver approximately 3
Fig, 29-4. Composite tracing of P. R's
ounces of pressure at the labial surface of the incisor, or pretreatment growth.
about 1.5 ounces at the incisor apex. To deliver the same
force values when a fourfinger torquing wire is indicated,
Case P.R. START
0.016 wire is used. When such a force is delivered, the ANB 6'
incisors can be torqued approximately 4 per month if the FMA
incisor root surface area is of average amount.
Torquing rate of incisors and uprighting rate of teeth
FMIA
!- ~~: ~
NS 91'
proximating extraction sites will vary with their root
T-AP
surface areas. Thus, uprighting a premolar against a -6m~
canine is not precisely a reciprocal action. Since the root
surface area of a canine is somewhat greater than that of a
premolar, it can be expected that some small increment of
anchorage will be consumed when uprighting such a pair
reciprocally.
Occasionally, labial root torque is necessary on one or
both maxillary lateral incisors. A 0.014 reverse torquing
wire can be employed successfully. Sometimes reverse
root torque is needed on lateral incisors at the same time
lingual root torque is needed on central incisors. An 0.014
auxiliary wire will successfully execute this maneuver.
Uprighting springs for premolars and canines can be
constructed of 0.014 wire. Helices bent on an arbor of
Q.050 with four turns of the helix will deliver about 3
ounces of force to the crown and 1 ounce at the apical
area when activated through 90. This is true if the Fig. 29-5. Headplate tracing of
uprighting spring has a 12-o'clock bend in it when formed P. R. at start of treatment.
on an 0.050 arbor. A 0.012 wire is used for making
uprighting springs for lateral incisors, which nave
0.050 arbor. They will produce effective and rapid change
considerably smaller root surface areas than premolars or
in their axial inclinations when constructed with a 12-
canines. Such uprighting springs can be made with three
0'clock bend and activated through 90. An 0.016
turns.on an
uprighting wire is used to fashion uprighting springs for
molars on the same 0.050 arbor for helix size. Three coils
are employed on the helix.
442 . The Begg Technique
These springs do not incorporate a 12-0'clock bend but are fluence how much anterior retraction of the dentition will
activated 90 and deliver about 4 ounces at the crown and be accomplished.
2 ounces at root apices. There are a number of successful
variations of spring design and incisor torquing auxiliaries
ILLUSTRATIVE CASE HISTORIES
which are known to produce changes in axial inclinations
of teeth with equal effectiveness. An examination of treatment records of the different
basic types of malocclusions may help to clarify the
fundamentals and technicalities of the Begg therapy. The
following cases show typical reactions to Begg treatment.
DIAGNOSIS IN BEGG TR A TMENT
The problem constantly facing the clinician is to
reposition maloccluded teeth into a stable position over Typical on extraction Treatment
the supporting bone of the jaws. 0 achieve both stable
dentition and favorable lip balance, it is desirable to place Patient is a girl 12 years and 1 month of age at the start
the incisal edge of the lower incisor at or close to the AP of treatment. Original malocclusion was Class II, Division
(A Point-Pogonion) line. The normal relation of the incisal I, deep anterior overbite without lower crowding (Fig. 29-
edge of the lower incisor to the AP line is +0.5 mm. 3). Pretreatment growth was trending favorably (Fig. 29-
Sometimes there is sufficient available supporting bone 4). The mandible was growing downward and forward at a
and sufficient growth potential to reposition the full rate exceeding that of the maxilla; the apical base
complement of teeth into a normal functional and stable difference was diminishing, and the mandibular plane
relationship at +0.5 mm. relative to the AP line. At other angle was also diminishing. At the start of treatment, the
times there is insufficient available supporting bony space lower incisor was 6 mm. behind the AP line (Fig. 29-5).
and insufficient growth potential to reposition all the teeth The combination of the favorable pretreatment growth
into a stable position over the supporting bone; then some trend, the expectation of continued favorable growth, no
teeth must be extracted. The magnitude of the mandibular crowding, and the initial position of the incisal
malocclusion will influence which teeth should be edge of the lower incisor at 6 mm. behind the AP line
extracted. suggested that a functional and stable correction of the
The clinician has two methods of controlling the final malocclusion could be achieved without resorting to
position of the incisal edge of the lower incisor. One is by extraction of dental units. Of all the possible diagnostic
differential force control, that is, by controlling tipping decisions, the one to treat a case on a nonextraction basis
and bodily movement of anterior or posterior teeth. The will result in the least amount of potential upper incisor
other is by selecting the location of the extraction sites. retraction. This seemed appropriate for the case under
Variation in the location of the extraction sites will consideration. Appliances were placed with attachments at
determine the amount of posterior root surface area which the suggested heights.
is matched against anterior root surface area and which First stage mechanics were then initiated (Fig. 29-6J.
influence the amount of anterior retraction realized. Either Starting 0.016 arch wires were placed, the upper archwire
of these methods or a combination of the two will greatly incorporating vertical loops between canines and laterals
in- so it could be inserted in all anterior brackets without
distortion. Tip-back bends
Fig. 29-6. Appliances in place. Commencement of treat-

ment for P. R. Fig. 29-7. P. R. at the end of Stages 1 and 2.
62. Illustrative Case Histories' 443
were placed in both upper and lower archwires just distal STAGE 1 &2
to the second premolar brackets. The archwires were not Case p. R. 0 to 5th MO.
engaged in the premolar brackets but were loosely ANB 6' 5'
FMA 27' 27'
confined by C clamps to the premolar brackets. Class II
FMIA 68' 48' ) \
elastics, delivering 2.5 ounces of pull, were engaged from
the integral hook on the mesial of the buccal tube to the
circle hook on the upper archwire just mesial to the upper
canine bracket. This circle hook did not touch the canine
f=:~M ~~\~~
bracket. At the very next adjustment visit, it was possible
to replace the upper archwire incorporating the vertical
loops by a plain upper 0.016 archwire without such loops.
It is always desirable to eliminate archwires with vertical
loops as soon as possible. Such loops tend to reduce the
effectiveness of the wires to open bites.
Tip-back bends were maintained in the upper and lower
archwires. The tip-back in the upper archwire induces
incisor depression and distal tipping of the upper molar.
Absolutely no stop against the molar tube was used. It is
contraindicated. The tipback in the lower archwire
induces lower incisor depression and serves to maintain
the lower molar in an upright position, resisting bodily
movement. The lower tip-back bend creates bodily
anchorage resistance in the lower molar, which is Fig. 29-8. First and second stage of treatment
matched against tipping movements of the entire of P. R.
As the bite opens, the entire maxillary dentition can tip-
back to more normal position over the supporting bone
and to more normal relationship with the mandibular
dentition. If bite opening is adequate, it does not take
much force to tip the entire upper dentition back to a
normal relationship with the lower dentition. If the bite
opening is rapid and adequate, lower molar anchorage
consumption will be small. Approximately 5 months after
starting treatment, the objectives of the first and second
stages had been achieved for this patient (Figs. 29-7, 8).
. Fig. 29-9. P. R. set up for commencement of Stage 3.
Fig. 29-10. P. R. at the end of Stage 3. Fig. 29-11. P. R. same day appliances were removed.
63.
65.
The third stage could now commence (Fig. 29-9). ginning the third stage, it was completed (Fig. 29-10). All
The objective of the third stage is to correct the axial appliances were removed (Figs. 29-11, 12, 13).
inclinations of all the teeth. In a nonextraction case this is Between appliance removal and placement of retainer
usually limited to improving the inclinations of the a week elapsed, and favorable settling of the dentition
incisors. For this the 0.016 archwires with tip-backs were was observed to have started, so no retainer was placed.
discarded and flat 0.018 archwires were inserted in both The trial period with no retainer was extended to even
upper and lower arches. These archwires were flat, had longer intervals to see whether the correction would hold.
ideal arch form, no tipback bends in the molar region, Eventually the dentition was observed to have settled
and no tip-ups in the anterior portion. Elastic circle hooks completely and with apparent stability. No retention was
were incorporated in the archwires just mesial to, but not undertaken. Intraoral views and tracing show that the
in contact with, the canine brackets. The anterior sector case, some four years after treatment, had retained its
of the arch wire is always constructed gingival to the stability (Figs. 29-14, 15, 16). Facial photographs before
posterior segments. Molar offsets were incorporated, treatment, at the end of treatment, the same day ap-
permitting easier engagement of the arch wire in the pliances were removed, and 4 years later show the
premolar brackets, premolar C clamps having been changes that occurred (Figs. 29-17 A, 8, C).
discarded to begin this third stage. The upper incisor
torquing auxiliary had two torquing fingers and was
made of 0.014 wire. The uprighting springs on the lateral
incisors were of 0.012 wire. The tendency of the upper Typical First Molar Extraction Treatment
incisor torquing auxiliary to drag the entire upper
Patient was a 13-year-old girl when active treatment
dentition forward off the supporting bone instead of
was started. The original malocclusion was Class II,
moving upper incisor roots lingually was inhibited by use
Division 2, with deep anterior overbite and maxillary and
of 2-ounce, Class II elastics. Thus, lower molar
mandibular dental arch crowding (Fig. 29-18). Skeletal
anchorage was expended in torquing upper incisor roots
development was well proportioned, apical base
to normal inclinations. If the dentition is able to accept
difference was within normal range, and the mandibular
this anchorage loss and yet remain stable after treatment,
plane angle is low. Mandibular incisor is -3 mm. behind
all is well. Some 4 months after be-
the AP line (Fig. 29-19). This fact plus the favorable
skeletal relations of the apical base, plus the minimal
anterior
STAGE 3 STAGE 1,2 &3

Case P.R. 5th to Case P.R. o to 9th mo.
ANB 5' ANB 6" 27" 6
FMA 27' FMA 6S' 91" '
FMIA 4S" FMIA 2S"
-6mm
!- 7S' - l-NS
NS 1MM T- 41" ~
T- AP
AP 94"
.,~ ...

n,"
,.
Fig. 29-12. Third stage of treatment of
P. R. P. R.
,'
Fig. 29-13. All three stages of treatment of
~.. (
."' -, :, )
<, .'
J ... :~;
- ,." /""1.'/ <'
:' \~
68.
66.
67.
Illustrative Case Histories' 445
42 MONTHS PRETREATMENT
STAGE 1 &2
Fig. 29-14. P. R. 52 months posttreatment.
52 MONTHS POST-TREATMENT
Case P.R. 9th to 61st mo.
ANB 6 4
FMA
FMIA 8 27 ~.,
41 61 .
I-NS
=
I-AP
+;;- -.mm\1\
94 93 .
STAGE 3
~ \ ...
W:
..
STAGE 1,2,&3
~ ~
:.:.:)
Fig. 29-15. Posttreatment reactions of P.R.
retraction desired (ANB is 4), dictated the desirability of

reducing tooth material by extracting the four first
molars. Extraction of first molars is the least effective of
all extraction procedures in producing anterior
retractions. However, it is somewhat more effective in
this case than no extraction. 52 MONTHS POSTTREATMENT
Appliances were placed with attachments at the
suggested heights. Round O.36-inch inside diarrteter
molar tubes with integral hooks on the mesial buccal
aspects of the tubes were used, the same tubes as used in
non extraction or first premolar extracttion cases. Oval
molar tubes are deemed unnecessary.
Fig. 29-16. Maxilla and mandible of P. R. :.- ... ~.~ \

before, during, and after treatment.
Ca,se D.H. START

ANB 4'
FMA l'
r~~~ 1b~: ) )
T-AP -3mm fi
rc) ~I
A
./
Fig. 29-19. Headplate tracing of D, H.

at start of treatment.
c
Fig. 29-17. Photographs of P, R, (A) at start of treatment; (B)
on the day treatment appliances were removed, and (C) 52
months after the removal of treatment appliances.
Fig. 29-20. Appliances in place. Commencement of treat,ment

for D. H.
Fig, 29-18. Original malocclusion of D. H.
First stage mechanics were initiated (Fig. 29-20).

Starting 0.016 arches with integral circle hooks just
mesial to the canine brackets and tip-backs were placed
midway in the area of the first molar extraction sites. To
engage the archwires in all the anterior brackets it was
necessary to incorporate vertical loops. Loose control of
the premolars was maintained by C clamps in the
premolar brackets which engaged Fig. 29-21. D, H. at the end of Stages 1 and 2.
69.
Illustrative Case Histories . 447
;~:
STAGE 1 &2
the archwire in both the first and second stages. Two Case D.H. too 9th
adjustment visits later it was possible to replace the 0.016 ANB 4' mo. 4'
r
A
vertical loop archwires with 0.018 plain archwires which FMA
incorporated circle hooks and tip-back bends. Vertical FMIA 77'
loops tend to reduce the effectiveness of archwires to open l- 101' -
bites, and it is desirable to remove such archwires as soon NS 3mm
T-AP
as possible. Tip-backs were maintained in both upper and 72' :
lower arches midway in the first molar extraction sites. 2mm .
Molar stops were not used.
To compensate for the longer archwire span between the
canine hook and the molar tube in first molar extraction
cases, an 0.018 first- and secondstage archwire can be
l;
used to advantage. This will compensate for the longer
posterior span, as compared with nonextraction or four
first premolar extraction cases, and will supply adequate
stiffness to produce the objectives of the first stage. Five
months after starting treatment, the objectives of the first
stage had been met, and the second stage was begun.
To accomplish the objective of the second stage, to close
posterior space, upper and lower horizontal elastics were
employed. They were engaged from the integral hook on
the mesial of the molar tube to the integral circle hook on
the archwire just mesial to the canine bracket. It is Fig. 29-22. First and second stages of treatment
frequently necessary to continue the Class II elastic of D. H.
traction during the second stage in order to maintain the
objectives of the first stage which have been achieved,
.J such as molar correction, bite opening, and edge-to-edge
incisor relationshi p.
Care must be maintained not to let the tip-backs slide
into the molar tubes. If this happens it can cause binding
of the archwire in the tube with a resultant lack of progress
as well as other undesirable sequelae. Therefore, it may be
necessary to remove the arch wires occasionally in order
to advance the tip-backs. Also, discomfort owing to the
extrusion of the archwire out the distal end of the tube
must be anticipated and reduced by clipping and folding as
needed. About 2 months later the second stage, the
extraction-space closing stage, was completed for this
patient (Figs. 29-21, 22).
The third stage of treatment was now in order (Fig. 29- , Fig. 29-23. D. H. set up for commencement of Stage 3.
23). The C clamps were removed from the premolar
brackets. Flat, 0.018 third-stage arch wires that had ideal
arch form, molar offsets, circle hooks mesial to the
canines, and that engaged the premolars were inserted. A
0.014 two-finger torquing auxiliary was applied to the
upper central incisors. All teeth that required uprighting
springs to correct their axial inclinations were ligated to
the 0.018 arch wire with 0.009 ligature wire through the
bracket.
ow 0.012 uprighting springs were applied to the upper
and lower lateral incisors. The 0.014 upright-
Fig. 29-24. D. H. at end of Stage 3.

STAGE 3
70.
71.
Case D.H. 9th to 16th mo.
ANB 4' FMA 3'
22' FMIA 70' l-
NS 72'
T-AP -2mm 103'
~~: ~:"
0(1\
J :
Fig. 29-27. D. H. 34 months posttreatment.
STAGE 1,2 & 3

Case D.H. 0 to 16th MO.
ANB 4' 3' ..
FMA 21' 20' ~~'
FMIA 77"0 62' i\
I-N 101 103' ..
....
r-j;?m o~'
Fig. 29-25. Third stage of treatment of D.

H.
ANB
f=~;;r
FMA 4
Case D.H. 16th to 50th MO.
3'
0'
FMIA 62'
2'
20'
66'
1~~~U'
Fig. 29-28. Posttreatment reactions of D.
H.
the uprighting springs on the lower premolars, canines,

and lateral incisors to tip the lower dentition forward off
the mandibular basal bone. To prevent a similar
occurrence to the upper dentition while the axial
inclinations of the teeth are being corrected, Class II
elastics that deliver about 2 ounces pull were necessary.
Approximately 9 months after commencing the third
Fig. 29-26. All three stages of treatment of stage, the objectives had been completed (Figs. 29-24,
D.H. 25). The axial inclinations of all teeth, upper and lower,
had been brought to normal range, and the appliances were
removed (Fig. 29-26).
ing springs were applied to the upper and lower canines For retention an upper Hawley with 0.030 wraparound
and premolars, and 0.016 reverse uprighting springs were wire and no pia tic anterior to the first premolar was worn
applied to the lower second molars, not only to upright for 3 months. Two years after con-
them but to resist the tendency of
72.
74.
73.
STAGE 1 & 2
fI"')
STAGE 3
".,: ':
.... :
STAGE 1,2 &3

,:.,.,~
. . ,', '
.. ,j ""'\"'--'
J
Fig. 29-30, Photographs of D, H. (A) at start of

treatment; (B) on the day treatment appliances
were removed; and (C) 34 months after removal of
treatment appliances.
Fig. 29-29, Maxilla and mandible of

D. H. before, during, and after
treatment. Fig. 29-31. Original malocclusion of S. W.
elusion of treatment, all four third molars had erupted into of the third molars. When fully matured, the dentition of a first
normal functional occlusion and were useful components of molar extraction case has all the appearances of a dentition
the dentition. Of all the diagnostic decisions, the one for which never had any extractions (Figs. 29-27, 28, 29). The
extracting the four first molars most nearly simulates the root development of the third molars after first molar
normal attritional reduction in arch length of aboriginal man extraction therapy is unexpectedly substantial and straight. Of
which allowed the unhindered eruption and development all the possible extraction procedures, as stated, the first
Case SW. START tissue changes at the start of treatment, at the end of
AND 5 treatment when appliances were removed, and 34 months
FMA 23 45
FMIA 117 after treatment (Fig. 29-30(A,B,C).
!-NS +1 mm
T-AP
Typical Four First Premolar Extraction Treatment
Pp. S. W. was a girl 12 years and 2 months old when
active treatment was started. The malocclusion was a
Class II, Division 1 with deep anterior overbite and
moderate lower crowding (Fig. 29-31). While the apical
base difference was slightly beyond normal range, the
young age of the patient (11 years) plus the low
mandibular plane would suggest that continued favorable
growth could be anticipated (Fig. 29-32). Coupled with
this, the mild crowding, the deep anterior overbite, the
position of the incisal edge of the lower incisor being +1
mm. to the AP line, indicated the necessity of removing
the four first premolars in order to created a stable, func-
tional dentition with favorable balance of upper and lower
lips. Extraction of four first premolars will allow greater
Fig. 29-32. Headplate tracing of potential anterior retraction of anterior segments than the
S. W. at start of treatment. first molar extraction procedure. The magnitude of the
malocclusion suggested that this would be an appropriate
decision for this patient.
After the premolar teeth were extracted, the appliance
was constructed with attachments at the proper heights,
and the first stage of treatment was begun (Fig. 29-33).
Initial 0.016 archwires with 400 tip-backs just distal to the
second premolar brackets were placed. Engagement of the
archwire in all the anterior brackets was possible without
the need for vertical loops. As in all treatment during the
first and second stages, the second premolar brackets are
not engaged but loosely held to the arch wire by C clamps
which gave mild vertical control of the premolars while
allowing free slippage of the arch wire mesidistally. This
Fig. 29-33. Appliances in place. Commencement of treatment of
free slippage must occur if anchorage is to be conserved.
S. W.
Initially the Class II elastic pull was from the lingual of
the lower first molars. This was done to upright them as
well as to correct their anterior posterior relationship. No
molar stops were incorporated in the arch wires. The
molar correction was made by a combination of lower
molar anchorage consumption and distal tipping of the
upper molar.
Nine months after starting treatment, the objectives of
the first stage were accomplished. The bite had been
opened, the molar relation overcorrected, the upper
incisors tipped back to an edge-to-edge relationship with
the lower incisors.
The second stage was started by the addition of
horizontal (intramaxillary) elastics to close the extraction
Fig. 29-34. S. W. at the end of Stages 1 and 2. sites. This was accomplished in 3 months
molar selection produces the least amount of potential

anterior retraction, but more than a nonextraction
procedure. Facial photographs show the soft
76.
77. STAGE 1 &2
Illustrative Case Histories . 451
Case S.W. 0 to 13th mo.

ANS 5' 5'
FMA 23' 23'
,_;;mm -lml~\
FMIA 45' 37' ;:
I - NS 117' 84' 11.\1
Fig. 29-37. S. W. at the end of Stage 3.
STAGE 3
Case S.W. 13th to 21st mo.
ANS 50 40
FMA 230 210
FMIA 370 350
ll:
Fig. 29-35. First and second stages of
treatment of S. W, ,-;:;mm +lml~
I-NS 840 980
Fig. 29-36. S. W. set up for commencement of Stage 3.

Fig. 29-38. Third stage of treatment of S,W.
(Fig. 29-34). Care was used to maintain the corrections

of the first stage, such as maintaining the bite opening,
the edge-to-edge incisor relationship, and the
overcorrected molar relationship (Fig. 29-35).
The third stage was started in the lower dentition at
one visit, and in the upper dentition at the succeeding
visit (Fig. 29-36). Flat 0.018 archwires were constructed.
Arch form was created which was felt to be harmonious
with the underlying basal bone arch formation. Molar
offsets were incorporated which allowed easy bracket
engagement of the premolars. Circle hooks were
incorporated just mesial to the canine brackets. In this
case an 0.014 twofinger torquing wire was placed on the
upper central incisors. On the upper and lower lateral
incisors, 0.012 uprighting springs were placed. On the
canines Fig, 29-39. S. W. same day appliances were removed.
79.
and premolars, 0.014 uprighting springs were placed. pleted in 8 months (Figs. 29-37, 38). The long axes of all
To accommodate the springs, the various teeth the teeth were brought to normal inclinations by means of
mentioned were ligated to the arch wire with 0.009 the auxiliaries (Figs. 29-39, 40). The appliances were
ligature wire. Since the upper incisors were in a Class III removed and an upper Hawley was placed and worn for 1
relationship at the start of the third stage, no Class II year, full-time, then discarded, as the dentition seemed to
elastics were used. It was anticipated that the upper show stability. The retainer was of the wrap-around type
incisor torquing wire would consume enough molar with no plastic anterior to the second premolars. The
anchorage so as to drag the entire upper dentition single 0.030 wire encompassed the entire dentition and
forward into a proper Class I relationship, which it did. passed around the distal of the second molars into the
Thereafter, it was necessary to use Class II elastics to palatal plastic (Fig. 29-41).
maintain the Class I relationship. The objectives of the Records of this case some four years after appliance
third stage were com- removal are included to give an idea of the posttreatment
reactions (Figs. 29-42, 43, 44, 45). While there was
significant and favorable growth during the period of
active treatment, it had nearly spent itself by the end of
STAGE 1,2,&3 active treatment and subsequently, there was relatively
Case S.W. 0 to 21st mo.
ANB 5' 4' little posttreatment growth. The only significant
FMA 23' 21' posttreatment change
FMIA 45' 35'
}.l\:, "
T-;;mm .,ml ~
I -NS 117' 98'
Fig. 29-42. S. W. 55 months posttreatment.
Case S.w. 21st to 76th mo.
Fig. 29-40. All three stages of treatment ANB 4 3'
of S.W. FMA 21 21'
FMIA 35 44'
!-NS 9B 98'
T -AP lmm Omm
rf
-~.~.~ ...
Fig. 29-41. Retainer used in retention of S. W. Fig. 29-43. S. W. 55 months posttreatment.
81.
80. Illustrative Case Histories' 453
STAGES 1&2
STAGE 1,2,&3
,:.:.~
_ ... ~
. :.'
/I
. .(/ ;
Fig. 29-45. Photographs of s. W. (A) at start of treatment; (8)
on the day treatment appliances were removed; and (C) 55 months
~~ MONTHS POST TREATMENT after the removal of treatment appliances.
Case J.R. START

ANB 8' 34'
FMA 48' 105'
FMIA +8mm
!-
NS
T-AP
Fig. 29-44. Maxilla and mandible of ;c
S.W. before, during, and after treatment.
r
was in the angulation of the lower incisor. This
spontaneous posttreatment change occurred without
compromising the integrity of the lower incisor segrn:nt
-.
or the stability of the treated dentition.
Typical Eight-Tooth Extraction Treatment

The patient was 13 years and 5 months of age when
active treatment was started. It was determined that the
skeletal and dental discrepancies of this malocclusion
were so severe that little hope for satisfactory resolution Fig. 29-46. Headplate tracing of
could be anticipated by removal J. R. at start of treatment.
Fig. 29-47. Original rnaloclussion of J. R. Fig. 29-48. Appliances in place. Commencement of

treatment of J. R.
STAGE 1 & 2
Case J.R. 0 to 15th MO.
ANB 8' 7'
FMA 4' 34' \
FMIA 8' 78' .
~~M~~\
Fig. 29-50. J. R. at the end of Stages 1 and 2.
vertical loops were needed in the anterior sections to

unravel crowded teeth. Tip-backs were incorporated in the
posterior sections with circle hooks just mesial to the
canine brackets.
As soon as the anterior crowding was eliminated, 0.018
Fig. 29-49. First and second stages archwires without loops but with circle hooks and tip
of trea trnent of J. R backs were installed. Class II elastic wear continued from
the first. Some 6 months after start-
of four first premolars only (Fig. 29-46). The extraction 'ing treatment, the requirements of the first stage were met.
procedure offering the greatest amount of potential The bite was opened, the molar relationship overcorrected,
anterior retraction is the extraction of four first premolars the upper incisors tipped back to an edge-to-edge
and four first molars. Due to the magnitude of this relationship with the lower incisors.
particular malocclusion, four first premolars and four first The second stage now was started. During this stage,
molars were extracted (Fig. 29-47). horizontal elastics were worn from an integral hook on the
, Appliances were placed with attachments at the mesial of the molar tube to a circle hook on the archwire.
recommended heights, and the first stage of treatment was At the same time it was found necessary to continue use of
begun (Fig. 29-48). Round buccal tubes with standard Class II elastics to maintain overcorrected molar
0.036-inch 1.0. (inside dimension) were used on the relationship and incisor edge-to-edge relationship. For a
second molars, oval tubes being unnecessary for short time it was also necessary to wear anterior space
buccolingual molar control. Such control is better closing elastics from canine pin to canine pin. The second
maintained by Class II elastics worn on the buccal or stage, the posterior space closing, required 9 months (Fig.
lingual side of the molars as appropriate. Initial arch wires 2949). At the end of this second stage the incisors
were of 0.016 wire because
83.
82. Illustrative Case Histories . 455
Fig. 29-51. J. R. at the end of Stage 3. Fig. 29-52. J. R. same day appliances were removed.
STAGE 3 STAGE 1,2&3

Case J.R. 15th to 34th mo. Case J. R. 0 to 34th MO.
ANB 7' 6 ANB 8 6
FMA 34' ' FMA 34 32
FMIA 78' 32' FMIA 48 58
L -NS 68' T- 58' !-NS 105 101'
AP -4mm 101'
Omm T-A: ~mm (m~ \. \ ..
~
JU ~ -v.
.....
Fig. 29-53. Third stage of treatment of J. R. Fig. 29-54. All three stages of treatment of J.
R.
had been tipped decidedly lingually. It will be found that nine brackets were installed. Premolar C clamps were
the more severe the original protrusion, the more severe removed. Premolar brackets were engaged in the
the tipping of incisors at the end of the second stage. The archwires. An 0.016 four-finger torquing auxiliary arch
operator should not worry about the unusual appearance was applied to the upper incisors. On the upper and lower
of the dentition in intermediate stages if the full benefit of lateral incisors, 0.012 uprighting springs were placed. On
the technique is to be obtained. Certainly no measures the canines and premolars, 0.014 uprighting springs were
need be undertaken to prevent such reactions, as the placed. The lateral incisor, canine, and premolar brackets
whole scheme of treatment will fall apart. For best results were ligated to the 0.018 flat archwires with 0.009
it is necessary to obtain the objectives of each stage in the ligature wire so that the brackets on these teeth could
prescribed sequence. accept the uprighting springs.
The case was now ready for the third stage mechanics Acting on the lower second molar was a reciprocal
to correct the axial inclinations (Fig. 29-50). Flat 0.018 0.016 uprighting spring, not only to upright the lower
third-stage arch wires with molar offsets, ideal arch form, second molar but to resist the anterior displacement factor
and circle hooks mesial to the ca- induced by the uprighting springs
84.
STAGE 1 &2
STAGE 3
Fig. 29-55. J. R. 17 months posttreatment.
37 MONTHS POSTTREATMENT
Case J.R. 34th to 71st MO. 5'
ANB 6'
FMA
FMIA
32'
58'
.!.-NS 101'
;~: ~
102'
+2mm
T-AP 0
reS ~
STAGE 1,2&3
Fig. 29-56. J. R. 17 months posttreatment.
on the premolars, canines, and lateral incisors in the lower

arch and the anterior displacement factor of all the
auxiliaries working on the upper dentition. The
combination of all these anterior displacement factors taxes
the anchorage resistance potential of the lower second Fig. 29-57. Maxilla and mandible of
molar. J. R. before, during, and after treat-
, Of the three stages of treatment, the greatest amount of ment.
anchorage is expended in the third stage when the axial
inclinations of all the teeth are changed to normal. Later in
the third stage, after most of the uprighting was completed, moved (Figs. 29-51,52,53). The axial inclinations of all the
it was found necessary in this case to torque the roots of the teeth had been brought to normal (Fig. 29-54).
lower central incisors lingually with an 0.014 auxiliary. A Hawley retainer with wrap-around wire was placed on
Some 19 months after starting the third stage, the the upper dentition. The retainer had no platic anterior to the
objectives had been met and the appliances were re- upper second premolar. The' wire passed around the distal
of the second molar
Fig. 29-58. Photographs of J. R. (A) at start of

treatment; (B) on the day treatment appliances
were removed; and (C) 17 months after the
removal of treatment appliances.
to the palatal plastic of the retainer. It was worn for 1

year in order to obtain good second molar settling. On
both eight-tooth extraction cases and first-molar
extraction cases, reduction of the lingual cusp of the
upper second molar is usually necessary in order to
Fig. 29-59. (A) Well-designed swept wing Begg bracket is

usefully employed on premolars and canines. (B) Welldesigned
long welded flange Begg bracket is usefully employed on
incisors. (C) Variations of locking pins used to engage arch wire
to bracket. (D) Well-designed molar tube has welding feet at
mesial aspect which allows tube to be welded at proper
angulation to buccal surface of molar. This provides good
control of molar rotation and arch-form. Integral hook at mesial
of molar tube minimizes rotational effect of elastic pull on the
molar. (E) Poorly designed molar tube has welding flange along
entire middle portion of tube. This prevents proper angulation of
tube to buccal surface of molar and makes it extremely difficult
to obtain good arch-form and to control molar rotations. (F) "C"
clamps in place. They are used to loosely secure arch wire to
premolars during Stages 1 and 2.
,'"
Fig. 29-60. Two-finger incisor torquing auxiliary of 0.014

wire. Four-finger incisor torquing auxiliary of 0.016 wire.
Fingers are constructed at 30 degrees up from horizontal and will
torque teeth of average root surface area at rate of about 4 Fig, 29-61. Flat 0.018 arch wires for Stage 3. Circular hooks or
degrees per month. loops for elastics are just mesial to the cuspid brackets and molar
offsets are just mesial to the molar tubes.
get good settling of the second molars, and this was done.
A Some 17 months after removal of appliances, the third
molars had successfully erupted into normal occlusion and
were useful, functional components of the dentition (Figs.
29-55, 56, 57). They also possessed good root
development. Normal eruption and development of third
molars may be expected after eight-tooth extraction
therapy. With the arrival of
Fig. 29-62. (A) Uprighting auxiliaries. Large springs with 90

activation are of 0.016 wire, have two coils in the helix, and are
for molar uprighting. Medium size springs are of 0.014 wire, have
three coils in the helix, have a twelve o'clock bend on that arm
inserted into the bracket and are used on premolars and canines.
The smallest uprighting spring is of 0.012 wire, has two coils in
the helix, has a twelve o'clock bend on that arm inserted in the
bracket and is used on incisors. All uprighting springs have rights
and lefts. (B) Arrow points to twelve o'clock bend. This bend
insures that the helix, not the arm, will absorb the force when the
spring is activated.
References 459
/
/
~ig. 29-63. (A) Anterior view of typical arch-

wires used in Stages 1 and 2 with incisor region
bowing and circular hooks for elastics in lateral
c
incisor-canine region. (B) Side view of typical
arch wires used in Stages 1 and 2 with
tip backs 4 to 5 mm. anterior to molar tubes. (C)
Archwire with loops, a type of arch wire
sometimes needed to start treatment where there
is much incisor irregularity. They should
be discarded for plain archwires as in ex-
amples A and B, as soon in treatment as possi-
ble because loop archwires have inferior bite
opening ability.
(
the third molars the dentition had all the appearances of a moved well distally, thus giving these teeth a favorable
dentition which had had no more than four first promolars mesioaxial inclination, something which is required for lower
removed for orthodontic purposes (Fig. 29-58). Figures 29-59 incisor segment stability.
to 29-63 show various components of the appliances used.
REFERE CES
RETENTIO 1. Begg, P. R. and Kesling, P. c. Begg Orthodontic Theory
and Technique. Philadelphia, W. B. Saunders, 1971.
Retention after Begg treatment can be adequately handled
2. Williams, R.: The diagnostic line. Am. J. Orthodont.,
with an upper Hawley retainer. No lower retention seems to
55:459, 1969.
be needed. Occasionally, proximal stripping of the lower
3. ______: The cant of the occlusal and mandibular planes
incisors is warranted so that they can maintain their with and without pure Begg treatment. J. Pract. Orthodont..
alignment. Beyond this, though, nothing in the way of a 2:496,1968.
retaining appliance seems to be needed in the lower arch. 4. ______ : Begg treatment of high angle cases. Am. J. Or-
The explanation for this probably lies in the fact that the thodont., 57:573, 1970.
uprighting potential of the auxiliary springs is so consistently 5. ______ : A cephalometric appraisal of the light wire
effective that the apices of the lower canines and lower lateral technique. In Begg, P. R. and Kesling, P. c.: Begg Or-
incisors can be thodontic Theory and Technique. Philadelphia, W. B.
Saunders, 1971.
30
The Twinwire Appliance: Construction and
Use in Treatment
EARL E. SHEPARD, D.D.S.
In 1917 the oft-rediscovered "light wire" was discussed years. The reaction to rotation of teeth attached by means of
in an article on "Further Experience with the 0.020 Arch bracketed bands to the twinwire labial arch has never been
Wire" by Ray D. Robinson, D. Willard Flint, and Allen surpassed (Fig. 30-1).
Suggett. In 1924, in Kansas City, Doctor Charles Hawley c:===- ---------.
spoke of the use of fine round wire in bracketed bands. END TuBES: -30MM;-+
,0.35 OUTSIDE DIAMETER .022 INSIDE DIAMETER
About this time a young man in Louisville, Kentucky,
Joseph E. Johnson, was experimenting with light forces and
WIRE: 1.3-INCH LENGTH OF .ou HARD TEMPER
aligning teeth without undue arch expansion.
CHROME ALLOY DOUBLED ON ITS LENGTH
One of the monumental discoveries of Johnson was that,
while an D.DIO-inch stainless steel wire was capable of
bringing about effective tooth movement, especially that of l.
rotation, the deformation of so small a wire reduced its END 5ECT IONS ARE THREADED ON THE .on WIRE
B- '''"
effectiveness. In time he constructed a labial archwire, of
parallel O.OlO-inch wires that reduced the deformation and
increased its effective action when it was fastened to a
banded tooth by means of a bracket. 2. ""'CEO w,,, E~",M'EO ON THE
The initial appearance and description of the technique COG WHEEL CRIMPER OF THE ARCH PULLER
and of its application as an appliance occurred in 1931 at
'6""'~~llJl
the meeting of the American Dental Association in 3
Memphis, Tennessee. The record speaks of the paper read .
there as "A New Orthodontic Mechanism." Not only did
Johnson describe the twinwire labial arch, he also demon-
strated the effectiveness of arch lengthening as a procedure
~
to overcome the overexpansion of dental arches so popular ARCH PULLER EXTENDS TWIN-WIRE ARCH TO DESIRED LENGTH
in that day. MIDSECTION
Fig, 30-2. Twin-wire labial arch construction.
THE LABIAL ARCH

The twinwire arch has been utilized for some 40
A B
Fig. 30-3, (AJ Diagrammatic occlusal view of auxiliary

spring force producing arch expansion (maxillary arch). (8)
Fig. 30-1. Diagrammatic occlusal view of twin-wire Diagrammatic occlusal view of staple spring force
appliance correcting torsiversion of anterior teeth. producing arch expansion (mandibular arch).
460
86. Anterior Bands . 461
Fig. 30-4. Basic maxillary molar appliance showing wrapped Fig. 30-5. Close-up of wrapped free-end spring.
free-end springs.
t
Fig. 30-6. Diagrammatic profile view of twin- Fig. 30-7. Diagrammatic profile view of twinwire
wire appliance correcting extrusion of anterior appliance correcting intrusion of anterior teeth and
teeth and intrusion of posterior teeth. extrusion of posterior teeth.
Although wires of many sizes may be employed, the

most popular labial arch is composed of two o.Olo-inch
paralleled stainless steel wires drawn into end section
tubes of 0.035" outside diameter (G. D.) X 0.022" inside
diameter (LD.) (Fig. 30-2).
THE BASIC APPLIANCE

This basic appliance, as utilized by Johnson, involves
banded first permanent molars with soldered lingual
arches (Fig. 30-3). Attached to the lingual arches may be
free-end springs, which may serve to attain arch
expansion of a small degree as advised by Johnson (Figs.
30-4, 30-5).
A critical adjustment in the construction of the
appliance is the angulation of the buccal tubes to regulate
the intrusive or extrusive force applied to the anterior
teeth by means of the twinwire labial arch (Figs. 30-6,
30-7).
ANTERIOR BANDS
Many bands have been employed to apply light wire
force to anterior teeth. The original bracket involved a
channel (0.022") and sliding friction lock. Although it Fig. 30-8 (Top) Diagram of original Johnson friction cap.
was effective, ligature tied brackets have (Bottom) Twin-tie channel bracket.
462 . The Twinwire Appliance: Construction and Use in Treatment
become much more popular. Practically any type of absent teeth .is efficiently accomplished. The concentric
bracket may be used as long as the channel is 0.022/1 wide posterior movement molars (often in conjunction with
(Fig. 30-8). extra-oral anchorage) is frequently employed (Fig. 30-9).
HEADGEAR ATTACHMENT
The use of headgear minimizes the need for inter- CASES INVOLVING EXTRACTION
maxillary elastic traction. In late mixed dentition The 0.016-inch labial arches with coil-spring action
treatment, or early complete dentition, the lengthening of against the canines in posterior movement of teeth is
the maxillary arch in many instances is enhanced by a employed in this method of treatment. Second premolars
combination of headgear and intermaxillary elastic are routinely banded, and lingual arches are employed
traction. until space closure is obtained, thereby assuring stable
molar position. Twinwire labial arches are customarily
utilized in anterior tooth alignment prior to posterior
COIL-SPRINGS
canine movement. All of the attributes of other light wire
Push-coil-spring action is a vital part of linear appliances, including root torquing, are routinely
movement in the application of the twinwire mechanism. employed in practice with the modern twinwire appliance.
Space management in cases of congenitally
Fig. 30-9. (A) Diagrammatic view of twin-

wire appliance creating posterior molar
movement by means of combined coil-spring
and intermaxillary elastic force. (B)
Photographs illustrating twinwire appliance's
ability to open space so as to permit eruption
of blocked-out teeth. (e) of case shown in (B).
A
Cases Involving Extraction . 463
Fig. 30-10. This case is typical of a Class I malocclusion. (A-C) Pretreatment (D-FJ posttreatment.
ANGLE CLASSIFICATION MALOCCLUSIONS Case 101. This illustrates a Class I malocclusion

TREATED WITH THE TWINWIRE APPLIANCE involving slightly constricted arches and closed bite with
torsi version of mandibular incisors. Treatment involved
the use of anterior free-end expansion springs on fixed
Class I (Angle)
lingual arches in conjunction with basic twinarch therapy.
Case 100. This case is typical of a Class I malocclusion Treatment time was 27 months (Fig. 30-11).
usually involving a closed bite. A basic twinwire Case 102. Case similar to 101. Treatment time was 24
appliance was used. Treatment time was 22 months (Fig. months (Fig. 30-12).
30-10).
Fig. 30-10. This case is typical of a Class I malocclusion. (A-C) Pretreatment (D-F) posttreatment.
A GtE CLASSIFICATION MALOCCLUSIONS Case 101. This illustrates a Class I malocclusion

TREATED WITH THE TWI WIRE APPLIANCE involving slightly constricted arches and closed bite with
torsi version of mandibular incisors. Treatment involved
the use of anterior free-end expansion springs on fixed
Class I (Angle)
lingual arches in conjunction with basic twinarch therapy.
Case 100. This case is typical of a Class I malocclusion Treatment time was 27 months (Fig. 30-11).
usually involving a closed bite. A basic twinwire Case 102. Case similar to 101. Treatment time was 24
appliance was used. Treatment time was 22 months (Fig. months (Fig. 30-12).
30-10).
Fig. 30-11. Case 101 illustrates a Class I malocclusion. (A-C) Pretreatment

(D-F) posttreatment.
Fig. 30-12. Case 102 was similar to Case 101.
Case 103. This case involved congenital absence of the Case 105. Case involving extreme labioversion of
left maxillary lateral incisor and an abnormal maxillary maxillary anterior teeth and out-sized temporary broken
frenum with anterior diasternas. This illustrates the use of anterior central incisor protection. Treatment time was 30
coil springs on a twin wire labial arch in space closure. months (Fig. 30-15A-15F).
Treatment time was 20 months (Fig. 30-13). Case 106. Class I malocclusion involving impacted
Case 104. Class I malocclusion similar to Case 103 maxillary right canine. The canine was chain-ligated and
with the exception of the absence of right and left moved into position by tension from a twinwire labial
maxillary lateral incisors (Fig. 30-14A-14F). arch. This is a very efficient method. Treatment time was
30 months (Fig. 30-16A-16F).
Fig. 30-13. Case 103. (Continued opposite page)

Fig. 30-13. Case 103. Continued
Fig. 30-14. Case 104 was a Class I malocclusion. (Continued on overleaf)

Fig. 30-14. Case 104. Continued
Fig. 30-15. Case 105.

Fig. 30-16. Case 106, a Class I malocclusion.
Class II (Angle) Treatment time was 32 months (Fig. 30-19A-19F).

Case 200. This is a severe Class II, Division 1 mal- Case 203. Class II, Division 2 malocclusion with severe
occlusion. Judicious use of light, Class II elastic traction overbite, lingually inclined central incisors. Treatment
was employed. There were no extractions, and no time was 27 months (see Fig. 30-20A-20F).
headgear was used. Treatment time was 32 months (Fig. Case 204. Class II, Division 1 adult, age 30 years.
30-17A-17F). Extraction of maxillary first premolars prior to treatment.
Case 201. A typical early permanent dentition Class II, Treatment time was 25 months (Fig. 3021A-21F).
Division 1 malocclusion. Treatment time was 9 months Case 205. Class II, Division 2 Subdivision. An unusual
(Fig. 30-18A-18F). opportunity was afforded for obtaining a 12year
Case 202. Class II mutilated dentition involving posttreatment record. Treatment time was 23 months (Fig.
congenital absence of maxillary lateral incisors and 30-22A-22F).
mandibular central incisors. Deep overbite was Case 206. Class II, Division 1 Subdivision adult
eliminated. Replacement of teeth was not necessary.
Fig. 30-17. Case 200 was a severe Class II, Division 1 malocclusion.
87. Cases Involving Extraction . 471
Fig. 30-18. Case 201.

Fig. 30-19. Case 202, a Class II mutilated dentition. (Continued opposite page)
.,
Fig, 30-19. Continued

Fig. 30-20. Case 203, Class II, Division 2 malocclusion.

88.
Cases Involving Extraction' 475
Fig. 30-21. Case 204 was a Class II, Division 1.

Fig. 30-22. Case 205, Class II, Division 2 Subdivision.

Bibliography . 477
89.
Fig. 30-23. Case 206, a Class II, Division 1 Subdivision.
with severe unilateral open bite and a history of with placement of teeth well upright on basal bony support.
thumbsucking. A palatal crib was utilized to eliminate the Treatment time was 26 months (Fig. 3025A-25H).
habit after which a maxillary twinwire appliance was used to
close the openbite. Treatment time was 22 months (Fig. 30-
23A-23D).
Case 300. A Class I malocclusion with bimaxillary
alveolodental prognathism necessitating the removal offirst BIBLIOGRAPHY
premolars (Fig. 30-24A-24F).
All maxillary and mandibular teeth were banded and a Allen, W. L: Mandibular stability with the twin-wire appliance.
0.016 labial arch was used. Coil-springs were employed on Am. J. Orthodont., 52:483, 1966.
the labial arches to move the canines distally. Twinwire labial Johnson, J. E.: A new orthodontic mechanism: The twinwire
arches were used to secure final anterior alignment. Treatment automatic appliance. 1- A. D. A., 19:997, 1932. ___ : The twin-
wire appliance. Am. J. Orthodont. & Oral Surg., 24:303, 1938.
time was 23 months.
___ : The construction and manipulation of the twinwire arch
Case 301. Class L Bimaxillary protrusion. Treatment mechanism. Am. J. Orthodont. & Oral Surg., 27:202,1941,
instituted was the same as in Case 300
Fig. 30-24. Case 300, a Class I malocclusion.
Fig. 30-25. Case 301, a Class I bimaxillary protrusion. (Continued opposite page)
Bibliography' 479
Fig. 30-25. Continued
-,-----: The treatment of different types of malocclusion with the Madden, C. K.: The Johnson twin arch appliance. Am. J.
twin-wire arch mechanism. Am. J. Orthodont. & Oral Surg., Orthodont. & Oral Surg., 33:420, 1947.
27:289, 1941. Robinson, R. D., Flint, D. W., and Suggett, A.: Dec. Items of
Interest. 40:352-355, 1918.
___ : The use of the twin-wire mechanism in the treatment of Weber, F. N.: The treatment of extraction cases using a modified
deep overbites. Am. J. Orthodont. & Oral Surg., 27:347, 1941. Johnson twin-wire technique. Am. J. Orthodont., 42:164, 1956.
___ : Some clinical applications of the modified Johnson twin
___ : The use of the twin-wire mechanism in the treatment of arch wire technique. Am. J. Orthodont., 43:90, 1957.
cases in which extraction is indicated. Am. J. Orthodont, &
Oral Surg., 33:582, 1947.
31
Labiolingual. Technique
H. K. TERRY, D.M.D.
Effective treatment with the labiolingual appliance of the tooth. In addition, the mesial root is the larger root,
requires a high degree of patient cooperation. The and the apical portions of the roots are curved distally. The
principles of this appliance include a treatment plan that first weld is' tacked lightly into place, visually examined
utilizes effective but minimal appliance manipulation and and adjusted with pliers to the desired position (Fig. 31-3).
early correction of conditions which if left uncorrected The final weld or solder is then applied. The 3 to 5
can adversely affect occlusion and facial harmony. inclination also serves to start the lingual archwire in a
Successful interceptive treatment of early malocclusions is slightly downward direction toward the gingival border of
effective for patients even under the age of 24 months the crowns of the incisors when it reaches the anterior
who have anterior crossbite (17 months), the mandibular teeth, thus reniforcing the anchorage.
molar region in internal occlusion (22 months) and the The half-round tubes on the lingual of the maxillary
posterior crossbite (17 months), the mandibular molar molar bands are placed as far gingivally as possible so as
region in internal occlusion (22 months) and the posterior not to impinge on the soft tissues (Fig. 31-4). The occlusal
crossbite (24 months). Fig. 3 -1 A-D). ends of the tubes are inclined mesially 3 to 50 to conform
with the inclination of the long axis of the teeth and so that
the anterior gingival approximation of the arch wire is
more easily accomplished.
APPLIANCE CONSTRUCTION The half-round tube may be welded or soldered onto the
metal band. Care must be taken to assure that solder is not
The construction of molar bands on the first permanent
allowed to flow into the tubes, lest it prohibit the
molars is usually accomplished with prior separation of
satisfactory insertion of the halfround posts attached to the
the teeth by means of 0.025-inch soft brass wires or elastic
lingual archwire.
ligatures. The tensile strength of the band material is
The buccal tube is tacked to the band. Its position should
important so that the band can be as thin as possible and
be as near to the gingival border as the soft tissue will
yet not break under the stress of mastication and removal
allow and rnesiodistally approximately 1 mm. more to the
for periodic recementing. A precious metal (0.007 x 0.187
mesial rather than equally dividing the crown. It should
inches) or a stainless steel (0.005 x 0.187 inches) material
also be approximately parallel to the occlusal surface of
is acceptable.
the molar crown. The band is replaced on the tooth and the
The teeth to be banded are examined for size and shape
buccal tube alignment is checked (Fig. 31-5). Any needed
(Fig. 31-2). Bands are tried on the tooth until an excellent
adjustment may be made prior to the final weld or solder
fit is obtained (Fig. 31-3). The band should not interfere
(Fig. 31-6). The final welding is then made.
with the occlusion (Fig. 31-3), and it should be festooned
The bands are completed with the buccal round tubes
to extend only under the free gingival margin so as not to
and the lingual half-round tubes properly placed and
irritate the soft tissue.
placed on the teeth in the position in which they will be
A half-round tube is soldered to each molar band prior
cemented. An impression is taken. The bands are then
to taking a work model impression with the two bands on
removed from the teeth and positioned in the impression,
the first permanent molars in place. The half-round tube is
waxed into place or held with a small amount of alginate
located on the lingual of the mandibular band 1 mm. from
over the buccal and lingual tubes (Fig. 31-7). The
the occlusal edge with the distal of the tube approximately
impression is poured with a good grade of dental stone
even with the lingual groove extension from the central
using the vibrator carefully so as not to dislodge the molar
fossa of the molar. The occlusal portion of the tube is
bands. Green colored stone has been found to be of
tilted 30 to 50 toward the midline. The purpose of this is to
sufficient hardness. It withstands the heat well
provide more effective anchorage by approximating the
geometric center of the effective root resistance
48
0
Band Technique . 481
Fig. 31-1. C. W., age 2, white male (A). The crossbite on the right side includes molars, canine and lateral incisor. (B) Bands
on the second deciduous molars with a vertical half-round tube on the left (normal) side and a horizontal round tube on the
right (crossbite) side. The lingual appliance is in place with the auxiliary spring last used to over-correct the canine crossbite.
(C) Slightly over-corrected- right side crossbite. (D) Occlusion on the normal side,
and is possibly better for avoiding eyestrain during merited, it is more comfortable to the patient and it saves
appliance construction. valuable chairside time to construct appliances in the
After the stone has set, the impression material is laboratory. It is practical in many instances, however, to
separated from the work model and the model is trimmed replace lost or broken appliances by constructing, fitting,
of all excess bulk leaving an outline of the sulcus of the and adjusting them at the chairside.
muco-buccal fold. The model base should be thick enough
The sequence of construction of appliances in the
to resist fracturing during. appliance construction.
The appliance is usually constructed on the work model. laboratory that conserves the models is as follows: (1) The
Although the appliance can be constructed directly in the mandibular lingual arch wire; (2) The maxillary lingual
mouth after the molar bands are ce- archwire; (3) The Oliver guideplane auxiliary attachment to
the maxillary lingual arch-
482 . Labiolingual Technique
Fig. 31-2. A mandibular molar band is checked to make

sure there is no occlusal interference.
Fig. 31-5. A tack-welded buccal round tube on the maxil-

lary left first permanent molar is being checked for align-
ment.
Fig. 31-3. The half-round tube on the molar band is Fig. 31-6. A tack-welded buccal round tube is being
adjusted with a plier to obtain a 3 to 5-degree mesial adjusted so as to obtain correct horizontal and vertical
inclination of the occlusal end. alignment.
wire; (4) The mandibular labial archwire; (5) The maxillary

labial arch wire; and (6) The auxiliary springs and other
attachments.
CONSTRUCTION OF THE PRECIOUS

METAL LI GUAL ARCHWIRE
The lingual arch is usually made to approximate the shape
of the dental arch as it originally exists, leaving clearance for
the lingual movement of any teeth in labioversion or
Fig. 31-4. The half-round tube in position on a maxillary
buccoversion. The lingual arch is used for anchorage can trol
molar band. In the illustration, the right of the band is mesial
and as the base
and the bottom is gingival.
Construction of the Precious Metal Lingual Archwire . 483
to which auxiliary springs are attached for desired tooth

movement.
The model is placed on a model holder. An adequate
length of O.040-inch round, annealed gold wire is selected
allowing extra length for working, Because the metric
system is to be adopted in the United States, a conversion
table for wire sizes may prove useful.
Inches Millimeters
0.001 0.025
0.005 0.127
0,007 0.178
0,010 0.254
0,012 0.305
0.018 0.457
0,020 0.508
0,022 0.559
0.025 0.635
0.027 0,686
0.030 0,762 Fig. 31-7. An alginate impression with the right and left
0.036 0.914 molar bands securely fixed in position with freshly mixed
0.040 1.016 alginate material over the buccal round tubes and the lingual
0.045 1.143
half-round tubes.
0.087 4.750
The solder, 650 fine, is placed on the filed flat end of the
half-round post. Solder should not be allowed to overflow without making a sharp bend. Hold the arch wire with the
the end area. The half-round post is soldered to the arch left thumb against the right canine area at the gingiva. Form
wire approximately 6 mm. from the right end of the the anterior portion of the archwire by bending with the
archwire. with the flat side of the half-round post facing the right hand, move the left thumb along the anterior portion
solderer. Extreme care is taken to prevent any excess solder of the arch wire to the gingival area of the canine, bending
from flowing on the flat side of the half-round wire and to by pressure with the right hand. Remove and refine the
avoid overheating the joint, which would change the crys- adaptation of the archwire to fit a slightly scored model as
talline molecular structure of the wire, The excess half- Iowan the lingual portion of the crowns of the anterior teeth
round post material is cut off leaving just enough soldered as possible without creating gingival irritation. There
to the archwire to completely fill the length of the half- should be an indentation of the gingiva after the archwire is
round tube but not to extend beyond it. The half-round post worn, but not an irritation.
on the archwire is held downward over the flame and The free end of the arch wire should now lie over the
allowed to heat to the melting point of solder, at which half-round tube of the left molar. The archwire is marked
time it centers itself on the archwire and assures a lightly with a file or marking pencil exactly at the midpoint
homogenous soldered joint. of the half-round tube and is then removed and a half-round
A grooved pliers is used to hold the arch wire at the half- post is soldered at the mark. The half-round post is cut, heat
round post. The post is warmed and immediately touched centered, lubricated, and placed into the left half-round tube
to soft carding wax. A film melts on the post and acts as a and the excess length of archwire is clipped.
lubricant during the repeated insertion in the half-round The rounded file is used again to adapt the distal end of
tube while adapting the archwire. the archwire against the band and to the embrasure. It is
The archwire is held at the post with the grooved pliers, also used to give a slight adaptation to the mesial and
and the post is placed in the tube and seated firmly with a slightly gingival embrasure. Holding the archwire with the
rounded end of a file. The same rounded end of the file is pliers off the model and bending with the fingers, it is fitted
used to press the distal end of the archwire into the to the lingual gingival crowns of the teeth. It can then be
interproximal embrasure and very slightly gingivally. The placed on the model and heat-treated with a flame to just
same procedure is carried out at the mesial embrasure of below a dull red using the holding grooved tweezers to
the banded molar, but guide
484 . Labiolinguul Technique 90.
its adaptation while being rendered into a molecular side of the archwire at 10-degree inclination distally from
passive state. perpendicular. The lock on the mandibular arch wire is
The posterior lock of the precious-metal lingual archwire soldered with a 0- to 10-degree lateral inclination lingually
is made by soldering 0.025-inch or 0.027inch annealed from the vertical, while the maxillary lingual archwire is
semiprecious metal lockwire 5 mm. mesially from the half- positioned 5 to 20 palatally. In both instances the purpose
round post on the gingival is to avoid impinging on gingival tissue when the archwire
is locked into position. The lockwire should be close
enough to the gingival tissue to be comfortable to the
tongue.
After all the auxiliary spring attachments have been
placed, the completed lingual appliance is removed from the
work model and heat-treated for grain growth to obtain the
desirable state of tempered elasticity. The temperature and
time should correspond to that recommended by the
manufacturer of the wire. Usually 15 minutes at 600 to
800F will produce adequate resiliency without rendering
the archwire brittle.
CO STRUCTIO OF THE ST AI LESS STEEL LI GUAL

ARCHWlRE
A stainless steel lingual archwire may be used. It requires
Fig. 31-8. The O.OlD-inch annealed dead-soft steel
accurate fitting and adjusting. The lingual half-round tube
measuring wire is inserted in the half-round lingual tubes
may be of the horizontal or vertical
on the mandibular molars.
Fig. 31-9. Measuring wire removed so that

the correct size lingual arch wire may be
selected.
Fig. 31-lD. Tissue area lingual to the mandibular incisors Fig. 31-11. The lingual archwire is approximated to the
is scored on the model to a depth of approximately 0.10 mm. lingual-gingival portion of the crowns in the molar and
premolar areas.
Construction of the Stainless Steel Ungual Archwire 485
Fig. 31-12. The lingual archwire is approximated to the Fig. 31-13. The lingual post on the right side of the arch
lingual-gingival junction of the incisor crowns. wire is inserted into the half-round tube on the right molar.
type. There may be some difficulty in insertion of the wire is scored on the model to a depth of approximately 0.10 mm.
when the horizontal type is used. (Fig. 31-10).
The end of an 0.010-inch annealed dead-soft steel The selected preformed (0.036-inch) Elgiloy-type lingual
measuring wire is bent 90, 3 mm. from its end. The 3-mm. arch wire is inserted in the left molar halfround tube and is
bend is placed in the left molar's half-round tube, cut 3 mm. approximated to the lingual gingival portion of the crowns
longer than the distance to the right half-round tube, bent 90 (Fig. 31-11). Using the thumb and fingers, the anterior
at the tube and inserted into the right half-round tube (Fig. portion is adapted on the model to an approximate fit at the
31-8). The annealed wire is removed and used as a linguogingival junction of the incisor crowns (Fig. 31-12).
measurement for the selection of the correct sized lingual
archwire (Fig. 31-9). The tissue area lingual to the incisors
91.
Fig. 31-15. The adjusted lingual archwire is checked to

make sure it is passive and correctly adjusted, by inserting
Fig. 31-14. A marking pencil is used to facilitate making one half-round post at a time. The other post should now lie
adjustments to the archwire to achieve a more accurate fit. over the opposite tube into which it should be able to be
The adjustments are made by using the pliers and fingers. inserted with ease.
The right half-round post is inserted into the right molar

half-round tube (Fig. 31-13). Refinements in adjustments
for a more accurate fit are marked with a marking pencil
(Fig. 31-14) and accomplished with pliers and fingers after
removing the arch wire from the model. It is refitted to the
model and adjusted until it fits correctly and is passive
when checked with only one half-round post inserted at a
time. The other post should lie right over its respective tube
and be inserted with ease (Fig. 31-15). The archwire is then
heat tempered in accordance with the recommendation of
the manufacture for rendering the wire passive, resilient,
and strong.
The distal ends are annealed by heating to a higher Fig. 31-17. The completed an-
temperature. Pliers are used to form the annealed softened nealed recurved lock of a man-
end into a recurved lock (Figs. 31-16 and 31-17). This dibular left lingual arch wire.
secures the arch wire in place when pressed under the half-
round tube after the halfround post is inserted and
completely seated. In this softened state, it is easily
unlocked at adjustment appointments with a lingual lifter
or a scaler, which is used also for the removal of the
lingual archwire.
CONSTRUCTION OF THE MAXILLARY LI GUAL

APPLIANCE
The construction of the maxillary lingual appliance
follows the same procedures with a few exceptions. The
appliance must not interfere with the normal functional
occlusion except when an Oliver guideplane auxiliary is
attached to it. It can be more com-
Fig. 31-18. The lingual arch wire is marked to indicate the

area of the incisive papilla.
Fig. 31-19. The archwire is raised with convex-concave

pliers to provide relief for the incisive papilla.
Fig. 31-16. After the archwire has been heat-tempered,

and the distal ends annealed by heating to a higher fortable to the patient if adequate relief is given the incisive
temperature, the ends are formed with pliers into a recurved papilla. The archwire is marked indicating the area of the
lock papilla (Fig. 31-18). A convex-concave
Construction of the Maxillary Lingual Appliance 487
92.
pliers is used to raise the arch wire for relief in the
indicated area (Fig. 31-19). Compensating bends are made
to keep the half-round post in the same axial plane they
were originally. The lingual appliance is rechecked on the
model for passivity before any auxiliary attachments are
added.
AUXILIARY ATTACHMENTS TO THE

LINGUAL ARCHWIRE
The posterior recurved spring is the most frequently
used auxiliary attachment to the lingual appliance. It is
used to upright teeth in the premolar area and frequently
includes the canine. Its purpose is to gain overall dental
arch length by increasing the dental arch width. An 0.022-
inch stabilizer wire is soldered onto the lingual appliance
at the embrasure of the canine and first premolar (Fig. 31-
20). The stabilizer needs to be only about 2.5 mm. long,
since its purpose is to prevent the posterior recurved
auxiliary spring from being dislodged easily. A visual Fig. 31-20. Mandibular work model with the labial and
estimate is noted or marked with a marking pencil on the lingual archwires in place. The O.022-inch stabilizing wire
lingual appliance approximately half way from the is being soldered to the lingual archwire in the area of the
extreme effective ends of the desired auxiliary spring. A embrasure between the left canine and first deciduous
450 fine solder is then used on the gingival side of the molar.
lingual appliance (Fig. 31-21). An 0.020-inch wire is
soldered at this point and positioned horizontally
occlusogingivally, but about 35 distal from perpendicular joint (Fig. 31-23). The U is held loosely with grooved
when viewed occlusally (Fig. 31-22). While holding the pliers (Fig. 31-24).
lingual appliance at the soldered point with pliers, the The D.Q2D-inch wire is flamed to a dull red (if gold) at
auxiliary spring is bent with the fingers gingivally and the distal of the second premolar (Fig. 31-25) and, while
buccally across the lingual appliance at 145, making a hot, the wire is bent buccally and mesially on itself and
small U-shaped curve in the D.02D-inch wire at the shaped with pliers to conform to the individual dental arch
soldered (Fig. 31-26). It is cut at the mesial third of the canine (Fig.
31-27), if the canine is included in the uprighting plans; if
not, it is clipped
Fig. 31-21. The lingual arch wire has the left and right
stabilizers soldered. Solder is being placed for attachment Fig. 31-22. The posterior recurved spring has been sol-
of the posterior recurve O.020-inch auxiliary spring wire. dered to the lingual archwire.
, [
Fig. 31-23. The lingual archwire is held with pliers and the
auxiliary spring is bent buccally 145 degrees. Fig. 31-24. The auxiliary spring is held loosely with pliers
near the soldered joint and is bent lingually from its buccal
position to become parallel to the lingual archwire.
Fig. 31-25. The distal point of recurve of the gold auxili- Fig. 31-26. The distal point of recurve of the auxiliary
ary spring is heated to a dull red in preparation for its being spring is pressed almost closed with grooved pliers. The
bent 180 degrees on itself buccally. recurve spring is also shaped with the pliers to conform to the
shape of the particular section of the dental arch on Which it
is being used.
just mesial to the stabilizing stub. The uprighting springs are malocclusion. Its use is recommended during the mixed
usually placed bilaterally (Fig. 31-28), but only if the dentition period, but favorable results have been obtained in
treatment plan calls for it. A single one is often used. young adults as well.
The guideplane is constructed for specific conditions
existing in the individual patient. The height and pitch vary
from patient to patient and must be adapted and acceptable to
The Oliver Guideplane
the patient so as to give effective guidance to the mandible.
The Oliver guideplane is an auxiliary attachment to the The guideplane must not allow the mandibular
maxillary lingual arch wire in Class II, (Angle)
Construction of the Maxillary Lingual Appliance . 489
Fig. 31-27. The left posterior recurved auxiliary spring on the

lingual arch wire has been completed and the excess wire
removed. Fig. 31-28. The mandibular archwire is inverted to show the
completed left posterior recurved auxiliary spring and initial
soldering of the right spring.
Fig. 31-29. J. W., female, age 10. Radiographs of the right

temporomandibular articulation of a Class II, Division 1 (Angle)
malocclusion. (A) The mandible is in its closed Class II position,
and the condyle is in the glenoid fossa before the placement of an
occlusal guideplane. (B) The mandible is in its guided "Class I"
closed position immediately after the placement of an occlusal
guideplane. The condyle is downward and forward on the
articular eminence of the temporal bone. (C) The mandible is in
the position of centric occlusion five months after the molars have
been corrected to a Class I relationship by the guideplane and
Class II intermaxillary elastic traction. The condyle has returned
to its normal relationship to the glenoid fossa.
incisors to be brought to occlude posterior to it. This can 70 per cent distal position of the mandible with a 50 to 30 per
result from its having too much pitch or from being cent mesial shift of the maxillary molars.
constructed too far anteriorly. In severe Class II cases, it is It is possible to control the distal vector of force on the
frequently necessary to use one guideplane to position the maxillary molars, as this force is caused by the contacting
mandible halfway to the desired position and then, some action of the guideplane on the lingual surface of the
months later, to construct the quideplane more anteriorly to mandibular incisors and also by the elastic traction. The
achieve a Class I (Angle) occlusion. If the guideplane is too maxillary labial archwire is adjusted to correspond to the needs
short, it may not provide the desired guiding effect to the of this posterior vector of force. As long as distal movement of
mandible. It should place the mandible in a forward position the maxillary molars is desired, the labial archwire is left out
upon closure, bringing the condyle downward and forward on of contact with the labial surfaces of the maxillary incisors.
the posterior slope of the eminentia articularis in the temporal When the molars have been overtreated distally about 1.5 mm.,
bone (Fig. 31-29 (a) and (b) ). This condyle-fossa relationship the labial arch wire is adjusted to contact the anterior teeth,
is temporary, and in a few months the normal anatomic thereby distributing the force and reducing the distal force
relation is found to develop (Fig. 31-29 (c. component acting on the maxillary molars.
Intermaxillary elastic traction is always used concurrently In Class II malocclusion the maxillary labial archwire is
wi th the guideplane. The elastic traction usually is continued always left in contact with the labial surfaces of the maxillary
for some months after improvement has exceeded the incisors. This assists in eliciting the maximum tendency for the
guidance effect of the guideplane and its use has been mandible to grow forward. Baurn e.! and more recently
discontinued. Storey," give histologic evidence that this can take place
Tarpley' noted the following advantages of the guideplane: physiologically. The biomechanical principles have been
1. Reduction of cuspal interlocking so that the teeth can be shown to be theoretically sound and clinically effective by
moved easily into proper occlusion. 2. The maxillary buccal Oliver,3,4,5 Irish.t Tarpley." Baurne.! Salzmann.t? Sleichter"
segments can be moved distally while the vector of growth in and others. _
the mandible is encouraged in a forward direction in response The maxillary lingual appliance is constructed on the work
to the stimulus provided by the guideplane and intermaxillary model. While not necessary, it is desirable when possible, for
elastic traction. this archwire to touch the anterior teeth surfaces at the palatal
A Class II molar relationship may result from 100 per cent surface of the gingival edge. If the anterior teeth are to be
mesial migration of the maxillary buccal segments, or from tipped
1QO per cent distal relationship of the mandible to the
cranium, with all degrees between these two extremes being
possible, The 100 per cent mandibular distal relationship
seems to be as rare as the true (Angle) Class III. In most Class
II malocclusions, the cases appear to be due to a 50 to
Fig. 31-30. K. MeG., female, age 9, a Class II, Division 1

(Angle) malocclusion. (A) The models are placed in their
corrected Class r position. The lines have been drawn on the
models to show the distance the mandible needs to be guided
forward by the guide plane. (B) The models are placed in their
centric occlusion, Class II position.
Construction of the Maxillary Lingual Appliance 491
lingually or moved posteriorly, obviously the archwire

must not be placed against them. The horizontal plane of
the lingual appliance should be modified to provide relief
for the usually prominent incisive papilla.
Construction of the Guideplane, The models are
positioned to duplicate the malocclusion, and a line is
drawn through the mesiobuccal cusp of the maxillary first
permanent molar and extended onto the mandibular work
model. The maxillary work model is then moved into the
Class I position. A line is drawn through the center of the
maxillary canine area and extended onto the mandibular
work model. A new line is drawn on the maxillary model
as an extension of the old line on the mandibular model in
the molar region. The guideplane is to be constructed so
that when the models are placed together the lines fall as
they are drawn (Fig. 31-30A). The indicating lines are
drawn on the left and right sides.
The models are held in the Class I relation and observed Fig. 31-31. A posterior view of the work models placed in the
from the lingual surface (Fig. 31-31) to ascertain visually Class I position of occlusal advantage. The relationship of the
maxillary lingual arch wire to the mandibular lingual archwire's
the required height and pitch of the occlusal guideplane for
anterior section is noted for estimating the height and pitch of the
this patient. A 450 fine solder (650 fine for gold) is then
guideplane.
used on the lingual archwire at the middle of the canine
and a 0.030-inch wire is soldered at that 'poin t and angled
(Fig. 31-32) to the visually estimated pitch, to rest above
and just anterior to the mandibular lingual archwire when
the models are occluded.
Holding the 0.030 guideplane bodywire with pliers so
that the visually estimated guideplane height will be nearly
correct, the wire is bent anteriorly (Fig. 31-33). It is then
held at this corner, bent with pliers, and shaped similar to
the form of the anterior portion of the mandibular lingual
archwire (Fig. 31-34). The two work models now are
placed in occlusion to check the height and pitch of the
guideplane to be formed by observing the space from the
lingual holding the models with the lines previously drawn
in the same continuous plane as in the desired occlusion
(Fig. 31-30A). The basic guideplane wire is adjusted until
it is in correct position to the mandibular incisor teeth and
the mandibular archwire, with the previously drawn pencil
lines on the same vertical plane, all of which determines 'Fig. 31-32. The O.030-inch body-wire of the guideplane is
the height and pitch of the guideplane. soldered to the maxillary lingual appliance in the area of the
A mark is placed on the bodywire of the guideplane in mesiodistal middle of the canine. It is angled in the direction of
the middle of the lingual aspect of the mandibular left the previously estimated needed pitch.
canine (Fig. 31-35), indicating where it is to be bent to
form the final vertical part of the bodywire. The bodywire
guideplane. The models are occluded again and the
is held with the pliers and bent with the fingers, so as to
correction of the height is observed from the lingual aspect,
contact the lingual arch wire near the center of the lingual
showing the height of that side to be too great. It is
aspect of the left canine (Fig. 31-36). The bodywire is cut
removed and cut or filed until the height is correct (Fig. 31-
exactly or slightly longer than the correct height of the
37). The bodywire of the guideplane is then soldered to the
lingual archwire.
The guideplane is ready for interlacing for strength.
A 450 fine solder (650 fine for gold) is melted in the
corner bend of the bodywire (Fig. 31-38), and a 0.022-inch
wire is soldered at a 30-degree angle for the interlacing
(Fig. 31-39). The bodywire and the
492 . Labiolingual Technique 93.
Fig. 31-33. The body-wire of the guideplane is held with

pliers at the previously estimated height requirement and the
wire bent forward, to a smooth right angle, with the fingers.
Fig. 31-34. The body-wire of the guideplane is held with the
pliers and formed in the shape of the anterior portion of the
mandibular lingual arch wire with the fingers.
Fig. 31-35. The work models are held

in the Class I molar position with the
body-wire of the guideplane in its proper
relationship to the mandibular lingual
archwire. A mark is placed on the body- Fig. 31-36. The right angle bend in the body-wire of the
wire in the area of the mesiodistal center guideplane is made with the excess length extending beyond its
of the mandibular left canine for the point of intersection with the lingual archwire,
location of the final right angle bend for
the height on the left side of the forming
body-wire. the lingual archwire is replaced on the maxillary work
model. It is again electrically rendered stress relieved.
The models are occluded, and the gUideplane now
lingual archwire may be divided with a marker pencil or directs where and how they occlude. It is observed from
may be visually spaced for four contacts to the bodywire the lingual to see that it fits and is seated properly (Fig.
and three to the arch wire with symmetrically equal 31-44). The previously drawn lines in the optimum
spacing. The interlacing is accomplished by holding with occlusal advantage position are now continuous showing
the pliers and bending the wire (Fig. 31-40). The points the accuracy of the pitch of the guideplane. The
of contact with the bodywire and the archwire are mandibular incisor teeth contact the lingual of the upper
soldered (Fig. 31-41 to 43). The guideplane is complete, incisors, indicating
and
Construction of the Maxillary Lingual Appliance' 493
Fig. 31-37. The work models are held in the Class I posi-
tion of occlusal advantage and the formed body-wire of the
guideplane is viewed from the posterior with corrected
height. It is now in position for the final soldering.
Fig. 31-38. Solder is placed in the right angle bend of the
completed body-wire in preparation for the interlacing.
Fig. 31-39. The 0.022-inch inter- Fig. 31-40. The a.On-inch interlacing wire is held with the
lacing wire is soldered bisecting the pliers and bent with the fingers to contact inside the
right angle bend in the bodywire of guideplane body-wire and the lingual arch wire.
the guideplane.
the correctness of the height of the guideplane (Fig. 31-45A

and B). The completed guideplane is heat tempered to a
highly resilient and stable form by passing electric current
through the wire or otherwise heating it. The temperature
and time should be in accordance with the recommendation
of the manufacturer of the wire.
Fig. 31-41. The interlacing wire is held in place, flamed

to relieve internal stress and soldered at the point of contact
to the guideplane body-wire.
Fig. 31-42. The interlacing wire is soldered at all points of

contact to the lingual arch wire.
Fig. 31-43. The interlacing solder points are remelted and

made of consistent size by the addition of solder. This should
avoid any necessity for finishing and polishing.
Fig. 31-44. (Left) The completed maxillary lingual appliance

with the Oliver occlusal guideplane is replaced on the work
model. The work models are held in the guided position and
rechecked from the posterior view as to the accuracy of the fit.
Fig. 31-45. (A) The completed maxillary lingual appliance with the Oliver occlusal guideplane is replaced on the work models. The
models are now guided into this position of occlusal advantage by the guideplane. The previously drawn lines are checked for
congruency on the right side. (8) The previously drawn lines are checked for congruency on the left side.
Construction of the Maxillary Labial Appliance 495
CONSTRUCTION OF THE MAXILLARY

LABIAL APPLIA CE
A work model is prepared which has the 0.036inch (0.040-
inch for gold) buccal round tubes on the first permanent
molar bands positioned as close to the gingival margin as
possible without irritating the tissues. The bands should be
parallel with the level of the mesial and distal marginal ridges
of the molar crown and centered slightly mesial to the
mesiodistal center of the band. The tubes should be welded or
soldered with sufficient space between the tube and the band
for easy insertion of the archwire and room for attachments
thereto without gingival tissue impingement anterior to the
molars. Sufficient posterior clearance from solder is required
for an intramaxillary or intermaxillary elastic band to be
attached or a 0.012 ligature wire to be used to secure the
archwire to the molar band.
The work model is placed in a model holder. The O.036-
inch Elgiloy-type wire is inserted in the mesial opening of the
buccal tube of the patient's right molar and allowed to extend
2 mm. beyond the distal end of buccal tube (Fig. 31-46).
The wire is held close to the teeth on the model and bent
around the crowns (Fig. 31-47) to the buccal tube on the
patient's left molar. Frequently the archwire will be too far
incisially on the maxillary model. A bend is made
approximately 1 em. anterior to the middle of the buccal tube Fig. 31-46. The work model, .with the molar bands in place
(Fig. 31-48) so that the anterior portion of the wire lies about and the lingual arch appliance constructed, is held in a model
at the junction holder. The O.036-inch Elgiloy-type wire is inserted into the
buccal tube to the operator's left for beginning the
construction of the maxillary labial archwire.
Fig. 31-47. While in the left buccal tube, the archwire is Fig. 31-48. The labial archwire is held with the pliers and
held against the buccal and labial surfaces of the teeth of the bent with the fingers 1 em. mesial to the mesial opening of the
maxillary work model then removed and formed with finger buccal tube. It is adjusted so that the archwire will contact the
bending until it passively contacts the labial surfaces of the labial surfaces of the maxillary incisors at the junction of the
anterior teeth. middle and gingival-thirds.
496 . Laoiolingual Technique
of the gingival and middle third of the anterior crowns. The

archwire is formed and shaped with pliers and the fingers
(Fig. 31-49) to the approximate shape of the dental arch. It
is reinserted in the left buccal tube, shaped, and tested until
it is passive and lies directly over the buccal tube on the
right of the model. The excess wire is cut leaving an esti-
mated 2 mm. to extend beyond the righ t buccal tube. A
bend is made on the right side 1 em. anterior to the middle
of the buccal tube to permit the anterior portion of the arch
wire to correctly contact the anterior teeth (Fig. 31-50).
The right end of the archwire is inserted in the right
buccal tube, the archwire adjusted with pliers and bent
with the fingers until the left end of the archwire inserts
passively into the left buccal tube (Fig. 31-51).
When treatment requires wearing Class II intermaxillary
Fig. 31-49. The labial archwire is held with pliers. elastics, hooks for attaching the elastics are placed on the
The fingers bend the wire to approximate the labial and maxillary labial archwire. The archwire remains on the
buccal surfaces of the maxillary teeth when placed on the model. Solder (450 fine for
model. The labial archwire is removed from the model and
formed to fit as needed by bending with the fingers and
thumb. The labial archwire is inserted in the left buccal
tube and adapted until it passively lies over the right
buccal tube. The excess length of the labial archwire is cut
allowing only 2 mm. to extend beyond the buccal tube.
Fig. 31-50. An adjustment bend is made in the

labial arch wire 1 cm. mesial to the mesial opening
of the right buccal tube so that the arch wire will
contact the labial surfaces of the incisors at the
junction of the middle and gingival third of the
crowns.
Elgiloy and 650 fine for gold) is melted on the archwire. It ~ The posterior loop-coil lock is made of 0.022-inch wire.
is important to avoid overheating, so as to retain the It is soldered to the archwire approximately 1 em. anterior
desired physical properties of the wire. A 0.030-inch gold to the mesial opening of the buccal tube (Fig. 31-55).
wire is soldered to form the hook for an intermaxillary Round nose pliers are used to form the loop of a half circle
elastic (Fig. 31-52). The 0.030inch wire is held with pliers about 8 mm. in diameter (Fig. 31-56). The loop is formed
at the desired length for the hook and bent anteriorly with
on the gingival side of the archwire. Its end is coiled
the fingers. The wire is cut leaving sufficient excess to
around the labial archwire twice, and the excess is
ball the end of the hook for the patient's comfort (Fig. 31-
53). Intermaxillary elastic hooks are attached on both removed (Fig. 3157). The loop-coil adjustment lock is
sides (Fig. 31-54). made on both sides. The labial arch appliance is replaced
on the model adjusting the loops for proper contact with
--... z
Construction of the Maxillary Labial Appliance' 497
Fig, 31-51. With the work model in the model holder, the
labial archwire is placed in the right buccal tube and adjusted
until it inserts passively into the left buccal tube. The archwire
should contact the incisor teeth in the area of the middle and
gingival thirds.
Fig, 31-52. Solder is placed on the passive labial archwire in

the area of the middle and distal thirds of the left canine. The
work model is in the model holder and a O,030-inch gold wire
is soldered to the labial arch wire in the area of the middle and
distal thirds of the left canine for the hook for an intermaxillary
elastic.
Fig, 31-53. The labial archwire is removed from the work

model and the O.030-inch wire for the intermaxillary hook is
held with the pliers at the proper height, approximately 4 mm.
It is bent forward with the fingers to slightly greater than a right
angle. The excess O.030-inch wire for the intermaxillary hook
is cut, leaving sufficient length to "ball" the end for tissue
comfort. The end of the intermaxillary elastic hook is "balled in Fig. 31-54. The maxillary labial archwire has a similar
the flame," intermaxillary elastic hook placed on the right side.
Fig. 31-55. The labial archwire is replaced on the work

model and a O.022-inch wire is soldered approximately 0.8
em. mesial to the buccal tube on the gingival buccal of the
archwire for forming the adjustable posterior loop-coil stop, Fig, 31-56, The posterior loop-coil stop is formed with the
round-nosed pliers, bending distally with the fingers,
Fig. 31-57. The posterior loop-coil stop is bent around the Fig, 31-58. The adjustable loop-coil stop is placed on the
distal beak of the round-nosed pliers to the labial archwire other side of the labial archwire using the round-nosed plier to
around which it is to be wrapped twice, The completed shape it. The completed labial appliance is replaced on the
adjustable loop-coil stop is on the labial archwire, The shape work model and the loop-coil stop is adjusted so that the
of the completed hook for the intermaxillary elastic also is labial archwire barely contacts the labial surface of the anterior
shown. teeth,
the anterior teeth (Fig, 31-58). The completed labial than those that receive the labial archwire. This permits easier
appliance is heat treated in conformance with the wire insertion of the face bow by the patient and gives adequate
manufacturer's recommendations, clearance for the normal use of the labial archwire.
When cervical anchorage or headgear is required, a 0.045 The mandibular labial arch wire is constructed in the same
X %-inch round buccal tube is soldered to the molar band manner as the maxillary. The arch wire is adjusted to contact
occlusally to the buccal tube used for the labial archwire (Fig. the labial surfaces of the anterior teeth at the gingival border
31-59 (A) and (8. The mesial of these buccal tubes which or in the area of the gingival third of these crowns. No
are to receive the face bow is placed about 3 to 5 more intermaxillary
buccally
Construction of the Maxillary Labial Appliance . 499
Fig. 31-59. A face bow is placed into O.045-inch buccal

tubes soldered occlusally to the buccal tubes of the labial
appliance (A). Right side with face bow inserted in its buccal
tube lying outside the labial appliance. The maxilIary right
canine is banded and an offset distolingual hook is used for
attaching an elastic thread for rotating the canines. (B) Left
side with the face bow inserted to receive cervical traction.
Fig. 31-~O. (A) O.020-inch loop-coil auxiliary spring on a maxillary

lingual arch wire. (B) The Hale attachment, a bilateral loop-coil
continuous anterior spring. A mandibular work model with the
appliances as used for 6 months. The bilateral loop-coil continuous
anterior spring is of O.020-inch wire and has increased dental arch
length by the amount it extends ahead of the lingual arch wire. (C) A
bilateral loop-coil continuous anterior spring in place as used to gain
archlength. A posterior recurved auxiliary spring may also be seen on
the patient's right side.
elastic hooks are placed, except in Class III (Angle) the labial archwire, the lingual archwire, or both. The
malocclusion. following is a description of some of the most frequently
used auxiliary springs.
An auxiliary attachment often used on the lingual
Auxiliary Spring Attachments
appliance is the loop-coil spring. Its purpose is to move a
Labiolingual technique lends itself admirably to the use tooth mesially or distally within the confines of the lingual
of various auxiliary attachments either to and labial archwires. The size
of wire used for this attachment is 0.020-inch and the The loop right-angle auxiliary spring (Fig. 31-62) may
spring is soldered to the lingual archwire, formed into a be used to correct rotated anterior teeth. A 0.020-inch
generous sized loop and then wrapped loosely around the spring wire is soldered gingivally on the labial archwire at
arch wire and extended across the alveolar ridge (Fig. 31- the interproximal area adjacent to the labially positioned
60A). It contacts the mesial surface of the tooth to be line angle of the rotated tooth. A generous U-shaped loop
moved distally or the distal surface of the tooth to be is made that curves beneath the labial archwire to the
moved mesially. gingival and continues to the lingually positioned line
The spring pressure is adjusted by closure of the loop angle of the tooth. The spring wire loop is then continued
with a plier, holding at the soldered point and the coil. A 1 beneath the labial arch wire toward the incisors until the
mm. closure is usually sufficient at each three- to five- height of contour of the crown is reached. Then it is bent at
week adjustment appointment. a right angle and continued to the labially positioned line'
A bilateral loop-coil continuous auxiliary spring, the angle of the crown. The spring is then adjusted to exert a
Hale appliance (Fig. 31-60'B and C), is often used on the light force on the rotated tooth when the labial arch is
mandibular lingual archwire to upright molars and to ligated to the molar bands by means of the loop-coil stops.
slightly increase dental arch length. It is constructed of Malocclusions complicated by an anterior openbite
0.020-inch wire, soldered near the mesial of the second frequently require more than habit-breaking and a tongue
premolar; the loops are formed and the coils placed mesial guard on the maxillary lingual archwire. Banding of the
to the first premolar. The coils are joined together by the anterior teeth, with attachments for vertical intermaxillary
continuous anterior section which lies gingivally under elastic traction is effective in obtaining a normal overbite.
the lingual arch wire. The coils are opened 0.5 mm. at Light elastics are worn at all times, except when eating
adjustment appointments. Unless intrusion of the (Fig. 31-63A to C). .
mandibular anterior teeth is desired in leveling the The retentive appliance used with this' type of
mandibular dental arch, the Hale appliance is never malocclusion is of the de'Castro type but with a high labial
adjusted enough to cause the anterior portion to lie on the archwire of 0.040-inch stainless steel. A 0.028-inch spur is
cingula of the anterior teeth. soldered onto the archwire corresponding to each
The loop-coil-loop auxiliary spring (Fig. 31-61) is often maxillary incisor, terminating at the gingival margin of the
used on the labial archwire to retract the canine in tooth. AU-shaped 0.025-inch wire is formed to fit the
malocclusions that require the extraction of the first labial cervical
premolars. The 0.020-inch wire is vertically soldered to
the labial archwire gingivally near the loop-coil stop. A
loop is formed; the wire is coiled around the archwire
twice; and another loop is formed with its end contacting
the mesial surface of the canine crown. The spring is
easily adjusted by closure of the distal loop with a plier.
The closure moves the coil distally approximately 1 mm.
at each adjustment appointment.
Fig. 31-62. The loop-right angle attachment to the labial

archwire is aU-shaped O.020-inch auxiliary spring used to
exert a rotational force on the mandibular left lateral in-
cisor. A O.022-inch spur from the lingual archwire
Fig. 31-61. Loop-coil-loop auxiliary spring on the labial contacts the lingual of the crown in the incisal area. This
archwire for retraction of mandibular right canine. The prevents the tooth from being forced lingually during the
mandibular right first premolar has been extracted.
clockwise rotation.
Case Reports . 501
Fig. 31-63. Open bite treatment and retention, (A) B. S.,

age'lO years, female with an anterior openbite and right
posterior crossbite. (B) B.S., nine years later. Patient here seen
wearing removable maxillary retentive appliance with a high
labial arch wire of O.040-inch stainless steel and soldered
O,028-inch spurs with O.02S-inch Ll-shaped wire contoured
to the cervical of the incisors.
(C) S. S.; age 19, female. Appliances used for openbite. Hooks
to receive vertical intermaxillary elastics are soldered onto the
caps of a Johnson twinarch appliance. Only two elastic bands
are used, one around the four left hooks, and one around the
four right hooks. In this case, the maxillary canines did not
follow of their own, accord and a ligature wire was placed high
around the neck with a hook bent for the attachment of elastic
thread. The elastic thread is attached from the hook to the
twinarch end section and then continues for a second tie going
around the distal end of the buccal tube. From the tension on
this type of elastic ligature, the canine receives pressure which
provides downward and distal movement. unit, with the lingual arch wire being the basic anchorage.
Some reinforcement of anchorage was received from the use
of a labial arch wire. A maxillary labial arch wire was
constructed, with hooks for intermaxillary traction and
area of the crowns and soldered to each spur. This contact with posterior loop-coil stops to contact the buccal tubes. The
the crown, gingivally to the height of contour, discourages Oliver guideplane was used as an auxiliary attachment to the
intrusion of the tooth. The Ushaped wire can be adjusted, maxillary lingual archwire (Fig. 31-6SC and D). Class II
along with the downward tension from the high labial intermaxillary elastic traction was used, as always, with a
archwire, for slight additional correction of the open bite. guideplane.
The maxillary incisors were spaced and protrusive.
It' was considered to be advisable, therefore, first to bring these
teeth together and reduce the protrusion with Class II
CASE REPORTS intermaxillary traction. Later, the force could be placed on the
maxillary first molars to move them distally.
N. F., a girl with a Class II, Division 1 malocclusion (Fig. The maxillary labial appliance had a tendency to be
31-64A, Band C; Fig. 31-65 A and B) was referred for displaced gingivally when the Class II intermaxillary elastics
consultation at age 9 years. Treatment necessitated distal were in use. A figure-eight dead soft steel ligature, 0.010 inch,
movement of the maxillary molars and premolars, in order to was placed around the central incisors and the labial archwire
gain enough space for the eruption of the maxillary canines. to keep the arch wire in position at the junction of the middle
The maxillary anterior teeth also had to be retracted and it was and incisal third of the crowns. In this position the archwire
necessary to increase the vertical dimension. exerted more palatal leverage than it did in its gingival
The prognosis was favorable, due to the fact that the patient position. The posterior loop-COil stops were adjusted so as to
was at a period when rapid growth might be expected. be free of contact with the buccal tubes, in order that the labial
The appliances were attached to the bands on the four first
permanent molars (Fig. 31-65C and D). The mandibular
dental arch was used as a single
Fig. 31-64. (A, B, C) . F., female, age 9 years. Complete mouth radiographic survey. A lack of space for the maxillary canines and the
mandibular right canine is shown. There is maxillary incisor protrusion. (D) Third molar radiographs taken during retention, at which time
their removal was advised.
archwire could slide distally through the tubes as the distally, and more so when a crowded canine is trying to
incisors were moved palatally. erupt.
As soon as the incisors had moved to a satisfactory The appliances were adjusted every 3 to 5 weeks, and were
position palatally-this required a period of approximately 4 removed, together with the molar bands, . every 6 to 8
months - the posterior loop-coil stops were adjusted against months, to check the teeth and clean them.
the buccal tubes, the figure-eight ligature wire was left off Growth was slower than had been anticipated, but still
the central incisors, and the labial arch wire was adjusted favorable, and the patient was ready for retention in 32
gingivally, out of contact with the labial surfaces of the months. A deCastro (Hawley type) retainer, with
incisors. In this manner, all the force of the Class II elastic continuous O.040-inch stainless steel wire was used in the
traction was exerted toward distal movement of the maxillary arch, and a mandibular lingual archwire attached
maxillary molars. The additional space gained mesial to the to the bands on the first permanent molars in the
molars was needed to enable the canines to erupt normally. mandibular arch (Fig. 31-66A to D).
The second and first premolars usually tend to follow the The partially formed third molars were radio-
molar
Case Reports . 503
~
Fig. 31-65. (A) Right occlusion at the beginning of treatment. (B) Left occlusion at the beginning of treatment. (C) Right
occlusion at the time appliances were placed. A portion of the guideplane is seen palatal to the right lateral incisor. The
figure-8 ligature wire around the maxillary central incisors is to close the space between these teeth so that the erupting
canines will be given a better opportunity to move the laterals mesially, thus facilitating their own eruption. (D) Left
occlusion at the time appliances were placed. Note the intermaxillary elastic traction which is always used in conjunction
with the guideplane.
94.
graphed during retention and their removal was dimension and relieve the palatal tissue irritation. It was
recommended. Six months after removal of the third necessary also to straighten the mandibular incisors and
molars, retention was discontinued. eliminate their rotations while improving the level of the
Four years past retention photographs were taken occlusal plane.
showing the satisfactory manner in which the corrected A maxillary labial archwire was constructed with hooks
occlusion and facial profile had been maintained (Figs. for intermaxillary elastics and adjustable loop-coil stops
31-67 A to D). anterior to the buccal tubes. In this case, the lingual
P.P., age 9, female, with a Class II, Division 2 (Angle) appliance was to be used to move the' retruded central
malocclusion. The extreme overbite was complicated by incisors labially, and therefore, compressed coil springs
some overeruption of the maxillary central incisors (Fig. were not inserted between the buccal tubes and the loop-
31-68A and B). Additional room for the maxillary canines coil stops, as is usually the case when the forward
was desirable. Two of the mandibular anterior teeth were movement is desired. The maxillary lingual archwire
slightly rotated, and the anterior occlusal level was included an Oliver guide plane which was positioned so as
uneven. The first permanent molars were in a Class II to rest on the inclines of the maxillary central incisors. In
relation. this way it would open the bite, exert pressure for labial
The treatment plan called for appliance therapy to move movement and depress the teeth at the same time: (Fig. 31-
the maxillary molars distally, depress and move the 68C and D); one vertical part only can be seen).
maxillary central incisors labially, establish conditions
favorable for an increase in vertical
504 . Labiolingu al Technique
Fig. 31-66. (A) Right occlusion at the time of retention. Note continuous type (modified Hawley) retainer. The bands have
been left on the mandibular molars so that the lingual archwire may be used for retention in the mandibular arch. (B) Left
occlusion at the time of retention. The labial wire is above the height of contour of the incisors so that the overbite may be
increased. (C) Right occlusion at the time retention was discontinued. (D) Left occlusion at the time retention was discontinued.
The mandibular lingual archwire was constructed so as to 2. Adjusting the guideplane gingivally by holding each
rest lightly on the cingula of the mandibular incisors, and half-round post with pliers and bending the archwire
the mandibular labial archwire was held in place by ligation gingivally with the fingers.
of the loop-coil stops to the molar bands. The latter was 3. Keeping space between the labial archwire and the labial
necessary because the patient lived at a considerable surface of the maxillary central incisors by opening the loop-
distance from the office and could only be seen every 4 to 6 coil stop against the buccal tube
months for appliance adjustments. Under normal 4. Bending the maxillary labial archwire gingivally with
circumstances, the mandibular labial archwire would have Howe pliers on the arch wire, in the mouth, just mesial to
been adjusted to lie approximately 3 mm. below the crowns the buccal tubes
of the incisors, when it would have been raised and ligated 5. Varying the amount of intermaxillary elastic pressure,
to each anterior tooth while under tension. This force would as indicated by response and molar mobility
tend to bring the banded molars upright and intrude the 6. Increasing the width of the labial and lingual archwires
mandibular incisors. very slightly so as not to impede normal arch width changes
Class II intermaxillary elastic traction was worn at all Six months after the beginning of treatment, it was
times, except while eating or brushing the teeth. recommended that the three deciduous molars suspected of
The appliance adjustments consisted of: being ankylosed should be removed. Their roots were
1. Adding very small increments of wire to the gingival resorbing, but the level of the crowns was below the
side of the guideplane resting on the lingually positioned occlusal plane. An added ad-
maxillary central incisors
Case Reports . 505
Fig. 31-67. Same patient as in Figs. 31-64, 65, and 66. (A) Right occlusion 4 years post retention. (B) Left occlusion 4 years post
retention. (C) Profile at the beginning of treatment. (0) Profile 4 years post retention.
vantage in their removal was that space would be gained therapy (Fig. 31-71A and B). The mandibular anterior
by the discrepancy in tooth size. bands were removed and the labial arch wire inserted in
One year after the beginning of treatment, at the third place of the twin-arch. By the next adjustment
adjustment, it was evident that some suppression of the appointment, 5 months later, the patient was ready for
overerupted maxillary central incisors would be retention. A maxillary removable retainer was
necessary, as well as rotation of the mandibular incisors constructed, which included an addition of acrylic, behind
and further bite opening (Fig. 31-69A and B). At the next the maxillary anterior teeth, as i.t was necessary to
adjustment, 5 months later, intrusion hooks were added to maintain the good vertical response during the time the
the maxillary labial archwire and adjusted so as to be second molars were erupting and coming into occlusion
under tension. The mandibular incisors were banded and (Fig. 31-72A and B). The mandibular lingual archwire,
a Johnson twin-archwire was inserted (Fig. 31-70 A and attached to the molar bands, was used as retention in the
B). Intermaxillary elastic traction was continued, but the mandibular arch. Retention was continued until the third
maxillary molar anchorage was now reinforced by the molars had been removed.
labial archwire resting against the labial surfaces of the In both the maxillary and mandibular dental arches
maxillary incisors. there was evidence of overtreatment. The maxillary
At the next adjustment appointment it was evident that molars were moved farther distally and more space was
there had been a good response to the appliance gained in the mandibular incisor
Fig. 31-68. P. P., age 10 years. (A) Right occlusion with molar bands in place before the placement of active appliances. (B)
The maxillary central incisors are in abnormal overbite. (e) Right occlusion after 4 months of treatment with active appliances but
after the guideplane had been raised. Intermaxillary elastic traction is worn with the guideplane. (D) Left occlusion after 4 months
of treatment with these appliances but after the guideplane had been raised.
region than was necessary. This allowed for some settling

leeway, which is often advisable (Fig 3173A to D).
D.T., girl age three years, (Fig. 31-74A). The right
maxillary quadrant is in crossb ite, with the exception of the
central incisor Fig. 31-74B shows left side. A fall at about age
two years had loosened the maxillary right central incisor
which was extracted when it became abcessed. Thumb
sucking was more frequent prior to the injury but still
continued at night. The previously injured deciduous right
central incisor was discolored, but not loose and there was no
evidence of suppuration.
The crossbite was corrected by banding the maxillary
second deciduous molars, using a horizontal
Fig. 31-69. P. P., age 11 years, 6 months. (A) Right occlu-

sion after 15 months of treatment with these appliances
including the guideplane and intermaxillary elastic traction
(not shown). (B) Left occlusion after 15 months of active
treatment with these appliances and a guideplane and
intermaxillary elastic traction. The elastic traction and the
guideplane have overworked the distal movement of the
maxillary first molar a desirable amount.
Case Reports . 507
Fig. 31-70. P. P. at 13 years. (A) Right occlusion after 27 Fig. 31-71. P. P., age 15 years. (A) Right occlusion and
months of active treatment. The hooks over the incisal edge of the appliances used at the time of retention. Intermaxillary elastic
maxillary central incisors are used to intrude them from their traction was also in use. (B) Left occlusion and the appliance used
overeruption, The mandibular anterior banding is for final to the time of retention. Intermaxillary elastic traction was also in
rotation using a twiriarch. (B) Left occlusion after 27 months of use.
active treatment. The hooks over the incisal edge of the maxillary
central incisors are used to intrude them from their overeruption,
The mandibular anterior banding is for final rotation using a
twinarch.
Fig. 31-72. P. P., age 17. (A) Retentive appliances used, induding
the mandibular removable lingual arch wire not showing. (B)
Retentive appliances used include the removable mandibular
lingual archwire not showing.
Fig. 31-73. P. P., age 18. (A) Postretention right occlusion. (B) Left occlusion, postretention. (C) Profile before treatment.
(D)Profile postretention 1 year.
round tube on the lingual of the crossbite side and a half- spring was then constructed to exert a buccal force on the
round tube on the normal side. The lingual archwire was right deciduous first molar and canine. An additional 4
adjusted to exert lateral expansion on the second months was required to cross these teeth after which time
deciduous molar on the crossbite side. Compound the deciduous molar bands were removed. A half-round
anchorage was obtained from the normal side by having tube was now placed on the lingual aspect of the right molar
the lingual arch wire contact the canine and deciduous first band to replace the horizontal round tube. The right side of
molar, in addition to using the half-round tube on the the lingual archwire was replaced and a half-round post was
deciduous second molar. The lingual arch wire was attached for insertion into the new halfround tube.
adjusted each month so that a 2-mm. expansive force was Posterior lateral expansion springs of 0.020gauge were
delivered to the crossbite side. placed bilaterally on the archwire. The bands were
The right deciduous second molar was corrected in 3 recemented and the lingual appliance inserted with the
months, at which time a passive lingual archwire was lateral expansion auxiliary springs
inserted. A 0.020-inch posterior auxiliary
Case Reports' 509
Fig. 31-74. (A) D. T., age 3 years; female, had a crossbite

malocclusion of the entire maxillary right quadrant except
the central incisor. (8) Left occlusion at the beginning of
treatment. (C) Right occlusion after discontinuing retention
of the crossbite correction. (D) Left occlusion after
discontinuing retention. (E) At age 4, the final maxillary
lingual appliance used in correcting the unilateral cross-
bite. The archwire was left passively in place as a retentive
appliance at this time.
activated so as to overcorrect and later act as a retainer The face shows that the mandibular shifting had been
(Fig. 31-74E). corrected.
The lingual appliance was removed 1 year later. The patient was seen at 4-month intervals. The
The crossbite was corrected and there had been 3 to 4 deciduous incisors had been exfoliated, but the erupting
months of adequate retention. The patient was seen in 3 permanent incisors had insufficient space and were rotated.
months. The crossbite remained corrected (Fig. 31-74C The mandibular right deciduous canine had been exfoliated
prematurely, owing to the pressure exerted by the erupting
and D). Figure 31-75A and B shows the patient at age 3
right lateral incisor. The mandibular left deciduous canine
years with her face unbalanced and the mandible shifted to then was removed to avoid any further shifting of the
her right. B, the patient at 10 years before corrective
orthodontics was initiated.
Case Reports' 509
Fig. 31-74. (A) D. T., age 3 years; female, had a crossbite

malocclusion of the entire maxillary right quadrant except the
central incisor. (B) Left occlusion at the beginning of treatment.
(C) Right occlusion after discontinuing retention of the cross bite
correction. (D) Left occlusion after discontinuing retention. (E) At
age 4, the final maxillary lingual appliance used in correcting the
unilateral crossbite, The archwire was left passively in place as a
retentive appliance at this time.
activated so as to overcorrect and later act as a retainer The face shows that the mandibular shifting had been
(Fig. 31-74E). corrected.
The lingual appliance was removed 1 year later. The patient was seen at 4-month intervals. The
The crossbite was corrected and there had been 3 to 4 deciduous incisors had been exfoliated, but the erupting
months of adequate retention. The patient was seen in 3 permanent incisors had insufficient space and were
months. The crossbite remained corrected (Fig. 31-74C rotated. The mandibular right deciduous canine had been
and D). Figure 31-75A and B shows the patient at age 3 exfoliated prematurely, owing to the pressure exerted by
years with her face unbalanced and the mandible shifted the erupting right lateral incisor. The mandibular left
to her right. B, the patient at 10 years before corrective deciduous canine then was removed to avoid any further
orthodontics was initiated. shifting of the
Fig. 31-75. (AJ D. T., age 3 years, full face photograph before appliance placement for the correction of the crossbite of the entire
maxillary right quadrant except the central incisor. (B) Age 10 years, 5 years after the removal of retention for the cross bite
correction, just prior to full appliance therapy.
Fig. 31-76. (A) D. T., right occlusion 6 years after the correction of a crossbite. There is insufficient space for the normal eruption of the
maxillary right canine. (B) Left occlusion 6 years after the correction of a crossbite, There is insufficient space for the normal eruption of
the maxillary left canine. (C) Age 13 years, right occlusion with the finishing appliance in place. The intermaxillary elastic traction has been
worn only during the daytime for one year. (DJ Age 13 years, left occlusion with the finishing appliance in place.
Case Reports' 511
.
'
Fig. 31-77. (A) D. T., age 13 years, right occlusion at the time of placing a removable maxillary and fixed mandibular retentive appliance. (8)
Left occlusion at the time of placing retention. (C) Age 14 years, right occlusion at the time of discontinuing the removable maxillary retentive
appliance. The mandibular lingual archwire is retaining the dental arch during the eruption of the third molars. (D) left occlusion at the time of
discontinuing the removable maxillary retentive appliance.
Fig. 31-78. (A) D. T., age 13

years, profile photograph at the
time of retention. (B) Age 14
years, profile photograph after
discontinuing the use of the
maxillary retainer.
midline to the right side. Observation was continued every 4 dibular lingual arch wire. The maxillary retainer was
to 6 months. discontinued after 6 months, but the lingual archwire was
At age 10 years, corrective treatment was started (Fig. 31- allowed to remain until such time as the third molars had
76A, B). Bands were made on the four first permanent erupted or were removed (Fig. 31-77C, D). Figure 31-78A
molars, and appliances were constructed. Maxillary and shows an orthognathic profile at age 13; it was still being
mandibular labial arch wires were constructed for insertion maintained at 14 (Fig. 31-78B).
after the extraction of the four first premolars (Figs. 31-76A
and B). Full appliances were placed 1 week later and very
light Class II intermaxillary elastic traction was used. The
mandibular canines were moved distally by means of loop- REFERENCES
coil-loop auxiliary springs (Fig. 31-76C and D). The 1. Baurne, L. J.: Principles of cephalofacial development
maxillary canines erupted without surgical exposure of the revealed by experimental biology. Am. J. Orthodont.,
crowns or the use of cervical ligatures. Loop-coil-loop 47:881, 1961.
springs were added to the maxillary labial archwire when the 2. Irish, Russell E.: A discussion of the occlusal guideplane.
canines had erupted sufficiently for the springs to make A.J.O.&O.S., 29:12,699-711, 1943.
contact with the mesial surfaces of the crowns at about the 3. Oliver, O. A.: The occlusal guideplane. A].O.&O.s.
height of the tooth contour and the maxillary canines were 29:148, 1943.
4. Oliver, O. A: The rational of the labiolingual appliances in
moved distally.
present day orthodontic treatment. AJ.O.&O.s. 31:381-
Routine adjustments were made to the archwire and 390,1945.
auxiliary springs until the canines were moved distally about 5. Oliver, O. A.: Indications for the occlusal guideline.
2 mm. beyond their correct position. Ligature wires were Am. J. Orthodont. & 0.5. 31:520, 1945.
used to align the mandibular incisors, but it was necessary to 6. Sleichter, C. G.: Some effects of the occlusal guideplane
use anterior bands and a Johnson twin-arch to rotate the in the treatment of class II, division 1 malocclusions. A. J.
maxillary incisors. All bands and appliances were removed Orthodont.,43:83, 1957.
periodically for routine dental examinations and cleaning. 7. Storey, Elsdon: Growth and remodeling of bone and
The erupted teeth were in position at age 13 (Fig. 31-77A, bones. Am. J. Orthodont., 62:162, 1972.
B). During the retention period, a maxillary removable 8. Tarpley, B. W.: The guideplane as an aid to labiolingual
technique. Am. ]. Orthodont., 34:153, 1948.
retainer was used with a man-
9. Tarpley, B. W.: Technique and Treatment with the
Labiolingual Appliance. St. Louis, C. V. Mosby, 1961.
10. Salzmann, J. A: Orthodontic principles and prevention in
the everyday practice of dentistry. J. Canad. Dent. Ass..
27:81, 1961.
32
The Crozat Appliance in Theory and
Practice
W. MARSHALL PARKER, D.D.S
Although the Crozat appliance is simple, it is actually one directly in tooth movement. When appliances are adjusted
of the exacting appliances. One cannot merely take an mildly at regular intervals and are worn regularly, patients
impression, send it to a laboratory and expect the finished experience no discomfort. If the appliances, for any reason,
appliance to produce satisfactory results of its own accord. are removed for an interval of sufficient duration, upon
The operator must first learn how to construct the appliance, replacing them the patient will experience discomfort. In
how to fit it in the mouth of the patient, and how to modify such instances, it may be necessary to readapt the appliance.
it as treatment progresses in order to obtain desired results. During planned rest periods appliances may be worn
Dr. Crozat explained the fundamental philosophy of his nights only and they are not adjusted except for stability of
appliance before the Sou them Society of Orthodontists in attachments. Holidays and vacations are favorable times to
1954. Quotations from his paper are presented here as are institute what we may term rest periods. It is impossible to
his method of approach in the actual treatment of patients. conceive treating an orthodontic case in a school term or
Crozat stated the following: two and to dismiss the patient with a retainer and consider
the case completed. A removable appliance can serve as a
treatment device and as a working retainer. It is surprising to
observe in some cases a greater amount of tooth movement
during these intervals than when under continuous active
I would seriously call to the attention of those interested in treatment. The change may occur to the extent that the teeth
the use of removable appliances that the primary object is will have moved beyond contact with the appliance.
not to devise or adjust an appliance to move malposed teeth Without experiences of this nature, one would assume that
by sheer force, but to be used as a means of applying stress the appliance had been distorted. On return of the patient,
in the direction of desired tooth movement. First in another phase of treatment is planned and instituted.
importance, the appliance must fit perfectly. It must be Basically the initial treatment is to attempt the necessary
adjusted with extreme moderation. Every attempt should be
arch change or changes and the axial positions of the
made to avoid pain and to interfere to the minimum with
permanent first molars.
function. A prerequisite, as with all mechanotherapies, is a
thorough analysis of the total dentofacial complex: muscle
habits and their dysfunctions; facial variation as related to Treatment of patients must be approached on the basis of
the individual patient's growth pattern, and to the norm. their chronological and developmental age as well as their
With removable appliances, application of treatment dental age. These considerations will make for the
deviates from the pure mechanistic trend of straightening difference in rapid or delayed treatment, or early or deferred
teeth, which does not usually allow nature to work for an treatment.
objective correction of the dentofaciaI deformity. In this It is of paramount importance that patients be impressed
application of treatment one must be ever conscious of the with their responsibility in conducting their treatment and in
child's state of development until completion of growth of managing and caring for the teeth and appliances. Without
the dental apparatus. the complete cooperation of the patient, very little can be
The attachment teeth (the anchor teeth that hold the achieved. From beginning to end, it is a question of
appliance in place) oppose an equivalent of the force instructing patients in every detail of treatment and of
applied by the appliance in the direction of desired tooth enlisting an enthusiastic attitude as their teeth are moved
movement. If forces are excessive the attachment teeth will into position. Treatment and retention occur coincidentally
be unstable. as treatment progresses. Retention is not a problem, as time
The appliance is not intended to move malposed teeth and function help us to produce pleasing and harmonious
directly, but to deliver stress through the teeth to the results.
supporting structures resulting in tissue changes and in-
513
514 . The Crozat Appliance in Theory and Practice
CONSTRUCTION OF THE APPLIANCE 4. The lingual sides of the maxillary molars are trimmed
lower gingivally than the buccal sides because of the
1. The clinical crowns of the teeth to be clasped
difference in height of coronal contour (Fig. 32-1).
frequently require some recontouring. Amalgam or gold
Conversely the buccal surface of the mandibular molar is
restorations with poorly carved marginal ridges must be
trimmed lower than the lingual (Fig. 32-2). A Cleve-Dent
smoothed with a disc to form a space for an 0.028-inch
99 trimmer is used to trim the stone cast.
wire to pass at the occlusal embrasure areas.
5. First molar tooth clasping is here described.
2. After the teeth to be clasped are properly recontoured,
However, if a case dictates, clasps may also be constructed
a colloid impression of each dental arch is taken and then
on second molars, premolars or even on canine teeth. Since
poured in stone.
premolars are usually conical, single-rooted teeth, both
3. Trim the clasp teeth on the stone cast. This is an first premolars are not clasped in the same appliance. This
important phase in the construction of the appliance. The prevents the appliance from rocking. For example, it is best
object of trimming the teeth is to idealize the coronal to clasp the right first premolar and the left second
portion in order to expose the ideal retentive form that the premolar in the same appliance.
tooth offers. A comprehensive knowledge of dental
anatomy is required for proper trimming. A study of molar The clasp must extend to the maximum retentive form
teeth can be helpful. that the molars offer. When the second molar is about to
erupt, the gingival margin on the distal surface of the first
molar extends almost to the marginal ridge. This tissue
must be carved away on the cast. However, there should be
no compression of the tissue by the clasp after the
appliance is inserted in the mouth. The clasp wire goes
around the tooth and fits between the tooth and the tissue
without causing any compression.
Clasp Construction
Clasps must be designed according to individual tooth
form and shape, but in keeping with the greatest retentive
capacity of the tooth. The crib extends to, but does not go
beyond, the greatest diameter of the tooth. The crescent
(See Figs. 32-10, and 11) goes just below the greatest
Fig. 32-1. The height of contour is lower on the lingual diameter of the tooth in order to provide maximum
than on the buccal of a maxillary first molar. retention. The crib and crescent as a unit are referred to as a
"clasp". The clasping quality of the claspwire depends on
the resilience of the wire. When the claspwire is too
, long occlusogingival1y, it will play up and down.
This will cause the appliance to break. This is especially
true if there is a high labial wire on the appliance and the
clasp is too long. The patient will
Fig. 32-2. The height of contour is lower on the buccal

than on the lingual of a mandibular first molar. Fig. 32-3. 137 5S White contouring "bird beak" pliers.
Construction of the Appliance' 515
use the upper lip to push the labial wire down a little and then
bite the clasps, repeating this pro.cedure until the clasp is
broken.
Bending the Cribwire

With 137 SS White birdbeak pliers (Fig. 32-3) a piece of
Ney o. 4 elastic gold-platinum 0.028-gauge wire is bent in a
series of right angles in the same plane (Figs. 32-4, 5, 6).
Notice that the buccal vertical section of the wire on the
mandibular molar is longer than the lingual. It is the reverse
on the maxillary molar. The difference in the individual tooth
form is responsible for this change.
The occlusal portion of the crib is made somewhat longer Fig. 32-4. First bend.
than the width of the crown. When the vertical extensions are
bent they are not jammed up into the interproximal areas,
otherwise the tooth cannot' be rotated. Figure 32-6 shows the
necessary length of the occlusal portion. The wire is now bent
around the lingual surface at the height of the contour of the
tooth. Figures 32-7 and 32-8 show the method of bringing the
wire over the occlusal embrasure areas of the tooth. With the
aid of a Schumacher 831 small contouring plier the occlusal
portion of the crib can be made to follow exactly the outline of
the tooth (Fig. 32-8). If the occlusal portion of the wire is not
bent accurately, the clasp will often interfere with the cusp of
the opposing tooth. Figure 32-9 shows the buccal ends swung
around to meet each other.
Fig. 32-5. Second right-angle bend.
Forming the Crescent elastic gold-platinum wire is bent in a flat plane (Fig. 32-10).
The ends of the crescent are tapered so that there will be no
The crescent made from O.028-inch Ney No. 4 discomfort to the tissues. Note that the crescent fits just below
the height of
Fig. 32-6. Third and fourth bends. Note all bends are in the
same plane. The occlusal is bent to follow exactly the outline Fig. 32-7. The wire is swung around the lingual surface of
of the tooth. the molar.
Fig. 32-9. The finished crib.
Fig. 32-8. Ready for the ends to be tucked inward.
Fig. 32-11. A completed clasp consisting of a crib and

crescent ready to be invested.
Fig. 32-10. The crescent held in place with sticky wax. After the second bend is made below the mesiclingual
cusp, the wire is brought around the curvature of the arch
in the same plane. Care must be taken that the wire passes
contour on the buccal surface of the tooth. Figure 32-11 above and free of the lingual frenum. If the wire needs to
shows a completed clasp consisting of a crib and crescent be raised to pass over the lingual frenum, it is done by
wire before soldering. bending the first bend from 60 to 650 or 700 keeping the
first portion of the wire parallel and touching the crib
The Mandibular Lingual Bodywire , wire.
After passing the lingual frenum and keeping 1 mm.
Figure 32-12 shows steps in the construction of the away from the tissue all around the arch, the wire is again
mandibular lingual bodywire, The bodywire is made of bent at a 120-degree angle at the mesiolingual cusp. Then
Baker 3 percent gold wire, 0.051 gauge. The wire starts at after continuing vertically for 8 mm. it is bent mesially 600
the lingual groove of the first molar and is bent 600 at the at the distolingual cusp and then cut at the lingual groove.
center of the distolingual cusp. A second bend of 120 The correct placement of the lingual bodywire is important
degrees is made below the center of the mesiolingual cusp to obtain correct archform and to prevent the bodywire
and about 8 mm. down from the first bend. At this point from impingeing on the soft tissue lingual to clasped
the horizontal ends of the wire will be approximately molars.
parallel. If the vertical section is made too short, the The lingual arms and the occlusal rest wires, made of
tongue will catch under the lingual bodywire and remove Baker 3 percent 0.040-inch gold wire, are added (Fig. 32-
the appliance from the teeth. The vertical section of the 13, 14). The lingual arms are generally contoured with the
wire must be bent slightly toward the tooth so that it is free shape of the teeth, and end at the interproximal area mesial
of the soft tissue. It meets the crib at a slight angle. to the first bicuspid. In
A
Fig. 32-12. (A) The mandibular lingual bodywire. First and
second bends are done at the same time. The first bend is a
0
60 angle and the second, 120. (B) The lingual bodywire is
placed on the modeL (C) An occlusal view of the lingual
bodywire. Notice how it is bent slightly just below the first
bend in order to meet the cribwire without touching the stone
modeL
Fig. 32-13. Addition of the lingual arm and the O.040-inch

Baker 3 per cent occlusal rest wire held in place with sticky
wax. Although the lingual arm is generally the contour of the
bicuspids, there is plenty of room in the interproximal area
mesial to the 1st molar to allow for rotation.
the mouth, the lingual arms should never touch the lingual
surfaces of the premolars. Care should be taken not to curve
the lingual arm too far into the interproximal area mesial to
the molar, since the molar often must be rotated. If the lingual
arm is adapted too far into the interproximal area mesial to
the molar, it will interfere with the molar rotation. To the Fig. 32-14. Finished lingual with both lingual arms and
arms are soldered lingual attachments later. Until attachments occlusal rest held in place with sticky wax. The appliance is
are needed, the arms give the appliance balance and are used now ready for investing and soldering.
in measuring the correct amount of basic adjustment.
when invested while the appliance is being soldered. After the

appliance is soldered, the occlusal rests are reduced by
Occlusal Rest Wires grinding them flat so that they will not interfere with the
occlusion of the opposing tooth. Since the lingual grooves in
Occlusal rest wires keep the appliance from settling too far the maxillary molars are usually out of functional contact,
and impinging on the tissue. The rest wires should be there is seldom any need to trim the opposing tooth to keep
extended to go over the occlusal portion of the tooth so that
the rest wires from interfering with the occlusion. In the
they will stay in place
mandibular molar the lingual groove is out of functional No. 4 elastic gold-platinum O.028-inch wire. The first bend is
occlusion and the rest extending somewhat over the occlusal made at the height of contour on the buccal surface of a
surface prevents the appliance from impinging on the mucosa. maxillary first molar (Fig. 32-15A). The second bend, (Fig.
When the appliance is placed in the mouth, the patient does 32-15B) is shown with the occlusal portion of the wire
not feel the occlusal rests. contoured to the curvature of the mesial marginal ridge. Room
Every bend has a purpose. The beginner should not try to is needed for the first molar to rotate, allowing the mesio-
improve on the method of construction as here outlined. An buccal cusp to continue buccally and distally. The amount of
important point in clasp construction is not to proceed with the rotation room necessary is accounted for before the vertical
next bend until all the preceding bends are perfectly shaped extension is bent; Figure 32-15B shows the necessary length
and fitted. of the occlusal portion. The wire is now bent around the
lingual surface at the height of contour of the tooth (Fig. 32-
15C). Note that the height of contour is lower on the lingual
than on the buccal surface of the maxillary first molar. Figure
32-15D shows the method of bringing the wire over the
Bending the Maxillary Crib wire occlusal
A 137 SS White contouring pliers is used to construct the
maxillary cribwire from a piece of Ney
Fig. 32-15. (Aj Right angle bend for upper crib held at the proper height of contour. (8) The bends following the contour of the
mesial margrnal ridge. (The mesial side is always bent first so the long portion of the wire does not interfere with the cast.) (C) The
lingual view shows the vertical bend is not jammed close into the mesiolingual interproximal area. This will allow room for the
tooth to rotate. (D) The wire bent over the occlusal is ready to be cut and tucked in on the buccal. (Note that all bends are perfect
before proceeding to the next bend.)
Construction of the Applicance . 519
embrasure area of the tooth. The vertical section on the

distobuccal cusp allows room for the tooth to rotate (Fig.
32-21).
Forming the Crescent

The crescent is made from 0.02S-inch Ney No.4 elastic
gold-platinum wire bent in a flat plane. The crescent fits
just below the height of contour on the buccal surface of
the tooth. The ends of the crescent are tapered as in the
mandibular crescent to avoid discomfort to the adjacent
tissue.
The Maxillary Lingual Bodywire

Fig. 32-16. The maxillary lingual bodywire is first bent at a
The lingual bodywire starts at the center of the 70-degree angle. The second bend is at 110 degrees.
mesiolingual cusp of the first molar and is bent 70 at the
center of the distolingual cusp. A second angle of 110 is
formed at the second bend which is made below the center
of the mesiolingual cusp and at the roof of the palate (Fig.
32-16). The wire is marked for the second bend by
situating it upside down in the palate of the maxillary cast
and marking the correct length at the crib with a china
marking pencil. After the second bend is made the
horizontal ends are parallel to each other.
If the vertical section is made too short, the bodywire
will make an impression on the dorsum of the tongue that
is sometimes painful. If the vertical sections are too long,
the palatal bodywire will impinge painfully into the palate.
There should be 1 to 2 millimeters of space between the
palate and the wire.
As much wire as possible is incorporated into the palatal
bodywire around the curvature of the palate in order to
achieve mild, long-lasting rotational adjustments. The wire Fig. 32-17. As much wire as possible is incorporated in the
is bent with a large Aderer-type clasp adjusting plier (Fig. bodywire.
32-17).
The vertical section of the bodywire is bent slightly
toward the tooth so that it is free of the soft tissue when
the tooth is rotated (Fig. 32-18). It meets the crib at a slight
angle. The palatal bodywire is waxed in place on the cast
(Fig. 32-19), and the lingual arms and the occlusal rest are
added (Fig. 32-20). These are made from Baker 3 percent
gold wire, 0.040-gauge. It is especially important to avoid
jamming the lingual arm into the interproximal area
between the first molar and second premolar. This will
allow the first molars to rotate when necessary. During
treatment the lingual arms should never touch the lingual
surfaces of the first or second premolars.
Baker O.051-inch 3-percent gold wire is used for the
buccal arms. These arms aid the patient in removing and
replacing the appliance. Elastic hooks
Fig. 32-18. The bodywire is bent toward the clasp to keep

from impingeing on the tissue as the wire meets the clasp.
Fig. 32-19. The completed lingual.
Fig. 32-20. The finished lingual bodywire with both

lingual arms and occlusal rests held in place with sticky
wax to the finished clasps. The appliance is now ready for
investing and soldering.
Fig. 32-22. A polished, well balanced appliance.
and, finally, a labial wire are later attached to the arms

Fig. 32-21. Side view of completed appliance held in (Fig. 32-21). A view of the completed appliance is shown
place with sticky wax ready to be invested and soldered. in Figure 32-22.
Soldering the Appliance

After an appliance is constructed, I t IS prepared for
soldering. As each piece is constructed, it is attached to
the cast with sticky wax, and when all parts are completed
the appliance is invested with HCr 70. HCr 70 is a heat-
absorbing substance that protects the cast and the wire not
being soldered from the excess heat (Fig. 32-23). This
keeps the cast from cracking and distorting and also keeps
change in the temper of the wire to a minimum. HCr 70
also acts as an anti flux thus preventing the solder from
flowing into unwanted areas, particularly the ends of the
crescents. Hcr 70 has an advantage over other types of
investments such as plaster in that no setting time is
required and the cast does not have to be preheated before
soldering. HCr 70 may be obtained from Codesco Dental
Fig. 32-23. Invested appliance with HPC 70 ready for Supply Com-
soldering.
pany or directly from the dealer: Hcr 70, Box 402,

Gatlinburg, Tenn. 37738.
The area around the wire to be soldered is heated to a
reddish color before the solder (Baker 650 wire solder, 28-
gauge) is applied. If the point of the flame is held too long
over the area to be soldered, the stone cast will disintegrate
and an excess of solder will flow onto the inside of the
attachment. The area to be soldered is heated above, in front,
and below, but no part of the wire is touched with the flame
until the entire area is red hot. Then solder is applied quickly
to the wire, the flame is touched to the wire, and the solder
flows. After the appliance has been soldered and allowed to
cool, the H'Cf' 70 is rinsed away with tap water and the
appliance is ready to be tempered, pickled, and polished.
Dry, Quick-Tempering Device No. 15, Electric" is used to
heat-treat appliances. The appliance is left in the tempering Fig. 32-24. When polishing the solder inside the clasp, do not
touch the clasp wire with the stone.
device for 7 minutes - 3 minutes with the electricity on and
then 4 minutes with the electricity off. The appliance is then
removed from the tempering device and allowed to cool to
room temperature before it is pickled. The pickling consists of
boiling the appliance briefly in 0.5 percent sulphuric acid
solution. A stronger acid solution may pit the solder joints; if
the appliance were pickled too long, the joints would weaken
and eventually break.
After the appliance is tempered, a small round stone is used
to freshen the interior soldered joints in order for the clasps to
be adapted smoothly to the teeth. The stone does not touch the
gold-platinum clasp wire, and only the excess solder is
removed (Fig. 32-24). A small Burlew wheel can be used to
polish the clasps and the bodywire. A wire brush wheel is
used to polish the gold. Figures 32-25 to 32-27 show the
finished appliances.
Fig. 32-25. Side view of polished appliance placed on soldering

cast.
INSERTION OF THE APPLIANCES
The patient is instructed at the very beginning to cooperate

in the treatment. Careful and exacting instructions are given
the patient at the first appointment so that when the appliance
is inserted the patient is anxious to wear it at all times and to
remove it only to clean it. The appointment when the
appliance is inserted is most important in order to start on the
right track. A parent should accompany the patient for this
appointment. Usually only one appliance is placed per
appointment so that there will be a minimum of discomfort
and the patient will be gradually accustomed to the
appliances.
Fig. 32-26. Occlusal view of polished appliance placed on

Available from Baker Dental Division, Englehard lndustries, soldering cast .
lne.
ADJUSTME T
The Basic Adjustment

Often in malocclusion the maxillary first molars present
with the mesial buccal cusps rotated lingually. This is more
frequently found in distoclusion cases associated with V-
shaped arches. To attain interarch relation and posterior
movement of the maxillary molars, it is desirable that the
molars be rotated to move the mesiobuccal cusp buccally.
In the process these cusps are rotated distally as well.
When adjusting the maxillary appliances for this desired
rotation, the arms of the appliance lingual to the premolars
should be relieved of contact with the premolar teeth. This
prevents overexpansion in the premolar areas. While the
molar rotation is being accomplished Class II elastics may
be worn. Once the molars are in Class I position a high
labial wire may be used to retract the anterior teeth. Ex-
traoral headgear is not indicated as an aid in moving the
molars distally because it interferes with the reciprocal
rotational process of the first molars.
The purpose of the basic adjustment is to rotate the
mesiobuccal cusps of the first molars distobuccally and
establish normal arch form. This is accomplished with a
pair of bridgemeters and an 55 White No. 137 contouring
pliers (Fig. 32-28). First, two measurements are obtained:
first at the end of the two occlusal rests (Fig. 32-28A) and
the second at the outside of the ends of the lingual arms
Fig. 32-27. Completed maxillary (A) and mandibular (B) (Fig. 32-288). Then the appliance is held in a horizontal
appliances. plane (Fig. 32-28C) at right angles to the contouring plier,
and a pinch is made in the center of the body wire, causing
each occlusal rest end to rotate buccally 0.5 mm. This is
The crescent ends may impinge on the gum. Before an
checked with the first bridgemeter (Fig. 32-28D).
appliance is seated, the ends of the crescent must be bent
ow the right crib is grasped with the pliers on the lingual
occlusally. The appliance is tried in the mouth and
surface and distal to the occlusal rest (Fig. 32-28E), and
removed several times until the fitting is completed. The
rotated so that the end of the arm is moved outward
patient should not be permitted to try it on immediately by
approximately 0.5 mm. This is checked with the second
himself or to handle the appliance until it fits comfortably.
bridgemeter (Fig. 32-28F). The crib on the left side is
The patient is asked to move the mandible through various
rotated in the same manner (Fig. 32-28G). It is a good rule
occlusal excursions and to report any feeling of discomfort
to adjust one side first all the time to avoid confusion. Care
during occlusion or from appliance impingement on the
should be taken to make all bends on the same horizontal
tissues. When the patient experiences no discomfort from
plane, otherwise adverse tooth movement will result. After
the appliance with the mouth open, closed, or while
both cribs have been rotated buccally, each lingual arm
chewing, he is instructed in inserting and removing the
will meet end-to-end with the second bridgemeter (Fig. 32-
appliance.
28H). ext each lingual arm is grasped mesial to the crib and
Instruct the patient not to remove the appliance to show
moved 0.5 mm. toward the lingual (Fig. 32-28I-J-K). With
it or for any reason except to clean it and to brush the
the bridgemeter it will be ascertained that each arm was
teeth. Unnecessary handling or dropping the appliance and
returned to its original position (Fig. 32-28L). The lingual
bending it will interfere with its fit. The appliance should
arms should never be allowed to touch the lingual surfaces
be cleaned thoroughly every night. The whole appliance is
of the premolars.
held in the hand, the clasp passing between the thumb and
finger. A Butler clasp brush is used to polish, not brush,
the clasps. Bon-Ami, silver polish or grey Lava soap may
be used with a cotton ball to polish the appliance.
Adjustment 523
Fig. 32-28. (A) The mandibular adjustment. First measure the distance between the occlusal rests, using the first
bridgemeter. (B) Measure outside the ends of the lingual arms with a second bridgemeter. (C) While holding the appliance
in a horizontal plane, pinch the center of the bodywire with a SS White o. 137 contouring plier. (0) This causes each clasp
to move buccally l/2 mm. as measured by the first bridgemeter. (E) Then, grasping the clasp distal to the rest, or the
strongest area, rotate the right crib so that the end of the lingual arm moves buccally Ih mm. (F) Check the rotational
adjustment. (Continued on overleaf) (G) Rotate the left crib so that the end of the lingual arm moves buccally V2 mm. (H) Both
lingual arms should meet end-toend with the bridgemeter. (l) The right lingual ann end is moved back to its original
position. (J) Check the adjustment. Notice only one lingual arm is inside the previously established bridgerneter
measurement. (K) Now the left side. (L) Both lingual arms are now in their original position in relation to the bridgemeters.
The upper and lower appliances are adjusted in the clasps rotate outward with the first bend, the arms may
same manner. Figures 32-29A-29L show the sequence of tend to be rotated inward.
adjustments for the maxillary appliance. A word of In unilateral distocclusions the routine is to expand the
caution: to accomplish a rotating adjustment in either occlusal rest 1 mm. as in a bilateral case, then to rotate the
appliance, measure the molar width and at that moment maxillary molar of the normal side. The lower appliance is
use the second caliper and measure the anterior arms. The similarly adjusted to rotate the molar on the opposite side.
reason is that as the The objective is to estab-
lish widths that reach the point of centric accommodation. form is the "Crozat premolar-molar relationship." A
Correlating arch widths to establish or influence the measurement taken from the tip of the buccal cusp of the
normal anteroposterior relations of one arch to the other is maxillary right first premolar to the buccal cusp of the
thus provided. maxillary left premolar will correspond to the distance
Arch Form. It is desirable to ascertain the relative from the mesiolingual cusp of the right maxillary first
widths of both arches in the positions that will obtain molar to the mesiolingual cusp of the left maxillary first
when the anteroposterior relation is corrected. The patient molar. This relationship has a coefficient of correlation of
is instructed to place the incisors in the relatively desired .876, as determined by the University of Alabama
position. If the incisors are protrusive the canines will be orthodontics department.
engaged. The operator then notes the anteroposterior
relation of the molars and premolars and will obtain a
Activating the Appliance
relative idea of how much the maxillary incisors should
move back. One can also obtain some idea of how much As the molars are being rotated and a better arch form is
the upper molars should be rotated to fit with the lower being established, auxiliary attachments are added to the
molars. appliance. The placement of the attachments is governed
Another guide used to determine adequate arch by the case and is limited
Adjustment 525
Fig. 32-29. (A) The maxillary basic adjustment. First measure the distance between the occlusal rests, using the first
bridgemeter. (B) Measure outside the ends of the lingual arms with a second bridgemeter. (c) While holding the appliance
in a horizontal plane, pinch the center of the bodywire with a SS White No. 137 contouring plier. (D) This causes each
clasp to move buccally lfz rnrn. totaling 1 mm. as measured by the first bridgemeter. (E) Then, grasping the clasp mesial to
the rest, or the strongest area, rotate the right crib so the end of the lingual arm moves buccally liz mm. (F) Check
rotational adjustment. (Overleaf, G) Rotate the left crib so the end of the lingual arm moves buccally 112 mm, (H) Both
lingual arms should meet end-toend with the bridgemeter. (I) The right lingual arm end is moved back to its original
position. (J) Check the adjustment. otice only one lingual arm is inside the previously established measurement. (K) Now
the left side. (L) Both lingual arms are now in their original position in relation to the bridgerneters.
only by the imagination of the operator and the individual or laterally and at the same time distally to escape the
case needs. Some of the basic auxiliary attachments will anterior constriction or curvature which is natural to all
be included here. It is best for the person unfamiliar with arches. Thus, the molars appear to move distally into the
the appliance to gain experience with fairly simple cases wider portion of the arch, and spaces are seen to develop
before advancing to the more complex. in the teeth anterior to the molars.
Expansion of the appliance exerts force outward As the molars are rotated and Class II elastics
are worn. After the molars obtain a Class I or neutro- the treatment in the maxillary arch. By this method
clusion relationship, "golf sticks" (auxiliary wires) are advantage is taken in the presence of deep bite which
placed anterior to the maxillary canines and are adjusted offers a degree of resistance to the labial movement of the
to move the canines and premolars distally thereby mandibular anterior teeth. These stresses, therefore, are
closing the spaces. At this time, the patient must continue expended distally with satisfactory molar response. With
the use of elastics to maintain the distally positioned this accomplished, the case is treated as a distoclusion.
molars. In very deep bites, anterior springs are placed lingually
When an appliance is activated, there is a tendency for and incisally to the cingulums of the mandibular incisor
the appliance to extricate itself from the teeth. This is one teeth. The spring force is thus directed to the apices. In
of the factors conducive to the vertical dimensional cases presenting slight overlap of the incisal edges, the
growth of the posterior teeth. The posterior movement lingual springs are placed at the very neck of the tooth to
may be augmented or increased by the addition of lingual avoid stress in the direction of the apices. This is to
springs at the necks of the lower or upper lateral incisors prevent a depressing force on the contacted incisor teeth
in crowded arches. Frequently, it may be desirable to treat by the springs or a tip-back action upon the molars. These
the mandibular arch to some extent before advancing to forces
Case Histories' 527
must be very mild to maintain the axial position of the molars and Much of the malocclusion will correct itself automatically. After
prevent opening the bite. The foregoing is an attempt to control the molars are in neutrocclusion, the high labial with the "golf
the balance maintained between a mild mechanical stress and the sticks" and fingers are added.
stresses of occlusion. By such control teeth maintaining their Treatment extends over the development of the dental
occlusion in function will move distally and still maintain their apparatus to about maturity. In most instances, retention is
axial relations. This will occur whether they are moved distally or achieved with night use of the appliances.
buccally.
Having obtained an approximation of normal arch sizes for the
accommodation of the teeth and having positioned first molars in
Class I or neutrocelusion, additions may be made at this time to CASE HISTORIES
the appliances such as high labial wires with pins and extensions
to position the individual anterior teeth. A serious mistake would
T.W., age IS-Class II, Division 1 malocclusion
be made if the high labial wire was placed right from the start and
an attempt was made to expand the arch and/or rotate the molars. The diagnostic casts were studied to see if the teeth to be
Everything should be done in sequence. The molars come first, clasped required reshaping (Fig. 32-30 A, B, C). None was
and therefore must be adjusted first. Start by having the patient required in this case. The lower appliance was inserted first so that
wear the appliances, to become thoroughly adapted to them, the patient could become accustomed to one appliance before the
comfortable to the patient, and the patient manipulating and second one was placed. At this appointment the patient was
handling them properly. Then begin to rotate the molars. shown how to clean and care for his appliance. The necessity for
cooperation was reemphasized.
The upper appliance was placed in the mouth 1
TABLE 32-1 MATERIALS A D TOOLS FOR CROZAT APPLIANCE CONSTRUCTIO
Item LIse Order From
Wire )
0.028 gold platinum Clasp and crib auxiliary a The J. M. Ney Company, Drawer 990, Hartford, Conn.
ttachmen ts 06002. Ask for Elastic No.4, 0.028.
0.040 gold Lingual arm and rest Baker Dental Division of Englehard Industries, 700
Labial arch Blair Road, Carteret, N. J. 07008
Ask for 3% wire.
0.051 gold Body wire and maxillary labial arm Baker Dental Division of Englehard Industries
ends
0.040 blue Elgiloy Labial arch } Rocky Mountain Dental Products Co., Box 1887,
0.028 blue Elgiloy Auxiliary attachments (labial Denver, Colo. 80201
finger)
Heat shield 70 Investing and repairing Heat Shield 70, Box 402, Gatlinburg, Tenn. 37738 (or
Codesco Dental Supply Co.)
Ransom & Randolph Soldering
soldering investment
Wire solder (28-gauge)
Soldering flux paste 450 and 650 wire solder Soldering Baker Division of Englehard Industries
gold-platinum wires S. S. White, Division of Pennwalt, Three Parkway,
1 Philadelphia, Pa. 19102 or from local supply house

Amend Drug & Chemical Co. 117 E. 24th St., New
stainless steel flux Soldering non-precious wires York 10, N. Y.
(2 potassium fluoride,
V2 Arm & Hammer borax)
Bird-beakNo, 137 Flat-nosed Construction S. S. White. Local Dental Supply House.
office Construction Dixon.
plier
Small contour plier, No. 831 Construction Karl Schumacher, Germany. U. S. Office in
Philadelphia.
Ivory bridge meters Adjustments Cleveland Dental Manufacturing Company.
Local Supply House.
Fig. 32-30. Case 1. (A, B, C) Before treatment diagnostic cast. (0) Mandibular appliance placed on cast showing the correct position of
the lower lapping sweep springs. (E) Maxillary appliance, occlusal view, showing the position of the elastic hooks. (F) The correct
position of the mandibular elastic hook. (Opposite G) Side view of maxillary elastic hook. (H, 1) Appliances in place with 5/Hl-inch 3112-
oz. latex elastics. Finger spring is shown engaging the mesial of each maxillary cuspid. 0, K L) Front and lateral views at the end of
active treatment. During retention the patient wears his lower appliance at night only as shown. (p. 530, M, N, 0) Front and lateral views
6 years after active treatment.
week after the lower appliance. The patient was then After this interval a full adjustment was made in the
allowed 4 weeks to become fully accustomed to the maxillary appliance, as previously explained, and lapping
appliances. sweep springs were soldered to the
Case Histories . 529
ends of the lingual arms of the lower appliance and lasting stress in the desired directions. These sweep
contoured so that they touch the cingulums of all the springs are usually made from O.028-inch blue Elgiloy
incisors and end, in this case, at the cuspid teeth (Fig. 32- wire. A low-fusing solder (Baker 450 fine gold wire) is
300). In very deep bites the lower lingual sweep springs used, and a flux consisting of half borax and half
may be soldered to the bodywire just under the clasps. potassium acid fluoride. All additional auxiliaries are
This allows more wire to be incorporated in the sweep added with the low-fusing 450 solder.
spring, giving a mild, longer Four weeks later, the lower appliance was given
time the hooks for attaching elastics were added. In order

to add the hooks, the appliance must first be thoroughly
cleaned. A piece of O.028-inch blue Elgiloy wire is
soldered free-hand to the mesial portion of the crescent. A
higher-fusing solder (Baker 650) was used to solder the
crescent to the crib wire. The low-fusing solder flows onto
the high fusing solder, and the attachment is made. Too
much heat will cause the 650 solder to melt, and the clasp
will fall apart. Figures 32-30, D, F show the mandibular
hooks added to the appliance.
At this same appointment elastic hooks were added to
the upper appliance (Fig. 32-30, E, G). Blue Elgiloy,
Fig. 32-30. Continued. 0.036-inch wire is used for the maxillary elastic hooks,
which are soldered with Baker 450 solder. The Elgiloy
wire is soldered to the end of the buccal arm and is
a full adjustment, as previously explained (Figs. 32-28 and extended to the distal of the cuspid. The wire is then bent
32-29). The next appointment was after another 4 weeks' downward and backward so that the curvature for the hook
interval. The second basic adjustment should be activated will be approximately on a level with the mesial aspect of
only 1 0101. and no more. It must be determined if the the first bicuspid. A 511 s-inch, 3.5-oz., latex elastic
previous l-rnm. adjustment has been utilized. The , is used. The elastic should have a pull of about 2 to 2.5 oz.
following method describes the procedure used. As can be seen, the hooks can be adjusted to the necessary
The appliance is removed from the patient's mouth and distance in order to obtain the correct elastic pull. Fig. 32-
is measured from occlusal rest to occlusal rest with a 20 H, I show patient wearing his elastics.
bridgemeter as described earlier in the first measurement One month later the appliances were measured, and it
of the basic adjustment. Then the appliance is placed in was found that the adjustment previously given was spent
the patient's mouth and is measured with the same and a full upper adjustment again was made at this
bridgerneter that was used to measure when the appliance appointment. Five weeks later, while the patient continued
was out of the mouth. If the measurement is exactly the to wear the elastics, it was ascertained that he had used up
same as when the appliance was out of the mouth, a the adjustment made at the last appointment, and a third
second basic adjustment may be made. If the measurement full upper adjustment was made and the patient was
is not the same as when in the mouth, no more ad- instructed to continue wearing the elastics.
justments should be made. The clasps are made snug, and It was noted on one of the following monthly
the patient is instructed to return in 1 month. This patient's appointments that the cuspids were not assuming their
teeth had not fully utilized his previous adjustments and at Class I position although the bicuspids were
this appointment no further adjustment was given.
However, at this
Case Histories' 531
close to their correct positions. A finger spring was Four months after the use of elastics was started the
soldered to the buccal arm above the elastic hook and bent molars achieved a Class I relationship, and spaces
to engage the mesial of the upper cuspids (Fig. 32-30H, I). developed between the maxillary premolars. Up to this
The wearing of the elastics was continued. point the canines have moved very little. Now a wire was
When the cuspids were in normal relation, the patient soldered to the existing buccal arm and engaged mesial to
was instructed to wear his elastics at night only, but to the canines.
wear his appliances at all times. Three months later he was Although the patient was checked at regular monthly
instructed to wear his appliances at night only. At this intervals, nothing was changed until the canines were in a
time active treatment was completed. The patient was seen Class I position. It took 4 months for the cuspids to assume
at 3 month intervals for 1 year. We then removed his their normal position. The entire maxillary elastic hook
upper appliance at night, and he was instructed to wear wires then were removed, and a labial wire was added. An
only his lower- appliance at night. At this point he had a 0.040-inch blue tip Elgiloy wire is soldered to one buccal
tour in the Navy. However, he wore his appliance at night arm. Then with a large contouring pliers, the wire is bent
during this time. Figure 32-30], K, L shows the around the labial portion of the mouth (32-31G) and then
photographs of the teeth at the end of active treatment. marked with a china marking pencil 1 mrn. past the end of
Figure 32-30M, N, 0 show the occlusion 6 years after the buccal arm. The appliance is removed from the mouth
active treatment. and the 0.040-inch labial wire cut on the mark. The free
end of the wire is soldered to the right buccal arm (Fig. 32-
31H).
The necessary auxiliary wires are added in the following
manner:
M.G.W., age 12-C1ass II, Division 2 The appliance is inserted in the mouth, and the labial
subdivision wire is marked at the points where the auxiliary wires are
Impressions were taken (Fig. 32-310, E, F), periapical x- needed (Fig. 32-311). The appliance is removed and the
ray films were obtained, and 35-mm. slides were made 0.028-inch blue Elgiloy auxiliary wires are soldered to the
(Fig. 32-31A, B, C). The routine for placing appliances in labial wire at the marked points. The appliance is then
all patients is the same. Patients are seen at 4- to 6-week inserted into the mouth so that the newly soldered wires
intervals, averaging 5 weeks. may be marked (Fig. 32-31]) and subsequently cut and
The patient returned 4 weeks after receiving both her tapered to their correct length (Fig. 32-31K).
appliances and was given a basic adjustment in the Auxiliaries shown are: 1. Elastic hooks, maxillary and
maxillary appliance, for rotating the maxillary first molars. mandibular. 2. "Golf stick," an 0.028-inch blue Elgiloy
Four weeks later a basic mandibular adjustment was made. Rocky Mountain wire bent at a right angle toward the
Both maxillary and mandibular adjustments may be given interproximal area and engaging to the mesial of the
at the same appointment. canine. The purpose of this wire is to move - and/ or keep
At the next regular appointment, 5 weeks later, the maxillary canine in a Class I position. It also helps to
mandibular right and left lingual sweep springs and the stabilize the maxillary appliance when elastics are worn. A
mandibular hooks for elastics were added. The sweep golf stick may be used on any tooth.
springs are placed just below the cingulum of the teeth and "Three Fingers," an 0.028-inch blue Elgiloy Rocky
should exert no more than 1 to 1.5 oz. of pressure. The Mountain wire is soldered to the labial arch wire and tapered to
high point of the sweep spring viewed from the lateral a fine point touching the centrals or laterals at or near the
aspect should contact the incisor just below the cingulum. height of contour on the labial surface. The maxillary
If the wire touches above the cingulum, the tooth will be appliance of this patient with the labial and auxiliaries attached
depressed. Sweep springs must be initiated before elastics is shown (Fig. 32-31L-O). After the labial archwire was added,
are started or the elastics will pull the lower first molars the patient was seen at monthly intervals for a year. At each
mesially. visit the finger springs were examined to be sure they had no
After another five weeks elastic hooks were added to the more than a half ounce of pressure. This pressure is checked by
maxillary appliance. Elastics were instituted at this passing the tip of an explorer between the tooth and the finger
appointment. These 5!l6-inch latex elastics exert a force of spring and/or golf stick. If the instrument will not pass easily,
2.5 oz. or less. The maxillary elastic hook can be adjusted allowing the finger to snap back touching the tooth, then the
mesially or distally to get the correct amount of elastic pressure is too light.
pull. Five weeks later the second basic upper adjustment Retention was simple. The patient was instructed'
was given to this patient. Elastics were continued for the
next 3 months.
Fig. 32-31. Case 2. (A-C) Intraoral views before treatment. (D-F) Beginning cast. (Opposite, CJ Construction of the labial archwire. An
0.040 blue tip Elgiloy wire was soldered to the left buccal arm, and large contouring pliers were used to bend the labial around the arch. (H)
Labial appliance in place with labial arch at proper position after the free end is soldered to the buccal arm. (l) Marking the labial arch wire
for the placement of auxiliary wires. (j) Marking the auxiliary wires at their proper height prior to cutting. (KJ Appliance inserted with
auxiliaries cut and tapered. Notice how inconspicuous the appliance is. tp, 534, L-O) Different views of the appliance used. (P-R) Views of
dentition 10 years after termination of active treatment.
to wear her appliances at night only. We continued to

check her at 3-month intervals until her wisdom teeth had
been accounted for. When we establish that no more Figure 32-31P, Q, R shows intraoral photos 10 years after
growth will take place, at age 18 or 19, and the third active trea tmen t.
molars have not erupted, we usually suggest their Although most patients soon lose interest in their teeth
removal. This patient had her third molars removed at age at the termination of active treatment, the Crozat appliance
21. The patient still wears her appliances approximately offers those who are proud of their teeth a guarantee that
every other night. She visits her orthodontist as she does they will never have a relapse. Since extraction of
her dentist and physician, once a year. This way, if a permanent teeth does not insure a patient that there will be
minor irregularity should occur, it can be corrected very no subsequent relapse, having an appliance to wear at
easily. nights once
or twice a week seems to be an acceptable and simple and photos were taken. Appliances were placed, as usual,
solution to retention problem. 1 week apart. After wearing both appliances for 1 month,
the patient was given a full adjustment in both appliances.
The purpose was to rotate the first molars so that space
Patient CC, age 13
could be obtained mesial to the first molars to move the
Impressions were made for diagnostic casts (Fig. 32- premolars distally. This afforded space for the left
32A-C) and occlusal views (C, H), Panorex x-rays maxillary canine and lateral
Fig. 32-32. Case 3. (A, B, C), Casts at beginning of treatment. (0, E, F), Casts after active treatment. (Overleaf, G, H). Occlusal views
J! occlusal views after treatment. (K) Overlay showing addition of O.028-inch lapping sweep spring ending at the left
before treatment; (1,
cuspid and right lateral, (LJ Upper appliance in place, (M p. 537) Lower appliance in place shows lapping springs and a lingual rest to the left
second molar to prevent the attachment teeth from tipping.

patient wore her mandibular appliance at night only until

her third molars erupted.
T.J., age ll-Class II, Division 1

Diagnostic casts (Fig_ 32-33A, B, C, G, H), Panorex
and cephalometric x-rays, and photographs were made.
Stone casts which were used to construct the appliances
are always made from new impressions. (It is inadvisable
to use duplicates of the diagnostic casts to construct
appliances.)
The patient returned 4 weeks after receiving both
appliances and was given a basic adjustment of the
maxillary appliance. Four weeks later a basic adjustment
was made in both appliances.
After another 4-week interval, the lower sweep springs
were attached (Fig. 32-330). One purpose of these lingual
sweep springs is to provide anchorage to keep the lower
molars from shifting forward when Class II elastics are
worn. After the maxillary arch was moved into
neutroclusion and elastics no longer were needed, the
lingual sweep springs were raised to the incisal edges of
the lower anterior teeth. This corrects any minor rotations
incisor (Fig. 30-32L). It also allowed room for the lower that may occur in the lateral and central incisors. An
right cuspid to be moved into the arch after the lower right extremely slight amount of force is used, less than Y2 oz.
first premolar was moved distally. After another 4 weeks the elastic hooks were added, and
Five weeks later one lower sweep spring was soldered Class II elastics were started. At this time maxillary sweep
to the left lingual arm of the mandibular appliance and springs were placed against the laterals. This aids in
contoured to touch at the cingulum of all the incisors, creating spaces between the premolars as the molars
ending at the right lateral incisor. This sweep spring had assume a Class I position and the springs no longer touch
less than 1 oz. pressure. Two months later the second the laterals. Six weeks later a basic upper adjustment was
basic adjustment was given to the mandibular appliance. made.
After 4 weeks a second sweep spring was added, this time Seven months after treatment was started, the molars
on the mandibular right lingual arm, contouring to touch were in Class I position and the labial arch was added with
the cingulum of the mandibular incisors and ending at the auxiliary finger springs to the maxillary centrals and
left lateral (Fig. 30-32 K-M). lateral incisors. Auxiliary "golf sticks" were added to the
For the next 6 months at each monthly visit the sweep cuspids (Fig. 3233K-N).
springs were lowered to their proper position at or below , The patient was seen at monthly intervals for 12 months
the cingulum. There is a tendency for the sweep springs to to make certain that a correct amount of tension was
slowly drift incisally as the arch unfolds. This can also placed on the anterior teeth and that the patient is wearing
cause the anchor or clasp teeth to tip. To prevent this from the elastics. Eighteen months after treatment started the
happening a rest is placed in the lingual groove of the patient was instructed to wear the appliances at night only
second molar (Fig_ 30-32M) (occlusal view). The 0.032- (Fig. 32-33D-F). At this point the case needs to "settle-in"
inch blue Elgiloy wire is attached to the bodywire and or finish. This is accomplished with the normal functional
bent occlusally to engage passively in the lingual groove wearing of the cusps as the teeth assume their new and
of the second molar. corrected positions. The patient is shown 3 years after
Six months later active treatment was terminated and active treatment (Fig. 32-331, J, P, Q, R, T).
n-
casts were made (Fig. 32-320, E, F, I, The
Fig. 32-33. Case 4. (A, B, C) View of beginning casts. (0, E, F) Intraoral views at completion of active treatment 18 months from start.
(Opposite, G, H) Occlusal views before treatment. (T, j) Occlusal views after completion of treatment. (K, L. M, p. 540) View of labial arch and finger
attachments for closing spaces. (N, 0) Appliances in position. (P, Q, p. 541, R) Front and lateral views after 3 years of wearing the appliances only at
night. (5) Pretreatment profile. (T) Posttreatment profile. This is a good example of what happens to the facial profile when mandibular rotation
is retrognathic.
Case Histories : 539


Case Histories' 541

33
Midpalatal Suture Opening
ROBERT A. WERTZ, D.D.S., M.S.
The maxilla seemingly offers the most favorable maxillary narrowness may be present together with a lateral
potential for direct skeletal alteration in attempts to treat mandibular displacement. This demonstrates a unilateral
skeletal dysplasia or imbalance associated with dental cross bite when only the occluded position of the teeth is
malocclusion. Opening the mid palatal suture or palatal studied (Figs. 33-2, 33-3).
disjunction and the attendant widening of the maxillary Differentiation must be made between true bilateral
skeletal base by use of a rapid maxillary expansion maxillary deficiency and unilateral maxillary deficiency. A
appliance has moved orthodontics into the realm of "facial bilateral maxillary deficiency or constriction may produce a
orthopedics." By this means one type of skeletal bilateral buccal cross bite Of, in a less pronounced bilateral
imbalance, known as bilateral maxillary constriction, has constriction, a unilateral crossbite may be seen as the
proven treatable. mandible deviates or is displaced laterally from the rest
position to full occlusion which produces a normal buccal
dental relationship on one side and a crossbite on the
HISTORY opposite side. The condyle-to-fossa relationship is
constantly disturbed by the latter condition. Correction of
Since E. C. Angell's! first report in 1860, numerous maxillary constriction allows the mandible to change its
authors have discussed maxillary expansion by opening the path of closure from rest to occlusion so that the
midpalatal suture. In the early 1900's much interest in this mandibular displacement is eliminated and' a normal
procedure was generated among physicians specializing in condyle-to-fossa relationship is established. This is
rhinology who sought a means to increase nasal demonstrated in Figure 33-4.
perrneahility.s-": 6,7.11 Orthodontic investigators such as A unilateral maxillary constriction should usually not be
Dewey.P Wright,24 and Cryer'? considered the histologic treated by rapid bilateral maxillary expansion. Bilateral
and anatomic aspects while others such as Barnes- and expansion of a unilateral maxillary constriction may cause
Black" reported the effects upon the dentition. the mandible to be displaced laterally toward the normal
After much was written in the early 1900's, there was a side by following the guidance of the dental cusps as the
dearth of information until European authors revived normal side is over-expanded. Such treatment may
interest. Korkhaus!? and Derichsweiler!" were notable for permanently displace the mandible and can result in joint
their contributions in the 1950's and were responsible for disturbance (Fig. 33-5).
redirecting clinical interest. Recent investigations have A high narrow palatal vault is often associated with a true
shed light upon the forces employed,15,16 histologic bilateral maxillary constriction. Owing to disproportionate
response at articular sites,9.19 skeletal and dental widths, an exceptionally wide mandible and mandibular
aJterations,I418,21,22 and nasal-respiratory changes." arch is sometimes seen with a maxilla of normal width and
a normally contoured palatal vault. When buccal segment
crossbite exists together with this skeletal imbalance, com-
pression of the mandible is not possible, and successful
treatment entails widening of the maxilla by opening the
INDICATIONS mid palatal suture. Rapid expansion of a maxilla of normal
Bilateral maxillary constriction is probably the only width to match a wide mandible may be considered as
condition that warrants midpalatal suture opening." In this another indication for this procedure.
type of skeletal imbalance the constriction may be severe One may also consider midpalatal suture opening as an
enough to cause a bilateral crossbite of the buccal adjunct to the treatment of narrow dental arches where
occlusion. Thus, both maxillary buccal segments, and there is no crossbite but where mod-
sometimes, the maxillary anterior teeth, will be seen to be
in cross bite. A representative case is seen in Figure 33-1.
On other occasions, a less pronounced bilateral
542
95. Indications . 543
Fig. 33-1. (A, C, D are pre-

treatment photos). A severe
maxillary constriction, (A, C, D).
Over-correction (B, E, F).
Spontaneous closure of created
maxillary midline diastema (H).
Continuing therapy (G, H). The
abutment bands cemented to the
first premolars were removed,
these teeth were extracted, and
retraction of the canines was
begun. The appliance was
utilized as a stabilizing device.
The buccal segments were
further supported by direct-pull
face-bow traction to the
maxillary molars. (l) Stripping
for retention, anterior view; (J)
Palatal view; (Overleaf, K) Right
buccal segment; (L) Left buccal
segment.
544 . Midpalatal Suture Opening
K
erate expansion can correct arch length problems. In this

case, skeletal widening to carry the buccal musculature
laterally may be the key to increased dental arch stability
following expansion. Orthopedic maxillary widening is
especially indicated for a patient who also has difficulty
breathing because of anatomical narrowness in the anterior-
inferior portion of the nasal cavity. Nasal implications are
discussed later in this chapter.
To summarize, the indications for midpalatal suture
opening is primarily intended for correction of bilateral
maxillary constriction. When the teeth are occluded, this
condition may be manifest as a unilateral crossbite
associated with lateral mandibular displacement. A severely
constricted maxilla may create a bilateral buccal cross bite
with li ttle or no mandibular displacement. Either of these
mandibular positions may be seen with an exceptionally
wide mandible and mandibular arch and a normal maxilla.
Such a procedure provides stable expansion when mild
expansion is desired to correct archlength
, deficiencies. This therapy has been used with patients from
4 to 29 years of age.
Fig. 33-2. Intraoral photographs of maxillary constriction

accompanied by lateral mandibular displacement (A)
pretreatment; (B) at appliance stabilization; (C) after
appliance removal. No other bands or appliances were used
except the suture opening device. Correction of mandibular
displacement is noted as the mandibular midline changes its
position at occlusion due to elimination of the lateral
mandibular displacement. Overcorrection by expansion to
the extent that the lingual cusps of the maxillary buccal
segments are riding up the buccal cusps of mandibular
buccal segments is desirable. (Wertz, R. A.:
Am. J. Orthod., 58:41, 1968.)
96. Indications . 545
Fig. 33-3. Photographs of

casts demonstrating pretreat-
ment (A), stabilization (B), and
appliance-removal (C). Stages in
treatment of a mild bilateral
maxillary narrowness
accompanied by a lateral
mandibular displacement.
Correction of the problem by
means of mid palatal suture
opening eliminated the func-
tional shift of the mandible.
Overcorrection, change in
midline relations, and settling of
the occlusion should be noted.
Of special interest is the
spontaneous improvement of
the anterior open bite that
accompanied the closure of the
induced maxillary midline
diastema. (0) Comparison of the
palatal aspects of the casts
before treatment, immediately
after suture opening and at re-
moval of the suture opening
device 3 months later.
..~
,
Fig. 33-4. Schematic representation of bilateral maxillary

expansion of bilateral maxillary constriction associated with
lateral mandibular displacement. Correction of the lateral
mandibular displacement is effected by gaining sufficient
maxillary width. (Wertz, R. A.: Am. J. Orthod., 58:41, 1968.)
necessarily to midpalatal suture ossification. Some mature

late-teen-age patients may show resistance to lateral
displacement of the maxilla, while sutures have
successfully been opened in other patients well beyond
the age of 20 years.
Patients with a severe tendency to gingival hyperplasia
- such as seen in the so-called dilantin hyperplasia - must
be observed closely. Gingivitis should be treated prior to
placement of a palatal suture opening device, and a person
who shows soft tissue pathology in the pressure-bearing
areas is not a candidate for tooth-tissue-borne appliances
until the pathologic condition is successfully treated.
RECORDS
In order to document actual results of therapy, three
complete sets of orthodontic records should be made:
prior to opening the suture, at the time of completion of
Fig. 33-5. Schematic representation of bilateral maxillary
the suture opening, and when the appliance is removed.
expansion of a unilateral maxillary constriction creating a
Complete records include orthodontic study casts,
displaced mandibular position. Risk of production of such a
displacement is to be avoided by treating unilateral constrictions posteroanterior and lateral cephalograms, occlusal x-ray
with conventional unilateral orthodontic therapy not midpalatal films, intraoral photographs, and facial photographs. All
separation, which is mostly bilateral in effect. pretreatment records should be studied prior to proceeding
with the palatal disjunction.
CO TRAINDICA nONS
APPLIANCE CO STRucnON AND
A true unilateral crossbite should not be treated by
MANIPULATIO
midpalatal separation. A limitation based on age must be
considered. Recent work indicates that maxillary
Plan of Construction
articulations elsewhere than the midpalatal juncture may
offer the major resistance to lateral displacement of the A rigid fixed appliance capable of producing strong
maxillary halves. Older patients will usually resist suture force is necessary. Suture opening cannot be obtained
opening to a greater degree and only limited suture with a low-load appliance, nor can it be effective with a
opening has been found possible. This is presumably due removable appliance (Fig. 33-6). To prepare such an
to a general increase in the rigidity of all sutures and not appliance, abutment teeth are selected. These are usually
the maxillary deciduous
Fig. 33-6. Various aspects of

typical fixed mid palatal suture-
opening appliances. Rounding
of the acrylic edges and
elimination of acrylic in the area
of the free gingiva should be
noted. Soldered joints should be
of maximum size to ensure the
rigidity of the appliance. (Wertz,
R. A.: Am. J. Orthodont., 58:45,
1970)
Appliance Construction and Manipulation' 547
Fig. 33-7. Direct-indirect fabrication of midpalatal suture

opening device. Bands are placed on the abutment teeth, usually
the maxillary first permanent molars and the first deciduous
molars or first premolars. Impressions are taken with the bands
in their respective positions. The bands are placed in the Basepla te wax
impression, waxed to the buccal surface, and the cast is poured.
Expansion Screw
The lingual aspects of the bands are provided with O.045-inch
.045 55 Wire
round stainless steel wire with the free ends bent palatally to be Solder Joints
embedded in the acrylic palatal sections. The expansion screw
mechanism is mounted as deeply as possible at the midline in a
piece of baseplate wax placed vertically along the midline. After
two thin applications of separating medium, the acylic portions
are added by the powder-spray method. When the acrylic has
set, the appliance is removed from the cast and polished. ,045 55 w.i r e
Removal of the wax leaves the midline space in which is located
the adjusting portion of the screw mechanism. Care must be Baseplate wa x
Acrylic Expansion
taken to round off the edges of all tissue-bearing surfaces, thus
Screw
minimizing the possibility of irritation. ote that the free gingival
area is cleared of acrylic and no relief of the palatal surface is
made.
first molars or their successors and the first permanent

molars, but other abutments may be utilized when
necessary. Clinical judgment must be exercised
regarding the anchorage value of resorbing deciduous
roots when selecting abutment teeth. Solder Joint
The appliance I use is a combination acrylic and wire Bands Acrylic
device held in place by cemented orthodontic ban'ds .045 s s Wire
Screw Mechanism
(Fig, 33-7). The lingual surfaces of the orthodontic bands
are soldered to O.045-inch stainless steel wires, the ends
of which are extended and
Fig. 33-8. A commonly used screw mechanism is the Rocky

Mountain #611. (A) The closed position of this mechanism; the
width is 15 mm. (B) With the mechanism opened 7 mm. the total
width is 22 mm. and the guide bars are extended to the edge of
their housing. (C) Fully extended position of the screw
mechanism shows an increase of width to 25 mrn., a gain of 10
mm.
curved palatally to be imbedded in the acrylic portions of quarter turn is made each morning and each evening by the
the appliance. The midline of the acrylic portion is parent. A loop of dental floss should be tied to the key and
divided, except in the area where an expansion screw looped about the wrist when activating the appliance to
mechanism connects the two halves. The screw prevent aspiration or swallowing if the key is dropped. The
mechanism should have anterior and posterior guide rods patient is observed twice weekly until expansion of the
for stability (Fig. 33-8). One full turn or revolution of buccal segments is considered sufficien t.
most expansion screw mechanisms results in For better results in older patients, a reduced activation
approximately 0.9 mm. expansion. The widest opening schedule is recommended. Here the activation may be
mechanism that will fit the case should be utilized in reduced to a quarter turn per day or even to a quarter turn
order to obviate remaking the appliance to achieve over- every second day.
correction in narrow arches. The sensation of pressure at the abutment teeth
Several factors are most important in fabricating as following an activation is experienced by almost all
rigid an appliance as possible. The guide bars of the screw patients and must be explained to the parents and the
mechanism should extend directly laterally. This is patient. Pressure may also be expected at any site of
absolutely necessary to insure minimal lateral rotation of maxillary bone articulation. About twenty per cent of
the maxillary halves. To produce a very rigid appliance, patients report pressure at nasion or at the zygomatic
the wires connecting the bands to the acrylic should be sutures. About 50 per cent of all patients claim to feel
exposed from the acrylic as little as possible, and heavy sensation at the midpalatal area, but this may be a
solder reinforcement should be incorporated on the misinterpretation of pressure upon the teeth or palatal
lingual surfaces of the bands. The lingual wires are held mucosa. The usual duration of the pressure sensation is
in place while soldering by the use of moist asbestos or a from a few seconds to several minutes. Rarely do the
piece of Mortite (Fig. 33-9). abutment teeth become tender or sensitive, as might be
expected following a conventional orthodontic adjustment,
and rarely does pain accompany mid palatal separation. In
a young patient, tissue irritation either from improper
appliance construction or food impaction may be a source
Activation of pain. Older patients may express symptoms ranging
Activation of the appliance is initiated with one full turn - from discomfort to painful sensations, these are usually
that is, four one-quarter turns - on the day the appliance is due to suture rigidity and attendant pressure from the
placed. The operator makes the first three one-quarter acrylic palatal sections as the appliance is activated faster
turns with the parent observing the third. The parent then than the skeleton can respond.
makes the fourth one-quarter turn under the guidance of The operator can easily cope with any painful reaction.
the operator. Usually these turns are separated by a time In the young patient a few reverse turns of the appliance
interval of about ten minutes each. Thereafter, one one- and a few days without activation usually allows the pain
to subside. This should be combined with careful hygiene
instructions. If tissue irritation from sharp areas of acrylic
is suspected, the appliance should be removed, modified,
and immediately recemented. After comfort is achieved,
activation may be resumed in a few days.
In older patients, a few reverse turns, and several days
without activation should bring comfort. This should then
be. followed by a reduced schedule. Reduced activation
means one one-quarter turn of the screw mechanism each
day or, possibly, every other day. If improper appliance
construction or lack of good hygiene is the problem, the
appliance must be removed, adjusted and recemented
immediately.
The parents and patient should be made aware of the
temporary spacing of the central incisors as the halves of
the maxilla are carried laterally.
When treating skeletal patterns with a predisposi-
Fig. 33-9. Palatal wires held in place for soldering.

Stabilization . 549
tion for vertical development and openbite tendencies, it is

advisable to accompany suture opening with vertical-pull
facebow traction, or vertical pull chin-cup traction. This
will counteract the tendency for the maxilla to drop
downward during suture opening.
STABILIZATIO
Midpalatal separation is followed by fixation or

stabilization of the appliance, which is best accomplished
by placing a small amount of self-curing acrylic between
the acrylic halves of the appliance. This should be done so
that a sluiceway is maintained along the exposed palatal
surface between the acrylic halves (Fig. 33-10). In the
event the guide-rods remain well within the opposite side
of the screw mechanism, the appliance may be stabilized
by passing a piece of brass wire through the keyhole in the
expansion screw and looping it about the anterior guide-
rod. The wire ends are twisted and tucked inward. When Fig. 33-10. Stabilization of the suture opening device
expansion is so great that the guide-rods are extended following midpalatal separation is usually accomplished by
beyond the opposite side, fixation must be made with placing a small amount of self-curing acrylic between the
acrylic to prevent collapse and possible burying of the acrylic halves of the appliance. Notice the sluiceway that
appliance in palatal tissue. must be maintained along the exposed palatal surface to
The appliance is left in place as a rigid stabilizer. facilitate lavage.
This stabilizes not only teeth, but more important, it retains
the maxillary bone segments in their new separated lateral migrate together. Figure 33-11 shows the radiolucency
positions. The usual length of time of stabilization is 3 produced at the midpalatal area when the suture is opened
months. and the regeneration of the midpalatal area that occurs
The most important happening during stabilization is during the period of stabilization.
sutural adjustment. This sutural adjustment permits the If the rigid appliance, including the palatal acrylic, is not
dissipation of the created residual force and is used as a retainer during the period of fixation, the force of
accomplished in about 6 weeks by cellular reaction at the resistance at the maxillary articulations can force the bone
various maxillary articular sites. Coincidentally, bone is segments together just as the force of expansion had
seen to fill the gap created at the midpalatal suture, and the originally opened the suture. The acrylic at the central
central incisors that were separated as much as 1/ inch 4 portion of the appliance is necessary for stabilization of the
spontaneously bone segments, since it acts as a splint that holds the bone
segments in their
Fig. 33-11. X-ray films of

anterior position of mid-
palatal suture (A) pretreat-
ment; (B) midpalatal gap pro-
duced by opening the suture;
(c) Regeneration of mid-
palatal area bone.
new lateral positions. Even a heavy labial archwire or well-fitting plate or Hawley-type retainer. The acrylic
removable acrylic plate used during the period of fixation margins serve as a fulcrum of rotation and allow the
will only retain the teeth, while the force of resistance at overexpanded buccal teeth to become upright during
maxillary sutures may initiate an orthodontic response function. This is continued for 6 months to a year, unless
around the retained teeth and allow the maxillary bones the buccal teeth are banded and controlled by arch wires;
themselves to relapse. This should not be confused with in that case the palatal retainer may be discontinued. The
the placement of an acrylic plate following the period of stability of the result is excellent when expansion is
stabilization. At this later stage, no residual force of carried to overcorrection and when stabilization and
resistance at the articular sites remains." the bone retention are properly applied.
segments are stable, and the removable plate is used to
serve as a fulcrum of rotation for uprighting the flared
and overexpanded buccal teeth.
The acrylic portion must be trimmed from the free FORCES
gingiva and rounded at its edges, but maximum tissue
The force build-up during appliance activation is
coverage is desirable. The palatal surface should not be
heavy. An average range of 3 to 13 pounds is produced
relieved. Entirely tooth-borne devices that do not have
and sometimes more. This is a necessary level of force
an acrylic central portion can certainly open the
for orthopedic movement of bone segments as opposed to
midpalatal suture, but without the acrylic central portion
the lighter forces used in orthodontic tooth movement. It
to aid in stabilization of the newly positioned maxillary
must be stated that suture opening normally creates no
halves, orthodontic response from residual forces may
pain. Mild pressure symptoms at maxillary articular sites
allow the maxillary bone segments themselves to relapse
are usually evident for as much as several minutes
medially while the teeth are held in their new lateral
following activation, but discomfort is minimal. A force
position. Some gain in skeletal repositioning and nasal
value of 5 to 10 pounds now is believed optimal for most
airway widening would thus be lost. Because the buccal
cases. However-and this is important-some heavily
bar sometimes advocated to connect the abutment bands
structured faces may require more than 10 pounds of
appears to bear no stress and only increases the difficulty
force.
in seating the appliance, it is omi tted. High-grade
A comparison or orthodontic and orthopedic force
acrylic must be used to allow for maximum tissue
values should be considered. When moving teeth, sound
tolerance.
orthodontic concepts direct us to approximate a
After the appliance is fixed other orthodontic
physiologic response in the periodontal ligament and
procedures can readily be initiated. Face-bow therapy
adjacent bone. Low-load, high-range, constant forces are
with cervical or high-pull traction or Class III mechanics
utilized for the most effective movement of teeth.
can be accomplished without fear. Anterior banding is
According to Storey and Smith." 5 to 10 ounces of force
usually delayed until the central incisors have shifted
is optimal for canine retraction. By contrast, rapid
almost back together, and then, using the suture opening
maxillary expansion, or palatal disjunction, is induced by
appliance as a stabilizer, the anterior teeth may be easily
heavy forces designed to produce a minimum of tooth
aligned. If indicated, maxillary anterior teeth can be
movement and a maximum of
advanced to produce sufficient space for canine eruption,
, bone repositioning. A contrast is seen between the half
or the appliance can be used to support the buccal
pound of force utilized in canine retraction and the many
segments when first premolar abutment bands are
pounds that may be built up in the movement of the
removed, first premolars extracted, and canine retraction
maxillary segments.
initiated. Extraoral support of the buccal segments may
Strain gauges":!" show that the force of the earlier
be added to the canine retraction technique when
activations of suture opening appliances dissipates
anchorage requirements dictate. When used in con-
'rapidly. As widening continues, there tends to be a
junction with other therapy, the appliance may remain in
slower dissipation of the force, and some amount of
place as long as desired. Many appliances have been
residual force remains at the time of subsequent acti-
worn for more than 1 year.
vation. As activation continues, this residual force tends
to accumulate into higher and higher values. The residual
force tends to build up faster in older patients, and the
assumption is that the articular sites in older patients offer
more resistance than in the young. a ill effect has been
apparent from the build-up of residual force in young
RETENTIO patients, but a reduced activation schedule that builds up
less
Removal of the appliance after a minimum of 3
months fixation is followed by the placement of a
Nasal Area Changes' 551
residual force might allow for more successful suture midpalatal suture opening is replete with claims of
opening in older patients. increased nasal permeability, but most of such claims are
The time required and degree of expansion obtained in subjective in nature. In 1965, Wertz reported on the
opening the suture to a sufficient width depends on the respiratory effects of midpalatal separation." A method
amount of width required in the individual case and on was developed for measuring the volume of air passing
the activation schedule. Ten to 24 days are needed to through the nasal chambers during both inspiration and
effect the necessary amount of opening in an average expiration. This method utilized the warm-wire
case. Exceptions are seen in older patients with reduced anemometer principle, which measures air velocity in feet
activation schedules. Lateral displacement, or widening per minute. By converting velocity to volume,
of the dentition, by as much as 12 mm. has been pretreatment nasal air volume was compared with
recorded. Wider opening is possible but would very rarely posttreatment nasal air volume. In this study, the
be needed. midpalatal suture was opened by a fixed split-palate
The buccal segments should be carried laterally until appliance and respiration was measured at rest, after mild
the maxillary teeth threaten to go into buccal crossbite. exercise, and during maximum effort ventilation.
This is an important point; inexperienced operators tend Most patients measured at rest and after mild exercise
to discontinue suture opening when the cross bite is demonstrated an increase in nasal air volume, but some
minimally corrected. Because the teeth have flared showed a mild decrease. All cases recorded an increased
somewhat buccally owing to some tipping movement and capacity for nasal air volume when measured during
to lateral arcing of the maxillary components, allowance maximum effort.
for uprighting must be made by overexpansion. This also Variations in the findings at rest and after mild exercise
permits the maxillary bones themselves to be brought to a indicate that nasal air volume is related to the degree of
more lateral position enhancing the harmony of maxillary patient respiratory effort. While at rest, such effort might
to mandibular skeletal width and resulting in maximum vary with the state of anxiety of a patient. When measuring
correction of the primary problem of bilateral maxillary air volume during mild exercise, there is variation in the
insufficiency. degree of effort and the resulting variation in need of
additional air volume.
All patients exhibited a gain in air volume when
maximum ventilation was examined, but the degree of
NASAL AREA CHANGES gain varied greatly. This variation probably lies in the
An important clinical consideration is the change in the anatomical configuration of the lateral walls of the nasal
nasal airway and nasopharyngeal function following cavity and their spatial alteration resulting from the rapid
maxillary disjunction. The history of maxillary expansion.
A study of occlusal radiograms showed that even though
the maxillary portion of the midpalatal suture was
definitely opened by rapid expansion, the opening was
Fig. 33-12. (A)
Pretreatment occlusal x-ray oblique. The opening commonly was
film showing normal
midpalatal area and a narrow
crowded dental arch. (B)
Occlusal x-ray film at
stabilization. Nonparallel
opening of midpalatal suture
is a routine response to mid-
palatal separation. The open-
ing appears to be at about a
3 to 1 ratio, with the anterior
opening being widest. The
image of the vomer is
clearly seen in the posterior
aspect. (C) Occlusal x-ray
film at time of suture open-
ing appliance removal. Note
the increased dental arch
Width, restoration of ossifi-
cation at midpalatal area,
and retraction of cuspids into
area of extracted first bicus-
pids.
,
widest at the anterior limit and narrowed toward the As a supplement, two dried skulls, one adult and one
posterior (Fig. 33-12). The extent of opening in the with mixed dentition, were subjected to the same therapy
palatine portion of the hard palate could not be and examined specifically for skeletal displacement (Fig.
determined. This finding focused interest on work on 33-13).
monkeys that demonstrated the suture opening to be
limited to the maxillary portion of the hard palate, the
palatine portion being iritact.P Analysis of cephalograms RESULTS
demonstrated an arclike movement of the maxilla in the The results showed the following general findings:
frontal plane with the fulcrum located about at nasion. 1. Rapid maxillary expansion was definitely
Anteriorly, the lateral wall of the nasal cavity is accomplished in all cases. With advancing maturity,
formed by the medial aspect of the body of the maxilla. rigidity of the skeletal components limited the degree of
More posteriorly, the medial wall of the maxilla is' orthopedic correction.
overlayed with the vertical plate of the palatine bone. 2. Downward displacement of the maxilla is almost routine,
Posterior to this the lateral wall of the bony nose is but forward displacement to any degree is limited to isolated
determined by the medial pterygoid 'plate. With the cases.8,22 Recovery of maxillary displacement during the
maxilla arcing in both the occlusal and frontal planes of period of stabilization varied with only 50 per cent of the cases
space, it is postulated that a stenosis caused by an demonstrating posttreatment recovery of position.
obstruction in the more anterior-inferior portion of the 3. Mandibular rotation and subsequent recovery is
nasal cavity could possibly be relieved by midpalatal usually noted.
suture opening, while a stenosis located in a more 4. The maxillary halves arc laterally with the fulcrum
posterior or superior area would have minimal benefit located close to the maxillofrontal suture (nasion).
from this procedure. The location and degree of stenosis 5. Skeletal widening progresses inferiorly. Apparently
may then account for the variation among patients in alveolar bending and possibly some extrusion of teeth
gain of nasal airflow accompanying midpalatal
account for proportionally increased lateral denture
separation when measured under conditions of
displacement relative to that of the skeleton.
maximum effort. The foregoing allows the clinician to
6. Skeletal stability in the frontal plane of space is
understand and believe patients who claim increased
excellent.
capability for nasal respiration following midpalatal
7. The maxillary central incisors always separate as
suture opening.
the halves of the maxilla are carried laterally during
active treatment and always move mesially and generally
are uprighted following stabilization. The uprighting or
SKELETAL-DENTAL REACTION decrease in the sella-nasion-maxilla central incisor angle
helps to account for the rapid closure of the large midline
In 1968, Wertz analyzed 60 cases of rapid maxillary diastema produced by maxillary disjunction. Concomitant
expansion treated in his own practice to determine the with the up,righting or decrease in the sella-nasion-
effects of this treatment in routine clinical practice." The maxilla
following is a summary of the investigation and the central incisor angle, a shortening of gained archlength is
results. evident. Increased muscular tension on the dental arch
Examination was made of 60 cases treated for bilateral produced by the maxillary expansion together with
maxillary narrowness by means of rapid expansion of interseptal fiber tension is offered as an explanation for
the midpalatal suture with a rigid, fixed, split-palate this behavior.
device. Frontal and lateral cephalograms, occlusal x-ray . 8. Viewed occlusally, the midpalatal suture appears to
films, and dental casts were studied before treatment, at open obliquely with the widest opening being at the
the completion of rapid maxillary expansion, and again anterior nasal spine while diminishing posteriorly. The
at least 3 months after completion of the therapy. Of palatine portion of the hard palate is opened in many
special concern were the direction and magnitude of cases, but the success of such in all cases cannot be
maxillary displacement, behavior of mandibular definitely established.
position, and change in selected tooth relationships. A 9. There is a general parallelism of widening between
saggital analysis and a frontal analysis were developed
the anterior and posterior abutment teeth. The occlusal
to study skeletal alterations as seen on the headfilms.
tips usually move more laterally than the cervical area.
The dental casts were measured for changes in tooth
This indicates the need for overcorrection to allow for
relations, and the occlusal x-rays were examined to
subsequent uprighting after
study the configuration and extent of palatal separation.
Results' 553
Fig. 33-13. Effect of rapid

maxillary expansion on the
mixed-dentition skull. (A)
Lateral arcing of the maxillary
components is evidenced in the
frontal view as a maximum
width is produced at the incisal
edge of the teeth. The gain in
width diminishes toward the ap-
parent fulcrum of rotation at
nasion. (B, C, D) Occlusal
views demonstrate nonparallel
opening at the midpalatal area,
with widest opening at ANS
and a gradual narrowing toward
PNS.
treatment. The apparent conflict between the parallel of the midpalatal suture with the rigid fixed splitpalate
opening of the abutment teeth and the oblique opening of appliance for the purpose of correcting bilateral maxillary
the midpalatal suture may be explained by the theory that constriction is a safe, dependable procedure that can be
there must be more alveolar bending and tipping of dental advantageous in routine clinical practice.
units in the posterior area. Lateral cephalograms show the maxilla to move
10. In the adult skull, although the mid palatal suture downward but rarely forward (Fig. 33-14). Extrusion of
opens readily, lateral displacement of the maxillary the teeth together with the dropping downward of the
halves is limited. Dry skull observation substantiates this maxilla account for the general opening of the mandibular
finding (Fig. 33-13A, B). plane angle.
11. The mixed dentition skull exhibits maxillary he rotational effect upon the mandible and BPoint
displacement of great magnitude (Fig. 33-13C, D). (supramentale) dictates an increase in the A-N-B (A-
12. Careful appliance design is necessary to limit Point-nasion-B-Point) angle. This would be accentuated
irritation. Rounding of the acrylic margins and relief of by any forward movement of APoint but it must be
the acrylic from the free gingiva, but not from the palatal emphasized that A-Point usually does not move forward
surface, minimizes tissue irritation. appreciably, and in some cases A-Point actually moves
Examination of the 60 cases shows that opening slightly back-
554 . Midpalatal Suture Opening 97.
4-12-67 ___ Pre-treatment the over-expanded maxillary buccal segments tending to

5-16-67 Stabilization upright the mandibular antagonists.
The adult skull offers no resistance to opening the
midpalatal suture, but the rigidity of the other maxillary
articulations prevents maximum repositioning of the
maxillary halves. This bears out the concept that in most
older cases the rigidity of suture other than the midpalatal
suture prevents highly successful rapid maxillary
expansion. Reduction of the activation schedule allows for
more successful opening in older patients by allowing more
time for cellular adjustment at articular sites.
Unfortunately, this decrease in activation schedule also
permits more extrusion of teeth, bending of alveolar
process, and orthodontic tooth movement. While the dental
arch width may be improved in older aged patients, the
, skeletal repositioning may be less than desired.
Although the limitations of drawing conclusions from
dry skull material are fully realized, the reaction of the
I
,
I
mixed dentition skull appears to provide a possible answer
for the rare instance where A-Point and the entire maxilla
are moved forward a significant distance. The disjunction
I of the maxilla-palatine complex from the pterygoid
, processes discloses irregular articular surfaces. These seem
, to cause the displacement, and their resorption could allow
, for posttreatment settling such that APoint and the entire
maxilla tend to recover their original A-P position when
I forward displacement is seen. A similar reaction is
I hypothesized relative to the recovery of downward
\
displacement of the maxilla.v-?
\
' ... ,
.......
The primary purpose of rapid maxillary expansion is to
gain skeletal and dental width. Numerous studies indicate
" excellent skeletal stability and a far superior dental stability
""
", than witnessed in strict dental expansion. The procedure is
,
Fig. 33-14. Typical movement of the maxilla in a safe, dependable adjunct to conventional orthodontic
response to mid palatal
" suture opening
I is downward therapy and definitely is orthopedic in nature.
'I
displacement with rarely" a I significant forward
"
displacement. Such movement ,; I creates mandibular rotation
... _/ plane angle. Recovery
and opening of the mandibular
during the period of stabilization is variable.
ward. Anterior movement of A-Point would be a

disadvantage in Class II cases and, conversely, an aid in
Class III cases. However, posttreatment adjustment
REFERENCES
permitting settling backward of A-Point sometimes
compensates for the iII effect in the Class II situation. 1. Angell, E. c.: Treatment of irregularities of the perma-
Forward response of A-Point in Class III situations is more nent or adult teeth. Dent. Cosmos, 1:540, 1860.
stable. This is probably due to occlusal adaptation and ; 2. Barnes, V. E.: Dental impaction and preventive treat-
functional retention of the forward positioned maxilla. In a ment. Dent. Cosmos, 54:1, 1912.
few Class I and Class II cases, forward positioning of the 3. Black, G. V.: Expansion of the dental arch. Dent. Rev.,
mandible in response to the occlusal disruption is apparent 7:218, 1893
4. Black, N. M.: The relation between deviation of the
and also appears to be dictated by occlusal adaptation.
nasal septum and irregularities of the teeth and jaw.
Although the majority of cases fail to show significant
J.A.M.A., 52:943, 1909.
mandibular arch widening when studied on a short-term
5. Brown, G. V. L: The application of orthodontia prin-
basis, longer follow-ups should disclose such a gain. This
ciples to the prevention of nasal disease. Dent.
would be due to function of
Cosmos, 45:765, 1903.
6. _____ : The surgical and therapeutic aspect of the
maxillary readjustment with special references to
References . 555
nasal stenosis, hare lip, cleft palate, and speech. Dent. Cosmos, produced by rapid maxillary expansion. Angle Orthodont,
51:7, 1909. 34:256, 1964.
7. ______: Discussion of Dr. Cryer's paper. Dent. Items 16. Isaacson, R. J., and Zimring, J. F.: Forces produced during rapid
Interest, 35:94, 1913. maxillary expansion. Angle Orthodont., 35:178, 1965.
8. Byrum, A. G.: Evaluation of anterior-posterior and vertical 17. Korkhaus, G.: Discussion of report: A review of orthodontic
skeletal change vs. dental change in rapid palatal expansion research (1946-1950). Int. Dent. J., 3:356, 1953.
cases as studied by lateral cephalograms. Amer. J. Ortho., 18. Krebs, A.: Expansion of the mid palatal suture studied by means
60:419, 1971. of metallic implants, European Orthodont, Soc. Rep.. 34:163,
9. Cleall, J. F., Bayne, D. L Posen, J. M., and Subtelny, J. D.: 1958
Expansion ofthe midpalatal suture in the monkey. Angle 19. Starn bach, H. K., and C1eall, J. F.: Effects of splitting the
Orthodont., 35:23,1965. midpalatal suture on the surrounding structures. Amer. J.
10. Cryer, Mathew H.: The influence exerted by the dental arches in Orthodorit., 50:923, 1964.
regard to respiration and general health. Dent. Items Interest, 20. Storey, E., and Smith, R.: Force in orthodontics and its relation to
35:16, 1913. tooth movement. Aust. J. Dent., 56:11, 1952.
11. Dean, 1. W.: The influence of the nose on widening the palatal 21. Wertz, R. A.: Changes in nasal airflow incident to rapid maxillary
arch, J.A.M.A., 52:941, 1909. expansion. Angle Orthodont., 38:1, 1968.
12. Dewey, M.: Bone development as a result of mechanical force, 22. _______ : Skeletal and dental changes accompanying
report on further treatment in attempting the opening of the rapid midpalatal suture opening. Amer. J. Orthodont., 58:41,
intermaxillary suture in animals. Dent. Items Interest, 36:420, 1970.
1914. 23. West, I. M.: Histologic study of sutural tissue changes
13. Derichsweiler, H.: La disjonction de la suture palatine mediane. accompanying palate splitting in the monkey. Unpublished
Trans. Euro. Orthodont, Soc., 1953. master's thesis, University of Illinois, 1964.
14. Haas, A. J.: Rapid expansion of the maxillary dental arch and 24. Wright, G. H.: A study of the maxillary sutures. Dent.
nasal cavity by opening the mid palatal suture. Angle Cosmos, 53:633, 1911.
Orthodont., 31:73,1961.
15. Isaacson, R. J., Wood, J. L., and Ingram, A. H.: Forces
34
The Activator
DONALD G. WOODSIDE, D.D.S., M.SC.(D) F.R.C.D.C.
As originally modified by Andresen, the activator was the erupting teeth of children with malocclusion into more
intended to correct malocclusion solely through the muscles acceptable relationships, each system emphasizes particular
of mastication. Although its exact mode of action has not been aspects of the neuromuscular physiology of the
clearly established, there is a sufficient body of clinical stomatognathic system that its originator considered
experience based on the application of neuromuscular important. These time-tested and ingenious methods of
physiology to present a rational approach to orthodontic treat- orthodontic treatment provide useful adjuncts to the
ment with the activator. This chapter will outline the practitioner's orthodontic techniques. However, judged by the
possibilities and limitations of activator treatment, the clinical occlusal and facial esthetic standards currently demanded in
management of Class II and Class III malocclusions with the North American orthodontics, the method has serious
appliance, and the construction of the activator. limitations. The same statement, however, might be made
The activator or Andresen appliance (Fig. 34-1) and its about that other useful orthodontic adjunct, headgear. This
derivatives, the Bimler (Fig. 34-2) and Frankel appliances chapter will discuss the activator. After gaining a basic
(Fig. 34-3) are removable orthodontic appliances derived from understanding of the appliance, the interested practitioner can
the original monobloc designed by the French dentist, Robin, proceed to study associated functional appliances.
in 1902. While each of these "functional appliances" activates The method is particularly useful in the treatment guidance
neuromuscular tissues and reflexes to guide phases of orthodontic interception. It is also useful in the
management of severely mutilated
Fig. 34-1. A typical activator for the correction of a Class II, Fig. 34-2. The Bimler Appliance. This appliance may be
Division 1 malocclusion. The appliance consists of two acrylic described as a wire activator with accessory functions. The
plates joined together in a bite registration which fixes the Simler appliance fixes the mandible in a particular bite
mandible downward and forward in relation to the maxiIla. registration in relation to the maxilla. One advantage of this
This appliance is usually worn when sleeping and as many appliance is that it may be worn during the day as well as
extra hours during the evening as is possible. during the evening and while asleep.
556
The Activator 557
Fig. 34-3. A typical Frankel Appliance for the correction of

Class II, Division 2 malocclusion is illustrated. The bite
registration used in this appliance also fixes the mandible
downward and forward in relation to the maxilla. The mandibular
labial portion of the appliance is used as a labial muscle appliance
while the buccal acrylic portions act much in the same fashion as
a labial shield.
dentitions when the practitioner wishes to apply

therapeutic procedures at the correct interval in the
patient's growth cycle but at a time when it may not be
mechanically feasible to commence treatment by routine
multi-banded procedures, owing to the premature loss of
several teeth in the buccal segments. In these instances,
the orthodontist routinely follows the period of activator
treatment with a period of multi-banded therapy to achieve
detailed alignment. If the general practitioner wishes to YPE 1 J
utilize the activator, he must select his cases carefully,
since in most instances he will not follow such treatment
with more complex procedures.
Fig. 34-4. The photographs illustrate the profile

changes obtained in a two-stage orthodontic treatment for
a Class II, Division 1 malocclusion. The initial stage of
treatment consisted of activator therapy in conjunction
with serial extractions leading to the removal of four first
bicuspid teeth. An initial reduction of apical base
dysplasia and correction of the Class II, Division 1
malocclusion was obtained during this phase of
treatment. The second phase of treatment consisted of a
short period of multi banded edgewise mechanotherapy
to achieve a detailed alignment of the teeth and a second
moderate reduction in apical base dysplasia. The activator
is extremely useful when it is used in the mixed dentition
to achieve an initial reduction in apical base dysplasia
followed by a second reduction as the patient enters the
prepubertal acceleration in facial growth. Profile and full-
face views before (top) and after (bottom) treatment.
558 . The Activator
Fig.' 34-5. The photographs illustrate the softtissue

profile changes obtained in the correction of a Class 1I,
Division 1 malocclusion solely through the use of an
activator and is selected to illustrate the potentialities
and limitations of the method in respect to profile
changes. Profile and full-face views before (top) and
after (bottom) treatment.
POSSIBILITIES AND LIMIT A TIO S Skeletal Dysplasia Correction and Differential Control
of Tooth Eruption
Facial Changes
Cephalometric analysis of the results of treatment (Fig. 34-
Figures 34-4A,B and 34-SA,B illustrate the soft tissue 7) illustrate that the method can be used to achieve moderate
profile changes achieved through the use of the activator alone reductions in skeletal dysplasia between the maxilla and the
and the activator combined with bicuspid extractions followed mandible but will not reduce mandibular incisor protraction.
by multi-banded orthodontic therapy. As the figures illustrate Indeed, unless the practitioner exercises considerable care, the
the method can assist in achieving marked facial changes both mandibular incisors may move labially into an abnormal
position relative to the lips and may subsequently show a
through nonextraction and extraction therapy.
tendency to relapse. The tracings also show that it is possible
to exert differential control over the eruption of teeth in the
maxillary and mandibular buccal segments. By this means the
maxillary buccal teeth may be permitted minimal eruption
Occlusal Changes
while the mandibular buccal teeth are allowed to erupt
A typical course of activator treatment can be used to vertically in harmony with the vertical component of
achieve major mesiodistal and vertical changes, restore arch mandibular growth. The usefulness of this inhibition of
form, but the appliance cannot correct crowding and does not maxillary buccal seg-
lend itself to the management of detailed tooth positioning
(Fig. 34-6).
98. Possibilities and Limitations . 559
Fig. 34-6. The photographs illustrate the

occlusal changes achieved during a typical
activator treatment before (top left) and after (top
right) treatment. The buccal views show that
activator therapy can be used to achieve major
mesiodistal and vertical changes (center)
occlusal views of dental arches before treatment.
(Bottom) after treatment. The occlusal views
show that, although arch form can be restored,
the appliance cannot be used to correct
crowding by itself and does not lend itself to the
management of detailed tooth positioning.
ment eruption will be discussed later (see Functional Occlusal (Fig. 34-8). This measure assists in the conservative reduction
Plane). of moderate prognathisms by the vertical manipulation of the
jaws and dentition rather than by the conventional
Changing the Direction of Mandibular Growth anteroposterior approach to the correction of Class III
malocclusions in which the maxillary teeth are moved mesially
The activator can be used to alter prognathic mandibular and the mandibular teeth distally. This same approach may be
growth directions to more vertical directions
560 . The Activator
99.
P.S. A9I SNA SNB ANA FMA TtoNB P9 to

Ocl.'67 lIyclm8J05 77 65 315 6-0 79 50 NB 4
Moy'69 12y.Bm.84 33 7'5 2'5
Fig. 34-7. The tracings of the entire face illustrate the changes that took place during the
correction of a Class II, Division 1 malocclusion. The tracings on the left have been super-
imposed on comparatively unchanging structures in the anterior cranial base. This tracing
illustrates that the chin point descended in a much more vertical fashion than is seen with
normal growth changes. In addition, the anterior nasal spine did not advance horizontally as is
usual. This change at the anterior nasal spine would be considered desirable in the management
of a Class II, Division 1 malocclusion, while the change at the chin would be considered
undesirable. The change at the chin is probably due to overeruption of the lower buccal
segments which was accomplished with the activator. The tracings on the right illustrate the
tooth movements accomplished in the maxilla and in the mandible separately. It can be seen
that eruption of the maxillary buccal segment was inhibited while the maxillary teeth were
tipped distally a small amount. The mandibular tracings show that the mandibular incisor teeth
were displaced labially. Such loss of anchorage is considered undesirable. The mandibular
tracings also illustrate the eruption in mandibular buccal segments which was permitted and is
considered desirable if this eruption is in harmony with the vertical component of mandibular
growth.
used to manage incisor crossbites with superimposed mesial Vertical Dimension

functional displacement of the mandible.
Figure 34-9 illustrates the soft tissue profile changes
achieved during the 16-month treatment period of a patient
who required no extractions and no space closures. The
improvement in his facial contour was associated with
Intrusion of Teeth
marked increase in lower face height. This change illustrates
While the activator is effective in the correction of a basic concept in activator therapy, namely, that the mesio-
overbite, it does not achieve such correction through the distal correction of Class II malocclusion is achieved through
intrusion of incisor teeth but rather by permitting the an apparent vertical manipulation of the dentition. This
eruption of teeth in the buccal segments. The activator does vertical manipulation occurs most readily in those patients
not routinely produce active intrusion of teeth but rather who have a vertical growth component accompanying the
simulates intrusion of incisor teeth by inhibiting their normal normal growth expressed at the chin. Indeed, the clinician
eruption. Since the teeth in the buccal segments are may inadvertently increase the lower face height through
permitted to follow their normal eruption paths while the careless manipulation of the activator (Fig. 34-7) by
incisor teeth are not permitted to erupt, the effect of intrusion permitting the buccal teeth to erupt further vertically than the
is achieved without actually intruding the incis-v teeth. vertical growth expressed in the man-
100. Possibilities and Limitations . 561
Fig. 34-8. The tracings illustrate the

growth changes and tooth movements
accomplished in the correction of a Class III
malocclusion utilizing the activator. The
tracings of the total face on the left illustrate
that the activator may be used to alter
prognathic and orthognathic mandibular
growth directions to more vertical directions
and thus assist in the conservative reduction
of moderate mandibular prognathisms. This
reduction is achieved by a vertical
manipulation of the jaws and the dentition
rather than by the conventional
anteroposterior approach to the correction
of Class III malocclusions in which the
maxillary teeth are moved mesially and the
mandibular teeth distally. The treatment
consisted of two intervals of activator
therapy. The tracings of the maxilla and the 90.1.
mandible on the right illustrate that the FMA SNA
mandibular buccal segments were not
SNB ANB f to NB Md. unit-Mx. unit lower Face HI.
- 10.8.63 18. 0 78. 0 82. 0 4. 0 3. Smm.
Pg to NB
permitted to erupt during the first period of ------
. -. -. 2. 12.64 20.5 81. 83. SO 2.0 I.Smm.
activator therapy while the maxillary buccal 1. 5mm. no - 86 2Smm. 52.0mm.
----- 28. 4. 67 21- 0 83. 0 82. SO O. SO 3. Omm.
segments were allowed to erupt. 1.5mm. 112. S-86. 0'26. Smm. 57.0mm.
2.5mm. 118.5-91. 5=27. Omm. 58. Smm.
dible. Thus excess lower face height at the beginning of

treatment provides a definite contraindication to Class II
A 9 c
activator treatment owing to the tendency for such treatment
to inadvertently increase lower face height to levels that
might result in a further deterioration in facial esthetics.
Obviously, individuals who have excess freeway space and
reduced lower face height owing to mandibular overclosure
are excellent cases to manage with the activator (Fig. 34-10).
Facial Growth
From the foregoing paragraphs it wil1 be apparent that the
activator controls alveolar growth and functions most
effectively in those individuals who experience active phases
of mandibular growth with a minimal forward component of
growth in the mid-face. Serial height recordings (Fig. 34-11)
provide a useful method for determining whether the patient
is likely to experience a period of active mandibular growth
during orthodontic treatment. There is no evidence available Fig. 34-9. The tracings indicate the suc-
to date to support the view that activators stimulate cessive soft tissue changes during a sixteen
month treatment period with the activator in a
mandibular growth. Instead, it is more likely that successful
patient who does not require extractions or
activator treatment coincides with normal periods of active
space closures. The tracings illustrate that the
mandibular growth (Fig. 34-12). improvement in the patient's facial contour
was associated with a marked increase in
lower face height.
562 . The Activator
Fig. 34-10. Case 5.5., Class II,

Division 1. (Upper lefl) before treatment.
(Upper right) after treatment, This case
showed severe overclosure with an
excess freeway space and reduced
lower face height at the beginning of
treatment (top left). Treatment was
accomplished by lingual tipping of the
maxillary incisors with an automatic
Hawley appliance prior to activator
therapy. Very favorable growth
expressed at the chin relative to
moderate growth expressed in the
rnidfacial area permitted satisfactory
correction. (Center) Radiogram before
(left) and right after (right) treatment.
In overclosure cases such as this,
eruption in both maxillary and man-
dibular buccal segments is permitted,
and the vertical development is
obtained wherever the clinician can
obtain it. However, it is desirable to
permit more eruption in the mandibular
buccal segment than is permitted in the
maxillary buccal segment as in this
case. (Bottom left) Before and right after
treatment.
101.
103.
102.
(I
i:' ( -,
L_.z
;f
'-- ~ =
" -, D, ,
"
,
,,
,
"
-, ~
~ \ ....
' \
U SNA SNB ~ FMA T~B PgtoNB ~'rJ. Unit M>:. Unit Oift. Lower Face HI.
Mar. 65 76.5 10.5 0.0 29.0 3.0 0.0 10 91 1 6

Jun.6I! 1 . 0 72.5 3.5 no 5.5 $ 1
5.0 9 %
11 1 1
1 , 3
Types of Facial Morphology Best Managed by the cause Class II malocclusion is merely a common symptom of a
Activator large number of very different facial morphologies (Fig. 34-
13). The underlying cause of this system may be
Our knowledge regarding the true nature of the Class II dentoalveolar, skeletal, or neuromuscular, but all produce the
malocclusion has advanced surprisingly little since the early same Class II malocclusion even though the treatment and
1950's when surveys concerning the true nature of the Class prognosis may differ markedly in the various facial mor-
II malocclusion found conflicting results, asserting, for phologies. The orthodontic specialist uses static cephalometric
example, that the Class II malocclusion was characterized by radiography to assist him in distinguishing the different types
a small mandible, or by a normal size mandbile, or in others of Class II malocclusions. Activators should not be used by
by large mandibles. Such inconclusive results will probably general practitioners who will not or cannot use cephalometric
continue as long as samples for such studies are selected on
radiographs in order to assist in establishing
the basis of occlusion be-
104.
Possibilities and Limita tions . 563
Fig. 34-11. (A) Tanner GROWTH AND DEVELOPMENT RECORD

Growth and Development
Record Chart for Boys. Serial Name Palll Shiel
height recordings on such
growth and development rec-
ords provide a useful method in
for determining whether the .
patient is likely to experience
active facial growth during
orthodontic treatment. Continued
on overleaf, (B) Tanner Growth
and Development Record for
Girls. (C) Tanner chart for
expressing age as a decimal of a
year.
160
60
50
12
0
110
40
90
J. .
r
80
30
70
6
0
50 20
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
A Chart Prepared by ___________________________________________ _
the true nature of the facial morphology to be treated. terized by lingually positioned mandibular dentition . and
Figure 34-14 illustrates six types of facial morphology labially positioned maxillary dentitions (Fig. 34-14A).
associated with similar Class II malocclusions. Some of 2. It is less appropriate in skeletal problems associated
these morphological variations will respond better to with extreme apical base dysplasias due to mandibular
activator treatment than others. For example: retrognathism. Unless the patient has favorable amounts
1. The activator constitutes a form of Class II in and directions of growth in the mid-face and mandible,
termaxillary therapy; if it is used incorrectly, it can cause the maxillary dentition must be retracted bodily to
the mandibular dentition to slip labially (slipping the camouflage the skeletal dysplasia. The activator is not
anchorage). It follows, therefore, that it can easily be suited to perform active bodily retractions of incisors (Fig.
modified to slip anchorage and thus correct dentoalveolar 34-140).
Class 11 malocclusions charac- 3. The activator does better in the management of
564 . The Activator
105.
GROWTH AND DEVELOPMENT RECORD Fig. 34-11. Continued.
Name Maria Bates Date of Birth 28.6.59 Chart No.~
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
em.
I 'I' in.
, ,
190 ' I
I
, I
180
70
170
160
150 60
140
130
50
120
110 I I 1
I, ..1.
I
/ c;.l
100 I
40
I
--l
, 11.1.. + r
I , L JT
1- J , I r
90 II Stngle ~ Time - - ----- 97
Sland.,d
- -----_.
SO
. -- ------
(cross- se<1ional) ______ ~ _____ 3
80
30
70
Repeated - \ii:s.i t mer':::J.%~fuillW97
Standa,d Jl!l8riiil;':;'iiii;;&,* so
60 (lo"9itudinal) trttffi?sr:m?:=: 3
I ,
I
50 20
234 5 67 8 9 10 11 12 13 14 15 16 17 18 19
B Chart Prepared by
Class II malocclusions due to mid-facial prognathism axial inclination. Since the appliance does tend to
when amounts and directions of mandibular growth are -incline the maxillary incisors lingually, it is not suited
favorable. In such patients the clinician does not want to for children whose incisors are vertically upright or in a
retract the maxillary dentition in order to avoid moderately lingual position at the beginning of treatment
overemphasizing a prominent nose. Since the activator (Fig. 34-148).
does not perform active bodily retractions of teeth it is 4. This appliance is well suited to the management of
suited for use in children who need more moderate Class II malocclusions due to moderate skeletal
amounts of maxillary incisor movement. However, dysplasias between the mid-facial area and the mandible,
children with mid-face prognathism frequently exhibit where moderate amounts of mandibular growth and
Class II, Division 2 malocclusions or environmental moderate amounts of maxillary incisor retraction may
distortions of such malocclusions in which the maxillary combine for successful treatment. It is not suitable for
incisor teeth have an upright the management of skel-
Possibilities and Limitations ' 565
I 2 3 4 5 6 7 8 9 10 II 12
JA FEB. MAR. APR. MAY JU E JULY AUG SEPT. OCT. NOV. DEC.
1 000 085 162 247 329 414 496 581 666 748 833 915
2 003 088 164 249 332 416 499 584 668 751 836 918
3 005 090 167 252 334 419 501 586 671 753 838 921
4 008 093 170 255 337 422 504 589 674 756 841 923
5 011 096 173 258 340 425 507 592 677 759 844 926
6 014 099 175 260 342 427 510 5\15 679 762 847 929
7 016 101 178 263 345 430 512 597 682 764 849 932
8 019 104 181 266 348 433 515 600 685 767 852 934
9 022 107 184 268 351 436 518 603 688 770 855 937
10 025 110 186 271 353 438 521 605 690 773 858 940
II 027 112 189 274 356 441 523 608 693 775 860 942
12 030 115 192 277 359 444 526 611 696 778 863 945
13 033 118 195 279 362 447 529 614 699 781 866 948
14 036 121 197 282 364 449 532 616 701 784 868 951
15 038 123 200 285 367 452 534 619 704 786 871 953
16 041 126 203 288 370 455 537 622 707 789 874 956
17 044 129 205 290 373 458 540 625 710 792 877 959
18 047 132 208 293 375 460 542 627 712 795 879 962
19 049 134 211 296 378 463 545 630 715 797 882 964
20 052 137 214 299 381 466 548 633 718 800 885 967
21 055 140 216 301 384 468 551 636 721 803 888 970
22 058 142 219 304 386 471 553 638 723 805 890 973
23 060 145 222 307 389 474 556 641 726 808 893 975
24 063 148 225 310 392 477 559 644 729 311 896 978
25 066 151 227 312 395 479 562 647 731 814 899 981
26 068 153 230 315 397 482 564 649 734 816 901 984
27 071 156 233 318 400 485 567 652 737 819 904 986
28 074 159 236 321 403 488 570 655 740 822 907 989
29 077 238 323 405 490 573 658 742 825 910 992
30 079 241 326 408 493 575 660 745 827 912 995
31 082 244 411 578 663 830 997
JAN. FEB. MAR. APR. MAY JUNE JULY AUG. SEPT. OCT. NOV. DEC.
1 2 3 4 5 6 7 8 9 10 11 12
Chart prepa red by J_ M. Tanner and R. H. Whitehouse Uni v ersuy of London. Institute of Child Health, for The Hospital for Sick Children
Great Ormond Street. London, W.CI.
TABLE OF DECIMALS OF YEAR
DECIMAL AGE
The system of decimal age has been used in all charts. Thus the year is divided into 10. not 12. Each date in the calendar is marked (from the table bela","! rn terms of thousandths of the year.
Thus January 71h 1962 is 62.016. The child's birth date is srrmlarly recorded, c.g. a child born on June 23rd 1959 has the birth day 59.474. Age at examination is then obtained by simple
subtraction, e.g, 62.016-59.474-2.542, and the last [igurc rs rounded off. This system greatly facilitatcs the computing of velocities, since the proportion of the year between two
examinations is easily calculated.
Source of standards
The details of the source data and of the construcuon of these standards arc set forth In J. M. Tanner. R. HI. Whitehouse and M. Takaishi, Archives of Diseases III Childhood 1966 Volume 41.
For the most part heights and weights for the age 0-5 are from thc data of the UniverSIty of London, Institutes of Education and Child Health. Child Study Centre. and the Oxford Child Health
Survey. and for the ages 51-lSI from the London County Council survey reponed by SCOll m 1959. Height attained and height velocity percentiles were calculated OIl the assumption of a
Gaussian distri but ion at each age, weight attained and weight velocity percentiles were estimated directly from the frequency disrribuuons. Srnoorhrng was in general earned Out graphically.
The shape at the repeated visit standards are based on longitudinal data frorn the Harpenden Growth Study.
- Fig. 34-11. Continued. C
etal dysplasias of any morphological types that exhibit closure. In the overdosed position such malocclusions
extreme dysplasia between the mid-facial area and the appear to be Class I; examined in the rest position they are
mandible (Fig. 34-14C). really Class II malocclusions with a total openbite
5. It is ideal for the management of Class II maloc- superimposed. Such cases are obviously more
clusions resulting from environmental influences such as retrognathic when examined in rest posi tion and will be
thumb-sucking and chronic mouth breathing if some more difficult to correct if the excess freeway is reduced
growth still remains and the habit can be eliminated. through eruption of teeth in the buccal segment. Such
Many of our so-called skeletal Class II malocclusions are overclosures complicate Class II treatment because the
probably environmental simulations of skeletal problems mandible must be treated closer to its rest position than to
(Fig. 34-14F). The exact prevalence of this type of Class its overclosed position. The activator is an ideal appliance
II malocclusion is not known, but any Class II to effect the differential tooth eruption required in the
malocclusion exhibiting excessive lower face height maxillary and mandibular buccal segments (Fig. 34-16).
should be suspect. The activator can be used to restore Such eruptive movements occur most readily in actively
correct facial morphology in growing individuals where growing patients.
the environmental impact can be eliminated. However, if It must be repeated at this point that the general
the excess lower face height is not due to environmental practitioner of dentistry must have a thorough working
factors, the activator can produce further deterioration in knowledge of cephalometric radiography if he hopes to
facial contour as the Class II malocclusion is corrected. identify patients with severe skeletal dysplasia, excess
6. Figure 34-15 shows a Class II malocclusion lower face height, and overclosure characterized by
characterized by excess freeway space and over- reduced lower face height, and thus select suitable cases
for activator treatment.
566 . The Activator
VELOCITY CURVE OF MANOIBULAR GROWTH BY

AGE FOR FEMALES
Case /I ........................................................................ .
Name .............................................................................................................. .
M.M.IYR.
CHRONOLOGICAL AGE IN YEARS

Fig. 34-12. The graph illustrates a velocity curve of mandibular growth superimposed on a population standards for mandibular
growth in females. There were two distinct acclerations in mandibular growth with peak velocity in mandibular growth occurring at
7.4 years of age for the first acceleration and at 12.3 years for the second acceleration. Two periods of activator growth were applied
with the first period initiated at 4.7 years of age and ending at 6.3 years. The second period of activator growth was applied at 8.6
years of age and ended at 11.1 years. It can be seen that the treatment had no effect on the mandibular growth rate during the treatment
interval. If treatment had been applied coincident with the two accelerations in mandibular growth there would be a great temptation
to assume that the treatment was responsible for what, in effect, was a normal variation in mandibular growth rate.
Possibilities and Limitations . 567
3 4
Fig. 34-13. (A) Four Class II, Division 1 malocclusions of approximately the s.ame severity. It is not possible to
differentially diagnose the underlying cause of these similar appearing, but actually radically differing malocclusions,
by examining the occlusions only. (B) This shows the four profiles and varying facial skeletal structures underlying and
responsible for the similar appearing malocclusions illustrated above. (1) All, individual with a skeletal Class II, Division
1 malocclusion due to midfacial convexity superimposed on all, orthognathic or mesiognathic facial type. (2) All,
individual with a similar appearing Class II, Division 1 malocclusion due to moderate midfacial convexity
superimposed on moderate mandibular retrognathisrn to produce total severe dysplasia. (3) All, individual with a similar
appearing Class II, Division 1 malocclusion due to extreme mandibular retrognathism. (4) All, individual with another
similar appearing Class II, Division 1 malocclusion due to extreme midface protrusion superimposed on extreme
mandibular retrognathism to give a total very severe facial dysplasia.
568 . The Activator
SOME ETIOLOGICAL POSSIBILITIES IN THE ORIGIN OF CLASS II DIVISION I MALOCCLUSIONS
DENTOALVEOLAR SKELET NEU ROMUSCU

AL LAR
A B c o E F
Fig. 34-14. (A) Class II, Division] malocclusion in which the parts of the face are harmoniously related while the teeth and alveolar bone
have been distorted by environmental force. This represents a dentoalveolar malocclusion with excellent prognosis for a simple and
successful therapy. (B) Class II, Division 1 malocclusion due to the unfortunate combination of a very convex nasomaxillary complex on a
mesiognathic facial type to create convexity of the facial profile too great to be compensated for by lingual adjustment of the maxillary
incisors and labial adjustment of the mandibular incisors. Such skeletal malocclusions are very susceptible to the creation of overjet with the
application of labially directed environmental forces to the maxillary incisors. (C) Class II, Division 1 malocclusion due to the unfortunate
random combination of a moderately retrognathic facial type with a moderately convex profile type to produce a total severe dysplasia. (D)
Class II, Division 1 malocclusion, due to an extremely retrognathic facial type. The nasomaxillary complex may be back but the mandible is
even more so. (E) A severe Class II, Division 1 malocclusion due to the superimposition of extreme midfacial convexity on extreme
mandibular retrognathism. (F) Class II, Division 1 malocclusion in which the mid facial area and the mandible were previously
harmoniously related. With permanent alteration in the rest position of the mandible as in chronic nasal obstruction the mandible assumes
an environmentally created retrognathic position. This represents a neuromuscular malocclusion since its origin involves the alteration of
some very basic neuromuscular reflexes.
FUNC IONAL OCCLUSAL PLANE CHANGES IN pOS) non by differential control of tooth eruption. Since,
CLASS II TREATMENT however, this tends to increase lower face height and mandibular
retrognathisrn, it will not be the best procedure to follow in most
Harvold emphasized the concept of the "functional occlusal mature, patients. Furthermore, in such patients, it may be
plane" and the role played by its manipulation in the successful necessary to assist the mandibular buccal teeth to erupt to a new
correction of Class II malocclusions. This plane represents the vertical level by the use of Class II elastics attached to a lip
functional table of occlusion in the first permanent molar, second plumper and used in combination with the activator (Fig. 34-17).
bicuspid and first bicuspid areas. The level and inclination of the
Figure 34-
functional occlusal plane is the resultant of the neuromuscular
'18D illustrates an activator trimmed to permit the desired vertical
and developmental forces acting on the dentition. The correct
manipulation of the functional occlusal plane involves inhibition eruption of the mandibular buccal segments and to inhibit
of eruption of the maxillary buccal segments which normally eruption of the maxillary buccal segments. 3 to 5 mm. vertical
follow a downward and forward curved eruption path (Fig. 34- change in the position of the buccal segments is usually
16). At the same time, the mandibular buccal segments are considered adequate to effect the change from Class II to Class I
permitted to erupt vertically in harmony with the vertical growth occlusion. However, this change cannot be used to achieve a total
of the lower face. Since the mandibular molars erupt at right- Class I relationship in Class II cases with severe skeletal
angles to the functional occlusal plane, this facilitates a change dysplasias and steep occlusal planes.
from Class II to Class I malocclusion as illustrated in Figure 34- Since the direction of mandibular growth at the chin usually
16. This change may be achieved in mature individuals if the diverges from the inclination of the functional occlusal plane, any
mandible is rotated into a more vertical position and the occlusion
attempt to make the functional occlusal plane more closely
allowed to adjust to the new mandibular
parallel the direction of growth at the chin will permit such
direction to be expressed along the plane of ortho-
Functional Occlusal Plane Changes In Class II Treatment 569
106.
107.
108.
,
,,
,,r
'L
z:
, L .----......
CASE:
D\,
-,
Centric Occlusion --Rest
D Position
....
,
"
...
,
Fig. 34-15. (A) The photograph illustrates an apparent deep overbite when the occlusion is examined in centric occlusion. (B) When the
occlusion is examined in the rest position it can be seen that an excess freeway space exists. If the patient were permitted to close 2 to 3
mm. in the buccal segments an excess interocclusal clearance would exist and an edge to edge bite would probably exist in the incisor
area. Obviously this case is not a case of deep overbite but rather, of apparent overbite. The case would more correctly be classified as a
complete openbite. (CJ This photograph illustrates that the cause of this excess interocclusal clearance or this complete openbite is an
abnormal posture of the tongue during rest. This condition is distinct from tongue thrust. Since the tongue rests between the occlusal
surfaces of all teeth, the teeth are not permitted to erupt while the jaws continue their normal downward and forward growth. As growth
continues the inhibition of tooth eruption creates an increasing excess freeway space. When the patient closes the tongue is withdrawn
and the jaws overclose. (D) The tracings illustrate the position of the mandible in this patient when the mandible is examined in centric
occlusion and at rest position. Orthodontic treatment for this patient would more correctly be planned around the jaw relations indicated
by the rest position tracing rather than the overdosed centric occlusion tracing which gives a more prognathic position of the mandible
than actually exists. Such vertical malocclusions are very suitable for treatment with an activator.
570 . The Activator
109.
Fig. 34-16. The diagram -illustrates the different eruption direction of the
maxillary and mandibular buccal segments relative to the functional occlusal
plane. The type of occlusion which is established will be dependent upon the
c/
C/oss relative amounts of vertical eruption accomplished in the maxillary and
III s mandibular buccal segments. For example, if there is minimal eruption of the
C/os I maxillary buccal segments and overerupticn of the mandibular buccal
oss II segments, there will be a distinct tendency for the establishment of a Class rrr
malocclusion as the functional occlusal plane establishes itseLf at a higher
level. Conversely, if there is minimal eruption of the mandibular buccal
segments and overeruption of the maxillary buccal segments, the functional
occlusal plane will be established at a lower level and the mesial component
of maxillary buccal segment eruption will be over-emphasized. These
changes will combine to lead to the establishment of a Class II tendency. It
follows that the change from a Class II malocclusion to a Class I will be
I facilitated if maxillary buccal segment eruption is inhibited while the
... <, I mandibular buccal teeth are permitted to erupt. The correction of Class III
" malocclusions will be facilitated if mandibular buccal segment eruption is

inhibited and maxillary buccal segment eruption encouraged.
\
" <; \\ I- . "
\
position that any muscle and soft tissue action that attempts to
return the mandible to its normal position will apply an
intrusive force to the maxillary and mandibular incisors which
impedes further vertical alveolar development (Fig. 34-19). In
addition, it delivers intrusive forces to the maxillary buccal
teeth, which are in contact with an acrylic buccal shelf. Since
the activator shields the mandibular buccal segments from the
forces delivered by the muscles of mastication at the moment
of initial contact, these teeth are free to erupt unimpeded. Since
the appliance contacts the mesial surfaces of all the maxillary
buccal teeth, forces tending to retract the mandible or those
delivered to the appliance from the labial tissues, provide a
distal thrust to the maxillary teeth and prevent their normal
downward and forward eruption. Mesial thrusting forces
directed at the mandibular dentition are intercepted by
removing all acrylic contact with the teeth except at the
Fig. 34-17. In severe overclosure problems in both growing
mandibular incisal edges. Mesial forces di-
and non growing patients, it may be necessary to assist the
mandibular buccal teeth to erupt to a new vertical level by the , rected against the mandible are delivered to the basilar
use of Class II elastics attached to a lip bumper and used in structures to keep the mandibular anchorage from slipping
combination with the activator as illustrated. (Fig. 34-20).
As originally modified by Andresen, the activator was
intended to correct malocclusion solely through the action of
dontic correction (the functional occlusal plane) and hence the muscles of mastication. Although its exact mode of action
enhance the effect mandibular growth has in correcting the still has not yet been clearly established, four basic
malocclusion. neuromuscular concepts have evolved which represent three
different philosophies of bite registration.
1. The bite registration in a number of areas in Europe
BITE REGISTRA nON AND THEORIES OF commonly uses a wax bite to register the mandible in a
ACTION position protruded to approximately 4.0 mm. distal to the most
The single most important point in the construction of the protrusive position the patient can achieve. Vertically the bite
activator is the registration of the wax bite which determines is registered at the level of the patient's freeway space. The
the relationship of the mandible to the maxilla when the pro-
appliance is in the mouth. The appliance consists of a
maxillary and a mandibular plate joined together in the bite
registered. Bite registration places the mandible in such a
Bite Registration and Theories of Action . 571
LATERAL VIEW OFTRIMMED ACTIVATOR A D I STA L V I EW OF THE R' GHT BUCCAL SEGMENT OF
AN ACTIVATOR
1
1 3_
5_
3 III
~ OCCLUSAL SHELF
4 !f~!if~f~i
5WlilJ
. NOTE RELI EF
Fig. 34-18. (Left) An activator trimmed to permit the desired vertical eruption of the mandibular buccal segments and to inhibit eruption
of the maxillary buccal segments. (1) Areas of hard acrylic contact with basal structures and also the labial surfaces of the incisor teeth. (3)
Acrylic which is left in contact with the occlusal surfaces of the maxillary buccal teeth and also the mesial surfaces of the maxillary buccal
teeth. (5) Acrylic which is removed to permit eruption of mandibular teeth and distal movement of maxillary teeth. (Right) A view from the
distal of a correctly trimmed activator. The lingual surface of the mandibular buccal segments should be clear of the acrylic the thickness
of an explorer in order that no friction stops will impede eruption of the mandibular buccal teeth. (1) Areas of hard acrylic contact with
basal structures and also the labial surfaces of the incisor teeth. (3) Acrylic which is left in contact with the occlusal surfaces of the
maxillary buccal teeth and also the mesial surfaces of the maxillary buccal teeth. (4) Firm acrylic contact with the alveolar processes. (5)
Acrylic which is removed to permit eruption of mandibular teeth and distal movement of maxillary teeth.
ponents of this method believe that the presence of a 22) is activated so that, in addition to the muscle force
loosely fitting activator increases the frequency of reflex delivered during swallowing and in biting, reflex stretch
contractions in the muscles of mastication against the stimulation of the muscle spindles also elicits reflex
appliance. Intermittent movements of the appliance in muscle activity. Since the appliance locks the maxillary
swallowing and biting deliver distal and intrusive forces teeth to the mandibular arch, the force elicited in
to the maxillary teeth engaged in the appliance. This attempting to return the mandible to its test position is
results in tooth movement and bone remodelling. transmitted through the appliance to the maxillary teeth.
Since the appliance is trimmed loosely, it will drop This force may either prevent further forward adaptation
when the jaws relax. The patient must then be of the maxillary den toalveolar process, move it slightly
conditioned to bite into the appliance to keep it in distally, or more frequently may direct its normal
position, and, if correctly motivated, soon develops a downward and forward mesial eruption distally. While
conditioned reflex and performs this act while sleeping. these changes are proceeding, the mandible continues its
When the mandible moves mesially to engage the normal rate and direction of growth. Obviously, if the
appliance, the muscles are activated and deliver force to change in eruption direction is to be effective, the vertical
the teeth. When the teeth engage the appliance, the component of mandibular growth must be adequate.
myotatic reflex (Figs. 34-21, 34-
572 . The Activator
Fig. 34-19. (A) Existing malocclusion. (B) the working bite for a
Class II mono bloc. Bite registration places the mandible in such a
position that any muscle and soft tissue action that attempts to return
the mandible to its normal position will apply intrusive force to the
2. The bite registration, most commonly used in North
maxillary and mandibular incisors. In addition, intrusive forces are
America, registers the mandible protruded to a point
delivered to the maxillary buccal teeth which are in contact with an
acrylic buccal shelf. The mandibular buccal teeth are free to erupt
approximately 3.0 mm. distal to the most protrusive
unimpeded. The intrusive forces generated by an activator do not position, while vertically the bite is registered
usually cause active intrusion on teeth. Rather, these intrusive forces approximately 4.0 mm. beyond the rest position.
prevent eruption of teeth in growing individuals and hence obtain the Clinicians using this bite registration maintain that the
effect of active intrusion. appliance induces activation of the myotatic reflex in the
muscles of mastication and that the frequency of biting
and swallowing
Fig. 34-20. (Opposite, A) A frontal view of the activator. Note that the undercuts in the mandibular portion of the appliance are left in place to
assist in retaining the appliance in position. The patient must insert the appliance sideways. (1) Areas of hard acrylic contact with basal structures
and also the labial surfaces of the incisor teeth. (2) Areas of relief lingual to the maxillary and mandibular incisor teeth. (3) Acrylic which is left in
contact with the occlusal surfaces of the maxillary buccal teeth and also the mesial surfaces of the maxillary buccal teeth. (4) Firm acrylic contact
with the alveolar processes. (5) Acrylic which is removed to permit eruption of mandibular teeth and distal movement of maxillary teeth. (B) A
lateral view of an untrimmed activator. Note that the acrylic is removed in the mandibular buccal segment in order to allow free eruption of
mandibular teeth. The acrylic extends well up on the labial of the maxillary and mandibular incisor teeth to assist in anchorage control. The acrylic
is extended deep into the mandibular retromolar-area to assist in retaining the appliance in position. (J) Areas of hard acrylic contact with basal
structures and also the labial surfaces of the incisor teeth. (2) Areas of relief lingual to the maxillary and mandibular incisor teeth. (3) Acrylic which
is left in contact with the occlusal surfaces of the maxillary buccal teeth and also the mesial surfaces of the maxillary buccal teeth. (4) Firm acrylic
contact with the alveolar processes. (5) Acrylic which is removed to permit eruption of mandibular teeth and distal movement of maxillary teeth. (C)
The acrylic which presses against the mandibular basal bone structure constitutes the sole anchorage since this acrylic presses firmly against basal
bone structures. If this area is relieved, the appliance can move mesially and permit anchorage slippage. The area of relief lingual to the mandibular
incisor teeth affords further protection against anchorage slippage in the mandibular incisor area. (1) Areas of hard acrylic contact with basal
structures and also the labial surfaces of the incisor teeth. (2) Areas of relief lingual to the maxillary and mandibular incisor teeth. (3) Acrylic which
is left in contact with the occlusal surfaces of the maxillary buccal teeth and also the mesial surfaces of the maxillary buccal teeth. (4) Firm acrylic
contact with the alveolar processes. (5) Acrylic which is removed to permit eruption of the mandibular teeth and distal movement of maxillary
teeth. (D) This view illustrates the areas of hard contact (3) which are left in contact with the mesial of each maxillary buccal tooth. umber 5
indicates the areas of relief on the distal of each maxillary tooth. This trimming permits the maxillary buccal segments to be guided distally.
Expansion may be achieved if the acrylic contacting the palatal vault is relieved moderately. The full thrust of the forces will then be dissipated
laterally through the alveolar processes to those portions of acrylic (4) which are in contact with the buccal segment alveolar processes. The
dislodging spring is activated approximately 0.5 mm. to provide continuous dislodging action and assist in activating the muscles of mastication.
Bite Registration and Theories of Action' 573
FRONTAL VI EW OF ACTI VATOR LATERAL VI EW OF UNTRI MMED ACTI VATOR
3.
1
1 2
2 ~!!!~!!:!:
i~~11~li 4
Hl B
:~~~
311I A :~~~
4,~j t~
~~) 5:ffuJ
t I NFERI OR VI EW OF
SUPER lOR VI EW OF TR I MMED ACTI VATOR
5:::WiH TRIMMED ACTIVATOR
RELIEF LINGUAL TO INCISORS
ACRYLI C CONTACT ON MES I AL OF

EACH BUCCAL TOOTH
RELI EF 0 I STAL TO EACH BUCCAL
TOOTH
1.
3.
1
2 iii!'!!!!
2 311
!!1!~!!!!! 4@@
D
4 tH:~:: NOTE THE ANCHORAGE WEDGE EFFECT
5 dEE AGAINST MANDIBULAR BASAL BONE FOR
c~ ANCHORAGE PURPOSES Fig. 34-20. Legend, page 572.
574 . The Activator
110.
111.
PYRAMIDAL CELLS ;'
OF 8ETZ
CORTEX
MES~NCEPHALIC NUCLW; k,. ~

~ TM. JOINT SYNOVIAa~.\.CAPSUL. . '
l MANDI87JLAR MUSC;;t!J*(JRf
PERIODONTAL MEMBR')~~{~~ \(
4:
BRAIN
STEM
(PONS) it LOWER MOTOR
NEURONE
MASTlC~TOR ~
NUCLEUS / REFLEX AND
OF
MASTICATOR
Fig. 34-21. Description of the neural pathway for reflex and volitional control of the masticator nucleus.
The proprioceptive fibers arising from the periodontal membrane, the muscles of mastication and the temporomandibular
joints ascend via the trigeminal nerve to the brain stem. Unlike the other sensory nerve tracts, the proprioceptive nerve tract
has its cell body in the mesencephalic nucleus, which is located in the brain stem. The other sensory nerve tracts have their
cell bodies in the trigeminal or gasserian ganglion (outside the brain stem).
From the mesencephalic nucleus the tract descends to the masticator nucleus on the ipsilateral side, where it synapses with
the lower motor neurone that carries the motor impulses to the muscles of mastication via the third division of the trigeminal
nerve.
The voluntary or volitional control of the masticator nucleus, and therefore, the muscles of mastication, comes from the
pyramidal cells of Betz, located in the cerebral cortex and descends via the upper motor neurone. (Courtesy Or. M. Roberts)
increases only during the first few days of therapy. They , tained during the whole period of contraction.
maintain that the main force is provided through increased Studies conducted at the University of Toronto confirm that
active tension in the stretched muscles of mastication. In increased levels of masseter and digastric muscle activity
their view, this more extreme vertical separation of the are sustained to a high level during 10 to 12 hours of wear.
jaws is necessary because the appliance is worn mostly at It is for this reason that the activator is preferred to the
night and the rest position of the mandible is altered during Bimler appliance; the compressibility of the Bimler
sleep, so that the freeway space may be approximately appliance permits more isotonic muscle contraction and re-
double what it is when the patient is awake. Thus, the more duced force levels although the wearer bites into the
extreme vertical separation of the jaws ensures that the appliance more which tends to initiate further muscle
myotatic reflex will act when the musculature is more activity. As a basic principle, activators should be
relaxed while sleeping. constructed of a rigid material to obtain the force levels
Since the activator does not permit muscle shortening, generated in isometric muscle contraction.
the contractions produced are isometric rather than 3. The third bite registration (originated by HarvoId and
isotonic. During isometric contraction, muscle fibres gaining increasing acceptance) places the
develop higher tension, which is well sus-
112.
TENDON
ORGAN
TRIGEMINAL GANe~/O
-",' ... "MUSCLE SPI NOLE
MESEN;CEPHALIC NUCLEUS; \ SENSORY lA

___ a. NUCL EAR BAG
"~ .......( non - contractile)
+\ +-\
TRIGEMINAL NUCLEUS +
(MASTICATOR NUCLEUS) (o<.EFFERENT)
-MOTONEURONS ~ .. b.INTRAFUSAL FIBRES
(contracfi Ie)
"fXTRAFUSAL FIBRES
MYOTATIC REFLEX
(01 AGRAIol IolATIC)
Fig. 34-22. Mechanism of the stretch or myotatic reflex: The stimulus for the stretch reflex is the stretch of the muscle.
The stretch reflex, when elicited, causes contraction of the stretched muscle.
Muscle stretch receptors are proprioceptive nerve endings called muscle spindles. The muscle spindle is located within the
muscle itself and consists of a bundle of 2 to 15 thin intrafusal muscle fibers, The long slender ends of the intrausal fibers are
striated and contractile; whereas, the central or nuclear bag region is non-con tactile.
The impulses arising from the muscle spindle (nuclear bag) are conducted by the Group I A sensory nerve fibers. These sensory
nerve fibers synapse with the motor neurons called alpha efferents that supply the extrafusal muscle fibers responsible for the
contraction of the stretched muscle.
The myotatic or stretch reflex is therefore, a monosynaptic reflex arc.
The functional significance of the stretch reflex is that it serves as a mechanism for upright posture or standing. Natural stretches
are usually imposed on muscles by the action of gravity, During standing, the quadriceps muscles are subjected to stretch because
the knee tends to bend in accordance with gravitational pull. The stretch of muscle acts as a stimulus to elicit the stretch reflex,
causing a sustained contraction of the stretched muscle, so that the upright position is automatically maintained despite the action
of gravity. The same stretch reflex acts in the mandibular musculature to maintain the postural rest position of the mandible in
relation to the maxilla. (Courtesy Dr. M. Roberts)
mandible approximately 4.0 mm. distal to the most protrusive primary force to the appliance (Fig. 34-24). Thus the power to
position the patient can achieve; vertically an extreme produce tooth movement and alveolar remodelling is obtained
separation of the jaws is used, so that the mandible may be from the inherent elasticity of muscle and tendon without
opened 8 to 10 mm. beyond the freeway space. The author motor stimulation. Muscle spindles have not been clearly
uses a vertical separation of approximately 12 to 15 mm. demonstrated in the labial muscles, and therefore there seems
beyond the daytime rest position of the mandible (Fig. 34- to be no mechanism for turning off the reflex muscle activity
23). The proponents of this concept contend that the myotatic through a modification of myotatic reflex (Fig. 34-25). Thus,
reflex and attempts to increase frequency of biting and the more these muscles are stretched, the greater the force
swallowing should be largely ignored, letting passive tension delivered to the activator. It is quite possible that the forces
(viscoelastic properties) in the stretched labial and oral generated by this extreme bite registration represent a
musculature deliver the
576 . The Activator
113.
114.
60 Resting length
Totil tension
C) ......
!
c
-i-, '/ : \
0 : \ Active tension
.;;:;
c
w
20
o ~5 1.0 1.5 2.0 2.5

Increne in muscle length
(inches)
Fig. 34-24. The total tension in muscle is the result of
active tension from the myotatic reflex and passive tension
Fig. 34-23. The photograph illustrates an activator used from the viscoelastic properties of the tissues. The more
in an extreme vertical separation of the jaws with the moderate bite registrations used in the activator attempt to
mandible opened 8 to 10 mm. beyond the freeway space. use active tension to guide the dentition. The more extreme
This type of bite registration attempts to utilize passive openings in which the mandible is opened 8 to 10 mm.
tension in the stretched labial and oral musculature to beyond the freeway space use a passive tension in the
deliver the primary force to the dentition. stretched tissues as a primary source of force.
combination of forces generated by swallowing, biting,

activation of myotatic reflex in the stretched muscles of
mastication and the power delivered through the
viscoelastic properties of stretch muscle, tendon tissue, and night. The BirnIer appliance is suitable for daytime wear
activated labial musculature. The reason that the bite is and for bite registrations opened vertically to the freeway
registered for 3.0 mm. to 4.0 mm. distal to the most space.
protruded position the patient is able to achieve in all three One point of caution should be noted in the use of bite
bite registrations is to avoid the possibility of initiating registration number 3. Activators tip the maxillary incisor
Golgi organ tendon activity (Fig. 34-25) that would teeth distally. It follows, therefore, that they may tend to
minimize desirable myotatic reflex activity. create an excessive lingual inclination of the maxillary
4. Schwartz believed that the patient could be incisor teeth. This tendency is emphasized with bite
conditioned to maintain a continuous sustained biting on registration number 3 because of the force levels applied
the activator. He claimed to have recorded sustained
tetanic contractions for up to four hours while the patient ., with extreme vertical
opening. Therefore, bite registration number 3
was sleeping. Figure 34-26 indicates that hyperactivity is
physiologically possible in properly motivated patients should only be used where the maxillary incisor teeth are in
through the media of signals from the higher centres of the pronounced labioversion. Where the maxillary incisor teeth
brain. Such activity would require conditioning of the are upright or have a very moderate lingual inclination, the
patient and possibly auto-suggestion. practitioner should use registrations number 1 or 2 and
In North America, bite registrations with the vertical attempt to treat the Class II malocclusion by utilizing
dimension opened to the freeway space are not used available mandibular growth rather than retracting the
extensively with activators. Most clinicians prefer to use maxillary incisor area.
bite registrations 2 and 3 which apply more continuous In summary, the various actions claimed by the
forces and maintain good activity during the night. The proponents of the three bite registrations described here
activator does not lend itself to long hours of daytime wear
probably act to a greater or lesser degree at various times
to provide biting and swallowing activity during the day as
and probably act accumulatively. The greatest action
well as at
probably results from the initiation of myotatic reflex
activity and through the harnessing of the viscoelastic
properties of muscle tissue.
115.
+ EXCITATORY
(racililafion) -I NHIBITORY
TRIGEMINAL
O MUSCLE SPINDLE
ME SEN7PHALIC NUCLEUS ~ ............ .

. ... NUCLEAR BAG
(non - con/raelile )
IN TERNEURON 1
\ (0< EFFERENT) - O EXTRAFUSAL FIBRES
TRIGEM I NA L NUCLEUS MOTONEURONS+

(MAST/CATeR NUCLEUS)
~:,~ -\ \\\ lflo'MUSCLE

CLASP KNIFE REFLEX
(""RA"""") \ I\. I
Fig. 34-25. Mechanism of the clasp knife reflex: If one attempts to flex forcibly the spastic limb of a patient, resistance is encountered
as soon as the muscle is stretched throughout the initial part of the bending. This resistance is, of course, due to the hyperactive
reflex contraction of the muscle in response to stretch (myotatic or stretch reflex). If flexion be forcibly carried further, a point is
reached at which all resistance to additional flexion seems to melt and the previosuly rigid limb collapses readily. Because the
resistance of the limb resembles that of a spring-loaded folding knife blade, this phenomenon is called the clasp-knife reaction,
i.e., the muscle first resist, then relaxes. The excessive or rapid stretch of the muscle brings into play some new influence which
annuls the stretch reflex and allows the muscle to be lengthened with little or no tonic resistance. Thus the stimulus necessary to
elicit the clasp-knife reflex is excessive stretch and when elicited, it inhibits muscular contraction, thus causing the muscle to
relax.
The receptors for the clasp-knife reflex are the Golgi tendon organs located in the tendon of the muscle. The impulses are
conducted by the Group 1. B. sensory nerve fibers. The impulses act on the motor neuron or alpha efferent supplying the
stretched muscle. However, it is a disynaptic reflex arc because an inter neuron is interposed between the sensory neuron and the
motor neuron.
It follows that during muscle stretch, the motor neurons supplying the stretched muscles are bombarded by impulses delivered
over two competing pathways, one facilitating and the other inhibiting muscle contraction. The output of the motor neuron pool
depends upon the balance between the two antagonistic inputs. The functional significance of the claspknife reflex is to protect
the overload by preventing damaging contraction against strong stretching forces. (Courtesy Dr. M. Roberts)
..
Since the muscles are not permitted to shorten, the muscle force is also delivered to the maxillary teeth to impede
contractions are isometric rather than isotonic, generated further their horizontal development. Relieving the acrylic
with a greater resultant force. Bite registrations numbers 2 occlusally in the mandibular buccal segments and placing a
and 3 purposely create an excess interocclusal clearance, and relief lingual to the mandibular incisors shields the
neuromuscular activity is activated by one of the methods mandibular teeth from these forces. The mandibular buccal
discussed above to re-elevate the mandible. Intrusive force is teeth are thus permitted to erupt vertically in growing
thus placed on the entire maxillary dentition to impede children in harmony with the vertical component of
further vertical alveolar development; distal mandibular growth (Figs. 34-19, 20). A greater degree of
vertical
578 . The Activator
116.
(foci/ilo/ion)
RETICULAR FORMATION j f
SENSORY PATHWAYS ..... =.; 1 + rr= 0(
T R I GE M\I N A L . G~ ~~L IO~.::LftI7 .... - .. --, .....

__, ';,. "MUSCLE SPINDLE
~..... .. .....
. ~.,
i
: :+
_II
. ~ "0. NUCL EAR BA G c
" I I . (non .. contractile)

MESENCEPHALIC NUCLEUSr., ... ....,.
l . U
TRIGEMINAL NUCLEUS .. _,j .... .,
I
0< -EFFERENT ----')0...
MOTONEURONS \'
.,~;~ .. ; b./NTRAFUSAL FIBRES
',,,,1 (contractile)
(MASTICATOR NUCLEUS) ::+ . -EFFERENT ---+ (.!.00HTRAFU5Al
.-1, ~'~ 00 '0 FIBRE
. '-~::r'" S
~~NTR9D~D"g"~nc~EFL~iIJi~;
Fig. 34-26. Regulation of the myotatic reflex from the higher centers of the brain via the reticular formation:
MUSCLE
In addition to the a (alpha) efferents or motor neurons supplying the extrafusal fibers of the muscles, smaller motor neurons or
y (gamma) efferents supply the intrafusal fibers of the muscle spindle (both contractile poles).
Activation of the y (gamma) efferents will cause polar contraction of the intrafusal fibers and therefore, put the noncontractile
nuclear bag region under tension. This will produce in the receptor endings a mechanical distortion indistinguishable from that
occasioned by passive stretch of the whole muscle. In this way, the y (gamma) efferents may initiate spindle discharge in the
absence of external stretch or in the presence of stretch, so increase the sensitivity of the spindle that frequency of the sensory
discharge is markedly increased. They (gamma) efference thus serve as a biasing mechanism regulating the sensitivity of the
muscle spindle receptors. It is through this y (gamma) efferent system that the higher centers of the brain via the reticular
formation influence the stretch or myotatic reflex. This is significant because it helps us explain how emotional or psychic
disturbances affect the symptoms of T.M.}. dysfunction.
The reticular formation influences the myotatic or stretch reflex mainly by facilitation or inhibition of the small y (gamma)
efferents which cause contraction of the intrafusal fibers of the muscle spindles, thereby increasing the rate of the spindle firing,
which in turn influences the amount of 0: (alpha) motor neuron firing. (Courtesy Dr. M. Roberts)
eruption may be permitted in individuals with excessive mandible to permit the extrusion of a deep lingual flange,
interocclusal clearance. which assists in holding the appliance in position (Fig. 34-
20A).
Decide whether to use bite registration 1, 2, or 3 as
CONSTRUCTION OF THE ACTIY ATOR
described previously, and register the bite using a thick roll
The activator is constructed of exothermic selfcuring of softened baseplate wax. Insert into a bundle of tongue
acrylic on stone casts of the maxillary and mandibular depressors the wax in the incisor area to provide a guide for
arches. The mandibular impression should be extended the patient's vertical closure (Fig. 34-27). The thickness of
deeply on the lingual side of the first and second permanent the bundle will be determined by the space between the
molar areas. The impression thus extends into an undercut maxillary and mandibular incisal edges when the patient's
area of the
Construction of the Activator' 579
mandible is placed in the correct vertical and protrusive bite

registration. After the bundle is inserted into the wax bite, ask
the patient to advance the mandible as far as he can, retract 3
mm., and close his mouth to the vertical dimension permitted
by the tongue depressor bundle. Mark the tongue depressor
bundle at the points where the incisal edges contact it.
-
Grooves cut into the bundle provide definite anteroposterior
and vertical guides to assist both patient and clinician to
establish the correct bite relationship. Register the bite; -
remove the assembly from the patient's mouth and chill it.
Remove the tongue depressors and return the bite to the mou
th to check that the midlines are correct. When the midlines do
not match, they may be matched in the bite registration if:
(1) The deviation is due to a lateral functional displacement of
the mandible with the maxillary midline matching the
mid-sagittal plane of the head when the mandible is at
rest.
(2) The discrepancy is not more than 2.0 mm. in deviations
that are not characterized by functional mandibular
displacements.
If the midlines are matched in the bite registration in
patients with large midline discrepancies owing to dental shift
or skeletal asymmetry as distinct from functional mandibular
displacements, the treated result will show the midlines
matching occlusally but both the maxillary and the mandibular
midlines may not match the mid-sagittal plane of the face. The
median line should also be checked with the casts in the wax
bite before the casts are mounted on an articulator. Wax bites
should be kept in a jar of water at room temperature to Fig.34-27. (Top) A bundle of tongue depressors inserted into
minimize distortion until assembled to the casts for mounting a wax bite in the incisor area to provide a guide for the
on ararticulator. patient's vertical and anteroposterior closure during bite
When the casts are mounted on an articulator the final coat registration. (Bottom) The patient is instructed to advance the
of plaster on the upper articulator arm should never be more mandible as far as he can, retract 3 rn m., and close his mouth
than V4" thck, because setting plaster may distort the casts to the vertical dimension permitted by the tongue depressor
relations. All adjustments on the articulator should be locked bundle. Pencil marks are made on the tongue depressor bundle
in centric and the pin made flush with the upper arm of the at the point where the incisal edges contact it. Grooves cut into
articulator. This is important because the pin may be removed the bundle provide definite anteroposterior and vertical guides
during the construction of the wire work and then replaced to assist both patient and clinician to establish the correct bite
accurately. The design of the labial archwire and dislodging relationship.
springs is illustrated in Figures 34-1 and 34-208, and its
construction is described in Figure 34-288.
Hawley retainer and the other as used in the Andresen

appliance. A modified Andresen design is used when the
maxillary arch has narrowed considerably in the canine area
owing to muscle contraction force. This design relieves the
force of the cheeks from the maxillary canine area and permits
normal arch form to be restored in this area.
Design of the Labial Archwire Lingual Relief

The design of the labial archwire and dislodging spring In the Class II activator, relief is placed lingual to the
wires are constructed according to the needs of each case (Fig. incisor teeth in both arches. In the maxillary arch, this relief
34-1; 34-20). Two types of labial arch wire are commonly permits remodeling of the alveolar process as the incisors are
used. One is similar to the guided lingually; in the man-
580 . The Activator
Fig. 34.28, (A) The form of the labial arch for a Class II
activator is outlined on the relief tape and teeth. (B) Four
thicknesses of buccal tape relief for the labial arch on a Class II
activator, If the wire design is of the Hawley type, the tag ends
are carried anteriorly in a symmetrical arc at the middle of the
freeway space and kept approximately 1 to 2 mm. labially to
the maxillary incisors. All bends made in the tag ends for the
purpose of retention should be in the horizontal plane of space.
If the labial wire is of the Andresen type, the form is outlined
on the relief tape and teeth as illustrated, The crest of the loop
gingival to the canine areas should not be high enough to
impinge on the mucobuccal fold.
Adapt a length of 0.032 to 0.036-inch wire to the labial
surfaces of the incisors at the junction of the gingival and
middle thirds of the crowns. This wire is kept straight in the
horizontal plane from the junction of the middle and distal
vertical thirds of one lateral incisor to the same location on the
opposite side of the arch. The arch form should be kept
symmetrical to avoid perpetuating minor irregularities in
incisor alignment. The middle loop should lie over the canine
area with 1 to 1.5 mm. clearance to the labial to permit
freedom for movement of the canine tooth. This loop is
occasionally used in the final stages of treatment to gUide
erupting canine teeth lingually when required. Check that the
labial wire is passive and seal it to the cast on the gingival side
of the wire along the central incisors and at the loops over the
canines. Wax should not be permitted to flow incisally to the
wire. (C) Four thicknesses of adhesive tape relief for the labial
arch on a Class III activator.
extrusion of the incisors. This relief is carried from cuspid to

cuspid in an arc which provides about 2 mm. lingual relief
when the distal of the cuspid is reached. In the mandibular arch
(Fig. 34-29C) the relief is on a level plane flush with the incisal
edges of the central incisors and carried lingually for ap-
proximately 3 mm. arcing to the distal of each cuspid with
lingual extension of approximately 2 mm.
The relief in both arches is carried apically to a point
approximating the junction of the apical and middle thirds of
the roots of the incisors tapering and blending in with the soft
tissue at this point. It must not be carried any closer than 5 mm,
to the lingual fold on the mandibular cast, since the appliance
must contact the tissue overlying basal bone in order to
reinforce the mandibular anchorage (Fig. 34-20B).
In a Class III activator, relief is placed on the lingual of the
mandibular cast only, and no relief is placed on the maxillary
cast.
dibular arch, it ensures that no force will be applied by the

appliance to tip the incisors labially. The relief in the
maxillary arch is carried lingually from the central incisors
approximately 5 mm. on the same plane as the incisal edges
Forming the Dislodging Springs
and usually in a horizontal plane (Fig. 34-29, A, B), 'A slight
inclination from horizontal is sometimes used to control Dislodging springs (Fig. 34-30A) are made of 0.035-0.036-
intrusion or inch wire, so that they can apply an
Construction of the Activator . 581
Fig. 34-29. (A) The pencil outline for relief areas lingual to
the maxillary and mandibular incisors. (B) The wax relief
lingual to the maxillary incisors is illustrated. This relief is
carried lingually from the central incisors approximately 5.0
mm. on the same plane as the incisal edges and usually in a
horizontal plane. A slight inclination from horizontal is
sometimes used to control intrusion or extrusion of the
incisors. The relief is carried from cuspid to cuspid in an arc
which provides about 2 mm. lingual relief when the distal of
the cuspid is reached. The illustration also shows wax placed
over the active arm of the molar springs. If exothermic self-
curing acrylic is used, baseplate wax is adequate for the relief.
If endothermic heat-cured acrylic is used, plaster-of-paris
should be used to afford a contrast with the stone cast. If
exothermic acrylic is to be used, flow enough baseplate wax
on the active arm and helix of the spring to secure it to the cast
and to prevent acrylic from contacting these parts. Wax must
be kept away from the tag end which is to be embedded in the
acrylic. If endothermic acrylic is to be used, the spring is held
in place with temporary cement or plaster-of-paris. (C) The
wax relief lingual to the mandibular incisors is illustrated.
This relief is in a level plane flush with the incisal edges of the
central incisors and is carried lingually for approximately 3
mm. arcing from the distal of each cuspid with a lingual
extension of approximately 2 mrn. The illustration shows that
the occlusal surfaces of the buccal teeth in the mandibular cast
are prepared with a wax platform which is carried occlusally
to an approximate height of 5 to 7 mm. and is as wide as the
buccolingual width of the buccal teeth. This platform should
be parallel to the wax on the maxillary cast.
undermining force to the molars and intermittently dislodge

the appliance from close contact with the teeth. The spring for
a Class III activator is the reverse of that for a Class II (Fig.
34-30B).
Prefabrication of Trimming
A considerable amount of chair time can be eliminated
from the trimming procedure if areas are blocked out on the
casts, with wax for exothermic acrylic appliances and plaster
for endothermic acrylic appliances. The activator will then
have the trimming processed into it. The method for wax is
described. Relief is placed on the lingual surfaces of the mandibular
In the Class II activator, eruption of teeth should be arrested buccal teeth so that acrylic will not contact the lingual
in the buccal segments of the maxillary arch while letting the surfaces. This lets them erupt unimpeded. Figure 34-34
teeth erupt in the buccal segments of the mandibular arch. At illustrates the placement of wax on the labial portions of the
the same time the appliance should provide for posterior labial arch. It is necessary to build an acrylic shelf that inhibits
movement of teeth in the maxillary buccal segment (Fig. 34- the eruption of the maxillary buccal teeth (Fig. 34-20B).
19 and 34-31). This is accomplished by the formation of Figures 34-29, 33A, and 33B illustrate the wax-up required to
"wedges" which can transmit a posterior force to the mesial of build this shelf.
each buccal tooth in the maxillary arch (Fig. 34-32). The Class III activator should arrest eruption of teeth in the
buccal segments of the mandibular arch while permitting the
buccal teeth to erupt in the
582 . The Activator
,
Fig. 34-30. (A) The dislodging spring design used in a Class TI activator. The diameter of the helix is established by shaping the
spring around the round beak of a pair of 139 or 390T pliers at a point near their throat to produce a coil with an outside diameter of 8
to 9 mm.
The straight part of the level arm should be approximately 15 mrn. long. The end of this arm, which fits into the embrasure, should be
bent back vertically on itself for approximately 2 mrn. to afford more contact against the proximal surface of the tooth and eliminate
any sharp ends.
The spring for a Class II activator is placed over the palate, with the anterior arc of the coil opposite the rnesio-proximal surface of
the first permanent molar. The only part of the spring which touches soft tissue is in the embrasure and at the helix, the rest having a .5
to 1.0 mm. palatal relief. The active arm of the spring always rests on the occlusal side of the helix in such a manner that the helix will
unwind when activated. The tagend, which will be embedded in acrylic, extends approximately 15 mm. anteriorly where it terminates in
a hook for retention. It is shaped to the contour of the palate with .5 to 1.0 mm. relief at all points. (B) The dislodging spring design used
in a Class III activator. It unwinds with the thrust in a mesial direction and, in its placement on the palate, the distal part of the helix lies
in lines with the distoproximal surface of the first permanent molars.
Fig. 34-31. An occlusal view of the maxillary arch. At the same time, it should provide for posterior
maxillary buccal segment with the movement of all mandibular teeth and anterior movement of all.
acrylic of the activator contacting the maxillary teeth. Figs. 34-35A-C show the wax-up required to
mesial surface of each tooth and facilitate tooth movements and avoid tedious chairside trimming
relieved on the distal surface. Thus, the
and create the acrylic "wedges" required to transmit a posterior
trimming provides for posterior
force to each mandibular tooth.
movement of the teeth in the maxillary
buccal segment and wedges of acrylic
are formed which can transmit a
posterior force to the mesial of each
buccal tooth in the maxillary
arch. -
Fig. 34-32. Considerable chair time can be saved in trimming

an activator if the trimming is waxed into the processing of the
activator. The occlusal surfaces of the buccal teeth in the
maxillary cast are covered with baseplate wax and this is built
up occlusally until only the cusp tips are exposed. A flat spatula
may be used to level the wax to a flat plane. The figure also
shows wax, approximately 1.0 mm. thick, flowed onto the
entire distolingual surface of each posterior tooth into the centre
of each embrasure. No wax is applied to the mesiolinguaI
surface of the teeth. Thus, when the acrylic is applied, wedges
are formed which can transmit a posterior force to the mesial of
each buccal tooth in the maxillary arch.
Construction of the Activator' 583
117.
Fig. 34-33. (A) The illustration shows the maxillary and mandibular casts mounted on an articulator in the bite which was registered
previously. Wax reliefs have been placed on the maxillary and mandibular casts lingual to the incisor teeth, occlusal to the mandibular
buccal teeth, and distal to the maxillary buccal teeth. In addition wax strips have been placed on the labial surfaces of the gingival
portions of the incisor teeth in order to prevent acrylic from extending beyond these areas when the appliance is processed.
The occlusal surfaces of the buccal teeth in the mandibular cast are prepared with the wax carried occlusally to an approximate height
of 5 to 7 mm.; this builds a flat platform which is as wide as the buccolingual width of the buccal teeth. The platform should be parallel
with the wax on the maxillary cast. If these steps are followed there should be a space of 2 to 3 mm. between the two arches in the
buccal segments. Acrylic will extend into the space between the maxillary and mandibular occlusal wax platforms to form an occlusal
shelf which will inhibit the eruption of the maxillary buccal teeth. In addition, acrylic will flow between the incisal surfaces and
encompass the retentive portion of the labial arch wire which is centred in the interincisal freeway space. (B) The frontal view illustrates
the build-up of wax in the mandibular arch which will permit eruption of the mandibular buccal teeth and the lack of occlusal wax build-
up in the maxillary arch.
The acrylic of the Class II activator is extended as a lip bumper to hold the lip away from the maxillary
through the incisor freeway space from the distal of one incisor teeth and facilitate their downward and forward
cuspid to the distal of the other in both arches. Thus eruption. The construction of this arch wire is described in
acrylic is carried gingivally on the labial surfaces of the Fig. 34-37.
maxillary and mandibular teeth to a distance equal to
two-thirds the height of the crowns of the central incisor
teeth (Fig. 34-36).
The acrylic of the Class III activator is extended
through the incisor freeway space from the distal of one
cuspid to the distal of the other in the mandibular arch
only (Fig. 34-37).
Design of Labial Archwire for Class III Activator

The O.036A labial wire for the Class III mono bloc
(Figs. 34-28C, 37) is designed to recurve on itself in the
maxillary incisor vestibule. In the Class III activator the
maxillary portion of the labial wire acts
Fig. 34-34. This illustration shows the placement of a piece of

wax over the lateral portion of the labial arch in order to prevent
this part of the archwire from becoming embedded in the acrylic.
584 . The Activator
Fig. 34-35. (A) The wax-up for the occlusal surfaces of the
maxillary arch of a Class III activator. The wax is carried to
an approximate height of 3 to 5 mm. and a flat platform
shaped to the buccolingual width of the posterior teeth. This
platform should be parallel with the wax on the mandibular
cast. Wax approximately 1 rnm. thick is flowed on the entire
mesiolingual surface of each maxillary buccal tooth to the
centre of each embrasure, No wax is applied to the
distolingual surface of these teeth. Thus, when the acrylic is
applied, wedges are formed which can transmit a mesial force
to each maxillary tooth. (8) The occlusal wax-up of the
mandibular arch for a Class III activator. The occlusal
surfaces of the buccal teeth of the mandibular cast are covered
with baseplate wax and this is built up occlusally until only
the cusp tips are exposed. Approximately 1 mm. thickness of
wax is flowed on the entire distolingual surface of each
posterior tooth to the centre of each embrasure. No wax is
applied on the mesiolingual surface of these teeth. Thus, when
the acrylic is applied wedges are formed which can transmit a
posterior force to each mandibular tooth. (C) If the wax-up in
the maxillary and mandibular arches has been performed cor-
rectly a space of 2 to 3 mm. remains between the two arches
in the buccal segments. An acrylic shelf will flow into this
space and will remain in occlusal contact with the mandibular
arch while the maxillary buccal segments are permitted to
erupt occlusally.
allowing the first coat to dry before applying the second. Take
care to see that the separator flows over the labial surfaces of
the incisors and that any excess is drained off. Figure 34-38
illustrates the addition of a wax sheet on the labial surfaces of
the construction to enable molding of the labial acrylic
extension and Figure 34-39 illustrates the placement of
acrylic on the casts.
An undercut area is sometimes present in the gingivolingual
area of the mandibular molars. This undercut must not be
relieved because its presence provides one of the key methods
by which the patient is conditioned to retain the appliance in
position while asleep. When such an undercut is present the
appliance must be inserted sideways. The lingual flange
should be kept as deep as possible in this area (Fig. 34-20A,
B) to obtain maximum use of the undercut. Extra thickness
should be left in this area for strength.
c Trimming Procedure in Activator Construction

An important step in the fabrication of a wellfunctioning
activator is the proper trimming of the finished appliance. The
Application of Separating Medium
following method must be carefully observed to direct the
Soak the casts and articulator in water at room temperature forces to the maxillary teeth and avoid applying these forces
for 5 minutes, and shake off the excess water before applying to the mandibular dentition. It is much easier to wax in all the
the separating medium. Brush two thin coats of separating following to be trimmed as was described pre-
medium on the casts,
118. Construction of the Activator' 585
Fig. 34-36. The acrylic of the Class II activator is extended Fig. 34-37. The acrylic of the Class III activator is ex-
through the incisor freeway space from the distal of one tended through the incisor freeway space from the distal of
cuspid to the distal of the other in both arches. The acrylic is one cuspid to the distal of the other in the mandibular arch
carried gingivally on the labial surfaces of the maxillary and only and should not cover the labial surfaces of the maxillary
mandibular teeth to a distance equal to two thirds the height incisors. The acrylic is carried over the labial surfaces of the
of the crowns of the central incisor teeth. The vertical height mandibular incisors for a distance of twothirds the heights of
of these labial acrylic extensions is obtained by softening a the crowns where it approximates the labial wire.
Y2-inch wide strip of doublethickness baseplate wax and The labial archwire is constructed from 0.036 wire. The
adapting it over the labial surfaces of the six maxillary arms lie on each side of the frenum parallel with the occlusal
anterior teeth and the labial wire. The incisal two-thirds of plane approximately 2 to 3 mm. gingival to the incisors and
the crowns is left exposed and the wax sealed to the cast recurving about 2 mm. short of the frenum. These arms
with a hot spatula. Similarly, a Y2-inch strip of double- recurve in a distal direction approximately 5 mm. gingival to
thickness baseplate wax is adapted over the labial surfaces and parallel with the lower arm. The upper portion of the
of the six mandibular teeth and the incisal and middle two arm is bent occlusally at the distal embrasure of the cuspid or
thirds of the crowns is left exposed and the wax sealed to the further distally if muscle attachments permit; this portion
cast with a hot spatula as shown in Fig. 34-33. continues to the middle of the freeway space where it is bent
horizontally and carried to the midline. The retention tags
provided on this arm should lie in the middle of the freeway
space over the incisor teeth.
The vertical extension of the lower arm is bent occlusally
viously. The steps to follow are for an untrimmed activator.
about 1 mm. anterior to the vertical part of the upper arm.
Mandibular Portion. The basic aim is to remove all
This arm must have room to move posteriorly without
mesially directed forces from the mandibular teeth and permit
~ontacting the arm behind and yet it must not be placed so
free eruption of the buccal teeth. In the mandibular arch, the
far anteriorly that it impedes the anterior movement of the
acrylic should rest only on the incisal edges, the most inferior
cuspid. This arm is carried from the maxilla to the mandible
portion of the alveolar process and as much as possible on the
where it turns at right angles to the junction of the gingival
"basal" bone area, in order to avoid delivering forces that
and middle-thirds of the mandibular incisors. At this point, it
might move the mandibular teeth labially. The lingual
is shaped symmetrically over the labial stu;faces of the
interproximal portions of acrylic in the buccal segments are
mandibular incisors to the cuspid on the opposite side where
trimmed so that the acrylic rests only on the soft tissue areas
it again returns vertically.
inferior to the teeth (Fig. 34-20B). A 1.0 mm. clearance is left
between the acrylic and the lingual surface of all mandibular
buccal teeth to permit their full eruption. If the mandibular
posterior teeth are allowed to erupt, the acrylic is removed
from the occlusal area.
Maxillary Portion. The basic aim of trimming in this area
is to prevent all eruption in the maxillary arch and, by the further forward development of the maxillary dentoalveolar
delivery of distal forces, to prevent process. Because the forces must be directed through the
labial archwire against the maxillary incisors, against the
molars through the molar springs, and against the
mesiolingual surfaces of the other maxillary posterior teeth,
the trimming of the maxillary portion of the activator must
be precise.
586 . The Activator
WAX SHELL WAX SHEET OVER WIRE ASSEMBLY AN 0

WAX RELI EFS
Fig. 34-38. (A) Wax shell to contain the acrylic.

(B) A sprinkling is formed around the buccal and
labial surfaces of the maxillary and mandibular
arches by shaping a strip of baseplate wax over
the mounted casts from the posterior of one side
to the posterior of the other. The wax strip should B
be wide enough to cover the crowns of the teeth
on both arches and the wax on the labial surfaces
should not touch the maxillary and mandibular
incisors but rather bridge the gap between the arch wire can be kept in contact with the labial surfaces of
jaws. The wax is sealed around the entire border the teeth by adjusting the cuspid loops.
with a hot spatula.
FURTHER CONSIDERATIONS IN APPLIA CE

CONSTRUCTION AND MANIPULATION FOR CLASS
II CORRECTION
The portion of acrylic covering the maxillary incisors is A properly constructed activator maintains the
trimmed in such a way that the acrylic contacting the predetermined bite registration vertically through contact
labial surfaces is left intact and covers the incisal edges at between the acrylic of the appliance and
a level of the junction of the incisal and middle-thirds of 'basal bone structures in the maxilla and the mandible. Any
the central incisors. vertical contact with the dentition is passive. The acrylic
A layer of acrylic is removed flush with the incisal therefore contacts only the palate and those deepest points
edges of the maxillary incisors and lingual to the teeth and on the mandibular basal bone where there is no frenum
the "premaxilla" soft tissue area, thus establishing a flat impingement (Fig. 3:4.-20A, C). Since the mandibular
plane for the incisors to slide on as they are guided portion of the activator is wedge-shaped and since it fits
lingually, and provide room for remodelling of the lingual accurately against mandibular basilar structures (no relief
alveolar bone and the bone of the "premaxilla" (Fig. 34- should be permitted), the mandibular anchorage is
19). effectively controlled. Any forces that the appliance directs
The interproximal portions of the acrylic in the mesially against the mandible as the mandible attempts to
maxillary buccal segments are trimmed in such a way that retract to centric relation will be dissipated against basal
the acrylic will rest only against the mesiolingual and bone, not teeth. Anchorage preservation is reinforced
occlusal surfaces of the teeth and the palate. This provides further through the relief afforded lingual to the
a flat shelf with acrylic contacts on the mesial of each mandibular incisor teeth (Fig. 34-20C) and through the
buccal tooth (Fig. 34-37). incisor protection
As the maxillary incisors move lingually, the labial
Further Considerations in Appliance Construction and Manipulation for Class II Correction . 587
Fig. 34-39. This illustrates the completed spraying of

acrylic and powder over the various relief areas illustrated
previously. Apply liquid and powder in the incisor protection
section. The mixture should be fluid enough to flow around
the labial surfaces of the incisors and thus not trap air.
Powder and liquid are added to the exposed occlusal
surfaces of the wax over the buccal teeth and around the
lingual surface of the mandibular arch finally filling in the
palate.
The articulator should be turned continuously during the
application of powder and liquid to keep an even thickness of
acrylic. Spraying should be continued until the acrylic
reaches an even thickness equivalent to two sheets of
baseplate wax.
Curing the acrylic: Separating medium should be applied
to the surface of the acrylic with a brush as soon as the excess
monomer has evaporated. The casts are then immersed in
room temperature water in the pressure cooker, at a pressure
of 30 lb. per square inch for 30 minutes. ( .B. the temperature
of the water in the cooker must not exceed room temperature.
Any greater temperature may soften the wax bites and distort
the appliance.) The usual safety precautions should be
observed when releasing the air after curing.
This method of curing prevents excessive evaporation of
monomer and produces increased density and decreased
porosity.
The sheet of wax, which was placed on the labial surface,
is removed and the labial and buccal extension of the acrylic
is inspected for any large air bubbles. Such spaces are
repaired with acrylic powder and liquid. It is not necessary to
return the appliance to the pressure cooker to cure such a
repair.
The appliance is carefully pried from the casts with a
plaster knife that is placed under the posterior border of the
plate and under the lingual border of the mandibular portion. FLg 34-40. The configuration of the labial arch on the Class
A chisel is used to trim acrylic in the areas adjacent to the II activator may be altered to deliver a torquelike effect to the
wire work to avoid nicking or cutting of the wire. A maxillary incisor teeth. Several degrees of torque may be
o. 7 wax spatula or carver is used to trim away the wax obtained through the lingual activation of the torque
around the molar springs. Where possible the acrylic is extensions added to the arch wire although it is difficult to
trimmed to a thickness of one sheet of baseplate wax to obtain extensive torque with the activator.
reduce bulk. The appliance is then polished as any acrylic
mold.
the mucoperiostium and irritate the tissues. This effect
encourages the patient to maintain a firm contact between the
appliance and basal bone and occlusal surfaces.
The maxillary labial arch extends from bicuspid to bicuspid
and is in passive contact with the maxilary -inci sors (Figs.
obtained by covering as much as possible of the labial 34-1A, s. 34-20B; 34-28A, B) If the maxillary arch is kept
surfaces of the mandibular incisor teeth (Fig. 34-36). With
as close as possible to the gingival margin of the teeth
while the incisal edges are in firm contact wi th the acrylic
relief on the lingual and acrylic covering the labial of the
on their labial surfaces, it will counteract the tendency for
maxillary incisor teeth, the appliance can apply very little the incisor crowns to assume an overly upright or lingual
mesial force to the mandibular dentition even if the mandible position. Occasionally the configuration of this arch may
drops out of it. be altered to deliver a torquelike effect to the maxillary
To further assist in retaining the appliance in position incisor teeth (Fig. 34-40). Several degrees of torque may
while sleeping, the lingual flange is extended (Fig. 34-20B) be obtained through the lingual activation of torque
deeply to condition the patient to retain the activator in his extensions added to the archwire although it
mouth. If he tries to remove it with his tongue, the deep
flanges, which are undercut, will rub on the undercut surfaces
of
588 . The Activator
119.
is difficult to obtain extensive torque with the activator. in environmentally narrowed maxillary arches, but this is
It is important to avoid cutting out the palate in the not necessary if the clinician pays attention to the details
maxillary arch because definite basal bone contact in the noted above.
maxillary and mandibular arches is needed to assist in Heavy gauge dislodging springs are placed passively
maintaining the stretch of muscles and associated tissues against the maxillary first permanent molars and adjusted
that provides the activating forces. If, however, one wishes distally 0.5 mm. These are not intended to move the molars
to expand the maxillary arch, the palate may be distally but to create a dislodging action within the
temporarily removed so that the vertical thrust of the appliance. Such action conditions the patient to bite firmly
appliance against the maxillary arch is delivered against into the appliance to keep it in position; for this reason, the
the lateral portions of the buccal segment alveolar process, dislodging springs act as addi tional activators of the
which is then thrust laterally. Alternatively the palate can muscles of mastication. They also provide friction against
be shaved lightly with an acrylic bur to produce the the mesial of the maxillary first permanent molar and, in
expansion required to change an occlusion from Class II to activators where the acrylic has been trimmed occlusally in
Class 1. The maxillary arch must expand approximately the maxillary buccal segments, tend to prevent its eruption.
one-fourth inch to achieve this change. As an additional Thus dislodging springs assist in the correct manipulation
measure, the maxillary acrylic can be cut on an outward of the functional occlusal plane.
slope (Fig. 34-41) to allow the maxillary buccal teeth to In children with marked overcIosure arid resultant deep
erupt to a greater width. However, this is unnecessary overbite, a vertical relationship of the jaws should be
because the width will change along the maxillary shelf established in which the rest-position face height
(Fig. 34-19) in activators that permit no eruption of the approximates the occlusal-position face height at the
maxillary dentition. A more elaborate wire configuration completion of treatment. To accomplish this objective,
in the buccal area using heavy-gauge wire will hold the considerable eruption must be obtained in the buccal
cheeks laterally and permit further expansion of the segments to eliminate the excess freeway space maintained
maxillary arch if this is desirable. In addition, such a by these patients. In such cases, eruption is permitted in the
configuration will assist the cheeks to hold the appliance maxillary buccal segment as well as the mandibular buccal
in position. Some practitioners routinely expand the palate segments, but the acrylic should only be removed in the
with a removable expansion appliance before placing the maxillary buccal segment area after considerable eruption
activator has been obtained in the mandibular arch. Thus, the buccal
teeth are permitted to erupt in both arches, but the
mandibular buccal teeth are permitted to erupt 3 to 5 mm.
more than the maxillary buccal teeth. This facilitates
correct manipulation of the functional occlusal plane while
at the same time enabling a practical closure of excessive
iriterocc1usal clearances. A lip plumper may be used in
conjunction with light Class II elastics to assist in the
elevation of the mandibular buccal segments
'(Fig. 34-17).
Buccal segment trimming

when expansion is desired THE USE OF THE ACTIVATOR IN THE
MANAGEMENT OF CLASS III
MALOCCLUSIONS
The activator forms a useful method of intercepting
moderate Class III malocclusions that exhibit normal or
slightly less than normal lower face heights. The bite
registration in such cases is obtained by rotating the
Fig. 34-41. The maxillary arch may be expanded by mandible to open at the desired vertical amount outlined in
cutting the acrylic on a outward slope to allow the maxil- bite registrations 1,2, and 3. No protrusive excursion of the
lary buccal teeth to erupt a greater width. While many mandible is obtained in the Class III bite registration.
clinicians achieve expansion in this manner, this is un- The appliance is trimmed to encourage a functional
necessary because the width will change along the maxil- occlusal plane manipulation opposite to that
lary shelf in activators that permit no eruption of the
The Use of the Activator in the Management of Class III Malocclusions' 589
Fig. 34-42. (AJ The lateral LATERAL VIEW OF ACTIVATOR FOR FRONTAL VIEW OF ACTIVATOR
view of a Class III activator
illustrates the acrylic shelf in the
CLASS III CORRECTION FOR CLASS III CORRECTION
buccal segment which inhibits
eruption of the mandibular teeth.
The maxillary teeth are permitted
free downward and forward
eruption. In addition, the acrylic
is trimmed so that the maxillary
incisor teeth are totally free and
contact is made against the
palate opposite the apical third of
the maxillary incisor roots. The
appliance is trimmed in the man-
dibular arch to permit only a
distal eruption of the mandibular
buccal teeth. (1) Areas of hard
acrylic contact with basal
structures and also the labial
surfaces of the incisor teeth. (3)
Acrylic which is left in contact I B
with the occlusal surfaces of the
mandibular buccal teeth and also
3
the mesial surfaces of the III
I A
5sMU
mandibular buccal teeth. (5)
Acrylic which is removed to 3m
permit eruption of maxillary 5 4~1.
teeth and mesial movement of
maxillary teeth. (8) The figure
OCCLUSAL SHELF
illustrates that a total open bite is
created by the bite registration encouraged in a Class II malocclusion. In other words, no
and the appliance is trimmed to
eruption of the mandibular teeth is permi tted while the
permit downward and forward
maxillary buccal teeth are permitted a free downward and
eruption in the entire maxillary
arch in order to allow the forward eruption. In addition, the acrylic is trimmed so
artificially created open bite to that the maxillary incisor teeth are totally free and contact
close. (1) Areas of hard acrylic is made against the palate opposite the apical third of the
contact with basal structures and maxillary incisor roots. A total openbite is thus created by
also the labial surfaces of the the bite registration and the appliance is trimmed to
incisor teeth. (3) Acrylic which permit downward and forward eruption in the entire
is left in contact with the maxillary arch in order to allow the artificially created
occlusal and mesial surfaces of openbite to close (Fig. 34-42A, B). The appliance is
the mandibular buccal teeth. (5) trimmed in the mandibular arch to permit only a distal
Acrylic which is removed to
migration of the mandibular buccal teeth. (It is postulated
permit eruption of maxillary
that the vertical stretch created in all muscles affected by
teeth and mesial movement of
maxillary teeth.
insertion of the appliance will cause a migration of either
the origins or insertions of the muscles and ultimately
restore the resting length of the musculature.) When such
a change is accomplished in combination with vertical
eruption of the maxillary incisor teeth, the direction of
growth expressed at the chin may be altered from
downward and forward to a more vertical direction if the
therapy is long range and is carried through the
prepubertal growth acceleration. Therefore the appliance
is used in an attempt to obtain a permanent alteration in
mandibular posture and mandibular growth direction.
590 . The Activator
Since such an alteration will increase the lower face It was noted previously that the activator cannot
height, it may also increase the lower face height to produce a detailed precise finishing of the occlusion. In
unesthetic levels in those patients who have excessive some instances, it is possible to further refine the
lower face height at the beginning of treatment, Excess occlusion through the use of a tooth positioner. If, before
lower face height is a definite contraindication to Class III initial fabrication of the positioner, the positioner set-up is
treatment with activators. Management of Class III cases mounted on the articulator in a protrusive and vertically
with activators is much more effective in those patients opened bite registration, the positioner achieves an
who have Class III skeletal tendencies in combination activatorlike effect as well as a tooth-positioning effect.
with mesial functional displacement of the mandible and This effect can correct a Class II malocclusion to the
the overclosure that accompanies such conditions. In such extent of one-fourth to one-third of a cusp. Such an
children, the changes initiated by the activator will do articulator mounting must never be used where positioners
much to resolve the total problem without causing further are used to detail the occlusion in cases which were
deterioration in the face. previously Class III. In such problems, the articulator pin
The labial wire configuration (Fig. 34-42A) is used in is merely opened, and the mandible is rotated vertically
the maxillary arch as a maxillary lip plumper or labial without the protrusive bite registration used in Class II
muscle appliance. At each appointment the maxillary bite registrations.
labial portion is activated labially to hold the lips away Specialists in the United States and Canada use the
from the maxillary teeth so that they can continue their activator primarily for orthodontic interception and
downward and forward eruption unimpeded. The labial preorthodontic guidance in the management of major
musculature provides additional thrust to the appliance. It malocclusions. In such management, part of the original
is relieved lingual to the mandibular incisors if the apical base dysplasia is corrected with the activator while
operator desires a moderate amount of lingual tipping of the teeth erupt into improved positions, either in a
these teeth. The precautions relative to contract between conservative or an extraction approach. The activator
maxillary and mandibular basal bone structures and the treatment is then followed by a short phase of multibanded
acrylic (outlined for the Class II activator) apply also to therapy to detail the occlusion and obtain additional
Class III activator. reduction in apical base dysplasia. The general practitioner
should keep in mind that an occlusion finished to the
standard customarily demanded in North America can be
obtained only in highly selected activator cases, and that
additional periods of multibanded therapy are frequently
ADVANTAGES AND DISADVANTAGES OF required.
ACTIV ATOR THERAPY In spite of these limitations, the activator does have
The activator is a limited appliance for use in highly many advantages in the preorthodontic guidance of the
selected cases only. Careful case selection requires a clear occlusion. Its chief advantages are that it provides
understanding of the use of cephalometric radiography in excellent control in the vertical dimension, particularly in
assessing the facial morphology underlying the overclosure cases, and, in the correction of malocclusion,
malocclusion and particularly an understanding of the it uses the existing
assessment of excess lower face height, which constitutes -growth of the jaws to the maximum. During treatment, the
a clear cut contraindication for activator treatment in both patient experiences minimal oral hygiene problems and
Class II and Class III cases. While all orthodontic minimal tissue damage and tissue irritation. In addition,
appliances require patient cooperation, successful use of the intervals between adjustments may be longer than with
the activator requires superb patient cooperation. The conventional orthodontic therapy although it is wise to see
practitioner should not spend undue time with the patient briefly at six- to eight-week intervals to
uncooperative patients but, in his presentation to the maintain the patient's interest. Such appointments are brief
parents, should make provision to change to headgear and usually consist of checking to make sure that none of
therapy or other forms of multi-banded therapy. However, the mandibular buccal teeth are impeded in their vertical
the patient who does poorly with the activator will usually eruption through contact with the acrylic on the lingual of
do poorly with other forms of orthodontic treatment these teeth and recording the overjet so that its reduction
unless the reason for lack of cooperation was nasal may be checked from visit to visit. Since the initial
stenosis. Lack of patient co-operation poses an especially appliance construction and the treatment appointments are
difficult problem for the general practitioner who may not brief, the method can provide more economical treatment
have sophisticated orthodontic mechanisms to fall back in those cases that are suitable for activator correc-
on if the patient does not trust or function correctly with
the appliance first provided.
Indications and Contraindications . 591
ticn. It is further useful in the correction of malocclusion dibular growth trends owing to the increase in lower face
with associated habits, such as thumb sucking and tongue height which usually results if the use of the appliance is
thrusting and indeed the patient may substitute the carried through and beyond the prepubertal growth
activator for the thumb and obtain excellent action with acceleration. Because many problems of severe open bite
the appliance. are associated with excess lower face height, the appliance
will not be useful in the mangement of such problems.
Since incorrect manipulation of the appliance tends to
INDICATIO 5 AND CONTRAI DICATIO S
make mandibular incisor teeth more procumbent relative to
The indications for the activator may be summarized as basal bone, it should not be used in children who have even
follows: moderate amounts of such procumbency before the
It is used primarily in actively growing individuals with initiation of treatment.
favorable facial growth patterns. The appliance cannot be used effectively in children wi
The maxillary and mandibular teeth should be well th nasal stenosis due either to structural problems within
aligned and the mandibular incisor teeth should be the nose or chronic untreated allergy. Some clinicians
positioned upright over basal bone structures. routinely place breathing holes in the appliance to assist
It provides a superb treatment in children who lack their patients during periods of temporary nasal stenosis
vertical development in lower face height because associated with nasorespiratory infections.
differential vertical alveolar development can be readily The appliance has limited application in mature
obtained in either the maxillary or mandibular arch as individuals, although it may be used successfully in such
desired. individuals if the clinician has determined that the patient's
It provides a useful preliminary treatment before major facial morphology will tolerate an increase in lower face
multibanded orthodontic mechanotherapy. height. However, treatment changes tend to be slow in
It is useful for posttreatment retention in children with a adults because the appliance makes use of vertical eruption
deep overbite due to overcIosure. of buccal teeth, and such eruption may be very slow in
The appliance is contraindicated in the following mature individ uals.
situations: Finally, it must be recognized that this method of
The appliance is not useful in the correction of Class I orthodontic treatment is not a panacea. Patients must be
problems of crowded teeth due to disharmony between selected with care and attention must be paid to every
tooth size and jaw size. It may, however, be used to assist detail in its manipulation. Indiscriminate application of the
in the correction of Class II malocclusions where method will do much to discredit this useful addition to the
disharmony between tooth size and jaw size has been clinician's orthodontic armamentarium.
superimposed and is being managed concurrently through
serial extractions.
The appliance is contraindicated in children with excess
lower face height and extreme vertical man-
35
Tissue Changes in Orthodontic Tooth
Movement
KAARE REITAN, D.D.S. PH.D.
This chapter deals with the general aspects of tissue tooth eruption and migration. There may also be movement
changes as observed in various experiments of which the of teeth adjacent to an extraction space, a displacement
conclusions are largely based on observation of humans. partly caused by the pull exerted on the periodontal fibers
Some recent investigations of the anatomy and biology during tissue contraction and healing of the extraction
of the jaws have provided new information on anatomical wound,42,72, partly as a result of bone changes.
details, composition, and behavior of the supporting tissues Guided by the occlusal force certain teeth tend to alter
as submitted to normal function of the dental mechanism. their position, especially following the eruption period.
In spite of the fact that great variations exist anatomically Also, muscular pressure may cause tooth movement. A
and histologically during tooth development and eruption, protruded tooth position in a Class II case may partly be
these variations are nevertheless characterized by the result of stimuli caused by imbalance in the muscle
physiologic tissue behavior and, at times, static periods. function. Experiments have shown that movement of teeth
In comparison, the alterations observed during requires a comparatively light force only. It is the sustained
orthodontic tooth movement are of a more dynamic nature force rather than the amount of force that causes the tooth
as exemplified by increased cell proliferation, changes to move (Fig. 35-2). In young patients a sustained mus-
observed in the root substance, and greater thickness of the cular force need not be greater than 4 or 5 g. to produce
free gingival fibers which become manifest following tooth changes in the position of teeth84 (Fig 35-3).
movement. These observations cannot be made in sections On the other hand, teeth will not change their position
derived from anatomical material. Information of value to during mastication when conditions of equilibrium exist in
the orthodontist must therefore be based on experimental the dental occlusion, when the force is not great enough to
evidence. disturb the equilibrium, or when the force is not sustained.
TISSUE CHANGES AS RELATED TO THE

PHYSIOLOGIC TOOTH MOVEMENT ANATOMICAL ENVIRONME T
From a biological standpoint physiologic tooth Of the two structures, the periodontal ligament and the
movement cannot be produced through the use of alveolar bone, the latter has been in the center of interest
orthodontic appliances. Pressure and tension of varying for a long time. While the English biologist Haver
magnitudes exerted on the periodontal ligament initiate observed osteones as a result of bone transformation (Fig.
tooth movement through bone resorption and bone 35-5), Hunter described bone deposition along periosteal
apposition. Initial compression of the periodontal ligament bone surfaces. The experiments that provided a new theory
is compensated by internal alveolar bone resorption (Figs. of bone transformation were carried out by the French
35-1,35-4) while the stretch of the periodontal ligament is biologist Flourens (1847). He was one of the first to
balanced by bone deposition (Fig. 35-18). demonstrate that pressure wiIl create bone resorption."
These changes-bone resorption on the pressure side and The Germans Wolff (1891) and Roux (1895) called
bone deposition on the tension side-are observed in all attention to the importance of function,66,86 observations
cases where the tooth position is being altered or was which later became part of a theoretical basis of functional
recently altered. In growing persons, physiologic tooth jaw orthopedics. Lack of function may lead to osteoporosis
movement occurs during around nonfunctioning teeth.
592
120. . Continuous Forces' 593
Functional stimuli may strengthen and even shape the bone. A

While these observations are valid for all bone structures,
they do not contradict the fact that orthodontic tooth
movement will cause bone resorption and deposition in
certain areas of the alveoli.
These latter tissue changes usually occur fairly rapidly.
There is nevertheless no evidence to prove that one cannot
combine the principles of active and functional tooth
movement. In the following, the forces exerted by fixed
appliances are called continuous; intermittent is the term +-- ~
applied when the forces are exerted by functional or other Fig. 35-1. (A) Direct bone resorption as
removable appliances. observed during physiologic tooth move-
ment. (8) Indirect bone resorption with
hyaliruzed zone; on the tension sides, bone
deposition.
Fig. 35-2. (Left) Bone re-
sorption during physiologic
tooth movement. Adult case,
fairly dense alveolar bone. H,
formation of Haversian system
(osteone); C, bone cell; 0, one
of several osteoclasts along the
bone surface; P, periodontal
ligament. (Right) Hyalinization,
]2-year-old patient, area
corresponding to B in Fig. 35-1.
Force = 40 g. duration, 6 days.
Arrow indicates direction of
movement of the root. C,
capillaries in hyalinized tissue.
Several pyknotic cell nuclei
persist. P, New connective
tissue cells accumulated around
the hyalinized zone. Height
from P to P approximately ],2
mm. B, Bundle bone divided by
line, L, from old bone. 0,
Osteoid tissue deposited along
the alveolar bone crest. R, Bone
resorption. 0, Bone deposition.
Note
large marrow spaces, M.
CO TINUOUS FORCES
Application of a light sustained force will lead to

compression of the periodontal ligament. There is
simultaneous transformation of some progenitor cells along
the bone surface into bone-resorbing cells, osteolasts. The
ensuing direct bone resorption occurs in physiologic
experiments, as seen in Figures 35-1 and 35-2. During
orthodontic tooth movement direct bone resorption is
observed only when the root is moved parallel to the bone Fig. 35-3. Arrangement for obtaining
surface without causing much compression (Fig. 35-4) and in physiologic tooth movement by muscular
some other carefully conducted experiments.>' In all other forces. Periodic measurements by Weinstein et
cases, with the exception of tooth movement by al. revealed that the experimental tooth moved
without producing any hyalinization on the
pressure side of the root.
594 . Tissue Changes in Orthodontic Tooth Movement
Fig. 35-5. Adult case, one of two semihyalinized zones

along the root surface shortly after undermining bone
resorption was terminated. A, remaining hyalinized tissue
undergoing reconstruction. 0, migrating osteoclasts in area
where originally the bone surface was located. B, Frontal bone
resorption. H, Dense bone, large Haversiar, system.
slightly expanded removable plates." there is initially an puzzle." Thus, in 12- and 13-year-old patients a rapid
indirect bone resorption with hyalinization of one or several widening of the suture may lead to compression and even
small areas of the periodontal ligament. These zones will fractures at the thinnest portion of the bone lamellae (Fig. 35-
subsequently remain ceJlfree until a certain area of the 7).
subjacent bone has been removed by resorption. Behavior of Cell-Free Zones. There has been a tendency to
assume that hyalinization can be avoided during orthodontic
treatment. This has been observed in only a few experiments.
Hyalinization With the exceptions mentioned in the foregoing, all teeth
moved with a continuous or an interrupted force undergo a
Hyalinization, i.e., periodontal tissue with a cellfree, tissue hyalinization period. Its incidence depends
glasslike appearance, was first observed by Sandstedt in
1904/0 rediscovered by Schwarz" and also described by Reitan
and Skillen." Later, semihyalinization was introduced as a
term to indicate a partly cell-free appearance of the
periodontal fibers (Fig. 35-5).58
Hyalinization must be regarded as a nonpathological
reaction to compression of fibrous tissue between two bone
surfaces or between bone and root surfaces. The subjacent
bone rarely, if ever, becomes necrotic in humans. The only
case reported so far has been observed by Oppenheim.v In
more recent experiments human bone cells persisted even
after compression of 50 days' duration.s" A few investigators
have observed necrotic bone in the rat,31,10 and in all
instances there is destruction of a certain n umber of cells and
fibers of the compressed ligament." Hyalinization has been
observed in the sutures of the maxilla (Fig. 35-6),33 and it
most likely occurs in humans during treatment, since in man
the interdigitating bone lamellae of the median suture have an Fig. 35-6. Experimental widening of the median palatine
outline resembling that of pieces in a jigsaw suture in Macaca mulatto. A, Compression of sutural tissue
between bone surfaces with hyalinization and undermining
bone resorption, B. C, Ends of interdigitating bone spicules.
(Courtesy L. Linge: Trans. European Orthodont. Soc. p. 553,
1970)
121.
Continuous Forces . 595
on the duration and magnitude of the compression. Even a A

strong horizontal force of short duration will not cause
formation of cell-free zones, but if such tooth movement is
repeated frequently or sustained there will be compression
and hyalinization. When heavily expanded plates are used,
circumscribed zones of the periodontal ligament may remain
hyalinized for a long time.51; Likewise, tooth posihoners
inserted several days after the fixed appliances have been
removed will cause formation of cell-free zones because
secondary changes in the tooth position will have occurred.
If the alveolar bone is dense, there may be a fairly long
period of hyalinization even if the force is light (Fig. 35-8
right),52 An interrupted strong force, like that obtained with
the extraoral face bow, causes formation of cell-free zones
and indirect bone resorption. Other types of interrupted force
- for instance small increments of torque performed with
Fig. 35-7. A, Median suture in man. B, Following rapid

widening of the suture with fractures of interdigitating bone
lamellae. C, bone resorption of the fracture surfaces before
bone deposition starts. Similar sequence in the calcified tissue
Fig. 35-8. Variation in al- reaction is observed following fracture of dental roots.
veolar bone types. (Left) 12- Compare Fig. 35-39. (Melsen. 5.: Acta Odont. Scandinva.,
year-old patient. Most frequent 29:295, 1971)
type of alveolar bone.
Persisting bone resorption
following movement as indi- measured forces - may lead to direct bone resorption because
cated by anow-duration, 8 the root has been moved over a short distance and parallel to
days; force, 70 g. subsequently the bone surface (Fig. 35-4). In other cases insertion of an
reversed movement for 5 days. archwire with more torque incorporated will always result in a
P, Cell proliferation, initial period of hyalinization.
reconstruction of hyalinized Significance of Hyalinization. The type and extent of
zone. 0, Persisting osteoclasts.
hyalinized zones may vary according to the mag-
M, Indirect bone resorption in
marrow spaces. D, Direct
frontal bone
resorption. R, Resting line in
the bone. C, Alveolar bone
crest. S, Supraalveolar tissue.
Electron microscopic exami-
nation reveals that human bone
subjacent to the hyalinized
zone does not become necrotic
even following application of
strong forces. (Right) Dense
bone, unusual type in 12-year-
old patient. Arrow indicates
"
movernen t of root. Force, 30
\
"
g.; duration, 21 days. X,
Pyknotic cell nuclei. B, Bone '1: ,I (.1 t
surface. 0, Osteoclasts,
undermining bone resorption. ;f
M, Marrow spaces without

formation of osteoclasts. D,
Width of periodontal space *
during hyalinization and F,
following resorption of the , ,
remaining bone.
*"
nitude and duration of the force. From an orthodontic tendency for resorbing cells to attack the bone in areas
standpoint it is desirable to obtain tooth movement as soon around the hyalinized tissue. Since the latter consists of
as possible. Since a small hyalinized zone is more readily compressed collagen fibers, it usually adheres closely to the
removed by bone resorption than a wide zone, it is practical bone surface (Fig. 35-8 right), and most of the cellular
to start movement of anterior teeth by applying a force not elements subjacent to the cell-free zone, including the
exceeding 70 or 80 g. When further tooth movement occurs mesenchymal or progenitor cells, disappear. Thus, usually
after the initial period one may even then obtain a more no resorption starts subjacent to the hyalinized tissue.
rapid displacement by not increasing the force to more than Several variations of undermining resorption exist, largely
100 or 120 g. dictated by the anatomical environment. Resorption around
The height of the cell-free zone shown in Figure 35-2 the hyalinized zone at the inner bone surface, also called
(right) is only 1.2 mm. with about the same width. The frontal resorption, is observed in most cases in addition to
duration of this hyalinization is approximately as seen in other resorbed bone surfaces (Fig. 35-8). If the bone is
Figure 35-13. Generally the initial hyalinization time may dense, as in some animals, the undermining resorption may
vary from 10 to .20 days on the average when the teeth are be of long duration, up to 70 or 80 days. This never occurs
moved with light continuous forces. in human tissue where the bone may contain several spaces
The bone type causes variations in the duration of the and open clefts in which resorbing cells can be forrned.>"
hyalinization period. A flat and dense bone tissue increases The small marrow spaces in certain areas of dense bone
the duration considerably in animal experiments. In young tend to remain without osteoclast formation (Fig. 35-8
patients the inner bone surface usually exhibits openings right). In only one case of a mass of human material could
and clefts, anatomical details that tend to shorten the osteoclastic resorption be observed at the bone crest. The
duration of the hyalinization (Fig. 35-2 righ r). periosteal type of undermining resorption was observed in
The fact that contraction of fibrous tissue during relapse the rat following buccal tipping of molars (Fig. 35-9).22
of the tooth moved also may lead to hyalinization on the The existing types of undermining resorption will then be
opposite side of the root tends to stress the importance of as follows: frontal resorption, resorption in marrow spaces,
the time factor. Even this very light force acting resorption at the alveolar bone crest, and resorption on the
continuously, may create hyalinized zones.t" periosteal side. The first two types are observed quite
Undermining resorption is another term for indirect bone regularly in humans; the latter type has not been seen in
resorption indicating that there is a monkeys, dogs, or humans.
Reconstruction of Hyalinized Tissue. Regardless whether
the force is Ugh t or strong the initial pressure causes
compression and flattening of the periodontalligament in a
circumscribed zone. The width of the periodontal space
before and after hyalinization is seen in Figure 35-8. Still
more compression occurs following application of a strong
force; the
, hyalinized zone will be wider and the hyalinization period of
longer duration. In the graph there may be steps or an
ascending line not indicating clearly the duration of the
hyalinization (Fig. 35-10).59
Very little has been known about what happens to the
soft tissue in a hyalinized zone. Following closure of an
extraction space epithelial and fibrous tissue accumulate
(Fig. 35-11).11 If guttapercha is softened and placed
interproximally so as to exert fairly strong pressure, most of
this accumulated tissue will disappear after a while. In
practice surgical removal is a better way to eliminate such
an excess of soft tissue. To some extent the experiment
illustrates what happens to a compressed hyalinized zone.
New experiments have shown that dissolution of cytoplasm
Fig. 35-9. Hyalinized tissue, H, in the rat. Continuous and cell nuclei starts early, an effect
buccal movement of first molar. S, Alveolar bone surface.
0, Several osteoclasts in Howship's lacunae along the
periosteal bone surface. C, Shrunken bone cell in lacuna.
Periosteal bone resorption in the rat tends to revert into
bone deposition after a certain period of time. (Reitan, K.,
and Kvam, E.: Angle Orthodontist, 41 :1, 1947.)
122.
Continuous Forces 597
Fig. 35-10. Initial hyalinization from the fourth to 1.

0
the 18th day. As a result of excessive increase in the
force, a second hyalinization period started on the
23rd day.
0.6
D.S
ID I~ 14 ID 18 zo ~~ ~3 ~! ~1 3D
which is called pyknosis (Fig. 35-8 right).67,69 There are

initial cellular and vascular changes, but many of the fibrils
in a hyalinized zone retain their cross striation (Fig. 35-12
right). In humans, following application of moderate forces, a
restricted number of compressed fibrils may lose their cross
striated appearence after pressure has been exerted for a
period of 15 to 20 days. Experiments have shown that the
reconstruction phase may occur more or less simultaneoulsy
with the tissue elirn ination.s" It is likely
Fig. 35-12. (Left) The usually

oval nucleus of a human
connective tissue cell partly Fig. 35-11. Accumulation of epithelial and fibrous tissue,
eliminated by enzymes during A, as a result of approximation of two teeth. B, Stretched
hyalinization as seen in the transseptal fibers. C, Bone resorption. D, Bone deposition.
electron microscope. N, Arrow indicates where guttapercha may be placed with the
Center of remaining nucleus. effect of eliminating soft tissue.
S, Clear zone revealing elimi-
nation of nuclear tissue. F,
Collagen fibrils of perio-
dontal ligament (X 20,000).
Similar pyknotic nuclei seen
at X Fig. 35-8. (Right) The
middle area of human hy-
alinized tissue, zone similar to
those observed in Figs. 35-2
and 35-8. Fiber bundles
consist of fibers, which again
are composed of thin fibrils
(diameter 500-800 A). In the
electron microscope one may
observe that the majority of
the fibrils persist during
hyalinization. L, Fibrils cut
longitudinally; C, partly
cross-sectioned. E, Area in
which the fibrils have been
eliminated. Force, 70 g.; du-
ration, 21 days. (X 2,000).
(Rygh, 0., and Reitan, K.:
Trans. European Orthodont.
Soc., In press)
nitude and duration of the force. From an orthodontic tendency f-or resorbing cells to attack the bone in areas around
standpoint it is desirable to obtain tooth movement as soon as the hyalinized tissue. Since the latter consists of compressed
possible. Since a small hyalinized zone is more readily collagen fibers, it usually adheres closely to the bone surface
removed by bone resorption than a wide zone, it is practical to (Fig. 35-8 right), and most of the cellular elements subjacent to
start movement of anterior teeth by applying a force not the cell-free zone, including the mesenchymal or progenitor
exceeding 70 or 80 g. When further tooth movement occurs cells, disappear. Thus, usually no resorption starts subjacent to
after the initial period one may even then obtain a more rapid the hyalinized tissue. Several variations of undermining
displacement by not increasing the force to more than 100 or resorption exist, largely dictated by the anatomical
120 g. environment. Resorption around the hyalinized zone at the
The height of the cell-free zone shown in Figure 35-2 (right) inner bone surface, also called frontal resorption, is observed
is only 1.2 mm. with about the same width. The duration of in most cases in addition to other resorbed bone surfaces (Fig.
this hyalinization is approxi-rnately as seen in Figure 35-13. 35-8). If the bone is dense, as in some animals, the
Generally the initial hyalinization time may vary from 10 undermining resorption may be of long duration, up to 70 or
to.20 days on the average when the teeth are moved with light 80 days. This never occurs in human tissue where the bone
continuous forces. may contain several spaces and open clefts in which resorbing
The bone type causes variations in the duration of the cells can be forrned.t"
hyalinization period. A flat and dense bone tissue increases the The small marrow spaces in certain areas of dense bone
duration considerably in animal experiments. In young tend to remain without osteoclast formation (Fig. 35-8 right).
patients the inner bone surface usually exhibits openings and In only one case of a mass of human material could
clefts, anatomical details that tend to shorten the duration of osteoclastic resorption be observed at the bone crest. The
the hyalinization (Fig. 35-2 right). periosteal type of undermining resorption was observed in the
The fact that contraction of fibrous tissue during relapse of rat following buccal tipping of molars (Fig. 35-9).22 The
the tooth moved also may lead to hyalinization on the opposite existing types of undermining resorption will then be as fol-
side of the root tends to stress the importance of the time lows: frontal resorption, resorption in marrow spaces,
factor. Even this very light force acting continuously, may resorption at the alveolar bone crest, and resorption on the
create hyalinized zones." periosteal side. The first two types are observed quite
Undermining resorption is another term for indirect bone regularly in humans; the latter type has not been seen in
resorption indicating that there is a monkeys, dogs, or humans.
Reconstruction of Hyalinized Tissue. Regardless whether
the force is light or strong the ini tial pressure causes
compression and flattening of the perio.dontal ligament in a
circumscribed zone. The width of the periodontal space before
and after hyalinization is seen in Figure 35-8. Still more
compression occurs following application of a strong force; the
~
hyalinized zone will be wider and the hyalinization
period of longer duration. In the graph there may be steps or
an ascending line not indicating clearly the duration of the
hyalinization (Fig. 35-10).59
Very little has been known about what happens to -the soft
tissue in a hyalinized zone. Following closure of an extraction
space epithelial and fibrous tissue accumulate (Fig. 35-11).11
If guttapercha is softened and placed interproximally so as to
exert fairly strong pressure, most of this accumulated tissue
will disappear after a while. In practice surgical removal is a
better way to eliminate such an excess of soft tissue. To some
extent the experiment illustrates what happens to a compressed
hyalinized zone. ew experiments have shown that dissolution
of cytoplasm and cell nuclei starts early, an effect
Fig. 35-9. Hyalinized tissue, H, in the rat. Continuous buccal

movement of first molar. S, Alveolar bone surface. 0, Several
osteoclasts in Howship's lacunae along the periosteal bone
surface. C, Shrunken bone cell in lacuna. Periosteal bone
resorption in the rat tends to revert into bone deposition after a
certain period of time. (Reitan, K., and Kvam, E.: Angle
Orthodontist, 41:1,1947.)
123.
Continuous Forces . 597
Fig. 35-10. Initial hyalinization from the fourth to 1.0

the 18th day. As a result of excessive increase in the
0.9
force, a second hyalinization period started on the
23rd day.
0.
1
0,6
0,5
10 12 11 16 18 20 22 23 25 21 JO J2
which is called pyknosis (Fig. 35-8 right).67,69 There are

initial cellular and vascular changes, but many of the fibrils
in a hyalinized zone retain their cross striation (Fig. 35-12
right). In humans, following application of moderate forces, a
restricted number of compressed fibrils may lose their cross
striated appearence after pressure has been exerted for a
period of 15 to 20 days. Experiments have shown that the
reconstruction phase may occur more or less simultaneoulsy
with the tissue elimination.s" It is likely
Fig. 35-12. (Left) The usually

oval nucleus of a human
connective tissue cell partly Fig. 35-11. Accumulation of epithelial and fibrous tissue,
eliminated by enzymes during A, as a result of approximation of two teeth. B, Stretched
hyalinization as seen in the transseptal fibers. C, Bone resorption. D, Bone deposition.
electron microscope. N, Arrow indicates where guttapercha may be placed with the
Center of remaining nucleus. effect of eliminating soft tissue.
5, Clear zone revealing elimi-
nation of nuclear tissue. F,
Collagen fibrils of periodontal
ligament (X 20,000).
Similar pyknotic nuclei seen
at X Fig. 35-8. (Right) The
middle area of human hy-
alinized tissue, zone similar to
those observed in Figs. 35-2
and 35-8. Fiber bundles
consist of fibers, which again
are composed of thin fibrils
(diameter 500-800 A). In the
electron microscope one may
observe that the majority of
the fibrils persist during
hyalinization. L, Fibrils cut
longitudinally; C, partly
cross-sectioned. E, Area in
which the fibrils have been
eliminated. Force, 70 g.; du-
ration, 21 days. (X 2,000).
(Rygh, 0., and Reitan, K.:
Trans. European Orthodont.
Soc., In press)
598 ' Tissue Changes in Orthodontic Tooth Movement 124.
that some fibrils will be eliminated by enzymes;82 others may who are looking for a more detailed explanation of the bone
become degraded and split up, but even in experiments of changes.3,5,45
long duration the number of split fibers never exceeded more Since the piezoelectric effect was described in 1957,1'
than 10 per cent of the whole fiber group of the compressed several investigators have stressed the importance of bone
area.68 A more complete elimination of fibrous tissue may bending during tooth rnovement.t-t? Kingsley and Farrar were
occur as a result of compression of accumulated tissue as already of the opinion that flexibility of the alveolar bone
shown in Figure 35-11. In the latter case it is assumed that might be partly responsible for producing displacement of
epithelial cells also may become active in eliminating fibrous teeth. Experimental evidence shows that pressure of the root
tissue." Hence the reaction in the periodontal space is slightly may cause a slight deflection of a thin bone wall in a young
different. Nearly total elimination of fibrous tissue as a result patient. If the bone crest is kept denuded, one may even
of hyalinization has been observed in animals with extremely measure the degree of deflection.
dense bone'" but not in humans. There is, however, one factor which will prevent a
Gradual reconstruction of the hyalinized tissue occurs during permanent bending of the bone.42 The hydroxyapatite crystals
tooth displacernent.w There will be formation of capillaries of bone are laid down in a network of collagen fibers which
and cellular elements with direct bone resorption all along the tend to become rearranged as soon as the pressure is relieved.
bone surface, but the epithelial remnants of Malassez will not If the pressure is maintained, there will be hyalinization and
be recons tructed. 47 undermining bone resorption until a space is created so that the
At this stage of tooth movement the periodontal space may deflected bone wall can move back to its former position (Fig.
become widened up to 0.4 mm. (Fig. 35-8 right). During this 35-14).
secondary period (Fig. 3513), i.e., after a fairly short initial Partly calcified bone on the tension side is frequently
period, there is an increased turnover rate in the periodontal deformed as a result of relapse. This has been observed in
ligament with formation of new cells that facilitate the tissue animal experiments, and it also occurs in humans during the
reaction during the ensuing treatment period (Fig. 35-5). day following treatment with face bow and extraoral force
Theories of Bone Deformation. Up to the present the general (Fig. 35-15, and 35-16).
principles of bone resorption and deposition have been based As regards the secondary effect of bone bending stimulation
on a descriptive interpretation. The finer chemical and of precursor cells, it has not as yet been clearly shown that
mechanical processes that make the tissues react to various there is always a bone deformation factor present in cases
stimuli are still to a large extent unknown. Although where resorbing cells, osteoclasts, are being formed."
. of great practical significance, the existing pressure and Experimental evidence has proved that even slight
tension theory may be considered as unsatisfactory from a compression of the periodontal soft tissue may cause
scientific point of view. A critical approach to the resorption- production of resorbing cells along the bone surface (Fig. 35-
deposition problems is being taken by several present-day 4). During bone formation it has for many years been observed
investigators that not only bone bending but even functional stimuli of short
duration may increase the number of osteoblasts. On the other
hand, the
mm
Fig. 35-13. Duration of the
hyalinization period varies
Fur ther tooth according to the bone type
llIovement (Fig. 35-8) and the force ap-
plied. It is generally shorter
during bodily movement. If
Hyalinization the force is excessive (300500
period g.), other factors, such as bone
Secondary period deformation and extrusion of
the tooth, tend to create an
ascending line instead of a
horizontal one during the
hyalinization period.
Time 10 to 20 days
125. Continuous Forces . 599
----+
~
0
o
a ...r-..:-..
i~
a Fig. 35-15. Bone formation, tension side, middle third of the

root. Rotation of teeth in the dog. New osteoid tends to be laid
~ down along stretched fiber bundles. Arrow indicates direction
A B of root movement. F, Fiber bundles arranged according to the
direction of pull. S, ew uncalcified bone spicule. 0,
Fig. 35-14. (A) Arrow indicates how the Osreoblasts. Compare Fig. 35-16.
tooth has been moved against the bone thus
creating compressed zones in the
periodontal ligament and bone deformation
(dark line). (8) Similar case following
undermining bone resorption and
uprighting of the deformed bone lamella
with periosteal bone formation. (Reitan, K.,
and Kvarn, E.: Angle Orthodontist, 41:22,
1971)
observations made by Bassett and Becker and other

investigntors--" tend to support the theory that sustained
bending may create electronegativity in a surface area of the
bone with formation of osteoblasts. These findings are
supported by autoradiographic experiments, and similar
methods have been used for observation of collagen
formation on the tension side." The most striking example of
periosteal cell production and deposition of osteoid as a result
of bone deformation is observed in the rat.50 In this animal
maxillary bone deposi tion occurs in all instances after a
period of two days' tooth movement. Similar effects have
been observed in the monkey.P-"
The fact that bone remodeling is observed not only along
the bone surface but also in subjacent spaces and canals of the
alveolar bone (U tley 1968), has led to the assumption that a
certain messenger mechanism may become manifest
following the application of forces.83 Justus and Luft have Fig. 35-16. Experiment in the dog, tension side, bodily
proposed a theory according to which mechanical stress movement interrupted during the day. (A) Root surface with
would modify the tension in the individual hydroxyapatite arrow indicating direction of movement during the night. Note
cristals, thus changing their potential solu bility. 28 These effect in the periodontal ligament. (8) Decrease in the cell
chemical alterations could then be transmitted to the bone number partly caused by compression of connective tissue
cells which again would act as a messenger mechanism cells between fiber bundles during tooth movement, partly a
inducing either bone result of the daily relapse movement. Similar effect is
observed in the new bone. (C) One of several deformed bone
spicules as a result of the relapse movement of the root.
Compare with bone spicule in Fig. 35-15.
-+-
~
a
o
a
a
d
A B
Fig. 35-14. (A) Arrow indicates how the
tooth has been moved against the bone thus
creating compressed zones in the
periodontal ligament and bone deformation
(dark line). (B) Similar case following
undermining bone resorption and
uprighting of the deformed bone lamella
with periosteal bone formation. (Reitan, K.,
and Kvam, E.: Angle Orthodontist, 41 :22,
1971)
observations made by Bassett and Becker and other

investigators--" tend to support the theory that sustained
bending may create electronegativity in a surface area of the
bone with formation of osteoblasts. These findings are
supported by autoradiographic experiments, and similar
methods have been used for observation of collagen formation
on the tension side." The most striking example of periosteal
cell production and deposition of osteoid as a result of bone
deformation is observed in the rat. 50 In this animal maxillary
bone deposition occurs in all instances after a period of two
days' tooth movement. Similar effects have been observed in
the monkey.33,38
The fact that bone remodeling is observed not only along
the bone surface but also in subjacent spaces and canals of the
alveolar bone (Utley 1968), has led to the assumption that a
certain messenger mechanism may become manifest following
the application of forces.83 Justus and Luft have proposed a Fig. 35-16. Experiment in the dog, tension side, bodily
theory according to which mechanical stress would modify the movement interrupted during the day. (A) Root surface with
tension in the individual hydroxyapatite cristals, thus changing arrow indicating direction of movement during the night. Note
their potential solubility.s" These chemical alterations could effect in the periodontal ligament. (B) Decrease in the cell
then be transmitted to the bone cells which again would act as number partly caused by compression of connective tissue cells
a messenger mechanism inducing either bone between fiber bundles during tooth movement, partly a result of
the daily relapse movement. Similar effect is observed in the
new bone. (0 One of several deformed bone spicules as a result
of the relapse movement of the root. Compare with bone
spicule in Fig. 35-15.
deposition or resorption in individual areas. Further tooth mobiliry.s-" These untoward effects may usually be
research may disclose whether such a mechanochemical avoided by spot grinding of prominent cusps or by
messenger process could be the explanation of how insertion of a biteplate.
undermining bone resorption or compensatory periosteal When occlusal stress is absent, one may observe that a
bone deposition can start even at some distance from the tooth, being moved bodily, may remain fairly stable even
original pressure sites. after a prolonged treatment period." Tooth mobility may
Observation of a large human material reveals that also be partly eliminated by insertion of a carefully
other factors must be included, especially in cases of adjusted edgewise arch. Initially minor new hyalinized
periosteal bone formation. As shown by Bjork degree and zones may reappear, but provided the teeth have become
onset of formative changes vary individually during the fairly well aligned by initial light wire treatment, the
growth period." Most investigators consider periosteal secondary compressed areas will usually be eliminated
bone deposition in humans as controlled primarily by cfter 10 to 15 days. Such uprighting movement of the teeth
growth hormones. Obviously mechanical stimuli is largely of the interrupted type. It should also be noted
constitute an important trigger rnechanism.':' but it has that a thin edgewise arch will exert a more gentle force
nevertheless been found that equally strong forces applied than a thicker arch and thus shorten the period of
in patients of the same age group may cause appreciable hyalinization.
variations in the production of new periosteal bone Internal Bone Deposition. The age factor. The tissue
layers." changes that occur on the tension side along the internal
The Posthyalinization Period. Increase in the number of alveolar bone surfaces are apparently less dependent on
new connective tissue cells is typical of the tissue reaction the existing hormonal factors, but one may stilI observe
observed following hyalinization, During this period the that the time of onset and the amount of new bone formed
osteoclasts in Howship's lacunae along the bone surface vary according to the age of the individual. In young
tend to overreact. These multinuclear cells are patients there are more cells in the periodontal tissue, and
periodically reconstructed. Some cellular units will move during tooth movement new cells are formed rapidly by
away from the original osteoclasts, and new units are mitotic cell division.:" In 'children, evidence of osteoid
added so that the resorbing cells are maintained.s? Once formation is observed after tension has been applied for a
started, bone resorption continues for a period of up to 10 period of 30 to 40 hours, occasionally after 20 hours (Fig.
or 12 days even if the force is interrupted.4858 In 35-17 and 35-18).84
comparison, physiologic tooth migration reveals a less Adults require more time to overcome the static
dynamic bone resorption which may be of shorter condition of the tissues. It takes about 4 times as long to
duration and without formation of overreactive osteoclasts initiate tissue changes in the adult as in the child. After a
(Fig. 35-2 left). period of 4 days, following application of a force of 50 to
Generally, the posthyalinization period is initiated as 60 g., the tension side of an adult tooth reveals only a
soon as the bone of the subjacent area has been slight increase in the cell number but no osteoid bone
eliminated, 3 or 4 weeks after the treatment was started. formation as seen in young patients.?' In adults, after a
During this period, a continuously acting light force, 70 to week, some osteoid is seen along stretched alveolar fibers
80 g. or less, not reactivated too frequently, will create and still more
more rapid tooth movement than will a stronger , bone formation occurs after periods of 2 or 3 weeks (Fig.
force.53,81 This light force effect is readily explained by 35-19).
what can be observed in the tissues. A strong force will On the pressure side, there is initially an incipient
create new hyalinized areas which again may delay tooth undermining resorption process observed in adjacent
movement (Fig. 35-10). marrow spaces, but only pyknotic cell nuclei i!l the
Tooth Mobility. During the posthyalinization period periodontal ligament, indicating that compression has
tooth mobility may become manifest as a result of started. This slow reaction is caused by the thickness and
widening of the periodontal space following undermining resistance of the periodontal fiber bundles in adults.
bone resorption;" This mobility is especially noted in Hyalinization occurs in all adult patients and, provided the
cases where the relationship between occluding cusps has force is light, undermining bone resorption is usually
been altered. In practice, it is usually not the orthodontic terminated after a period of 3 to 4 weeks. In adults, tooth
force, per se, but occlusal interference that produces any movement and bone changes occur with bone resorption
marked mobility. Certain biophysical changes in the slightly ahead of bone deposition. Extreme pressures
ground substance and the circulation may predispose to should be avoided since teeth with alveolar bone loss may
be jeopardized by such forces.
Fig. 35-17. Twelve-year-old

patient. (Left) Control material,
periodontal ligament with many
young connective tissue cells. P,
Preexisting thin cementoid layer. L,
Demarcation line between bundle
bone and old bone. 1, Interstitial
spaces cut longitudinally. R,
Primary cementum of root surface.
(Right> Same individual,
experimental tooth, arrow indicates
direction of movement. Force, 70
g.; duration, 46 hours. Note
increase and '5, spreading of
cellular elements, a finding which
is typical of initial tooth movement
in a young individual. 0, New
osteoid formed during 46 hours.
Fig. 35-18. Twelve-year-old patient, tension side, area

between marginal and middle thirds of the root. A, Epithelial
tissue. B, New bone formed during 10 days. D, Demarcation line
between new and old bone. Lower arrow indicates cell
proliferation zone in which new fibrils and bone spicules are
formed. Force, 70 g.
Fig. 35-19. Patient close to

40 years, tension sides, two
stages of bone formation, force
50 g. (Left) B, dense lingual bone
wall, typical of adult cases. P,
Periosteal tissue. 0, New
osteoid formed during 2 weeks.
R. Reversal line following root
resorption as a result of trauma.
5, Completely reconstructed
resorption lacunae after a period
of approximately 20 years.
(Right> Bone deposition fol-
lowing 3 weeks' movement. H,
Osteones, dense bone. D,
Demarcation line between new
and old bone. N, Bone spicules
along thick fiber bundles, bone
deposition not resembling that
observed in young patients (See
Fig. 3518).
During the posthyalinization period, tooth movement the apical portion is not fully developed. Initial tipping of
should be performed with light forces not too frequently adult teeth may reveal a fulcrum situated in the apical third
reactivated. Since there may be a tendency to resorption of of the root. This is caused by the stronger fiber attachment
the alveolar bone crest in adults, it is important to move the of adult teeth."
teeth within the existing bone limits and preferably in a Force Variation. Interrupted movement indicates that a
mesial or distal direction. Bodily movement constitutes the continuous pressure acting on a tooth is released after a
best method of displacing canines and premolars over a certain period or during certain rest periods (Fig. 35-20).
perceptible distance. Even strong forces may be applied in cases where the active
force is frequently interrupted.t? In treatment with a face
bow the extraoral force may vary between 200 g. and 800 to
900 g. Experiments have shown that the direction of mov-
METHODS OF TOOTH MOVEMENT
ing first molars against second molars constitutes an
Tipping Movement. In young patients one may important factor." There is always hyalinization and
frequently observe that a spring, exerting a force of only 30 undermining bone resorption. In certain cases the
to 40 g. on a tooth, will cause a rapid displacement of its interproximal bone lamellae will be partly eliminated, but
crown. In such a case undermining bone resorption, which the bone crest is always reconstructed in children during the
may not last more than 10 to 12 days, will be followed by posttreatment period.
direct bone resorption in an area adjacent to the marginal Interruption of continuously acting forces may be of
third of the root. At the same time the apical root portion great practical significance even when the force applied is
will be displaced in an opposite directiorr'" (Fig. 35-11). A light. Histologically the rest period is characterised by an
rapid tipping movement can be performed over a short increase in the number of young connective tissue cells on
distance without causing any untoward effects. Among the the pressure side as well as on the tension side. Even if
disadvantages of a tipping movement are jiggling of the there is an overreaction of resorbing cells on the pressure
tooth caused by occlusal interference and in some cases side: one may observe some osteoid deposited in adjacent
apical root resorption. A tooth moved by tipping alone may marrow spaces. There is also reorganization and
end, in an inclined position, thus enhancing tendencies to calcification of newly formed osteoid on the tension side. In
posttreatment disturbances of the supporting tissues. addition, there is a certain relaxation of
Tipping movement is nevertheless necessary in all types
of orthodontic treatment. It occurs when thin round
archwires are inserted for initial tooth alignment.
Radiographic examination of some teeth may be advocated
in order to control the effect of the forces applied.
Location of the fulcrum in a tipping movement varies
largely according to the length of the root and the age of
the patient. In young persons it may be located close to the
marginal third of the root if
Fig. 35-21. Effect on the supporting tissues during

tooth intrusion, middle third of root in the dog. A,
Fig. 35-20. Canine and second premolar approximated Epithelial remnants of Malassez. B, Partly calcified
by interrupted force, arch wire activated by ligature tied to tissue laid down along stretched fiber bundles. C,
staples. Periodontal ligament.
128. Methods of Tooth Movement 603
the supraalveolar fibers which apparently tend to become

rearranged during the rest periods.
In all types of tooth movement there are not only changes
in the alveolar bone but even alterations in the cementum and
dentin of the roots, such as root resorption. During the rest
period of an interrupted movement initial repair of resorbed
lacunae of the root has been observed. This finding may partly
explain the fact that generally tooth movement based on the
interrupted principle reveals less root resorption than
treatment performed with typical continuous forces.
There is no prerequisite that the active force in an
interrupted movement should be fairly strong. It is necessary Fig. 35-22. Light interrupted force. Since ex-
to apply a light interrupted force in certain types of movement trusion of teeth occurs rapidly, the force must not
such as displacement of anterior teeth in open bite and exceed 30 g. Thickness of spring 0.010" or 0.012".
closedbite cases. The interrupted light wire principle has been Vertical elastics must be placed between anchor
applied in cases where conventional methods tend to cause teeth.
apical root resorption. Intrusion of anterior teeth in adults can
be performed without any visible destruction of the root
substance provided the force is light enough and interrupted
during spaced penods." During this type of treatment thin
light wire sections (0.012") may be used for movement of the
anterior teeth. The force exerted on each tooth should not
exceed 30 g. (Fig. 35-21).
The interrupted principle is also a recommended method
for extrusion of anterior teeth in openbite.F' Light sectional
arches, as seen in Figure 35-22, may be ligated to the brackets
of the teeth to be extruded. The force should be 30 g. or less
and applied so as to
Fig. 35-23. Resorbed lacunae, R, as observed following

tooth rotation in a dog. This type of root resorption does not
lower the stability of the tooth.
Fig. 35-24. (Left) Rapid repair

by cellular cementum
following rotation of tooth in a
dog. Compare with areas
shown in Fig. 35-23. A, Aper-
tures of Haversian systems,
extremely dense bone. B, Re-
versal line between dentine and
cellular cementum deposited in
resorbed lacunae. C, ewly-
formed bundle bone. (Right) A,
fiber bundles not rearranged , '
after retention of rotated tooth
for several months. B, Control
tooth with interproximal tissue.
C, Area between displaced and
normally arranged supporting
fibers.
.....
.
A~ ,
'
act on individual teeth for a period of 5 to 6 weeks. This tinuous with the whole fiber system of the area. Fiber
movement causes elongation of individual supraalveolar tension of the supraalveolar ligament will cause
fibers. Changing the force application from one tooth to displacement of the tissues located even at some distance
another may in the end cause bone formation in the apical from the rotated tooth (Fig. 35-25). It has been observed
crest areas. Following further alignment by conventional that the rearrangement and the turnover rate seem to
arches, a stable tooth position will be obtained. remain slow as long as the stretching continues. In
Rotation of Teeth. Rotation constitutes a complex addition, when the tooth is released following rotation,
movement. During treatment the tooth may become partly there is always some contraction of displaced elastic tissue
tipped and pressure zones'" will form. Other areas of the which will result in relapse of the tooth moved."
root will be moved more or less parallel to the bone In spite of this effect, it has been observed ex-
surface. Because of the oval shape of the roots of some perimentally as well as in practice that overcorrection
teeth cell-free areas may be formed by compression followed by a prolonged -retention of the rotated tooth
against the alveolar bone, especially in the initial stage of may in the end lead to rearrangement of fibrous tissue and
tooth rotation. If the root does not move parallel with the a stable tooth position. Some relapse will occur initially,
bone surface, root resorptions are frequently observed but it will be compensated for by the over-correction. The
during rotation (Fig. 35-23). These resorbed areas are final result is largely dependent on a sufficiently long
repaired by cellular cementum when movement is period of retention which will provide time for
discontinued (Fig. 35-24). rearrangement of the supraalveolar fibers.
The periodontal fiber bundles are stretched and partly Surgical methods also have been applied to prevent
elongated in rotation rnovement.P Experiments have relapse following rotation. Sk6gsborg advocated
shown that there is a great difference between the reaction transsection of the interdental septums,"; a method which
that occurs in the supraalveolar tissues as compared with has been modified in our time. A circular incision in the
that of the principal fibers. Following rotation the fibers soft marginal fibrous tissue parallel to the root surface will
running from bone to root surface will be rearranged after relieve the tension caused by contraction of supraalveolar
a few months. The free gingival or supraalveolar fibers structures."
react differently." In many cases they seem to become The best method of retaining teeth is to perform rotation
slightly thicker, but they still appear to be without any early before the apical portion of the root is fully
marked increase in the cell number. In addition, during the developed. New fiber bundles formed during root
retention period they may remain stretched and displaced development will assist in maintaining the corrected tooth
for a long time (Fig. 35-24 right). Experimentally position.
displacement of these fibers was observed following a Bodily Movement. Bodily displacement of a tooth
period of 232 days.63 Marked stretching of the implies that the root is moved more or less parallel to the
supraalveolar structures occurs because the free gingival bone surface. The difference in the reaction between
fibers are con- tipping and bodily movement is due largely to mechanical
conditions. Initially, bodily movement
Fig. 35-25. Old and new

concepts concerning the ar-
rangement of fiber bundles of
importance during tooth
movement. (Left) F, fibers of
the periodontal ligament. AP,
Alveolar bone. C,
Cementum. (Churchill-
Meyer). (Right) A,
supraalveolar bundles con-
taining elastic and oxytalan
fibers. B, Dentogingival fi-
bers. Compare Fig. 35-40.
Intermittent Forces, Removable Appliances' 605
causes a slight tilting of the tooth being moved. Since the

tooth is maintained by the bracket, the root portion is
subjected to the mechanical principle called couple. In 3
practice this effect causes hyalinization, a compressed
area which will be located more towards the middle
portion of the root than in a tipping movement.P' After
undermining resorption has occurred, further bodily
movement tends to create bone resorption all along the
pressure side of the root. Likewise on the tension side all
the fiber bundles will gradually undergo stretching
followed by bone deposition in the areas subjected to fiber
tension (Murphy 1970).42
The force application in a bodily movement is largely
dictated by the principles discussed previously. It is
important to provide time for the undermining resorption
to be terminated. Application of a light initial force is the
recommended method especially in adult cases. Following
the hyalinization period a greater force can be applied
because the force is distributed along the entire length of
the root.
Fig. 35-26. Principle of frictionless
Bodily movement may be continuous or interrupted bodily movement. Experimental evi-
(Fig. 35-20). In a typical continuous movement over a dence has demonstrated that initial
given distance it should be noted that friction in the compression occurs in area 1. Fol-
bracket area may cause a delay in the movement. Thus, a lowing undermining resorption there
careful planning of the mechanics involved constitutes an is subsequent compression in areas 2
important part of the procedure. and 3. Initial force, 80 to 100 g_
The mechanical problems involved have led to the Stretched fiber bundles on the
constructions of frictionless appliances.P Such con- tension side cause uprighting of the
structions are only applied in special cases. The method tooth during further movement.
implies that the tooth is not maintained by the bracket but
instead uprighted by the action of the coils incorporated in
the archwire. (Fig. 35-26). The root will be alternately tissue alterations are nevertheless less marked as compared
slightly tipped and reuprighted, a principle which must with those elicited by intermittent forces.2155
include a careful planning of the appliance construction as The intermittent type of reaction as obtained by
well as the amount of force applied. Apical root resorption removable plates and similar constructions, including the
can only be avoided if these rules are followed. Crozat appliance.i" is characterized by the production of
An appliance which produces a typical bodily an abundance of cellular elements on the pressure side as
movement is the edgewise arch. By this method one may well as on the tension side. This effect is caused by the
even obtain parallel movement of groups of teeth. The fact that the teeth are submitted to movement for certain
force factor is important in this procedure. Application of periods with a series of interruptions. The teeth will
thin archwires causes a minimum of disturbances in the remain in normal function for a certain part of the
supporting tissues and the root. treatment especially when the appliance is temporarily
removed. These rest periods cause a relaxation of the
supporting tissues with formation of new connective tissue
cells (Figs, 35-27 and 35-28).
As an exception one may mention cases in which there
are individual variations with less tendency to proliferation
of cellular elements. In an experimental series including
tissue from 31 young patients five revealed less increase in
INTERMITTENT FORCES, REMOVABLE the number of new cells than was seen in the other cases.
APPLIANCES Such variations are primarily caused by individual
hormonal factors.
The difference between interrupted and intermittent
forces is primarily important from a histologic point of Fixed and Loose Plates. Much emphasis has been
view. Interrupted forces are related tofixed appliances placed on the fact that functional appliances, such as the
(Fig. 35-20). Although there is an increase in cellular activator, remain loose in the mouth.P Ex-
elements during the rest periods, these
Intermittent Forces, Removable Appliances . 605

3
subjected to the mechanical principle called couple. In
practice this effect causes hyalinization, a compressed area
which will be located more towards the middle portion of the
root than in a tipping movement." After undermining
resorption has occurred, further bodily movement tends to
create bone resorption all along the pressure side of the root.
Likewise on the tension side all the fiber bundles will
gradually undergo stretching followed by bone deposition in
the areas subjected to fiber tension (Murphy 1970).42
dictated by the principles discussed previously. It is important
to provide time for the undermining resorption to be
terminated. Application of a light initial force is the
recommended method especially in adult cases. Following the
hyalinization period a greater force can be applied because the
force is distributed along the entire length of the root.
Bodily movement may be continuous or interrupted (Fig.
35-20). In a typical continuous movement over a given Fig. 35-26. Principle of frictionless
distance it should be noted that friction in the bracket area bodily movement. Experimental evi-
may cause a delay in the movement. Thus, a careful planning dence has demonstrated that initial
of the mechanics involved constitutes an important part of the compression occurs in area 1. Fol-
procedure. lowing undermining resorption there is
The mechanical problems involved have led to the subsequent compression in areas 2 and
3. Initial force, 80 to 100 g. Stretched
constructions of frictionless appliances.t" Such constructions
fiber bundles on the tension side cause
are only applied in special cases. The method implies that the
uprighting of the tooth during further
tooth is not maintained by the bracket but instead uprighted movement.
by the action of the coils incorporated in the archwire. (Fig.
35-26). The root will be alternately slightly tipped and reup-
righted, a principle which must include a careful planning of
the appliance construction as well as the amount of force tissue alterations are nevertheless less marked as compared
applied. Apical root resorption can only be avoided if these with those elicited by intermittent forces.2155
rules are followed. The intermittent type of reaction as obtained by removable
An appliance which produces a typical bodily movement is plates and similar constructions, including the Crozat ap pli
the edgewise arch. By this method one may even obtain ance.P is characterized by the production of an abundance of
parallel movement of groups of teeth. The force factor is cellular elements on the pressure side as well as on the tension
important in this procedure. Application of thin archwires side. This effect is caused by the fact that the teeth are sub-
causes a minimum of disturbances in the supporting tissues mitted to movement for certain periods with a series of
and the root. interruptions. The teeth will remain in normal function for a
certain part of the treatment especially when the appliance is
temporarily removed. These rest periods cause a relaxation of
the supporting tissues with formation of new connective tissue
cells (Figs. 35-27 and 35-28).
As an exception one may mention cases in which there are
individual variations with less tendency to proliferation of
cellular elements. In an experimental series including tissue
from 31 young patients five revealed less increase in the
number of new cells than was seen in the other cases. Such
I TERMlTTE T FORCES, REMOVABLE variations are primarily caused by individual hormonal factors.
APPLIANCES Fixed and Loose Plates. Much emphasis has been placed on
The difference between interrupted and intermittent forces the fact that functional appliances, such as the activator,
is primarily important from a histologic point of view. remain loose in the mou th.P Ex-
Interrupted forces are related to. fixed appliances (Fig. 35-20).
Although there is an increase in cellular elements during the
rest periods, these
Intermittent Forces, Removable Appliances . 605

3
subjected to the mechanical principle called couple. In
practice this effect causes hyalinization, a compressed area
which will be located more towards the middle portion of the
root than in a tipping movement.s! After undermining
resorption has occurred, further bodily movement tends to
create bone resorption all along the pressure side of the root.
Likewise on the tension side all the fiber bundles will
gradually undergo stretching followed by bone deposition in
the areas subjected to fiber tension (Murphy 1970).42
dictated by the principles discussed previously. It is important
to provide time for the undermining resorption to be
terminated. Application of a light initial force is the
recommended method especially in adult cases. Following the
hyalinization period a greater force can be applied because the
force is distributed along the entire length of the root.
Bodily movement may be continuous or interrupted (Fig.
35-20). In a typical continuous movement over a given Fig. 35-26. Principle of frictionless
distance it should be noted that friction in the bracket area bodily movement. Experimental evi-
may cause a delay in the movement. Thus, a careful planning dence has demonstrated that initial
of the mechanics involved constitutes an important part of the compression occurs in area 1. Fol-
procedure. lowing undermining resorption there is
The mechanical problems involved have led to the subsequent compression in areas 2 and
constructions of frictionless appliances.!" Such constructions 3. lnitial force, 80 to 100 g. Stretched
are only applied in special cases. The method implies that the fiber bundles on the tension side cause
uprighting of the tooth during further
tooth is not maintained by the bracket but instead uprighted
movement.
by the action of the coils incorporated in the archwire. (Fig.
35-26). The root will be alternately slightly tipped and reup-
righted, a principle which must include a careful planning of
the appliance construction as well as the amount of force tissue alterations are nevertheless less marked as compared
applied. Apical root resorption can only be avoided if these with those elicited by intermittent forces.21,55
rules are followed. The intermittent type of reaction as obtained by removable
An appliance which produces a typical bodily movement is plates and similar constructions, including the Crozat appl
the edgewise arch. By this method one may even obtain iance.P is characterized by the production of an abundance of
parallel movement of groups of teeth. The force factor is cellular elements on the pressure side as well as on the tension
important in this procedure. Application of thin archwires side. This effect is caused by the fact that the teeth are sub-
causes a minimum of disturbances in the supporting tissues mitted to movement for certain periods with a series of
and the root. 'interruptions. The teeth will remain in normal function for a
certain part of the treatment especially when the appliance is
temporarily removed. These rest periods cause a relaxation of
the supporting tissues with formation of new connective tissue
cells (Figs: 35-27 and 35-28).
As an exception one may mention cases in which there are
individual variations with less tendency to proliferation of
cellular elements. In an experimental series including tissue
from 31 young patients five revealed less increase in the
number of new cells than was seen in the other cases. Such
INTERMITTENT FORCES, REMOVABLE variations are primarily caused by individual hormonal factors.
APPLIANCES Fixed and Loose Plates. Much emphasis has been placed on
The difference between interrupted and intermittent forces the fact that functional appliances, such as the activator,
is primarily important from a histologic point of view. remain loose in the mouth." Ex-
Interrupted forces are related tofixed appliances (Fig. 35-20).
Although there is an increase in cellular elements during the
rest periods, these
606 . Tissue Changes in Orthodontic Tooth Movement 129.
130.
mum will occur if the appliance is too much expanded. If not too
1.0 much force is exerted, direct bone resorption can be expected
to occur. Once started this resorption process will go on for
several days even if the appliance is removed. Occasionally
0.7 small hyalinized zones may be observed in the periodontal
ligament on the pressure side even when the force is moderate,
0.5 but the duration of these zones is usually shorter than in a
O.li continuous tooth movement.v-"
0.0 On the tension side deposition of osteoid may be observed
after a treatment period of 2 to 3 days. Osteoid tissue will not
be resorbed by osteoclasts and even if the tooth moves back
toward the tension side during the rest period, the osteoid
. 7 Q 11 13 15 layers will persist and new tissue will be added when the ap-
Days pliance is reinserted (Fig. 35-28).
Fig. 35-27. Graph illustrating duration of hyalin- The degree of tooth movement is especially influenced by
ization in tooth movement with removable plate, from the time factor. If a moderately expanded appliance is used
ninth to 13th day. Force approximately 80 g.
also during the day, there will be a fairly rapid tooth
movement. As a disadvantage one may mention that the teeth
periments have shown that the action of these appliances is are tipped. Gradual reuprighting of such teeth may occur in
also influenced by the individual variations in the properties many cases, but one may also observe that individual teeth or
of the tissues. In addition it is not always possible to groups of teeth may end up in an inclined position, especially
distinguish between the tissue response elicited by loose and in Class III cases.
fixed removable plates on the basis of histologic findings. On Reaction in Muscles. As a secondary effect one may observe
the other hand, there is definitely a histologic difference alteration in the contraction pattern of the masticatory
between the tissue reaction caused by fixed appliance muscles.' This is observed in some but not all Class II cases
treatment as compared with that seen following treatment by following application of appliances of the activator type.55
removable appliances. In the latter case the relaxed position Much of this effect is dependent on correct construction of the
of the root and the increased number of cells are characteristic appliance, secondly the type of intercuspation of the dental
of intermittent forces. arches as well as the degree of overbite. Under
In practice, the action of removable plates is subjected to
the time and force factors. Hyalinization
\ Fig. 35-28. (Lejt) Incidental

t \ finding in 12-year-old patient
following activator treatment,
_C fairly strong force acting for 12
nights. (Left) Pressure side. Hy-
alinization existed along the root
8 t. t
surface. A, Migrating osteoclasts.
B, Frontal resorption with
ostoclasts. C, Alveolar bone.
(Right> relaxed tissue on the ten-
sion side. D, demarcation line
between old and new bone. 0,
Partly calcified tissue bordered
with osteoblasts.
Tooth Movability' 607
ideal conditions activator treatment may cause rapid is light, one may even observe a similar opaque area ahead of
improvement of muscular imbalance, especially in extreme the root of the moving tooth. The lamina dura, therefore, may
Class II cases. This observation has led to thecombination of be used as a diagnostic aid to indicate the direction of tooth
methods: initial treatment by removable appliances and movement during active treatment and also during migration
subsequently fixed appliance treatment.s" of teeth (Fig. 35-29). It should be noted that the apparent
thickness of the lamina dura depends on the method of
radiography. The direct rays determine the thickness shown on
the radiogram.
TOOTH MOVABILITY
Actually the thickness of the lamina dura may not be as
The periodontal ligament is the most important structure in wide as that shown on the x-ray picture. The appearance of the
all types of tooth movement. The ligament supports the teeth, lamina dura on the radiogram depends on the shape of the
supplies sensory impulses, and carries nutrition. It is generally tooth and on the way in which the central x-ray beam faces the
recognized that the width of the periodontal ligament is lamina dura. Interpretations of the appearance of the lamina
greatest adjacent to the marginal and apical thirds of the root, dura, therefore, should be guarded because of distortions. In
anatomical characteristics which soon disappear as the tooth addition, areas examined histologically may disclose that what
is moved orthodontically. is shown on the radiogram as regards the thickness of the
Although most teeth subjected to orthodontic forces will lamina dura does not always correspond to the histologic
move, it is nevertheless found that the degree of movement findings. It is also a fact that what has been termed bone
varies according to the individual tissue reaction. As regards density is very seldom observed in young human structures.
the general aspects of tooth movability most practitioners On the contrary, examination of a great mass of material
agree that (1) teeth are moved more readily by light than by indicated that the bone in some young persons contain more
heavy forces, (2) tipping movement constitutes the fastest canals and spaces than in others,52 a factor which may
method of displacing the coronal portion of a tooth, and (3) influence tooth movability (Fig. 35-8 left).
teeth of young persons are moved more readily than those of Systemic Factors. Variation in tooth movability was
adults. observed in an experimental series comprising a fairly large
A closer examination of these statements will reveal that number of young patients undergoing observation over a
there are exceptions, some of which are related to the existing period of 12 to 13 months.
type of bone and fibrous tissue, others to systemic or Face bow combined with extraoral forces was selected as
hormonal imbalance?" and also local disturbances in the the method of treatment. Periodic measurement of the degree
periodontal ligament. of movement indicated that the magnitude of force was of
The Lamina Dura. As observed radiographically, the importance, but the influence of the individual tissue reaction
lamina dura becomes thinner and less radiopaque when the was of still greater significance. In some cases the tissues of
tooth comes into full occlusion following eruption.P" During sisters or brothers appeared to react similarly. The
tooth movement an increased thickness in the radiopaque
layer may be observed primarily on the tension side. If the
force
Fig. 35-29, Frictionless bodily

movement. (Left) C, canine moved
in contact with second premolar,
S. N, New bone layers. L, Lateral
incisor. (Right) Movement of
canine, C, arrested by piece of
root left in alveolus of first pre-
molar. X.
608 . Tissue Changes in Orthodontic Tooth Movement 131.
conclusion of these findings would be that certain hereditary as a small root tip left in the alveolus after extraction. Hence, it
factors may influence tooth movement. If one member of a may be considered a biological law that tooth movement will
family has molar teeth which are readily displaced, one may be arrested as long as pieces of calcified tissue, such as
expect that other members of the same family would react in a cementicles and odontomas, remain in the periodontal
similar manner. ligament. Following surgical removal of such obstacles the
The biological background of such findings is being adjacent teeth will move as intended. (Fig. 35-30).
investigated. Histologically there is a bone factor of large The Tooth Position. In addition to the factors related to an
marrow spaces (Fig. 35-2 right) and short hyalinization obstruction in the vicinity of the root, the inclination of the
periods. This type of human bone is entirely different from tooth to be moved may be the cause of a retarded movement
certain animal tissues (Fig. 35-24 left). Secondly there is a (Fig. 35-31). Although originally of a mechanical nature, such
fibrous tissue factor. Patients whose teeth are moved readily retarded tooth movability depends on biological factors, a
over a great distance reveal a turnover rate that facilitates a tendency to intrusion of the tooth to be moved and thus longer
rapid elongation and transformation of the supporting tissues. hyalinization periods and more bone to be resorbed. This well
These variations in the tissue reaction have not been fully known principle constitutes the basis of the prepared
examined and remain a problem for further investigation. anchorage philosophy. It has been observed experimentally
In contrast to the increased metabolic rate, a few cases have that inclined teeth will move much slower than teeth that are
been observed in which systemic disorders and hormonal upright before orthodontic force is applied. 53
imbalance may cause retarded eruption and slow movement Impacted Teeth. The same mechanical and biological
of the teeth. These cases are not numerous and it is not as yet factors are present in the movement of impacted teeth with
proved that the slow movability of these teeth is related to delacerated or curved roots. Certain teeth with malformed
hereditary factors. roots are difficult to extrude because there is recurrent
Local Disturbances. While there is no perceptible hyalinization and tissue compression with a large area of bone
difference in the degree of movability of devitalized and vital to be resorbed (Fig. 35-32). Theoretically surgical resection of
teeth either in their gross or histologic aspects,26,61 arrested the root end followed by root filling would facilitate extrusion
or retarded movement of a nonhereditary origin may be of the tooth. Another solution of the problem would be
caused by various obstacles located in the periodontal surgical removal of bone, a method which has been advocated
ligament (Fig. 35-29). The force applied in frictionless bodily by some practitioners."
movement varies around 80 to 100 g. Even conventional tooth In general, impacted teeth in the lower jaw can be extruded
movement may be arrested by obstacles such and moved into position more readily than teeth in the upper
jaw. Adult cases have been observed in which impacted
canines in the lower jaw could be brought into occlusion while
it was not possible to move the maxillary canines. To what
extent dense calcified centers of the maxillary sinus
A
I
I
-
Fig. 35-30. Adult case. C, Cementicle which will cause
retardation in the tooth movement. Similar effect may be Fig. 35-31. Mesially inclined canine, A,
caused by odontomas. B, Alveolar bone; M, epithelial will resist tooth movement. It can be moved
remnant. bodily when uprighted to B.
Tooth Movability . 609
walls may cause a retardation in the movement of canines

has not been clarified.
Hypercementosis. Generally ankylosis of impacted teeth
may be caused by two types of tissue disturbances. The
first is related to root resorption of unknown origin
followed by bone deposition in the resorbed lacunae of the
root (Fig. 35-33). In many instances arrested movement
may be found on one side only. The second type of tooth
impaction is caused by hypercementosis.s? Typical of the
roots covered by hypercementum are the incremental lines
observed in sections of the teeth. Although incremental
lines are seen in most electron microscopic sections of
normal teeth,17,73 these lines are usually not visible in the
light microscope.
In contrast, hypercementotic lines are conspicuous in
the light microscope (Fig. 35-34). Not unfrequently these
lines are laid down symmetrically like those observed in
the cross-sectioned trunk of a tree (Fig. 35-35).
Hypercementosis of a minor degree not influencing tooth
movement has been observed by me in an examination of Fig. 35-32. Extrusion of the premolar tends to create
an extensive human material.>' hyalinization of long duration in area X. Application of
a light force, frequently interrupted, may solve the
Other cases have revealed that hypercementosis causes
problem. F, New bone layers.
ankylosis and that it is a hereditary disturbance. Several
members of the same family may
become affected. It was also found that it is some time
before the effect of this anomly becomes manifest. Front
teeth were not involved, but premolars and molars were. In
molars, ankylosis usually starts in the bifurcation area the
effect of which is curva-
Fig. 35-34. Hypercementosis. A,

Ankylosis between alveolar bone and
Fig. 35-33. Drawing of section of canine root surface. B, Thick layer of
subjected to root resorption of unknown cementum. (Courtesy of Humerfelt,
origin. Stippled areas show bone formation. A. and Reitan, K.: Angle
Orthodontist, 36:179, 1966)
labial arches may not be sufficient to intrude the crown of

the tooth. In selected cases orthodontic movement of the
coronal segment may be advocated.
It has been shown experimentally that a spring exerting a
force of approximately 30 g. (Fig. 35-38) will move the
crown segment and gradually eliminate the fibrous tissue
layer. These changes are followed by some resorption of
the fractured surfaces. There is subsequent unification of
the segments by formation of cementoid tissue and
irregular dentin (Fig. 35-39). Vitality of the pulp structures
depends on the fact that edema of the pulp tissue will be
relieved through the fracture openings. Plasma cells and
macrophages were observed, and there is usually regressive
changes with transformation of the pulp structure into
fibrous tissue.
While such a procedure is indicated only in selected
Fig. 35-35. Typical cementum in 14-year-old patient
cases, the method nevertheless demonstrates how
with hypercementosis, case similar to that shown in Fig.
orthodontic interception may solve a problem
35-34. A, Dentin. B, Primary cementum. C, Incremental
line in thick hypercernentotic layer.
ture of the roots as they develop (Fig. 35-34). Surgical

removal of such a tooth is the recommended method.
Fractured Roots. Early bodily movement of teeth, such
as premolars, may cause curvature of the root end but this
will not lead to tissue disturbances except in cases of root
canal treatment.
Occasionally the root of an anterior tooth may become
fractured as a result of trauma (Fig. 35-36). Dislocation of
the coronal portion of the tooth may cause pseudarthrosis
with fibrous tissue organized between the two fragments
(Fig. 35-37). Stabilization of the crown portion of the root
by ligatures or
Fig. 35-37. Dislocated fragment in a case

where the tooth must be removed .
.
~
..
Fig. 35-36. Two types of root fracture, It
can occasionally be indicated to move a
dislocated coronal fragment into contact
with the apical portion in case B, but not Fig. 35-38. Mechanical arrangement for movement of a
when the fracture is close to the marginal dislocated coronal fragment. Thickness of spring 0.012" or
tissues as in A. 0.010". Force, 30 to 40 g.
Pulp Changes . 611
which for many years has been left without much

considera tion.
PULP CHANGES
Evidence of pulp changes following orthodontic

treatment has been observed radiographically in the form of
calcified structures located in the coronal pulp. To what
extent such alterations occur has only been clarified during
recent years.
Changes in the pulp ranging from simple hyperemia to
devitalization have been noted as a result of trauma or
severe pressure. Traumatized teeth may not always reveal
clinical reactions at the time of the injury. likewise pulp
disturbances of accidentally traumatized teeth may become
manifest only sometime after orthodontic treatment has
been discontinued. In some cases accurate pulp testing is Fig. 35-39. Section of fractured root, area located as seen
advisable, especially of maxillary incisors, to determine the in Fig. 35-36 B following intrusion of coronal segment by
status of the pulp prior to treatment." A lower threshold of light continuous force (Fig. 35-38). Fourteen-year-old
response to stimulation by the electric current of the pulp patient. D, Reversal lines as a result of resorption of dentin
tester may be indicative of pulp damage. during intrusion of crown of the tooth. C, Center of newly
Pulp Reactions During Tooth Movement. Earlier formed cementoid. R, Irregular dentin. P, Pulp.
experiments in dogs and other animals revealed that pulp
changes following tooth movement were insignificant.52,55 vided the force was interrupted. Presently, it cannot be
Stenvik and Mjor have shown that the pulp reactions in stated with certainty whether less extensive pulp reactions
humans are different.?? Vacuolization of the odontoblastic are to be expected in cases where the apical portion of the
Iayer was observed following intrusion of teeth with a tooth is fully developed, although such variations were
force of 90 g. during 5 weeks.?" observed in my material.
In the author's experimental series it was found that there Pulp disturbances are fairly common in operative
are individual variations.F' Generally forces as light as 25 dentistry" as well as during orthodontic treatment. In the
to 30 g. would lower the incidence of pulp disturbances. latter instance it would be advisable to avoid pronounced
Even a fairly strongforce would cause insignificant pulp tipping of teeth which may cause compression of the blood
changes pro- vessels supplying the pulp. The fact that pulp disturbances
are absent during treatment with removable appliances
stresses the importance of the time factor. During fixed
appli-
Fig. 35-40. (Left) Supraal-

veolar fibers as frequently
seen in the scanning electron
microscope after extraction
of the tooth. E, Enamel of the
crown. C, Cementoenamel
junction. S, Supraalveolar fi-
bers. Compare with Fig. 3525.
(Right) Initial root resorption
as seen in SEM, area adjacent
to the hyalinized zone of the
marginal third of the root,
resorption which may remain
undetected in the light
microscope. Note small size
as compared with the 0.5
mm. indicated above.
(Courtesy of E. Kvam)
ance treatment pulp disturbances exist, but these jected to root.resorption. Likewise the early eruption and
alterations do not cause pulp necrosis provided the well calcified root surfaces of first molars may explain
orthodontic forces are moderate and applied as indicated. why root resorption occurs fairly frequently in these teeth.
Initiation of Root Resorption. A detailed examination of
resorbed root surfaces has been included in more recent
ROOT RESORPTION studies. Details and form of the resorbed lacunae have
been visualized by scanning electron microscopy (Fig. 35-
Root resorption of permanent teeth has been observed 40 right). It has also been found that all teeth moved for a
for many years. Fairly large repaired lacunae may be period longer than 30 days will end up with small
seen in adult teeth as a result of trauma (Fig. 35-19 left). resorbed lacunae in the vicinity of the hyalinized zones of
Other factors causing root resorption may be of the root surface.P"
metabolic or genetic origin. The incidence varies in In a comprehensive study Reitan observed the initial
different teeth of the same person and is considered to be changes leading to root resorption. 51 It was found that the
higher in females than in males. anatomical environment is an important factor. Existing
In an extensive examination of roentgenograms cementoid on the root surface may delay root resorption,
Massier and Malone observed root resorption of one or but it was also seen that compression caused by an
more teeth in 708 persons who had never undergone orthodontic force can prevent further deposition or even
orthodontic treatment nor been subjected to any accidents diminish the thickness of the cementoid layers. During
involving their teeth." tipping movement the apical portion of teeth in a develop-
Trauma Causing Root Resorption. Trauma of varying mental stage will undergo changes similar to those
intensity can be followed by combinations of pulpal and observed in the bone (Fig. 35-41). The apical surfaces of
periodontal inflammation and root resorption. Gottlieb such teeth may be covered by thick layers of uncalcified
and Orban, and several other investigators, have tissue, and further development of the root cannot be
discussed the histologic changes during trauma. IS restricted even if there are resorbed lacunae close to these
Especially, bleeding along the root surface seems to uncalcified layers. The prerequisi te for such a reaction to
create resorbing cells, cementoclasts or dentinodasts, occur is that the force exerted is light or interrupted. A
cells which are of the same origin and appearance as persisting strong intrusive force may delay the
bone-resorbing cells, the osteoclasts. A degradation of development of the apical portion of teeth and even cause
the matrix covering the cementum may start formation of shortening of the root (Fig. 35-42).
resorbing cells.P" The most striking effect is observed in The initially resorbed lacunae are usually small and
roots of teeth that have been reimplanted, a procedure shallow.i'? Unlike bone resorption, root resorption may
which in nearly all cases, will lead to a marked foreign start even subjacent to the hyalinized tissue, especially if
body reaction with extensive root resorption. Only by the cementoid layer is thin or absent.55,73 Such small
autoimplantation of teeth with underdeveloped roots is it lacunae may be formed rapidly and, if the compression
possible to obtain further development of the apical decreases, become repaired even within a period of 30
portion and a stable tooth posi tion.I" days. 52
Orthodontic Treatment. While roentgenograms of , Apical Root Resorption. During orthodontic treatment
treated cases may reveal no visible changes in the root the apical area of the root is of special interest. The
surface, it is nevertheless a fact that most teeth moved initiation and extent of root alterations may be detected by
orthodontically will undergo root resorption. taking roentgenograms periodically. To some extent
Observations concerning the incidence of root re- uncalcified secondary cementum deposited in the resorbed
sorption have been made by Henry and Weinmann who lacunae will prevent further rdot resorption. If apical
observed that some individuals were more liable to show resorption has started, it is advisable to discontinue tooth
root alterations than others.P Persons with a higher movement for a few weeks until cementoid tissue has been
degree of root resorption prior to treatment would also deposited and apply lighter forces during the remaining
have more resorbed teeth during treatment. A careful treatment period. Since the occurrence of resorbed lacunae
examination of pretreatment roentgenograms is therefore in the marginal and middle thirds of the root never causes
important for treatment planning. any lowering of the function and stability of the teeth, it is
Some teeth are more frequently affected than others. apical root resorption especially which should be avoided.
The fact that teeth that erupt early have well calcified Generally apical resorption occurs less frequently
root surfaces and the small size of the anterior teeth may
explain why mandibular incisors and maxillary lateral
incisors are frequently sub-
132. References . 613
\
,
'
\
Fig, 35-42. Root of premolar, 13-

year-old patient, following tipping of
the crown in a direction opposite to
that indicated by arrow. Force above
200 g.; duration, 21 days. A,
Stretching of periapical fibers and
initial apical resorption. P, Predentin
layer. C, Compression and
Fig. 35-41. Apical area of premolar root, 12year-
deformation of predentin. D,
old individual, following tipping of crown in a
Diminution in thickness of predentin.
direction opposite to that indicated by arrow. Force,
,New cementoid laid down as a result
120 g.; duration, 14 days. P, Periodontal tissue. F,
of root movement. R, Large resorbed
Fibrous tissue in apical foramen, thick layer of
lacuna, finding never observed
predentin which ensures further development of root
following application of initial force of
even in case of resorption. C, Diminution in 50 to 70 g.
thickness of cementoid as a result of pressure, A,
Pressure exerted by fibrous tissue with some
deformation of predentin.
in bodily movement than in tipping movernent.v-" However, in 4. Bien, S.: Hydrodynamic damping of tooth movement.
all types of tooth movement the force factor and the duration of J. Dent. Res., 45:907,1966.
5. Bien, S. and Ayers, H. D.: Response of rat maxillary in-
the movement must be taken into consideration." There is less
cisors to loads. J. Dent. Res., 44:517, 1965.
apical root resorption during interrupted movement although 6. Bjork, A: Sutural growth of the upper face studied by the
resorbed lacunae are always formed in the marginal and middle implant method. Trans. Europ. Orthodont. Soc., 40:49,1964.
portions of the root. Following activator treatment small ,7. Brain, W. E.: The effect of surgical transsection of free
resorbed lacunae may occasionally be observed in the marginal gingival fibers on the regression of orthodontically rotated
third of the root, but there is no apical root resorption. teeth in the dog. Am.]. Orthodont., 55:50, 1969.
8. DeAngelis, V.: Observations on the response of alveolar
bone to orthodontic force. Am. J. Orthodont., 58: 284,1970.
9. Edwards, J. G.: A study of the periodontium during
orthodontic rotation of teeth. Am. J. Orthodont., 54: 441,
1968.
REFERENCES 10. Epker, B. . and Frost, H. M.: Correlation of bone resorption
and formation with the physical behavior of loaded bone. J.
1. Ahlgren, J.: An electromyographic analysis of the response
Dent. Res., 44:33, 1965.
to activators (Andresen-Haupl therapy). Odont. Rev.,
11. Erikson, E. H., Kaplan, K., and Aisenberg, M. S.: Ortho-
11:125, 1960.
dontics and transeptal fibers. Am. J. Orthodont. & Oral
2. Bassett, C. A. L., and Becker, R. 0.: Generation of electric
Surg., 31:1, 1945.
potentials by bone in response to mechanical stress.
10. Flourens, J. P.: Theorie experimentale de la formation des
Science, 137:1063, 1962.
os. Paris, 1847.
3. Baurnrind, S.: A reconsideration of the propriety of the
"pressure-tension" hypothesis. Arner. J. Orthodont., 55:12,
1969.
13. Fortin, ].-M.: Translation of premolars in the dog by Early tissue changes following tooth movement in rats. Angle
controlling the moment-force ratio on the crown. Am. ]. Orthodontist, 24:2, 1954.
Orthodont., 59:541, 1971. 35. Magnusson, B.: Tissue changes at erupting molars in germ
14. Frank, F. M.: Apposition et resorption de l'os alveolaire. free rats. J. Periodont. Res., 4:181, 1969.
Orthop. Dento-Faciale, 6:201, 1972. 36. Massier, M.: Changes in the lamina dura during tooth
15. Fukada, E., and Yasada, 1.: On the piezoelectric effect of movement. Am. J. Orthodont., 40:364, 1954.
bone. J. Phys. Soc. Japan, 12:1158, 1957. 37. Massier, M., and Malone, A. J.: Root resorption in human
16. Fullmer, H. M.: Observations on the development of oxytalan permanent teeth. Am. J. Orthodont., 40:619, 1954.
fibers in the periodontium of man. J. Dent. Res., 38:510, 1959.
38. Meikle, N. c.: The effect of Class II intermaxillary force on
17. Furseth, R.: Studies of normal and of clinically and ex-
perimentally altered dental cementum. [Thesis] Oslo the dentofacial complex in the adult Macaca mulatta monkey.
University, orway, 1970. Amer. J. Orthodont., 58:323, 1970.
18. Gottlieb, B., and Orban, B.: Tissue changes in experimental 39. Melsen, B.: Computerized comparison of histological methods
traumatic occlusion with special reference to age and for the evaluation of craniofacial growth. Acta Odont.
constitution. J. Dent. Res., 11 :505, 1931. Scandinav., 29:295,1971.
19. Graber, T. M.: Appliances at the crossroads. Amer. J. 40. Moss,]. P. cit. in Melcher, A. H., and Bowen, W. H.:
Orthodont., 42:683, 1956. Biology of the Periodontium. London, Academic Press, 1969.
20. Hasund, A: The use of activators in a system employing fixed 41. Muhlemann, H. R., and Zander, H. A: The mechanism of
appliances. Trans. Europ. Orthodont. Soc., 45:329,1969. tooth mobility. J. Periodontology, 25:128, 1954.
21. Haupl, K., and Psansky, R.: Histologische untersuchungen 42. Murphy, W. H.: Oxytetracycline microfluorescerit comparison
tiber die Wirkungsweise der in der Funktionskieferorthopadie of orthodontic retraction into recent and healed extraction
verwendeten Apparate (Aktivatoren). Deutsche Zahn-, Mund- sites. Am. J. Orthodont., 58:215,1970.
, u. Kieferheilk.. 5:214; 485, 1938.
43. Oppenheim, A: Biologic orthodontic theraphy and reality.
22. Henry, J. L., and Weinmann, J. P.: Pattern of resorption and
Angle Orthodontist, 6:69; 153, 1936.
repair of human cementum. J. A. D. A, 42: 270, 1951.
23. Hitchcock, H. P.: Pitfalls of the Crozat appliance. Am. 44. Oppenheim, A cit. in Weinmann, J. P., and Sicher, H.:
J. Orthodon t., 62 :461, 1972. Bone and Bones. St. Louis, C. V. Mosby, 1947.
24. Holland, D. J.: Surgical positioning of unerupted impacted 45. Picton, D. C. A: On the part played by the socket in tooth
teeth. Oral Surg., 9:130, ] 956. support. Arch. Oral. Biol., 10:945, 1965.
25. Hotz, R.: Periodontal reaction to strong forces following 46. Poulton, D. R.: Electric pulp testing in orthodontic patients. ].
treatment with fixed appliances. Fortschr. Kieferorthop., Dent. Children, 28:308, 1961.
27:220, ] 966. 47. Reitan, K: Behavior of Malassez' epithelial rests during
26. Huettner, R. J., and Young, R. W.: The movability of vital and orthodontic tooth movement. Acta Odont. Scandiriav., 19:425,
devitalized teeth in the Macacus Rhesus monkey. Oral Surg., 1961.
8:189, 1955. 48. Reitan, K: Bone formation and resorption during reversed
27. Humerfelt, Aa., and Reitan, K: Effects of hypercementosis on tooth movement. In Kraus, B.S., and Riedel, R. A (eds.): Vistas
the movability of teeth during orthodontic treatment. Angle in Orthodontics. Philadelphia, Lea and Febiger, 1962.
Orthodontist, 36:179, 1966. 49. Reitan, K: Clinical and histologic observations on tooth
28. Justus, R., and Luft, H. J.: A mechanochemical hypothesis for movement during and after orthodontic treatment. Am. J.
bone remodeling induced by mechanical stress. Calc. Tissue Orthcdont., 53:721, 1967.
Res., 5:222,1970. 50. Reitan, K., and Kvam, E.: Comparative behavior of human
29. Kvarn, E.: Preparation of human premolar roots for scanning and animal tissue during experimental tooth movement. Angle
electron microscopy. Scand. J. Dent. Res., 79:295, 1971. Orthodontist, 41 :1, 1971.
30. Kvarn, E.: Scanning electron microscopy of tissue changes on 51. Reitan, K: Continuous bodily tooth movement and its
the pressure surface of human premolars following tooth histological significance. Acta Odont. Scaridinav., 6:
movement. Scand. J. Dent. Res., 80: 357, 1972. 115,1947.
31. Langeland, K: Tissue changes in the dental pulp. An 52. Reitan, K: Effects of force magnitude and direction of tooth
experimental histologic study. [Thesis] Oslo, 1957. movement on different alveolar bone types. Angle
32. Lear, C. S. c.. Flanagan, J. B., and Moorrees, C. F. A.:
53. Reitan, K: Evaluation of orthodontic forces as related to
The frequency of deglutition in man. Arch. Oral Biol., 10:83, histologic and mechanical factors. Schweiz. Mschr.
] 965. Zahnheilk., 80.'579, 1970.
33. Unge, L.: A technique for the study of morphology in facial
54. Reitan, K: Initial tissue behavior during apical root resorption.
sutures under mechanical influence. Trans. Europ. Orthodont.
Soc., 46:553, 1970. Angle Orthodontist (In Press).
55. Reitan, K: The initial tissue reaction incident to orthodontic
34. Macapanpan, L. c. Weinmann, J. P., and Brodie, A G.:
tooth movement as related to the influence of function. Acta
Odont. Scandinav., [Supp!.]: 6,1951.
56. Keitan, K.: Orthodontic treatment of patients with
psychogenic, muscular and articulation disturbances.
Tandlaegebladet, 75:1182, 1971.
References . 615
57. Reitan, K: Principles of retention and avoidance of 73. Selvig, K A.: The fine structure of human cementum.
posttreatment relapse. Am. J. Orthodont., 55:776, 1969. Acta Odont. Scandinav., 23:423, 1965.
58. Reitan, K: Some factors determining the evaluation of 74. Sharnos, M. H., and Lavine, L. 5.: Piezoelectricity as a
forces in orthodontics. Am. J. Orthodont., 43:32, 1957. fundamental property of biological tissues. Nature (London),
59. Reitan, K: Tissue behavior during orthodontic tooth 213:267,1967.
movement. Am. J. Orthodont., 46:881, 1960. 75. Skogsborg, C: The use of septotomy in connection with
60. Reitan, K: Tissue changes following experimental tooth orthodontic treatment. Int. J. Orthodont., 18:659, 1932.
movement as related to the time factor. Dent. Record, 76. Slagsvold, 0.: Autotransplantation of premolars in cases of
73:559, 1953. missing anterior teeth. Trans. Europ. Orthodont. Soc.,
61. Reitan, K: Tissue reaction as related to the age factor. 46:473,1970.
Dent. Record, 74:271, 1954. 77. Spiegel, R. N., Sather, A. H., and Hayles, A. B.: Ceph-
62. Reitan, K: Tissue reaction during repair of fractured roots. alometric study of children with various indocrine diseases.
orske Tan. Tid., 57:367, 1947. Am. J. Orthodont., 59:362, 1971.
63.Reitan, K.: Tissue rearrangement during retention of 78. Stenvik, A.: Pulp and dentine reactions to experimental tooth
.orthodontically rotated teeth. Angle Orthodontist, 29: 105, intrusion (A histologic study-long-term effects). Trans.
1959. Europ. Orthodont. Soc., 45:449, 1970.
64. Reitan, K., and Skillen, W. G.: Tissue changes following 79. Stenvik, A. and Mjor, 1. A.: Pulp and dentine reactions to
the rotation of teeth in the dog. Angle Orthodontist, experimental tooth intrusion. A histologic study of the initial
10:140, 1940. changes. Am. J. Orthodont., 57:370, 1970.
65. Rinderer, L.: The effects of expansion of the palatal suture. 80. Storey, E.: Bone changes associated with tooth movement.
Trans. Europ. Orthodont. Soc., 42:1,1966. Austral. J. Dent., 57:57,1953.
66. Roux, W.: Gesammelte Abhandlungen tiber Entwick- 81. Storey, E.: The nature of tooth movement. Am. J.
lungsmechanik. vols. 1 and 2. Leipzig, Engelmann, 1895. Orthodont., 63:292, 1973.
67. Rygh, P.: Ultrastructural cellular reactions in pressure zones 82. Ten Cate, A. R.: Physiological resorption of connective
of rat molar periodontium incident to orthodontic tooth tissue associated with tooth eruption. J. Periodont. Res.,
movement. Acta Odont. Scandinav., 30:575, 1972. 6:168, 1971.
68. Rygh, P.: Ultrastructural changes in pressure zones of human 83. Utley, R. K: The activity of alveolar bone incident to
periodontium incident to orthodontic tooth movement. Acta orthodontic tooth movement as studied by oxytetracycline
Odont, Scandinav. (In press). induced fluorescence. Amer. J. Orthodont., 54: 167, 1968.
69. Rygh, P., and Reitan, K: Ultrastructural changes in the 84. Weinstein, S., Haack, D. C, et. at.: On an equilibrium theory
periodontal ligament incident to orthodontic tooth of tooth position. Angle Orthodont., 33:1, 1963.
movement. Trans. Europ. Orthodont. Soc. 1973. (In press). 85. Wieslander, L.: The effect of orthodontic treatment on the
70. Sandstedt, C: Einige Beitrage zur Theorie der Zahn- concurrent development of the craniofacial complex. Am. J.
regulierung. Nord. Tandl. Tidskr., 5:236, 1940; 6:1, 1905. Orthodont., 49:15,1963.
71. Schwarz, A. M.: Tissue changes incident to orthodontic 86. Wolff, J.: Das Gesetz des Knochenschwundes durch
tooth movement. Int. J. Orthodont., 18:331,1932. vermehrten Druck und der Knochenanbildung durch
72. Scott, J. H., and Symons, N. B. B.: Introduction to Dental Druckentlasrung. Arch. Klin. Chir., 13:302, 1891.
Anatomy. ed. 4. London, Livingstone Ltd., 1964. 87. Young, R. W.: Cell proliferation and specialization during
endochondral osteogenesis in young rats. J. Cell Bio!.,
14:357, 1962.
36
Retention and Relapse in Orthodontic
Therapy
CAUSES OF RELAPSE are in traumatic occlusion can be moved more quickly
and easily than those that have not recently changed
Postretention evaluation of orthodontically treated position. The greater mobility is due to the readiness with
patients shows a tendency in some cases for the original which recently formed, lightly calcified bundle bone
growth pattern and the malocclusion to reassert surrounding the recently moved teeth can be resorbed and
themselves, especially in the absence of or following to the presence of an increased number of young
inadequate retention. This tendency does not usually cofinective tissue cells. When orthodontic force is
result in malocclusion as severe as the original. The removed, the transitional bone is transformed into fully
mandible may tend to assume its incorrect position in formed alveolar bone. However, this transformation takes
keeping with the kinesthetic muscle functional pattern from about 6 months to 1 year, or even longer, after
established before the occlusion was corrected. active tooth movement is completed. During the period
of bone change, relapse can occur if the teeth are not
under retention.
The Area of Functional Tolerance
Since the teeth and jaws are a part of a closed force-
linked functional system their positions cannot be Muscle Balance
changed permanently by orthodontic means beyond the The fact that the force exerted by the tongue, the
limits of an area of functional tolerance or functional circumoral musculature, the buccinators, and the muscles
balance. Teeth moved to or located within this area will of mastication is not equal in amount indicates that there
remain stable because they are in line with the forces are other factors in addition to muscle balance
generated in function. Teeth moved or situated outside responsible for stability of the dentition. Among the
the area of functional tolerance will tend to show relapse factors responsible are the axial positions of the teeth, the
or recrowding. The placement of the teeth within the kinesthetics of the dentition that are developed by the
limits of the area of functional balance and tolerance, proprioceptors, and the quantity and quality of the
where the teeth will be maintained without relapse after functional forces involved in the movements of the
they are moved by orthodontic means, depends largely mandible.
on the clinical experience of the orthodontist. This is
almost always a subjective and pragmatic decision.
The tendency of the teeth to change position on the Equilibration of Forces
removal of orthodontic appliances, and occasionally also Teeth have to be moved into a position of static
retainers, can be attributed to the following: equilibrium. Otherwise, they are not stable and will
(1) Residual periodontal ligament tension, (2) lack of become displaced again after the use of retaining
functional adaptation of the teeth to their new locations, appliances is discontinued. A state of stable equilibrium
(3) inherent growth tendencies, (4) endocrine or other represents a condition of potential energy which cannot
systemic disturbances, (5) interference with the move the teeth out of position.
established functional forces, and (6) failure to remove
the original cause of the malocclusion.
Teeth that have changed position recently or that PREVENTION OF RELAPSE
61
Changes in Jaw Dynamics
6
Orthodontic changes in jaw relation bring with them
required changes in the pattern of jaw function.
Advantages of Early Treatment 617
Fig. 36-1. (Left> Canine

tooth undergoing rapid distal
movement (to right) in space
closure after extraction of 1st
premolar. Note the widened
periodontal space and lamina
dura on the left side and
narrow periodontal space and
cortical alveolar bone on the
right side. (Right) Teeth not
undergoing movement. Note
the thickness of the perio-
dontal ligaments are the same
width on both sides of each
tooth.
Fig. 36-2. (Top left> The thickened lamina dura on

the right side and the thin periodontal space and
lamina dura on the left side of the second premolar
tooth indicate that the tooth is in a state of
disequilibrium and is moving distally. If not
retained the space between the second premolar
and canine will be opened. (Top right) The space of
the unretained teeth on the opposite side shows
opening. (Bottom left) Wide periodontal spaces on
both sides of the second premolar and on the left
side of canine tooth show that they are under stress
and require occlusal equilibration to remove
traumatic occlusion in addition to retention. (Bottom
right) A stabilized second premolar. Note that the
premolars and molars did not undergo orthodontic
tooth movement.
This necessitates balancing of the periodontal and interdental muscles are in a state of active growth during which their
ligaments and changes in masticatory muscle insertions in origins and insertions are changing and can be more easily
the periosteum if muscle balance is to be achieved and the influenced in a direction favorable to the achievement of a
new jaw relation is to be permanent. Therefore, adequate use state of balance. Compensatory changes occur in the actual
of retaining appliances is necessary, especially during the extent and manner of muscle insertion. The changes in the
growth period, to assure that muscle insertion changes help periodontal ligament and in the interdental fibers also must
retain the teeth in their new positions. achieve stabilization. Some, if not all, of these changes take
longer for their adjustment than it takes to move the teeth into
their new position.
Skogsborg advocated slitting the labial and lingual frenum
ADVANTAGES OF EARLY TREATMENT attachments of the alveolar mucosa, especially in cases where
tooth rotations were present
Early treatment in young children is advantageous for
stability of orthodontic results because the
618 . Retention and Relapse in Orthodontic Therapy
before treatment, to overcome tensions remaining in the follows the use of extreme force in moving the teeth in the
tissues. Reitan advocates overtreatrnent of rotated teeth presence of weak musculature in which the tension on the
and active retention to prevent relapse. mandible will bring it bodily forward. Dual bite may be
also a voluntary action by the patient in the mistaken
RESULTS OF ORTHODONTIC THERAPY notion that since the orthodontist is trying to close the
overjet between the maxillary and mandibular incisors,
Desirable Results and the patient is anxious to have the appliances removed,
he brings the jaw forward, so that the orthodontist will
When we employ orthodontic appliances in treating terminate treatment sooner. It is important to recognize the
malocclusion we aim to obtain one or all of the following existence of a dual bite before beginning treatment. Dual
results: bite is found especially in patients who practice occlusal
1. Elimination of dental malocclusion mannerisms or jaw posturing.
2. Change in intra- and intermaxillary jaw rela- 3. So-called slippage of the dental occlusion when the
tions to an accepted normal maxillary dental arch slips forward after treatment is
3. An orthognathic facial profile completed in Class II malocclusion. This is seen
4. Maximum functional ability frequently after rapid tooth movement when strong
5. Acceptable esthetic appearance orthodontic force, extraoral or intermaxillary, is used to
move the maxillary teeth and the patient fails to wear
Undesirable Results retention appliances.
Among the untoward results that may occur through

continuing faulty dentofacial development by the patient,
choice of therapy or insufficient bony base are the MUSCLE REACTIONS TO ORTHODONTIC
following: FORCE
1. Relapse of the teeth in the dental arches into
irregularity, crowding, or spacing. Effect of Force on Muscle Tone
2. Establishment of a dual bite. This frequently Strong force fatigues the muscles and changes their
tonicity. When tonicity of the muscles is reestablished
after the force of the appliances is discontinued, muscle
function returns to the original pattern when retainers are
not worn long enough. The dental occlusion then tends to
revert to its former pattern. Long periods of retention are
especially necessary following rapid tooth movement.
VARIATION BETWEEN CENTRIC RELATION AND

CENTRIC OCCLUSION
Effect of Wide Variation Between Centric

Relation and Centric Occlusion
When orthodontic treatment neglects to correct
variation between centric relation and centric occlusion,
the patient finds it necessary to bring the mandible out of
centric relation in order to bring the teeth into full
occlusion. This eventually can result in a traumatic
occlusion and other undesirable sequelae.
Fig. 36-3. (Top) Mandibular second molars were moved

distally and encroached on the third molar eruption space. RETAINERS
When the third molars erupted they forced the second
molar crowns mesially. (Bottom) This shows the crowding
Removable retainers have the advantage of permitting the
teeth functional adaptation while they are being retained.
of the incisor teeth. Under ordinary circumstances the
The periodontal ligament around teeth, when retained
erupting third molars have no crowding effect on the
with rigid appliances, shows
anterior teeth in the dental arch.
Recrowding of Mandibular Incisors' 619
Fig. 36-4. (Top) Casts be-

fore treatment. (Second row)
Casts after treatment. (Third
row, left) Oral view of openbite
before treatment. (Right)
Incisor relation after treat-
ment. (Bottom) Activator ap-
pliance used to confine the
tongue during retention.
abnormal width, indicating that the teeth are under stress RECROWDING OF MANDIBULAR INCISORS
and that there is diminished or subnormal function. The
retaining appliance of the activator type can be worn after Recrowding of mandibular incisors is attributed by
school hours when the child is at home studying and Tweed to failure to locate them over "basal bone" during
during the night. An activator type of retainer is of treatment. However, many cases of recrowding of incisors
and space opening after orthodontic treatment can be found
advantage in preventing relapse and in correcting tongue
where teeth have been moved over so-called basal bone.
thrusting. Among the causes for incisor recrowding are the method of
The retaining appliances should allow a certain amount of chewing and swallowing, the type and degree of pressure
freedom for individual tooth positioning. They should not exerted when the teeth are brought into contact, dentofacial
hold the teeth in a state of rigidity. o matter how long pressure, and biting habits involving the teeth, the tongue,
teeth are retained under rigid conditions, they will relapse the lips, and other facial and
if the new position is not in consonance with functional
forces.
Fig. 36-5. (Top left) Denti-

tion before treatment. (Center)
After treatment. (Right) Lip
biting habit practiced by
patient. (Bottom left) Effect on
the dentition. (Right) The
mandibular appliance with
plumper used to change the
lip habit. This reminds the
patient not to practice the
habit, and makes it incon-
venient to continue the lip
biting.
masticatory muscles, psychic disturbances accompanied can show a tendency toward cusp-to-cusp occlusion on
by certain orofacial mannerisms, and other untoward one or both sides of the dental arches. The extraction space
factors. may reopen when the alveolar arch is large and also when
the tongue is large and active. Intruded or extruded
OCCLUSAL MANNERISMS mandibular incisors have a tendency to regain their
original height when pressure is released.
Occlusal mannerisms are the positions of incisor or
lateral series of teeth occlusion assumed by patients
involuntarily when they experience stress, anxiety, or
total concentration. The mannerisms are an important THIRD MOLAR ERUPTION AND INCISOR
cause of recrowding or relapse of mandibular incisors and RECROWDING
other teeth. Among these mannerisms are mouth twisting, With one important exception, third molar eruption, per
tongue chewing, cheek gnawing, and lip biting. se, is not a factor in mandibular incisor recrowding. When
Movements of the tongue, mimetic muscles, the the buccal teeth are moved or inclined distally by
mandible, and teeth in a child who is concentrating his orthodontic means so that the second molar encroaches on
entire efforts in performing some unaccustomed or the space of unerupted third molars, the eruption of the
difficult job are commonly observed. When practiced third molars and vertical axial positioning of the second
with sufficient frequency these occlusal mannerisms can molars can shift the distally inclined teeth forward and
reverse the satisfactory results obtained in orthodontic cause them to move mesially and impinge on the space
therapy. When an occlusal mannerism, or "tic occlusion," required by the incisors for normal alignment.
is present, the mandibular incisal edges show incisor
irregularities and highly polished facets uncommon in
young persons. When such a patient is asked to close the
teeth together, the teeth will frequently be brought into the RELATED FACTORS IN RETENTION AND
position they assume when the occlusal mannerism is RELAPSE
practiced.
Related factors in retention and relapse are the age of
the patient, the type of orthodontic correction effected, the
rapidity with which the correction was accomplished, the
degree and the number of tooth rotations, the depth of the
RELAPSE AFTER INCISOR EXTRACTION
cusps, the health of the tissues, and the distance that the
Treatment by extraction of a mandibular incisor teeth were moved.
Related Factors in Retention and Relapse' 621
Fig. 36-6. (Top) Anterior

view of dentition of ortho-
dontically treated patient. (Center
left) Occlusal mannerism in
nailbiting. (Right) Incisal edges
of mandibular incisor teeth are
worn and out of alignment due
to nailbiting. (Bottom) Bitten
fingernails of patient.
Overtreatment of arch relation has been advocated as Posttreatment Adjustment in Mandibular Dynamics.
a means of preventing relapse. Cuspal pressures (the After treatment is completed mandibular dynamics may
forces of occlusion-Angle) usually can overcome continue to show wide divergence between centric relation
overtreatment. In some cases traumatic occlusion may be and centric occlusion. Such divergence can be seen also in
initiated by overtreatment. the tendency toward persistent mandibular protrusion in
Overexpansion. An overexpanded maxillary arch the case of a corrected Class III malocclusion when the
tends to contract. If the expansion is prolonged with the patient continues to bring the mandibular incisors forward
use of removable appliances, there is a tendency for the of the maxillary incisors when attempting to bring the
alveolar bone overlying the palatal roots of the teeth to teeth into terminal occlusion.
become thinner, and occasionally the palatal root of the Some patients must be taught, through exercise,
first molars may be denuded.
\
Related Factors in Retention and Relapse . 621
Fig. 36-6. (Top) Anterior

view of dentition of ortho-
dontically treated patient. (Center
left) Occlusal mannerism in
nailbiting. (Right) Incisal edges
of mandibular incisor teeth are
worn and out of alignment due
to nailbiting. (Bottom) Bitten
fingernails of patient.
Overtreatment of arch relation has been advocated as a Posttreatment Adjustment in Mandibular Dynamics.
means of preventing relapse. Cuspal pressures (the forces After treatment is completed mandibular dynamics may
of occlusion-Angle) usually can overcome continue to show wide divergence between centric
overtreatment. In some cases traumatic occlusion may be relation and centric occlusion. Such divergence can be
initiated by overtreatment. seen also in the tendency toward persistent mandibular
Overexpansion. An overexpanded maxillary arch tends protrusion in the case of a corrected Class III
to contract. If the expansion is prolonged with the use of malocclusion when the patient continues to bring the
removable appliances, there is a tendency for the mandibular incisors forward of the maxillary incisors
alveolar bone overlying the palatal roots of the teeth to when attempting to bring the teeth into terminal
become thinner, and occasionally the palatal root of the occlusion.
first molars may be denuded. Some patients must be taught, through exercise,
Fig. 36-7. (Top) Right and

left sides of a posttreatment
occlusion. (Center left> Oc-
clusal mannerism practiced.
(Right) Periodontal condition
of mandibular left central
incisor tooth. (Bottom) The
incisal edges of the mandibu-
lar central incisor teeth are
worn and moved out of
alignment.
to occlude the teeth in the new position. Orthodontic

therapy cannot be considered completed until dynamic and
growth changes stop and the new functional pattern is
established. Retainers are required until the active
adolescent growth period is completed.
Length of Retention. The length of time it takes patients
to become accustomed to the change in oral environment
depends on the magnitude of the change effected in jaw
relation and in the dental occlusion, the length of time the
malocclusion existed before orthodontic therapy was
undertaken, and the functional pattern of the patient's
stomatognathic system. As yet there is no scientific basis
that can be used as a guide to indicate when retaining appli-
ances should be removed.
The following factors are essential either prior to or
during the retention period:
Fig. 36-8. (Top) Occlusal mannerism practiced by patient.

(Bottom)Resulting irregularly in mandibular incisor teeth.
Occlusal Equilibration : 623
Fig. 36-9. Mother and son

showing mandibular incisor
collapse when treatment was
completed and teeth were out
of retention. (Top, left) Re-
crowding of mandibular in-
cisors in mother who was
treated at 12 years of age.
(Top, right) Relation of maxil-
lary and mandibular incisors
when "occlusal mannerism"
was practiced. (Bottom, left)
Recrowding of mandibular
incisors on son now 17 years
of age who was treated at 11
to 13 years of age. Out of
retention for 4 years. (Bottom,
right) Relation of maxillary and
mandibular incisors in son
when "occlusal mannerism"
was practiced. The son stated
that he had frequently seen the
mother holding her lower jaw
in a forward position. The
mother said the same about the
son.
Both admitted that they were
at times conscious of practic- increasing amount of freedom from retention. All habits
ing this "occlusal manner- that contributed to the malocclusion should be eliminated
ism." before retention is stopped. There is no arbitrary period of
time for wearing retention appliances. If the appliance feels
tight when it is reinserted in the mouth after it is not worn
1. Proper intercuspal relation in maintaining teeth in the for some length of time, it is an indication that the teeth are
newly established occlusion not being retained in a stable position, or that the retainer
2. Proper arch form and arch relationship and correct requires adjusting.
overbi te
3. Normal proximal tooth contact within the respective
dental arches. OCCLUSAL EQUILIBRATION
Retention of Rotated Teeth. Following rotation of teeth
tension and displacement of alveolar tissues may persist Occlusal equilibration is a method for achieving
and require a long period of retention. Early treatment, maximum distribution of occlusal force and functional
overrotation, and prolonged maintenance can prevent stress through the long axis of as many of the teeth as
relapse tendencies of rotated teeth. possible, to avoid interferences of tooth height in lateral
Limits of Retention. After retention for 28 days, Reitan excursions of the mandible and to reduce areas of flat
found rearrangement of the periodontal ligament fibers in surface contacts when the teeth are approximated. Occlusal
the middle and apical regions of the teeth. Retention for 57 equilibration in its finer aspects requires thorough basic
days showed partial rearrangement of the marginal fibers. knowledge and exacting clinical technic, otherwise more
Complete rearrangement he observed between 21 and 33 traumatic contacts may be introduced than eliminated. Oc-
weeks. clusal equilibration, like orthodontic tooth movement,
Retention appliances should be discontinued gradually. requires a thorough understanding of the physiology of the
When it is planned to discontinue retention, the patient stomatognathic system. It is inadvisable to perform routine
should wear the appliance evenings and at night when occlusal grinding immediately after rigid orthodontic
sleeping and should be observed frequently at first to note appliances are removed.
any untoward changes. The duration of retention varies Occlusal equilibration seeks to create interarch tooth
with each patient. Usually it is necessary for a period of 1 contacts that are tolerable to the supporting tissues of the
year, during the last 6 months of which the teeth are teeth. Grinding of abnormal opposing
afforded an
Fig. 36-11. (Top) Traumatic occlusion of central incisor

teeth. (Center and Bottom) The periodontal ligament is
thickened due to the traumatic occlusion. There is also
apical root resorption of the maxillary and mandibular
incisor teeth.
especially likely to occur during the preadolescent and the

adolescent periods.
In traumatic occlusion the periodontal ligament appears
narrower than in normal function and there may be loss of
alveolar bone and root resorption. In severe trauma the
periodontal ligament may be injured, showing thrombosis
Fig. 36-10. (Top) Occlusal mannerism involuntarily of blood vessels, hemorrhage, and hyalinzation of bone in
practiced by patient when experiencing stress. (Center) The the area of pressure, and resorption of bone and cementum
maxillary left central incisor tooth shows the effect of the ,may occur. The teeth show abrasion of the incisal or
practice of the mannerism. The central incisor shows a occluding surfaces and are usually more mobile than other
close fit with the incisal edges of the mandibular central teeth in the mouth that do not experience trauma. Teeth in
incisors. (Bottom) The ground incisal surfaces of the now traumatic occlusion may be sensitive to percussion.
irregularly arranged mandibular central incisor teeth are Premature tooth contacts may result from pressure
shown. habits that displace the teeth, irregularities of eruption,
torsiversion, incorrect dental restorations, and sudden
changes in tooth position. Prematurities may induce
tooth contacts consists largely in reshaping occlusal planes repositioning of the mandible when the patient seeks
comfortable positions and thus bring about a new
without changing the vertical dimension of the dentition to
malocclusion.
any appreciable degree. Severe occlusal grinding can lead
Signs of traumatic occlusion are flat, shiny areas on the
to abrupt kinesthetic changes. Caution should be exercised occluding vestibular surfaces of the mandibular teeth and
against disturbing the proprioceptive and exteroceptive on the lingual cusps of the maxillary teeth as the surfaces
patterns to which the patient is accustomed. Tooth become worn. Flat planes should be altered into
grinding should be accomplished with great care. It is intercuspal contacts. When
especially important to consider that the teeth have to
adjust themselves in occlusion after orthodontic treatment
and that occlusal changes are
Occlusal Equilibration' 625
Fig. 36-12. (Top) Right and

left sides show canine inter-
ference when active treatment
was completed. (Bottom) Right
and left sides in occlusion after
canine interference was
corrected by spot-grinding.
(Courtesy Dr. M. R. Chipman)
133.
134.
135.
Fig. 36-13. Etiology and cor- PART I ETIOLOGY OF TRAUMATIC OCCLUSION

rection of traumatic occlusion. (6.
Iankelson: J. Am. Dent. Ass.,
50:673)
I K N
NONTRAUMATIC OCCLUSION HORIZONTAL WEAR TRAUMATIC OCCLU SION
OF CUSPS
PART 2 CORRECTION OF TRAUMATIC OCCl.,USION
RESHAPIN G TO RESTORE CUSPS RESHAPED TO FIT NONTRAUMATIC

ORIGINAL BUCCOLINGUAL WIDTH SULCUS WITHOUT JAMMING OCCLUSION
the cusps are severely worn, the surface area becomes traumatic occlusion will show varying degrees of
larger and increases the torque on the teeth during increased mobility. This is especially true of the
function. This increases tooth mobility. premolars and canines. Cusp grinding is limited to the
Traumatic occlusion shows itself radiographically in facets on the buccal aspects of the mandibular buccal
widening of the periodontal space between the root and cusps and the lingual aspects of the maxillary lingual
the cortical layer of the alveolus, thickening of the cusps.
lamina dura, hypertrophy of the cementum, and root Uneven marginal ridges should be eliminated to avoid
resorption. If adjustment does not occur, either food impaction. A method of examining for traumatic
spontaneously or by equilibration, teeth under occlusion is to place the tip of the fore-
finger against the buccal surface of the tooth and thus by ___ : Potentials in the pattern. Angle Orthodontist, 29:206, 1959.
palpation note movement during contact of the teeth into Gottlieb, B., and Orban, B.: Die Gewebsveranderungen bei
full occlusion. Digital palpation on the teeth, while the Uberbelastungen mit besonderer Beriicksichtigung von Alter
patient moves his mandible through gliding contact und Konstitution. Ztschr. Stomatol., 29:370, 1931.
movements, is used to detect premature contact (Fig. 36- Hawley, C. A.: A removable retainer. lnt. J. Orthodont. & Oral
13). 5urg., 2:291, 1919.
Hopkins, 5. c.: Bite planes. Am. J. Orthodont. & Oral 5urg.,
Equilibration of the occlusion is accomplished by
26:107, 1940.
marking the overbite with a pencil on the labial aspect of
Jacobson, 0.: Clinical significance of root resorption. Am.
the mandibular teeth. The relation of the incisal edges of
J. Orthodont., 38:687, 1952.
the maxillary teeth is used as a guide. Articulating paper Ketcham, A. H.: A progress report of an investigation of apical root
is used to determine centric, lateral, and protrusive points resorption of vital permanent teeth. lnt. J. Orthodont., 0, 5urg. &
of contact. Each movement should be checked Radiog., 15:310, 1929.
separately. The protrusive biting position is examined to Kronfeld, R.: The resorption of the roots of deciduous teeth. Dental
determine functional and esthetic conditions. An Cosmos, 74:103, 1932.
exaggerated forward movement is necessary to detect ___ : Calcification and decalcification of the human teeth. ew
incisor tripping. York J. Dent., 9:232, 1939. (Abstract) Marshall, ]. A.; The
Gross cuspal interferences and abnormally shaped classification, etiology, diagnosis, prognosis and treatment of
teeth should be corrected before placing the retaining radicular resorbtion of teeth. Int. J. Orthodont. & Dent. Child.,
appliance in the mouth. The finer grinding of cusps and 20:731, 1934.
tooth facets should be corrected after a period of careful Massier, M.: Changes in the lamina dura during tooth movement.
Am. J. Orthodont., 40:364, 1954.
observation to ascertain whether the adjustment of the
___ : Changes in the lamina dura during tooth movement. Am. J.
teeth in function will correct the occlusal inequalities.
Orthodont., 40:364, 1954.
Massier, M., and Malone, A. J.: Root resorption in human
permanent teeth. Am. J. Orthodont., 40:619, 1954.
Massier, M., and Perreault, J. G.; Root resorption in the permanent
teeth of young adults. J. Dent. Child., 21 :158, 1954,
Miller, B. G.: Investigation of the influence of vascularity and
innervation on tooth resorption and eruption. J. Dent. Res.,
BIBLIOGRAPHY 36:669, 1957.
Moore, A. W.: The mechanism of adjustment to wear and accident
Ahlgren, J., and Posselt, D.: eed of functional analysis and in the dentition and periodontium. Angie Orthodontist, 26:50,
selective grinding in orthodontics. Acta odont. scandinav., 1956.
21:187, 1963. Morse, P. H.: Resorption of Upper Incisors Following Orthodontic
Atherton,]. D., and Wynne, T, H. M.: A long-term assessment of Treatment. Dent. Practitioner, 22:21, 1971.
the facial pattern in children who had received orthodontic Oppenheim, A.: Die Veriinderungen der Gewebe insbesondere des
treatment. Dent. Pract. & Dent. Rec., 14:317, 1964. Knochens bei Verschiebung der Zahne. bst. Ung. Vjschr.
Berger, H.: The lower incisors in theory and practice. Zahnheilk., 27:302, 1911.
Angle Orthodontist, 29:133, 1959. ___ : Tissue changes particularly of the bone incident , to tooth
Bjork, A.: The principle of the Andresen method of orthodontic movement. Am. J. Orthodont., 3:56, 1911; 3:113,1912.
treatment, a discussion based on cephalometric X-ray analysis ___ : Bone changes during tooth movement. Int. J.
of treated cases. Am. J. Orthodont., 37:437, 1951.
Orthodont., Oral Surg. & Radiog., 16:535, 1930. ___ : Die
Campbell-Wilson, M. E. A.: Post-treatment loss of teeth in a
Krise in Orthodontie. Berlin, Urban, 1933.
group of orthodontic patients. Brit. D. J., 127:469, 1969.
_. __ : Biologic orthodontic therapy and reality, Angle
Edwards, G. S., [r.: An evaluation of overcorrection as compared
Orthodontist, 6:69; 153, 1936.
to correction in the treatment of rotated teeth. Am. J.
___ : Artificial elongation of teeth. Am. J. Orthodont. & Oral 5urg.,
Orthodont., 60:306, 1971.
26:931, 1944.
Geiger, A. M.: Occlusal studies in 188 consecutive cases of
___ : Human tissue response to orthodontic intervention of short
periodontal disease. Am. J. Orthodont., 48:330, 1962.
and long duration. Am. J. Orthodont. & Oral Surg., 28:263,
Goldman, H. M.: Spontaneous intermittent resorption of teeth. J. 1942.
A. D. A., 49:522, 1954.
___ : A philosophy for physiologic orthodontic movement. Am. J.
___ : Spontaneous intermittent resorption of teeth. Orthodont. & Oral 5urg., 30:277; 345,1944.
J. A. D. A., 49:522, 1954. Post-treatment appraisal of orthodontic results. Tr. European
Goldstein, A.: The dominance of the morphological pattern:
Orthodont. 50c., P. 73,1961.
Implications for treatment. Angle Orthodontist, 23:187, 1953.
Poulton, D. R., and Aaronson, S. A.: The relationship
Bibliography . 627
between occlusion and periodontal status. Am. J. Orthodont., Steadman, S. R: Changes of intermolar and intercuspid distances
47:690, 1961. following orthodontic treatment. Angle Orthodontist,
--_: Electric pulp testing in orthodontic patients. J. 31:207,1961.
Dent. Child., 28:308, 1961. Stoner, M. M., et al.: A cephalometric evaluation of fiftyseven
Ramfjord, S. P.: Bruxism, a clinical and electromyographic consecutive cases treated by Dr. Charles H. Tweed. Angle
study. J. A. D. A., 62:21, 1961. Orthodontist, 26:68, 1956.
Rosenstein, S. W., and Jacobson, B. .: Retention - an Equal Storey, E.: Bone changes associated with tooth movement: a
Partner. Am. J. Orthodont., 59:323, 1971. radiographic study. Australian J. Dent., 57:57, 1953. ___ : Bone
Rothner, J. T.: Occlusal equilibration a part of orthodontic changes associated with tooth movement, the influence of the
treatment. Am. ]. Orthodont., 38:530, 1952. menstrual cycle on the rate of tooth movement. Australian J.
Rudolf, C. E.: A comparative study in root resorption in Dent., 58:80, 1954.
permanent teeth. J. A. Dent. Res., 22:196, 1953.
--_: Bone changes associated with tooth movement.
Salzmann, J. A.: Area of tolerance in orthodontic tooth Australian J. Dent., 59:147, 1955.
movement. Am. J. Orthodont., 39:468, 1953. Stuteville, O. H.: A summary review of tissue changes incident to
__ c.: The area of tolerance in orthodontic tooth movement. In tooth movement. Angle Orthodontist, 8:1, 1938.
Salzmann, J. A.: Orthodontics: Practice and Technics. Strahan, J. D., and Mills, J. R E.: A preliminary report on the
Philadelphia, J. B. Lippincott, 1957. severing of gingival fibres following rotation of teeth. Dent.
-_: An evaluation of retention and relapse following orthodontic Practitioner, 21:101, 1970.
therapy. Am. J. Orthodont., 51:779, 1965. -_: Occlusal Subtelny, J.D.: The soft tissue profile, growth and treatment
mannerisms and relapse of mandibular incisors (Editorial). Am. changes. Angle Orthodontist, 31:105,1961.
J. Orthodont., 42:150, 1956. Sullivan, H. R, and Jolly, M.: Ideopathic resorption. Australian
Silverman, M. M.: Equilibration of the natural dentition D. J., 2:193, 1957.
following orthodontic treatment to prevent movement of teeth Taylor, P. P.: Pulp testing evaluation. J. Dent. Children, 27:107,
and other problems. Am. J. Orthodont., 54:831, 1968. 1960.
Skogsberg, c.: The use of septotomy (surgical treatment) in
Thompson, J. R: Function and growth. Angle Orthodontist,
connection with orthodontic treatment and the value of this 31:132, 1961.
method as a proof of Walkhoff's Theory of tension of the bone Tiegelkamp, K. H.: Changes in the region of the mandible and the
after regulation of teeth. Int. [. Orthodont. Oral Surg. & temporomandibular' joint during orthodontic treatment. Tr.
Radiog., 18:1044, 1932. European Orthodont. Soc., p. 204, 1960.
Sleichter, C. G., Jr.: Some effects of the occlusal guide plane in Wieslander, L.: The effect of orthodontic treatment on the
the treatment of Class 11, division 1, malocclusions: A concurrent development of the craniofacial complex. Am. J.
cephalometric and larninographic study of treated cases. Am. Orthodont., 49:15, 1963.
J. Orthodont., 43:83, 1957.
Williams, R L.: Occlusal Treatment for the Postorthodontic
Speidel, T. D.: Rate of vertical change induced by wearing Patient. Am. ]. Orthodont., 59:431, 1971.
anterior bite plates. ]. Dent. Res., 22:196, 1943.
37
Orthodontics in Public Health and
Prepayment Programs
The determining factor in the actual demand for 3. Advise in establishing an equitable fee scale for
orthodontic care in contradistinction to the need as orthodontic care
determined by dental personnel depends largely on the 4. Review selected cases periodically and advise on the
level of appreciation of "straight teeth" by the patient and progress and quality of treatment
the immediate family. This is influenced by the age and 5. Advise on continuing orthodontic educational
sex of the patient, the family's cultural and financial programs for professionals
status, and past experience with orthodontic care. Other 6. Prepare instructions to participating practitioners on
factors include the value and appreciation of orthodontic diagnostic aids, etc.
care by the patient's peers, the local community, the ethnic The Advisory Committee in New York State established
group, and by the general cultural environment. the following criteria for examination and acceptance of
Orthodontics as a public health function was defined by orthodontic care patients:
the U. S. Children's Bureau of the Department of Health, 1. Malocclusions interfering with masticatory function
Education and Welfare to be concerned with: 2. Malocclusions associated with cleft palate, cleft lip,
or abnormalities of the temporomandibular articulation
3. Malocclusions resulting from severe structural
deformities of the mandible and maxilla
The correction of dentofacial deformities when effi- 4. Malocclusions resulting from disease or trauma of the
ciency of the dental mechanism is threatened by a present mandible and maxilla
or potential condition which will cause tissue injury or 5. Malocclusions resulting in facial disfigurement and
interfere seriously with function or with mental or speech interferences
physical development. Required diagnostic aids include the following: 1. A
fully mounted series of periapical radiograms.
Additional radiograms to include lateral cephalometric,
ORGANIZATION OF PUBLIC HEALTH
ORTHODONTIC PROGRAMS lateral jaw, and occlusal views
2. Study casts
The American Public Health Association in a guide for 3.One profile and one full-face photograph showing head
public health personnel on Services for Children with and neck only, with the lips in rest position , and with
Dentofacial Handicaps states: posterior teeth in occlusion.
Since orthodontic care is often the principal service in
programs for dentofacial handicaps, there should be a
special advisory committee of orthodontic specialists,
preferably members of the American Association of PRINCIPLES IN ADMINISTRATION OF PUBLIC
Orthodontists, who are certified by the American Board of HEALTH ORTHODONTIC PROGRAMS
Orthodontics.
The following decisions must be made wherever
prepayment orthodontic programs are undertaken: 1. The
The Orthodontic Advisory Committee
results obtained should be comparable to those prevailing
Advisory committees on orthodontics can function in in orthodontic practice.
connection with prepayment programs as follows: 2. The educational and clinical experience of those who
1. Advise on criteria and priority for accepting patients are to render the service should be established as for
for treatment specialty practice.
2. Advise on the training and experience necessary to 3. The effect of the malocclusion on the personality of
qualify practitioners for participation in the program the patient should be a factor in accepting patients.
4. Orthodontics is a time consuming procedure.
628
Defining Handicapping Malocclusion . 629
There is an irreducible minimum cost below which capping malocciusion is needed by the dental profession
adequate care cannot be provided. that could justify the inclusion of orthodontic care in all
5. The retention period should be considered from the prepayment mechanisms, particularly if the prevalence of
standpoint of length of time required, service to be handicapping malocclusion were known and benefits were
rendered and costs involved. limited to those conditions; (2) that such a definition should
be available through the ADA but that the AAO is the
6. Educational material should be prepared on the
logical organization to establish the criteria and develop the
importance of patient and parent cooperation.
definition; (3) that since recommendations on prepaid
7. Cooperation of the orthodontist with the family dental care should be made by the ADA rather than by a
dentist while the child is undergoing orthodontic treatment specialty group, all data obtained from the study should be
and general dental care. presented to the ADA for its use.
Choosing Professional Personnel The AAO - Salzmann Treatment Priority Index of

There should be definite criteria for accepting Malocclusion
practitioners to render the service. Whether a malocclusion In order to provide a method for establishing priority in
is so severe as to require the services of a specialist or accepting patients in public health and prepayment
whether it can be treated by the general practitioner must programs in keeping with available professional personnel
be determined in each case. A ruling of the New York and budgetary requirements, the American Association of
State Court of Appeals states the public health authorities Orthodontists adopted an Index devised by Salzmann (Fig.
reserve the right to establish educational requirements of 37-9E; 1DE; 11E; 21).
participating orthodontists.
The index described here has received the approval of
the ADA Council on Dental Health and the ADA Council
on Dental Care Programs, and the recommendation of the
DEFINING HANDICAPPING MALOCCLUSION Conference on Dental Manpower conducted by the
American College of Dentists.
While it is important for public health epidemiologic This Index provides a method for assessing the severity
purposes to differentiate between a handicapping and a of a malocclusion according to numerical rating of the
non-handicapping malocclusion in order to establish maloccluded, missing, and malposihoned permanent teeth.
treatment priority, clinical orthodontic experience dictates The deviations and assigned point values (weights)
that a malocclusion that can handicap function and dental employed in the Index are based on a consensus among
health in one patient may not be handicapping in another. orthodontists of their contribution to the severity of
Furthermore. the handicapping effect of some occlusal and dentofacial deviations that interfere with
malocclusions in children is not always immediately dental health, function, and esthetics.
recognizable except in gross dentofacial deviations. The assessment can be made from dental casts or
Moreover, the handicap may not be evident at the time a directly from the patient's mouth (Fig. 37-18). The use of
child is examined but can manifest itself sometime later in the Index requires a knowledge only of the different
life. categories of teeth in the mouth, of the accepted human
Malocclusions that orthodontists consider hazardous to formula of the interrelation of the teeth in the maxillary
dental health, and masteratory and articular function and and mandibular dental arches, in the vertical, lateral, and
detrimental to facial esthetics are not always so rated by anteroposterior spatial dimensions. The point values
the patient. Conversely, malocclusions considered to be assigned to the respective deviations are indicated on the
minor by the orthodontist can impede a person's social and Index form.
environmental adjustment and achievement potential. The brief and exact instructions included in the Index
Such patients should be treated in prepaid and public provide guidelines for scoring the deviations in the
health orthodontic programs even if they do not fit the individual patient and for determining statistically the case
established categories for accepting patients. load of children with handicapping malocclusion in a
community and their relative severity (Figs. 37-1,3-8).
After brief training general dental practitioners, dental
hygienists, dental assistants, and clerks can use the Index
as well as qualified orthodontists. Time consuming
Index of Priorities for Accepting Patients
millimeter measurements are not required, and errors in
The American Dental Association Council on Dental measuring are thus avoided.
Health has issued the following statement:
The Council agrees with the American Association of
Orthodontists (1) that an index for determining handi-
630 . Orthodontics in Public Health and Prepayment Programs
Fig. 37-1. Division of dentition for scoring. The anterior

sections include the four incisors only. The posterior sections
include the canines, first and second premolars, and first
molars. The second molars may be used when the first molars
are missing; otherwise, they are not included in the
assessment. Score 2 points for each deviated maxillary
incisor. Score 2 points for each visible crest of a maxillary
incisor papilla. Score 1 point for each maxillary posterior
tooth deviation. Score 1 point for each deviated mandibular
anterior and posterior tooth. Score 1 point for each visible
crest of a papilla of spaced mandibular incisors and for each
spaced posterior tooth when both its mesial and distal
papillae crests are visible.
Fig. 37-2. Distribution of

200 Children 250 Children 450 children with handicap-
Below Cut-off Above Cut-off ping malocclusion. Only 250
children can be treated. The
100 cut-off point is set to include
250 children with the highest
e scores in decreasing order; the
Ql
cut-off here is at 20 points.
"'0
75 This bar graph illustrates
method of establishing a cut-
:.2 off point.
u
0
Ql
50
E
::t
Z
25
Points Scored
The total score for an individual provides an index to the a score that will include a sufficient number of children for
need for treatment unaffected by subjective considerations of treatment in keeping with available competent professional
etiology, treatment planning, difficulty and duration of personnel and funds budgeted for orthodontics. In a
treatment required, or other professional judgments.
community of 3,000 children, the sampling indicates that
However, special circumstances that affect the acceptability
450, or 15 per cent, have assessment scores of five points or
of an individual patient can be inserted under "Remarks."
Method of Establlshing Treatment Priorities. The range more, and professional personnel, or available funds, or both,
of severity and frequency of occurrence of malocclusion is will permit treatment of 250 children only. Priority for
obtained by assessing a random sample of the child treatment is then given to children with the highest scores in
population in the community under consideration. The cut- decreasing order, until 250 children are included. The cut-off
off point is then set at point is then set. (Fig. 37-2) Practical experience in using the
Index
Defining Handicapping Malocclusion' 631
indicates that a score of about 26 points or more usually since a rotated tooth is not scored also for crowding, and
indicates a high-priority malocclusion that requires vice versa.)
treatment. 5. Open spacing: crest of interdental papilla is visible.
Score each papilla in incisor section; score posterior teeth
when both adjacent crests of the interproximal papillae are
Use of the Index as a Base for Fees
visible.
The Index can be used for establishing fees for specific 6. Closed spacing: space is insufficient for complete
orthodontic treatment according to the severity of the eruption of a tooth.
malocclusion. Fees can be predicated on the number of B. Inter-arch Deviations (Fig. 37-58).
points or score shown in the individual's Index assessment 1. Overjet: labioaxial inclination of maxillary incisor
form. For example: alignment of a crowded tooth that teeth with mandibular incisors occluding on or over palatal
requires moving other teeth in the arch to obtain space mucosa.
should have a higher fee rating than a rotated tooth for 2. Overbite: maxillary incisors occlude on or opposite
which there is sufficient space for alignment in the arch labiogingival mucosa or mandibular incisors occlude
without moving other teeth. The "space" applies to closed directly on palatal mucosa.
and open spacing in intra-arch tooth alignment which 3. Overjet and overbite: score both when mandibular
mayor may not entail moving other teeth in the same arch.
incisors occlude directly on palatal mucosa and maxillary
Interarch deviations, such as overjet, overbite, crossbite,
incisors are in overjet.
openbite, and anteroposterior deviations that entail placing
4. Openbite: vertical separation between teeth in
an appliance on the upper or lower arch only, should have
opposing dental arches when the rest of the teeth are in
a lower point value than where both arches require
terminal occlusion. Edge-to-edge occlusion is not scored
insertion of appliances. The use of point values should be
as openbite (Fig. 37-6).
confined to the correction of maloccluded teeth that do not
require interarch correction. 5. Incisors crossbite: maxillary incisors are lingual to
Patients with patent malocclusion that involves tooth mandibular incisors when posterior teeth are in terminal
alignment in the upper and lower dental arches and occlusion (Fig. 37-7 A).
correction of interdental arch relation in general should be 6. Crossbite of posterior teeth: canines, premolars, and
treated on a case basis. This will obviate charges for first molars are buccally or lingually out of entire occlusal
change of appliances, progress radiograms, usual contact with their opposing teeth (Fig. 37-78).
breakage of appliances, and other unforeseen 7. Mesiodistal deviation: mandibular canine and
interferences with treatment.
INSTRUCTIONS FOR USING THE INDEX
Definition. Handicapping malocclusion and handicapping

dentofacial deformity are conditions that constitute a
hazard to the maintenance of oral health and interfere with
the well-being of the child by adversely affecting
dentofacial esthetics, mandibular function, or speech.
A. Intra-arch deviations (Fig. 37-3, 4).
1. Missing teeth are scored by actual count of teeth;
remaining roots are scored as missing.
2. Crowded teeth Insufficient space for alignment
without moving other teeth in the arch.
3. Rotated anterior teeth: insufficient space for
alignment of teeth so malaligned as to interrupt the
continuity of the arc of the dental arch.
4. Rotated posterior teeth: buccal or lingual surface
wholly or partially faces proximal surface of adjacent
teeth.
(Whether a tooth is scored as rotated or crowded does
not affect the magnitude of the final score, Fig. 37-3. Intra-arch deviations. (Top) Crowding, spacing,
and missing teeth. (Bottom) Anterior spacing.
Fig. 37-4. (A) Method of

placing casts for intra-arch
assessment. A, Missing anterior
tooth. B, Open anterior space
between maxillary central
incisor teeth. Score 2 points
for the papilla here visible. C.
Missing posterior tooth. D, The
right and left maxillary first
premolars are spaced on their
mesial and distal sides. Score 1
point for each premolar
(posterior teeth), not the
spaces. (B) Crowded anterior
and posterior teeth. A, The
mandibular incisors are
crowded; score 1 point for
each tooth. B, The mandibular
right second premolar is
crowded; score 1 point for this
posterior tooth. C. The
maxillary right and left lateral
incisor teeth are scored as
rotated because they can be
aligned without moving other
teeth in the arch; score 2 points
for each rotated incisor. D, The
buccal cusps of premolars occlude entirely mesial or distal to mandibular left second
their accepted normal relation, and first molar occludes the premolar is rotated (see text);
width of its mesiobuccal cusp, mesial or distal from the score 1 point for this posterior
accepted normal relation to the maxillary opposing teeth tooth. E, The maxillary right
(Fig. 37-8). canine is scored for closed
space because it does not have
sufficient space for erupting;
Example of Assessing Dental Casts score 1 point for the canine. F,
The casts in Figure 37-9A, B, C and 0 show the maxillary The maxillary left canine
space does not show the canine
right lateral incisor to be rotated. This is in the anterior
through the alveolar crest and
segment and is given a score of 2 points. The maxillary right
is scored as missing; score 1
canine is crowded. Since the canine is counted in the point for this missing posterior
posterior segment, in the assessment it is given 1 point. The tooth.
mandibular lateral incisors, canines, and second premolars
are
Fig. 37-5. Anterior interarch deviations: (A) Overjet-

maxillary incisors labial, mandibular incisors over
palatal mucosa. (B) Overbite-mandibular incisors on
palatal mucosa. (C) Overjet and overbitemaxillary
incisors labial, mandibular incisors on palatal mucosa.
A B c
137.
136.
INTERARCH DEVIATIONS
A. Anterior open bite
B
Normal Buccal cross-bite Lingual cross-bite
buccoliogua! relation
B ~ Buccal
l e lingual P
~ Palatal
Fig. 37-7. Interarch deviations. (A) Anterior crossbite. (8)

Crossbite of posterior teeth.
B. Posterior openbite
Fig. 37-6. Examples of interarch deviations.
all crowded. Since the mandibular teeth are all given a

score of 1 point, these 6 teeth collectively are given 6
points. The total intra-arch deviations is 9 points.
Three of the maxillary incisor teeth are in overjet.
Since maxillary incisor overjet rates 2 points, we have 6
points for interarch deviations. The total thus far is 15
points of which 9 are for intra-arch and 6 for interarch
deviations. The posterior segments show the canines and
first and second premolars and molars to be in distal
relation to their maxillary opponents. This gives the
posterior segment 8 points for mesiodistal relation. The
maxillary canine is in labial relation and gets 1 point. The
teeth are scored for deviation once in each category in
which they belong. While the canine was scored as
crowded in intra-arch deviation, it is scored again for
interarch deviation (Fig. 37-9A, B, C, 0 and E).
The posterior teeth show a score of 9 for a total of 24
points. As shown on the assessment form, the score of the
anterior teeth deviations is 15, therefore, 8 more points
are added. This makes a grand total of 32 points (Fig. 37-
9E).
Figure 37-10A-D show a score of 7 points for intraarch
deviations, 16 points for anterior interarch deviations, and
1 point for posterior interarch deviations. Plus 8 points
additional because the maxillary
Fig. 37-8. Mesiodistal deviations.
Fig. 37-9. See text.

Continued, opposite.
138.
1"\
incisor deviations show a score in excess of 6 points. The first premolar teeth are spaced on the mesial .sides
This makes a grand total of 32 points (Fig. 37-10E). only. Posterior teeth, to be counted as spaced, must show
The casts shown in Figure 37-11A-O show the visible papillae on their mesial and distal sides.
maxillary right incisor to be missing. The other three Therefore, these teeth are not scored as spaced. In the
maxillary incisors are spaced. Although it is obvious that mandibular dental arch when there is a space between the
if the right central incisor were present it too would be canine and first premolar it is scored. The space between
spaced, only three papillae are scored and not those the canine and lateral incisor is not scored, since it was
adjacent to the missing incisor. Therefore, the anterior scored with the anterior teeth.
score is 2 points for the missing central incisor, and 2 Interarch deviations include 3 teeth scored for overjet
points for each of the three visible papillae, making a and 4 teeth scored for overbite in the anterior section, or
total of 8 points for the maxillary anterior segment (Fig. 14 points additional for a total of 24 points. The
37-11E). mandibular posterior teeth on each side are distal to their
The maxillary canine teeth are spaced on both mesial maxillary opponents giving them a total score of 8 points
and distal sides. Since the canine teeth are assessed with for the right and left sides making a total of 32 points.
the posterior segment in this Index, 1 point is assigned Since the score of the maxillary anterior teeth, under 'A.
for each spaced canine tooth, not the papillae, or 2 points Intra-Arch Deviation' and the score for the anterior
for a total, thus far, of 10 points (Fig. 37-11E). segment under
DEFINITION AND CRITERIA FOR ASSESSING HANDICAPPING MALOCCLUSION PERMANENT

DENTITION
DEFINITION: Handicapping malocclusion and handicapping denlafacial deformity are conditions that cons tilule a hazard 10 the
mainlenance of oral health, and i nlerfere wilh the well-being of the chi Id by adversely of. fecI i n9 denlofac ic I e sther i c s , mond ibu I or
fu net i on, or speech.
HANDICAPPING MALOCCLUSION ASSESSMENT RECORD
I 2 3 4 S 6 7 8 9 10 II 12 13 14 15 16
Cos'!! No. ITIII'J Exami ... l!'f No. CTI Dot.1TTTlI Ar.,~
~
A. INTRA-ARCH DEVIATION
SCORE TEETH SPACING POINT
MISSING CROWDED ROTATED NO. VALUE SCORE

AFFECTED ONLY
OPEN CLOSED
ac
AnI.
17
" " I 21
I X2
MAXILLA
POSI. 22 2>
1 '4
" ae I Xl
z:I
2.7 z. '0
MANDIBLE
Ant. a to. " 2 Xl Z
Posl. aa
"f ae ae
f Xl
t
AnI, anterior te eth (4 incisors); Post. = poslerior teeth (include conine,
Total Score
9
premolars and firsl molar).
No . number of leeth affected.
B. INTERARCH DEVIATION
1. Anlerior Segment
SCORE MAXILLARY OVERJET OVERBITE C~OSSBITE OPEN BITE NO. P.V. SCORE
TEETH AFFECTEDONLY,
EXCEPT OVERBI TE' >7

3 33 40
3 X2 6
'Score maxi Ilory or mandibular incisors. TolOI score 6
Na, - number of teeth affected, P .V. = point value.
2. Posterior Segment
SCORE TEETH RELATE MAN DI BULAR TO SCORE AFFECTED
AFFECTED ONLY MAXILLARY TEETH MAXILLARY TEETH ONLY NO. P.V. SCORE
DISTAL M ESI AL CROSSel TE OPENel TE
~IGHi !-EFT 'RIGHT LEFT RlGH T LIE~T ~IGHT LE.F'T
ee 4 5> 51 es
" "
Canine 1 I I 3 Xl
3
50 54 5. a 70
"
1 st Premo lor I J 2- Xl '2.
47 51 55 so ea .7 7'
2nd Premolor I I Z. Xl
t:
4 s ee .0 7'
lsI Molar I
Z. Xl
I Z
No. = number; P.V. = point value; Total Score '1
'Add 8 points,when i ntrc-ond inter-o rch maxillary ~
inci sor score is 6 or more to denote esthetic hondicop. GRAND TOTAL' JZ-
REMARKS:
Prep ere d by Dr. J. A. Salz.tnal"ln, opprovod by Ih~ Boord" of D"(letor$ of Americ=on

the As aeete nen of OrthQdQnli!.u and the Ceun cl l e n
Den'ol Heel th of the American Dental A.$$ocigllon.
Fig. 37-9E.
140.
139.
Continued, opposite.
A?
'B. Interarch Deviations: equal more than 6 points, 8 Lower Lip Palatal to Maxillary Incisors. The as-
points are added. This makes an grand total assessment sessment of the rest position of the lower lip palatal to the
of 40 points for these casts (Fig. 37-11E). maxillary incisors is made with the lips relaxed and the
teeth in terminal occlusion (Fig. 3713). Jaw closure
Use of the Index in Direct Mouth Examination should be repeated until relaxation of the lips is obtained
before the assessment is made.
The Supplementary Oral Assessment Record (Fig. 37- Occlusal Interference. Occlusal interference refers to
21) is used when the assessment is made directly in the the presence of malpositioned teeth that interfere with
mouth of the patient. Dentofacial deviations, such as the lateral, protrusive, or other excursive movements of the
following, that are not apparent on dental casts can be mandible (Fig. 37- 4A)
scored when the Index is used in direct mouth Functional Jaw limitation. Functional jaw limitation
examinations. Eight points are scored for each dentofacial refers to malpositioned teeth that interfere with or limit
deviation. jaw movements usually required during mastication (Fig.
Facial and Oral Clefts. Facial and oral clefts (Fig. 37- 37-14B).
12) refers to malocclusion in association with clefts of Facial Asymmetry. Facial asymmetry refers to
the lip and palate. When the alveolar process is not malocclusion that necessitates lateral or protrusive
involved in the cleft, orthodontic treatment priority is shifting of the mandible to obtain terminal occlusion so
determined by the malocclusion score alone. that lateral asymmetry of the face becomes evident (Fig.
37-15). Mandibular prognathism is shown
DEFINITION AND CRITERIA FOR ASSESSING HANDICAPPING MALOCCLUSION PERMAN ENT

DENTI TION
DEFINITION: Handicapping malocclusion and handicapping dentofacial deformity are conditions that constitute a hazard to the maintenance of oral-
health, and interfere with the well-being of the child by adversely affecting dentofacial esthetics, mandibular function, or speech.
Ce s e No.
I
IliITI
2 3 4
Excmrne r No. r=o DOI.~
7 8 9 10 11 12
Arcol=rrIIJ
13 14 I, 16
~
A. INTRAARCH DEVIATION
MISSING CROWDED ROTATED NO. VALUE SCORE

AFFECTEO ONLY
OPEN CLOSED
'0 2,
MAXILLA
Ant. " " J / 'Z X2
4-
Post. 22 2> 24 as 26 Xl
27 28 '0 ar
MANDIBLE
Ant. I / Xl I
Post. '2 ae
2- '4 ae
,. Z Xl
z
Ant. ; anterior teeth (4 incisors); Post. ; posterior teeth (include canine,
Total Score
1
premolars and first molor).
No. ; n umber of teeth affected.
B. INTER-ARCH DEVIA nON
1. Anteri or Segmen t
SCORE MAXILLARY OVERJET OVER61 TE C~OSS6ITE OPEN61 TE NO. P.V. SCOR E

TEETH AFFECTEDONLY. i
EXCEPT OVER61 TE' 37
4- so
t I' '0
~ X2 /&
*Sc:ore maxillary or mondibulor incisors. Total SCore /6
No_ number 01 teeth affected; P .V. = POInt value.
SCORE TEETH RELATE MANDI6ULAR TO SCORE AFFECTED
AFFECTEO ONLY MAXilLARY TEETH MAXILLARY TEETH ONLY NO. P.V. SCORE
DIS1 AL MESIAL CROSS61TE OPEN6ITE
.R1-bHT '-EFT RIGHT LEFT RIGHT LEFT RIGI-IT t.EFT
4, 45 '9 53
" "
Canine
42 4' 50 ee
'"
ea '0
I Xl J
1 st Premolar
" Xl
se 53 71
2nd Premo I Or
" " Xl
44 >2 ee ec 6' 72
1st Molar
" Xl
No. = number; P. V. = point value; Total Score I

* Add 8 points, when intra-and i nter-o rch mo xi II ory ------- -------+ 11
REMARKS:
incisor score is 6 or more to denote esthetic handicap. GRAN D TOT AL ~
~z
Prepcred by Dr, J. A. Sol zmcnn, Qppro .. ed by ,h", BOO;Jrd of Dt-eerer s of the Americon A5-S0l;iQtion of Orthedent! sis and the Council on Dee tel Health ~'the Ame-
l ccn DcnlO;JI As s o cletlcn.
Fig. 37-lOE.
141.
Fig. 37-11. See text. Continued op-

posite.
in Figure 37-16, and a retrognathic mandible is shown in and 28 as indicated by esthetic deficiency, interference
Figure 37-17. Speech defect should not be assessed by with function, or dental health.
the orthodontist, general dentist, or hygienist without
special training in speech pathology.
Patient
The examiner checks squares 29, 30, and 31 as

indicated. If the patient requests treatment or replies in
TREATME T DESIRABILITY
the affirmative when asked if he desires treatment,
The assessor completes the Treatment Desirability squares 32, 33, and 34 are checked as indicated. If
section without conveying the findings to the patient, the treatment is not wanted, square 35 is checked.
parent, or the teacher, each of whom is interviewed
individually in turn.
Parent
The treatment desirability section shows some
rectangles to be omitted. The following instructions The examiner checks squares 36, 37, and 38 as
indicate by number the rectangles in which the various indicated. The parent is asked if he has any questions
scores are to be entered (Fig. 37-21). about the patient's teeth. If not, the assessor asks if
treatment is desired. If the reply is in the affirmative, the
Examiner or Assessor parent is asked if it is because it would correct the
patient's dental irregularity, improve facial appearance,
Treatment needed (TN). The assessor bases his chewing, or tooth cleaning. Affirmative replies are
decision on first impression. He checks Nos. 26, 27, checked as indicated in os.
Treatment Desirability' 639
DEFINITION AND CRITERIA FOR ASSESSING HANDICAPPING MALOCCLUSION PERMANENT

DENTITION
DEFINITION: Hondicopping molocclusion ond hondicopping dentofo eio l deformity ore conditions that constitute a hazord to the
maintenonce of orol heolth, end interfere with the well-being 01 the child by c dver selv al." fecting dentofcc io l esthetics, mondibular
lunction, or speech.
1 2 3 4 7 S 9 10 11 12 13 14 IS 16
Ca5i1t No.1=rJIJ E)(omlner No. ~

6
DOI.1TTTTl A'ooo=IITI
~
A. INTRA-ARCH DEVIATION
MISSING CROWOED ROTATED NO. VALUE SCORE

AFFECTED ONLY
OPEN CLOSEO
"
MAXILLA
Ant.
>7
I I' 20 .::i " 4- X2 ff

Post. n
"2.. Xl
23
20
24
eo
ae
Z e:
MANDIBLE
Ant. " " Xl
Post. aa
,. as Xl
Ant. = onterior teeth (4 incisors); Post. = posterior teeth (include canine,

T otol Score 10
premolors end lirst molor).
No. = n umber of teeth affected,
B. INTERARCH DEVIATION
1. Anterior Segment
SCORE MAXILLARY OVERJET OVERSI TE C~OSSBITE OPEN BITE NO. P,V, SCORE
TEETH AF FECTED ONLY.
EXCEPT OVERBITE' 37
3
1- ,. 40
1 X2
/1-
"Score moxillary or mandibulor incisors.
No. = number 01 teeth affected, P.V. = pornt vclue.
Totol score
If
SCORE TEETH REL ATE MANDIBULAR TO SCORE AFFECTED

AFFECTED ONLY MAXILLARY TEETH MAXILLARY TEETH ONLY NO. P.V. SCORE
DIST AL MESI AL CROSSBI TE OPEN srr s

RIGHT LEFT R((j.HT L.EFT RtGHT 'LEFT FUGH'T L~F'T
41 ee 4' ee 01 50
" 6'
Conine
r I Z Xl 7.-
50 54 02 50
" " "
1st Premolar I J 2- Xl ~
.7 " 55 59 03 67
"
2nd Premo I ur I I 2 Xl 2
44 '6 52 56 00 04
6. 12
1st Molor j I 2- Xl ~
No. = number; P.Y. ;;;; point val we; Totol Score ~
*Add 8 points,when intra-and inter-orch moxillary If
incisor score is 6 or more to denote esthetic hondicap. GRAND TOTAL *
REMARKS: 40
Prepered by Dr. J. A. Salzmann, oppro v e d by th~ BI;loQrd I;lof Dl rectcr s of ,h~ Am4!lrieor'll AS!Qdotion of Dr'''oo'ontists eed the Cl)Ur'IIeil on Dl:"Ilh:1I H4!loltJ-. of 'he-
American Dl!'r'II te I A$~Qc;iQtion.
Fig. 37-11E.
Fig. 37-14. A, B. See

text.
39, 40, and 41. If treatment is not wanted, square 42 is

checked.
Teacher or urse
The examiner (assessor) checks squares 43, 44, and 45
as indicated. If treatment is requested voluntarily or in
reply to a question, the assessor asks if the reason is to
correct dental irregularity, facial appearance, or as an aid in
chewing or tooth cleaning. Affirmative replies are checked
as indicated in
as. 46, 47, and 48. If treatment is not wanted, square 49
is checked.
The section on Treatment Desirability provides a Fig. 37-15. See
text.
Treatment Desirability 641
Fig. 37-16. See text. Fig. 37-17. See text.
A. 69 cases accepted by
index assessment
A,
A B
33 cases rejected by
index assessment
- 8 cases
rejected (see
4
8 cases
accepted
note 11 (see note 2)
B, 61 cases accepted by B. 33 cases rejected by
clinical judgment clinical judgment
same cases used for both
NOTE L OF 8 CASES WITH INDEX ASSESSMENT OF 17 POINTS OR MORE REJ ECTED

BY cu NICAL JUDGMENT, 2 REQUIRED PROSTHESES, 2 HAD REGULAR ARCH
ALIGNMENT WITH MESIODISTAL DEVIATIONS, CLINICALLY CONSIDERED NOT
HANDICAPPING, AND 4 WERE CONSIDERED OUTSIDE THE SCOPE OF THE STATE
PROGRAM. THE INDEX FORM PROVIDES FOR THESE NOTATIONS UNDER
"REMARKS".
DIRECT MOUTH ASSESSMENT WESTCHESTER
COUNTY, N,Y. SCREENING CENTER NEW YORK STATE
BUREAU OF DENTAL HEALTH ORTHODONTIC NOTE 2. OF 8 CASES WITH INDEX ASSESSMENT OF LESS THAN 17 POINTS, ACCEPTED
PROGRAM
BY CLINICAL JUDGMENT, THE DEVIATIONS WERE CONFINED TO THE INCISOR REGION
AND WERE CONSIDERED HANDICAPPING. THE INDEX FORM PROVIDES FOR THESE
Fig. 37-18. (Courtesy Dr. Norman D. Allen)
NOTATIONS UNDER "REMARKS".
Fig. 37-19. (A) Enlarging mirror used in examining for rotated,

crowded, spaced and missing teeth. (B) Metal mirror and cheek
retractor used in examining the dental arches.
Fig. 37-20. (A) Head position and cheek retraction for intraoral
examination except for overbite. (B) Retraction of cheek for
anteroposterior occlusion examination. (C) Intraoral examination
for overjet and overbite. (D) Intraoral examination for overbite. (E)
Intraoral examination for anteroposterior deviations (Courtesy M.
M. Feldman).
Bibliography' 643
SUPPLEMENTARY ORAL ASSESS.ffi~T RECORD
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Cue NO) III IJl9.rrnEx~miner NornD"telTTTllere~ IIIII
~ ~ Locution
C. DENTOFJlCIJlL DEVIATIONS
The following devietionc ere scored eB hendicopping when OBsociated

with melocclusion: Score 8 points for each devietion.
1. Faciel end orel c1@fts 142.

143.
2. Low@r lip pDlatel to mDxi11ery

incisor teeth
3. Occlusel interference
4
.
5. F~cial esymmetry
6. Speech impeirment
Totel Scor
D. TREATMENT DESIRABILITY
~. The exeminer should not suggest the need for treatment.
Check exJ>,MINER PARE-N'r TEI\CHER

repHe. T.N. T.R. T.N. T.R. N.W. 36'- T.N. T.R.C.W.
N.W
N.W. 39 42 43 46 49
Fechl . 35
26
esthet
ics
Function 27
Dental 28
ltygien"
T.N. - Treetment needed

T.R. - Treatment requested
~.W. - Treatmont not wanted or needed
Rernerksl Mention deviation not included in this ~sscssment record form.

Fig. 37-21. Supplementary Oral Assessment Record.
clue to the degree of patient and family cooperation that tion is a valid and practical method of assessment. Direct mouth
can be expected. This may help avoid wasting examinations can be used also in epidemiologic surveys of
malocclusion or the assessment of large numbers of children for
manpower and available funds.
prepayment or public health orthodontic care programs (Fig. 37-
Allen described the use of the Index in direct mouth 18).
examinations of prospective orthodontic patients in the
following manner:
The patient is seated in a dental chair with the head tipped BIBLIOGRAPHY
back and the mouth sufficiently open to permit a clear view of
the entire dentition (Fig. 37-18A, B, C). The assessor must be Allen, N. D.: Handicapping malocclusion assessment record in
able to view the dental arches from the front of the mouth for direct mouth examination. Am. J. Orthodont., 58:67, 1970.
assessing overbite and overjet, and the buccal series of teeth at a Ast, D. B., Carlos, J. P., and Cons, N. c.: The prevalence and
right angle to the occlusal plane, in order to assess the characteristics of malocclusion among senior high school
mesiodistal relation of the mandibular to the maxillary dental students in upstate New York. Am. J. Orthodont..
arch. A magnifying hand mirror and metal mirror cheek retractor 51:437,1965.
are useful for this purpose (Fig. 37-19A and B). The patient is Baumgartner, L.: Orthodontics as a public health service.
asked to "bite on the back teeth." The occlusion is checked to Am. J. Orthodont., 47:809, 1961.
ascertain that the mandible is not thrust forward or to one side. Byrne, J. J.: Assessment of malocclusion: Implications for dental
Overbite is assessed with the patient's head level and overjet prepayment programs. Am. J. Orthodont., 54:766, 1968.
with the head tipped back. Council on Dental Health, American Dental Association.
Allen examined 110 children to determine the accuracy of Prepaid dental care programs, Am. J. Orthodont., 48:778,
direct mouth examination using the Index. The results indicate 1962.
that the use of the Index in direct mouth examina-
Hixon, E. H., et al.: On Force and Tooth Movement. Am. J. --_: Orthodontics in prepaid dental programs, Am. J.
Orthodont., 57:476, 1970. Orthodont., 49:776, 1963.
Salzmann, J. A.: Principles and Practice of Public Health Salzmann, J. A.: Malocclusion severity assessment. Am. J.
Dentistry, Boston, Stratford, 1937. Orthodont., 53:109, 1967.
--_: Orthodontics as a public health activity. Am. J. Salzmann, J. A.: Handicapping malocclusion assessment to
Orthodont., 35:179, 1949. establish treatment priority. Am. J. Orthodont., 54:749, 1968.
Salzmann, J- A, et al.: Fact finding report on Strusser, H., and Simon, L. A: Orthodontics in public health
health services-Orthodontics. Am. J. Orthodont., practice. Am. J. Orthodont., 40:654-670, 1954.
37:50, 1951Salzmann, J. A, and Moore, G. E.: The Squires, F. A., Salzmann, J. A, Howes, A E., and Bedell,
White House conference and orthodontics. W. R: The advisory committee on orthodontics in
Am. J. Orthodont., 37:426, 1951- the public health program. Am. J. Orthodont., 46:220-
Salzmann, J. A: The Michigan workshop in 223, 1960.
orthodontics.
Am. J. Orthodont., 45:55, 1959.
Index
Numerals in italics indicate a figure, "t" following a page number indicate a table.
Abnormalities. See Malformation(s) modified, in edge-to-edge bite, 383 638, 643, 640-642
Activatorts), 556-591 occlusal changes and, 558, 559 establishment of treatment priorities in, 630-
action of, theories of, 570-578, 572-578 skeletal dysplasia correction with, 558, 560 631, 630
advantages of, 590-591, 619, 619 tooth eruption control with, 558-559, 565, 560, treatment desirability section of, 638-643
casts for, 578-579 570 use of, as bas for fees, 631 instructions for,
application of separating medium to, 584 trimmed, inferior view of, 572-573 631-638, 643, 631642
placement of acrylic on, 584, 587 lateral view of, 571 American Dental Association Council on Dental
Class II, correction of malocclusion with, 558, right buccal segment of, 571 Health, on acceptance of patients for pu blic
563-565, 556. 557, 558, 560, 562, 568, superior view of, 572-573 health orthodontic programs, 629
569, 570 trimming of, prefabrication of, 581-583, 582 American Public Health Association, on
eruption of teeth with, 581, 572, 572573. 582, procedure in, 584-586, 572, 572-573, orthodontics, 628
583 585 Analysis, cephalometric. See Cephalometric(s),
extension of acrylic of, 583, 585 untrimmed, lateral view of, 572-573 analysis
working bite for, 572 uses of, 556-567 Anchorage, 275-277
Class III, correction of malocclusion with, vertical manipulation of dentition with, 560-561, compound intermaxillary, 275
588-590, 589 560, 561, 562 definition of, 420
eruption of teeth with, 581-582, 584 exten Adams clasp, 298 extra oral, 276
sian of acrylic of, 583, 585 Adolescent, as patient, 3 labiolingual technique and, 498, 499 loss
labial archwire for, design of, 583, 580, 585 dentofacial growth changes of, influence of of, 276
construction of, 578-586 treatment on, 351-353, 352-354 Adult(s), occipital, 276
bite registration for, 578-579, 579 skeleton and musculature of, and of newborn, problem, hypothetical, 419
compared, 6 reciprocal tooth movement and, 419-420,
and manipulation of, for Class II correction,
skull of, 7 419,420,421
586-588,570,572,572-573, 585, 587,
treatment of, 373-386
588 reinforcing of, 276-277
case report of, 377-378, 379
contraindicatioris to, 591 resistance offered by, 276
Age, as factor in treatment, 146, 147 changes in
disadvantages of, 590-591 facial growth and dental development, 20-21. simple, 275
dislodging springs for, formation of, 580-581, dental, assessment of, 143 simple reciprocal intermaxillary, 275
582 simple reciprocal intrarnaxillary. 275
in deciduous dentition, 310 skeletal,
facial changes and, 558, 557, 558 simple stationary, 275
assessment of, 79-80, 142-143 tooth
facial conditions best managed by, 562- sta bili ty of, 276
eruption and, 29
565,568,569,570 Agenesis of teeth, 126, 127, 128, 129, 131 types of, 275- 276
facial growth and, 561, 563-565, 566 Alastics. 283 Angle, classification of malocclusions, 54-65,55
frontal view of, 572-573 Alveolar process, ankylosed teeth and, 131 edgewise appliance, 408-409, 408-409
growth of, 249 Ankylosis, in deciduous and permanent
functional occlusal plane changes in Class II
dentition, 130-132, 130
treatment with, 568-570, 570, 571 and maxilla, supraclus ion of, and buccoelusion
of primary molars, 240-241, 243
indications for, 591 of maxilla, 55
Anodontia, causes of, 126
intermittent forces of, tissue changes and, 605- American Association of Orthodontists,
Appliance(s), activator. See Activator(s)
606, 606 interceptive orthodontics defined by, 211
active, 277
intrusion of teeth and, 560 -Salzrnann treatment priority index, 629-643
Andresen. See Activator(s)
labial arch wire of, design of, 579, 556, assessment of dental casts in, 632-636, 633-639
antithumbsucking, 229, 228, 229
572-573, 580 assessment of patients for, 629-630, 630
arch-widening, 403
limitations of, 556-567 direct mouth examination and, 636-
in B gg technique, 440-442, 440, 457-459
lingual relief of, 579-580, 573, 581
Birnler, 556, 556
mandibular growth change with, 559-
biteplate, 162-163
560,561
in Bruxism, 381, 384
in mandibular relocation, 385, 386
masticatory muscle reaction to, 606-607
645
646 . Index
Appliance(s) - (Cont.) split-plate, 161-162,395,397,400 stabilizing nique, 482-484

cervical, 277. 302. 304 plate. See Stabilizing plate stainless steel. 292- stainless steel, for labiolingual tech-
chincap, 164, 310-312,303,311 293, 292 nique, 484-486, 484, 485, 486
for developing Class III malocclusion, 312,311 twinwire. See Twinwire appliance lingual holding, 237-238. 238 loops.
in mandibular prognathism, 313 upper traction, 299 281-283
construction of, 288-306 use of, 288-306 materials for, 410
model conservation and, 481-482 Archtes), anteroposterior adjustment of, from resiliency of, 414-417, 416
Crozat, See Crozat appliance edgewise. mixed to permanent dentition, 321 second-order bends in, 281
See Edgewise appliance extraoral, basal. areas covered by, 154 steel. force of. 278
asymmetrical, 301 changes in, cephalometric analysis and, 194 Articulation, mandibular, structure of. 99
cervical, 277. 302, 304 discrepancies in, 154 temporomandibular. See Temporomandibular
construction of, 304, 302 of maxilla and mandible, 95 articulation
distal driving and, 303-304 relationshi p of, 96 prognathism, Assessment, bone age, 79-80
facebow angulation of. direction of 364
tooth movement and, 301-303 Salzmann's, 89
force of, 300-301 branchial, abnormalities of, 107-111 collapse Band(s), contour of, 411 fitting
high-pull, 277 of, prevention of, 149-150, 151 constricted, of. 412-414, 414. 415 function
for nighttime use, 299 molar region of, 19 expansion of, twinwire of, 410
fixed, components of. 410 appliance in. in labiolingual technique, 480-482, 495,
interrupted forces and, 605, 602 fixed- 460-462, 460 482. 483, 495
removable. in crossbite, 226-227, 227 length, available, 211-213 materials for, 410-411
force exerted by, factors determining, 279 deficiency of, methods of correction methods of separating teeth for, 292, 289
Frankel, 556, 557 of, 409 placement of, 414
in labiolingual technique, 500, 499 increase in, 17 preformed, 410
hayrake, 161. 229, 159, 229 high-pull measurement of. 212-213, 212 required and in twinwire appliance, 461-462, 461
extraoral. 277 available, Tweed method Begg technique. 438-459
inclined plane, acrylic, 223-224,223,224, of establishing, 272 appliances in, 440-442, 440, 457-459
225 lingual, expansion of, round and halfround tubes fundamental concepts of, 438 retention
labial, 220 and, 290 following, 459
labiolingual. See Labiolingual technique mandibular, collapse of. and microglossia, treatment with, case histories illustra-
lingual, 288-291 333-334, 332-334 treatment of, 251 ting, 442-459, 441-457
activation of. 291 radiography of, 168, 170 diagnosis in, 442
applications of, 290 maxillary, alignment of, following cleft lip effectiveness of, 438-440
arch stabilizing, 149-150, 151 closure, with segment guidance, 405 stages of. 438, 439
auxiliary springs on, 291 without segment guidance, 404 collapse of, Benninghoff's lines of stress, profile of skull
holding, 237-238, 238 in clefts. 392, 396. 402-404 following showing, 95
locks and loops on, 289 premolar extraction. 252 narrow, midpalatal Bicuspids, band fitting and bracket place-
Porter, 220, 220 suture opening in, 542-544 ment on, 413, 413
tooth rotation and, 288-289 overexpansion of, 621 Bimler appliance, 556, 556
radiography of, 168-169, 169 Biomechanic terms, 274-275
wire in, gauges of, 292
lower traction, 299 normal, and shifting of teeth following Biomechanics in orthodontic therapy, 274-287
extraction, 116 Bite, dual. 618
Mershon, 289-291. 220. 289. 291 midpalatal
permanent, size of, estimation of, 262 width "jumping," 304-305
suture-opening. See Mid-
of. archwire and, 417 Archwire(s), arch width registration. for construction of activator, 578-
palatal suture opening
and, 417 579, 579
oral screen, construction of, 148, 149
in Begg technique, 440, 458. 459 configuration
orthorehabilitative. 215 neuromuscular concepts of. 570-578, 572-578
of. alignment of teeth and,
palatal bar, 161. 159 Bite opening, extraoral appliance and, 303
417-419, 417. 418
passive, 277 removable appliance for, 296
formation of, 414-419
in clefts, 405 plumper, Biteplanes, changes effected by, 162, 163, 295-
functions of, 410 ideal,
158, 158 removable, 277, 296
419, 418
293-297 for bite opening, Biteplate(s), construction of, 300-301 elongation
labial, of activator, Class III, design of, 583,
156 of posterior teeth and, 294-295, 303
580. 585
in crossbite, 224-226. 226 for tooth movement, 162-163, 294 Bi
design of, 579, 556, 572-573, 580
intermittent forces of. tissue changes and, 605- te-raising. 381-386
mandibular, for labiolingual technique, 498-
606, 606 Biting, fingernail, 121-122. 123
499
mandibular, 155 lip, 121
maxillary, for labiolingual technique, 495-496,
for movement of ectopically erupting Bjork's facial analysis, 204-206,204,205 Body
495, 496, 497
canines, 339 proportions, of newborn and adult, compared,6
lingual, for labiolingual technique, attachments
requirements of, 288 safety Body type(s), athletic, 75
to, 487-493, 487-494 precious metal, for
measures and, 288 leptosomatic, 75 pyknic,
labiolingual tech-
space maintaining, 148-149,215,150,216 75
space regaining, 215, 216 skeletal classification according to, 75
speech, in cleft palate, 402
Index' 647
Boley gauge in measurement of arch length, occlusal relation of, 45, 46, 45 lines, 186-189, 191
212, 212 premature loss of, 315 maxillofacial triangle in, Margolis',
Bone(s), age assessment, 79-80, 142-143 development of, from birth to age four- 203- 204, 203
alveolar, resorption of, tooth movement and, teen, 30-41 measurements, Downs', 198-200, 198-200
592-593, 594 ectopic eruption of, 126, 128, 134, 339 planes, 186-189, 191
teeth as functional matrix for, 25 bundle, extraction of, 250 radiographic, 176-182
arrangement of, and tooth movement. 604, high, 135, 137 clinical value of, 183
603, 604 impacted, Direct Bonding System in, in diagnosis and treatment, 183-196 in
centers, in hand, range of time of ap- 437, 436 examination, 143
pearance of, 83t changes, locating of, 337, 340, 341, 342 limitations of, 190-191
in adult, 373-374 cranial. See orthodontic therapy in, 339-340 reference lines in, 191-192
Skull surgical exposure of, 340-341, 342 techniques in, 176-179
deformation, theories of, 598-600, 599 movement of, force and, 279 tracings of, superimposition of, 195, 193, 194,
deposition, internal. in posthyaliniza- permanent, occlusal relation of, 46, 48, 47 195
tion period, 600, 601 shaped to resemble lateral incisor, 337 uses of, 176
. physiologic tooth movement and, 592, 593 Caries, dental occlusion and, 19 and standards, Downs', 198t
displacement of, in mid palatal suture opening, malocclusion, 3, 122 Ricketts', 202-203
552, 551, 553 and orthodontic treatment, 3 University of Washington, 202t
facial, development of, 6 Cartilage, Meckel's, development of, 11 Centric technique, standardization of, 183
of fetus, 9 occlusion, and centric relation, 618 of mandible, Yvaxis, 190, 194
formation, in abnormal labial frenums, 152 97, 98 Charts, diagnostic examination, 143-144
types of, 9-10 Centric relation, and centric occlusion, 618 of Child(ren), as patient, 2-3
grafting, in cleft palate, 401-403, 405 mandible, 97, 98 comparison of hands of, from age 6 to age 15,
growth of, types of, 26 Cephalogram(s), accuracy of, 176 45 89-93
lability of, 9, 9 degree, 179 development of dentition of, from birth to age
long, structural details of, 8 head position, natural, 178 14,30-41
orthodontic therapy and, 9-10 regeneration of, information obtainable from, 183
temporomandibular articulation of, and of adult,
following mid palatal lateral, 177-178, 178
compared, 99
suture opening, 549-550, 549 resorption, comparison of, by mesh diagram, 210
Chincap. 164,310-312,303,311
orthodontic tooth movement and, 593-594, oblique, 179
for developing Class III malocclusion, 312, 311
594 tracing of, 188
in mandibular prognathism, 313
physiologic tooth movement and, 592 593 without cephalometer, 179, 180
Chlorobutanol, 4
undermining, 596, 595, 596 magnification and distortion in, 176
Chromosomal aberrations, and clefts, 387, 390,
structure, factors influencing, 9 and mandibular rest position, 178
391
teeth, differences between, 30 posteroanterior, 178
Clasp, Adams, 298 Schwarz
type, hyalinization of periodontal tissue and, of ramus of mandible, 179
arrowhead, 298
596, 593 tracing of, 179-181, 188
Clasp knife reflex, mechanism of, 577
Bracketts), attachment of, to enamel. See Direct in check of efficacy of treatment, 248 use
Classification, in deciduous dentition, 53 dental,
Bonding System of, 176
variation of, 75-79
in Begg technique, 440-441, 440, 457 Cephalometer, 176, 177
of malocclusion, Angle, 54-65, 55 Class
edgewise, 409, 409, 410 Cephalometric(s), analysis, 197-210
I, 54
functions of, 410 denture, 194-195, 192
Downs', 197-202
n.
Class 54-55
modifications of, 411-412, 411 Division 1,55
placement of, 412-414, 41~, 416 facial, Bjork's, 204-206, 204, 205
Subdivision, 55
and tube set-ups, 412, 412 mandible, 193
Division 2, 58-65
Brain, case, growth of, form-function rela- maxilla, 193
Subdivision, 65 Class
tionship in, 25 Moorrees mesh diagram in. See Mesh III, 65
expansion of, 16 diagram, Moorrees' skeletal. 75-94 variation
Branchial arch abnormalities, 107-111 profile, 193,192 Ricketts', of, 75-79
Bruxism, 122-123, 381 202-203, 201 Sassouru's, Cleft Ii p, chromosomal aberrations and,
appliance in, 381, 384 206-207, 205 skeletal,
387, 390, 391
Buccoclusion, of maxilla, and maxillary and 193-194, 191
dental abnormalities in, 387-389
alveolar supraclusion, 55 angle(s), 190
etiologic factors in, 10, 387
Bumper, lip, 148, 151 Gonion, variations in, 192
formation of, stages of, 387 parent
in evaluation of growth, 195-196, 193, 194, 195
counselling in, 406
Frankfort-mandibular plane angle in, 190, 194
types of, 387, 388
Frankfort plane, 187-188, 194
Cleft palate, 387-407
landmarks, 183-186 commonly
bone grafting in, 401-403, 405 chromosomal
used, 189 lateral, 184, 186
aberrations and, 387, 390, 391
and measure points for clinical use in, 189, 190
collapsed, treatment of, McNeil's tech-
Calcification, of teeth roots, deciduous, 4 posteroanterior, 184. 185
nique for, 399-403, 397-398
permanent, 42 variations in, 192, 189
crossbi te in, 399-400,403
Calvaria, growth of, form-function relationship
dental abnormalities in, 387-389
in, 25
etiologic factors in, 10, 387
Canine(s), deciduous, grinding of incisal tips of,
316
1
648 . Index
Cleft palate- (Cont.) extractions histories of, 527-531, 537, 528-530, 538- renal, dentition and skeletal features in. 111-112
in, 392 formation of, stages 541 severe, dentition and skeletal features in,
of, 387 Division 2, Subdivision malocclusion, case 110-111
not involving alveolar process, 400 history of, 531-534, 532-534 construction of, Distoclusion. See Malocclusion. Class II
oligodontia in, 393, 403 514-521 Downs' cephalometric analysis, 197-202
orthodontic intervention in, 389-396 materials and tools for, 514, 527t crescent of, Ductility, definition of, 275
contraindications to, 393-394, 393 mandibular, formation of, 515-516, 516 Dwarf, achondroplastic, dentition and skeletal
results of, 394 maxillary, formation of, 519 features of, 108-109
timing of. 391-392 cribwire of, mandibular, bending of, 515, 515, Dyslalias, malocclusions and, 101 Dysostosis,
orthopedics, 396-403 516 orodigitofacial. dentition in, 107
parent counselling in, 406 postoperative maxillary, bending of, 518-519. 518 Crozat Dysplasia, ectodermal, hereditary, dentition in,
anomalies in, 396, 392 prosthesis in, on, 513 115
394-395, 401 radiography in, 391, 393 finished, 521, 522 skeletal, activator in, 558, 560
rehabilitation in, 394 insertion of, 521-522
speech, 403-406 lingual bodywire of, mandibular, construction
supernumerary teeth in, 395 of, 516-517, 517
transmission of, 387, 389 maxillary, construction of, 519-520, 519, 520
types of, 387, 388 occlusal rest wires of, 517-518 Ectodermal dysplasia, hereditary, dentition in.
Clicking of temporomandibular articulation, in rotation of molars for space gain, case 115
100 history of, 534-537, 535-537 soldering of, Ectopy, diagnosis of, 337
Coil, Pletcher, 305 spring Edgewise appliance, 408-433
520-521. 520, 521
force, 280, 282 band fitting in, 412-414, 414, 415
Curve of Spee, 19
-springs. in twin wire appliance, 462, 462 bodily movement and, 605 bracket,
Cuspids, band fitting and bracket placement on,
Condyle(s), changes in, 196 409, 409, 410
413, 413
mandibular, growth of, 10, 9 modifications of, 411-412, 411
movements of, 99 placement of, 412-414, 413 and
malocclusion and, 100 tube set-ups, 412, 412
Copalite,4 in complex malocclusions, case reports
Coronoid process, and temporalis muscle, form- of, 421-433, 422-432, 423t, 427t
function relationship of, 25 Cranium. See Skull Deformation, definition of, 275 components of, 410-412
Crossbite(s),215-227 Dental care, general, 3-4 development of, 408-410
anterior, 220-221 Dentinogenesis imperfecta, in ectodermal E arch, 408, 408
buccal, midpalatal suture opening and, 551 dysplasia, 115 modifications of, 409-410
in cleft palate, treatment of, 399-400, 403 in Dentist, family, orthodontics and, 1 pin and tube, 408, 409
deciduous dentition, 217, 316-318, Dentition. See Tooth(Teeth) ribbon arch, 408-409, 409
217.308.310 Development, of clefts, 10 uses of, 408
labiolingual technique in, 480, 481 in definition of, 6 Elasticity, definition of, 275
mixed dentition, 217, 217, 218 posterior, and growth, record charts, 563-565 of Elastics, force produced by, factors influencing,
degrees of. 220 mouth, 10, 10 283
functional, detection of, 219-220, 219 occlusal, guidance of, 145-166 intermaxillary, force of, 284-285
unilateral, 219 scope of, 145 hooks for, 300
right maxillary, with exception of central of teeth, deciduous, 30-35. 31-32 in space closure, 284
incisor, labiolingual technique in, 506- permanent, 35-42, 33-41 with mouth open and closed, space diagrams of,
512,509-511 of tongue, 11 284
simple incisor, characteristics of, 221. 221 Diagnosis, in deciduous dentition, 307-320 of vector diagrams of, 283
correction of, acrylic inclined plane appliance ectopy, 337 lingual and buccal, in space closure, 284
in, 223-224, 223. 224, 225 in mixed dentition, 321-334 modification of pull of. 283
fixed-removable appliances in, 226227,227 in permanent dentition', 335-372 of Oliver guideplane and, 490
gaining cooperation from patient in, 221-222 prognathism, 353-361 uses of, 283
removable appliances in, 224-226, 226 of supernumerary teeth, 120, 230-231. 231, 232, Enamel, direct bracket attachment to.
tongue blade technique in, 222-223, 218. 222 233 See Direct Bonding System
treatrnen t of, 220 of temporomandibular dysfunction, 100 Tweed etching, 4
early, 215-219, 217, 218 triangle in, 248, 270-271, 252 Diastemajs), Endocrine imbalance, dentofacial manifestations
Crozat appliance, 513-514 abnormal, causes of, 116-117, 152. 153 of, 111
acti vation of, 524-527 in deciduous dentition, 316 Environmental factors, effects of, on dental
adjustment of, 522-524, 523-524, 525-526 midline, in adults, treatment of, 374, 384 genotype, 43, 44
clasps of, construction of, 513-514, 516 in Differential force, 279 Equilibration, occlusal, 623-626, 625 Eruption,
Class II, Division 1 malocclusion, case Direct Bonding System, 434-437 control of. activator in, 558-559, 565, 560, 570
advantages of, 434 delayed, causes of. 126, 132, 136, 137, 139
bonding technique in, 434-435, 434-435 surgical exposure of teeth in, 238-239,
bracket removal in, 435 240, 241
clinical use of, 435-437, 436 ectopic, 126-128, 134,135, 137
disadvantage of, 434 facial growth in depth and, 15
Disease(s), periodontal, malocclusion and, mean ages of, 29
111,150-152 order of, 30
Index' 649
effect of. on deciduous dentition, 315-316, 314, second,250 son, compared, 75-79, 87
315, 317 serial, 262-273 contraindications to, in siblings, compared, 84-86 profile(s)
Etching, enamel, 4 262-263 goals of, 262 of, cephalometric analysis of,
Etiology, of malocclusion, 103-125, 103 improperly planned, 239 193, 192
acquired, 104106 indications for, 235, 262, 235, 236, 265 changes in, activator and, 560, 561
classification of, 103-106 lingual holding appliance and, 237- compared, 80
dentofacial pressure habits in, 120-123, 238, 238 dental occlusion and, 22
118-119, 120, 121 endocrine Nance's method of, 263 extraction and, 249-250, 250
imbalance in, 111 environmental, procedure in, 235-237, 235, 236 Tweed's factors influencing, 22
104-106 functional, 104 orthodontic guidance for, 270 without radiography of, 172, 180
genetic, 106-111 active mechanotherapy, 264 rhinoplasty and, 22, 253
mandibular incisor crowding in, 123 supernumerary teeth, 232-235, 234 prognathism of, 197 causes
midline deviations in, 115-119 tooth shifting following, 116 Tweed of, 206, 250
mouth breathing in, 112 diagnostic triangle and, 248 measurement of, 205
periodontal disease in, 111 twin wire appliance in cases involving, 462 proportions of, increase in, 12-15, 13
postnatal factors in, 103-104 without orthodontic therapy, 257, 258, 259,260 skeletal patternts) of, 75
prenatal factors in, 103 supernumerary Class 1, 85, 87, 349-351, 352-354, 355,
teeth in, 119-120 temporomandibular 357, 358, 360
disturbances in, Class 2, 86, 87, 345-346, 347-349
111 Class 3, 82, 83
tongue posture and function in, 113115 and phenotypical facial appearance, in mother
Examination(s), charts, diagnostic, 143-144 and son, compared, 75-79, 87
Facets), analysis of, Bjork's, 204-206, 204, 205
in siblings, compared, 84-86 relation of
history in, 142 asymmetry of, 8, 7 treatment in,
dentition to, in Downs' analysis, 200-201,
oral, 143 342-344, 343
200
parameters in, 142 balance of, and orthodontic therapy, 97-98
variations in, 75-79
photographic, 143 bones of, development of, 6 fetal,
types of, 78, 79
posture, 142 9
roentgenographic, 143 compared, 80
changes in, activator and, 558, 557, 558 Downs', 197-198, 197, 197t
scope of. 142-143 genetic influence on, monozygous twins
serial, 142 Tweed's, 271-272, 270, 271
illustrating, 322-324, 322, 323
skeletal signs in, 142 width of, dimensions of, 13
treatment timing and, 330, 328-329
of tongue thrusting, 159-160 growth in, 16-17
contour of, Ricketts' analysis of, 203 depth
Exfoliation, premature, 132-134 Fetus, facial bones of, 9
of, growth in, 15
Expansion screws, 161-162 gums and palate of, 30
esthetic line of, Ricketts' analysis of, 203
Extraction(s), in abnormal overjet or over- Finger sucking, malocclusion and, 120, 227-
expression of, muscles and, 14-15t growth of,
bite, 157 228, 318, 118, 2L7
6-24
of canines, 250 therapy in, chemical, 228
acti vator and, 561, 563-565, 566
child and, 3 mechanical, 228-229, 228
by age, 20-21
choice of teeth for, 250-257 psychological, 229-230
changes in, treatment and, 21-22 dental
in Class II, Division 1 malocclusion, 247 Fingernail biting, 318
development and, age changes
Division 2 malocclusion, 247-248 in malocclusion and, 121-122
in, 20-21 in
cleft palate, 392 Flory standard of appearance of osseous cen
depth, 15
criteria for, 246-248 ters, 83t
during first 9 months, 195
of deciduous teeth, indications for, 312-314, Fluoridation treatment, 3
factors influencing, 8
314, 315 Force(s), auxiliary spring, 278279, 278
favorable, 20
eight-tooth, Begg technique following, 453- coil spring, 280, 282
in height, 16
459, 453-457 continuous, tissue changes with, 593-602
method of, 15-19
facial profile and, 249-250, 250 of definition of, 274
occlusion and, 19-22
incisors, mandibular, 256-257 in differential, 279
overall, analysis of, 196, 193, 195
procumbency of. 247-248 relapse elastic, 283-285
Margolis maxillofacial triangle in, 203-
following, 620 extraoral, 300-301, 304
204, 203
of molars, first permanent, 251-253 occlusal intermittent, removable appliances and,
unfavorable, malocclusion therapy and,21
changes following, 117-119 second 605,606
in width, 16-17
permanent, 253-256, 256 interrupted, fixed appliances and, 605, 602
height of, growth in, 15-16
third, impacted, 256 light, in tooth extrusion in openbite, 603-604,
later changes in, 17-19
orthodontic therapy without, case histories of. 603
masks, construction of, 143 measurement(s)
264-270, 266-267, 268-269 in tooth movement, 602-603, 602
of, Downs', 198-200,
of overretained primary teeth, 239-244, 242, lack of force equilibration of, and re-
198-200
243, 244 lapse, 616
polygonal portrayal of, 201
of premolars, first, 25<l, 257 in midpalatal suture opening, 550-551 molar
middle, reference lines in, 191-192 muscles
case illustrating treatment following, 254-255 resistance to, 279
controlling expression of, 14-15t
without orthodontic therapy, results of, 259, muscular, physiologic tooth movement and,
phenotypical appearance of, and facial
260 592, 593
skeletal patterns, in mother and
optimum, 279
650 . Index
Forcers) - (Cont.)
and development, record charts, 563-565 Hypercementosis, tooth movability and, 609-
orthodontic, muscle reactions to, 618
evaluation of, orthodontic therapy changes 610, 609, 610
transmission of, methods of, 279 orthodontic
and, 195-196
appliance, and resistance,
facial. See Face, growth of
279
of head, cranial and visceral areas of, 6-9. 7 Impaction(s), 128-130
in physiologic tooth movement, 592, 593 causes of, 128
processes in, 26
spring, for moving teeth, 279
of jaws, muscle function and, 19 locating of, 337-339, 340, 341, 342
steel archwire, 278 processes in, 26 orthodontic therapy in, 339-340
steel wire, 277-279 treatment and, 145 second premolar, 138
trajectorial, in jaws, 95-96 mandibular. See Mandible, growth of surgical exposure in, 340-341, 342
types of, 274 maxillary, 11-12,196,12, 193, 195 normal,43 teeth susceptible to, 128-129
variation, in tooth movement, 602-604 Form- of palate, 12 of third molars, 129-130, 131, 135 Incisorts),
function relationship, functional matrix concept central, axial position of, treatment to change,
of skull, 6-9, 7
and, 25 399-400
transforrnative, 26
Frankel appliance, 556, 557 Frankfort- band fitting and bracket placement on, 414,413
translative, 26 deciduous, occlusal relation of, 45, 46,
mandibular plane angle, 190 cephalometric
Cui deplane, Oliver, advantages of, 490 45
analysis and, 194
applications of, 488-490, 489 construction deformed, 335
Frankfort plane, 187-188
of, 491-493, 490-494 Gums, of fetus, 30 impaction of, management of, 338
changes in, cephalometric analysis and, 194
of newborn, 30 maxillary, fractured, 336
Frenum(s), labial, abnormal, 152, 153
separated, 150, 152, 153, 340 permanent,
treatment of, 150-152, 154
occlusal relation of, 46, 47-48,47
Frontal process, development of, 11 Frontonasal
radiography of, 169
process, outward, excision of, 392
separa tion of, self-correction of, 309
split-plate in reduction of, 395, 397 Function,
crossbite of. See Crossbiters), simple incisor
and form, relationship between, functional
Habit(s), dentofacial pressure, malocclusion and, development of, from birth to age 14, 30-41
matrix concept and, 25 Functional matrix,
capsular, 26 120-123, 118-119, 120, 121 finger sucking, edge-to-edge occlusion of, treatment of,
Functional matrix concept, clinical applications 120,227-228,318,118.227 harmful, elimination 377-378, 379, 383
of, 26-27 and control of, 227-230, 318-319 extraction of, relapse following, 620
clinical orthodontics and, 25-28 mandibular lip biting, dentofacial structures in, 19, 319 intrusion of, activator and, 560
growth and, 27-28 Functional occlusal plane, nailbiting, 318 lateral, canine shaped to resemble, 337
changes in, in treatment of Class II malocclusion thurnbsucking, 120,227-228,318,119,227 Hale deciduous, occlusal relation of, 45, 46, 45
with activator, 568-570, 570. 571 appliance, in labiolingual technique, 500,499 mandibular, extraction of, in overbite, 162
Functional tolerance, area of, and relapse, 616 Hand(s), osseous centers in. range of time of maxillary, band fitting and bracket placement
Fusion of teeth, 128 appearance of, 83t on, 414, 413
radiographic comparison of, of boys and girls, missing, treatment in, 375
from age 6 to age 15, 89-93 skeletal permanent, missing, 335
components of, 88 occlusal relation of, 46, 48, 47 mandibular,
Hawley retainer, 162-163, 294-296 crowding of, causes of, 123 self-correction of,
construction of, 300-301 265
Hawley-Russell screws, 162 extraction of, 256-257
Genetics, influence of, on dentofacial changes
Hayrake, 161. 229, 159. 229 abnormal overbite following, 258
in monovular twins, 322-324, 322,323
Hep 70,520-521, 520 Head(s), permanent, development of, 249
malocclusion and, 106-111
areas of, 191 procumbency of, extraction in, 247-248
tongue thrust and, 114 increasing of, 251
growth of, cranial and ~isceral areas of, 6-9.7
Genotype, dental, ffects of environmental permissible, 247-248
processes in, 26
factors on, 43, 44
position of, natural, radiograph of, 178 in treatment of, 247, 248
Gonion angle, variations in, 192
space, cephalometric analysis and, 210,210 radiography of, 168, 168, 170
Grinding, of deciduous canines, 316 recrowding of, 619-620, 618,620
types of, 78, 79
in traumatic occlusion, 624-625, 625 Growth,
young adult, sagittal section of, 18 Headgear. See third molar eruption and, 620 maxillary,
changes, adolescent, favorable, 368
also Appliance(s), extraoral labiolingual impacted, surgical exposure of, 340-341, 342
influence of treatment on, 351-353. 352-354
technique and, 498, 499 with twinwire appliance, premature loss of, 315
favorable, and orthodontic treatment, case
462 radiography of, 168, 168
history of, 324-326, 324-325 two-stage,
Histories, in examination, 142 Inclined plane appliance, acrylic, in crossbite,
case history of, 330-33L 331, 332
Hooks, for extraoral appliance attachment, 305 223-224, 223. 224. 225
unfavorable, and orthodontic treatment, case
for intermaxillary elastics, 496, 300, 305, 497 Investment, HCP 70 as, 520-521, 520
history of, 327-330, 326-327
condyle of mandible, 10, 9 Hyalinization of periodontal tissues. See
Tissue(s), periodontal, hyalinization of Hygiene,
cranial, processes in, 26
oral, 3
definition of, 6
dentofacial, in clefts, 388-389
Jaw(s), discrepancies in, 154-155

Index' 651
dynamics, changes in, and relapse, 616617 pliance in labiolingual technique,' 496-498, edgewise appliance in, case report
growth of, muscle function and, 19 498 of, 423-433, 427-432, 427t
processes in, 26 of precious metal archwire in labiolingual extraction in, 247
treatment and, 145 technique. 484 interrelations of types of, 58t labiolingual
lower, growth oi, 10-11, 26, 27, 9, 11,12 on removable lingual arch appliances, 289 technique in, 501-503,
posterior view, 18 of stainless steel archwire in labiolingual 502-505
at molar region. sagittal section of. 19 technique, 486, 486 in mixed dentition, 59
transverse section of, 19 Loops, archwire, helical. 282-283 in monovular twins, 322-324, 322, 323
movements, interference with, causes of, 97 hor-izontal, 282 in permanent dentition, 62
muscle portions active in, 98 open, 283 Subdivision, 55
prognathism of. 65 torquing, 283 in mixed dentition, 60
radiography of, lateral view, 171-172, 171. 180 vertical, 281-282 in permanent dentition, 63
re-enclosure of teeth in, 131 labial arch, as stops. 289 twin wire appliance in, 469-477, 477
trajectorial forces in, 95-96 Jigs, treatment plan in, 56-57
sliding, 305, 305 twinwire appliance in, 469,470-471,
Johnson, twinwire appliance and, 460 475
Macrogenitosomia praecox, dentition and Type A. 66
"Jumping the bite," 304-305
skeletal features in, 113-114 Type B, 67
Malformation(s), branchial arch, 107-111 Type C, 68
chromosomal, and clefts, 387, 390, 391 Type D, 69
craniofacial, 22 Type E, 70
of dentition, eugnathic, 55 Type F, 71
Kidney disease, dentition and skeletal features and malocclusion, 126-141 Type G, 72
in, 111-112 dentofacial, psychodynamics of, 3 Type H, 73
Kretschmer classification according to body permanent dentition, 335 with unfavorable growth changes, 327-330.
types, 75 Malnutrition, dentition and skeletal features in, 326-327
110-111 Division 2, 86
Malocclusion(s), attitude of patient toward, 1 Begg technique in, 444-450, 446-449
Labiolingual technique, archwires in, spring Class J, 54 clinical manifestations of, 58-65
attachments to, 487-488, 499- arch length deficiency, edgewise appliance in in deciduous dentition, 57
500,487,488,489,499,500 case report of, 422-423, 422, 424, 426, extraction in, 247-248
band construction for, 480-482, 482, 483 423t labiolingual technique in, 503-506, 506-508
early application of. 480, 481 bimaxillary protrusion, twin wire ap- in mixed dentition, 60
labial appliance for, maxillary, construction of, pliance in 477, 478-479 clinical in permanent dentition, 351, 63, 349-351
495-501, 495-501 description of. 76-79, 87 in Subdivision, 65
labial archwire for, mandibular, construction of, deciduous dentition, 56 Crozat appliance in, 531-534,532-
498-499 in mixed dentition, 330, 59, 328-329, 331. 332 534
lingual archwire for, attachments to. 487-493, in permanent dentition, 355-356, 358359, in mixed dentition, 61
487-494 62,355-357,361-363 in permanent dentition, 64 twinwire
precious metal. construction of, 482484 requiring extraction, 246 appliance in, 469, 476
stainless steel, construction of. 484-486, 484, treatment of, without extraction. 264266, treatrnen t of, 58
485, 486 267-270, 266-267, 268-269 twinwire twinwire appliance in, 469, 474 functional
maxillary lingual appliance in, con- appliance in, 463-465, 463469 occlusal plane changes in, with activator
struction of, 486-487, 486 with bimaxillary alveolodental prognathism, treatment, 568-570, 570, 571
in open bite, 500-501, 501 twinwir'e appliance in, 477, 478 mutilated dentition, twinwire appli-
space closure and, 288 with deep overbite, 351-353, 352-354 ancein,469,472-473
treatment with, case reports of. 501-512, 502- Class II, 54-55, 344 Class III, 65, 82, 83
511 Division L 55, 85 activator in, 559-560, 588-590, 561, 589
activator in, 558, 563-565, 556, 557, apparent, 65
Lamina dura, tooth movability and, 607, 595,
558, 560, 562, 568, 569, 570 correct buccal torque in treatment of,
607
analysis of measurements in, 58t 280
Landmarks, cephalometric. See Cephalometricts).
anchorage control in, 420, 421 in deciduous dentition, 58 in
landmarks
Begg technique in, 442-444, 450453, 441-446. mixed dentition, 61
Leeway space, 211, 262. 322
449-453 in permanent dentition, 356-358, 359361,
Ligament, periodontal, and tooth movability, 607
case(s) of, compared, 76 64. 358-360, 364-366 Subdivision, 65
Lip(s), cleft. See Cleft lip
in permanent dentition, 344-350, treatment of, early, 310-312, 311-312
muscles of, 14t
350-351,336, 345-346, 347-349 stages of, 354 classification
posture, incompetent, 112
causes oi, 562-563, 567, 568 of, Angle, 54-65 in cleft lip, 387-
muscles and, 19
clinical manifestations of. 55-56 Crozat 389
Lip biting, dentofacial structures in, 19, 620 or
appliance in, 527-431, 537, in cleft palate, 387-389
sucking. malocclusion and, 121, 120 Lip
528-530,538-541
bumper, 148, 151 in deciduous dentition, 57
Lischer method of designating malposition of
teeth, 50
Lockjs), loop-coil, on maxillary labial ap-
652 . Index
Malocclusion(s) - tCont.) position(s) of, 97 abnormal, McNeil's technique in collapsed cleft palate, 399-
clinical manifestations of, 52-53 complex, causes of, 97 403,397-398
edgewise appliance in, case reports of, 421- Meckel's cartilage, development of, 11 Mershon,
changes in, cephalometric analysis and, 193
433, 422-432, 423t, 427t half-round shaft and locking wire, 220
"jumping the bite:' and, 304-305
eight-tooth extraction in, Begg tech- lingual appliance, 289-291, 289, 291 Mesh
radiography of, 168, 169-170, 168, 170,
nique following, 453-459, 453-457 diagram, Moorrees', in cephalo-
171
condylar movements in, 100 definition of, metric analysis, 207-210 construction of,
ramus of, radiographs of, 179
50-52 208-209, 207, 208 lateral cephalograms
reference lines in, 191,191
dentition anomalies and, 126-141 dentofacial compared by, 210 modifications of, 209,
relocation of, 98, 381-386, 98, 385 resection
pressure habits and, 120-123, 209
of, orthodontics in, 364-365,
118-119, 120, 121 Mesioclusion, See Malocclusion, Class III
369
etiologic factors in, See Etiology, of mal- Mesiodens, 230, 133, 139, 230
rest position of, 97
occlusion Mesiodistal space, loss of, causes of, 117
retrognathic, clinical findings in, 77-79, 87
finger sucking and, 120, 227-228, 318, 118,227 Metal(s), precious, arch wire in labiolingual
rotation of, 368
genetic evidence in, 106-111 handicapping, technique, 482-484
facial height and, 16
defining of, for public soldering of, 293-294
forward, types of, 11
health orthodontic programs, 629-643 Margolis, cephalometer, 176, 177 maxillofacial Microglossia, 333-334, 332-334
incidence of, 65 triangle, 203-204, 203 Masks, facial, Microtia, dentition in, 107
mandibular incisor crowding and, 123 construction of, 143 Mastication, condylar Midline deviations, 115-119 Midpalatal
midline deviations and, 115-119 mouth movements during, 99 suture opening, 542-555
muscles of, 14t appliance in, activation of, 548-549 force
breathing and, 112
control of, 574 build-up during, 550-551
nailbiting and, 121-122, 621 periodontal
reaction in, in activator therapy, 606607 construction of, 546-548, 546, 547, 548
disease and, 111, 150-152
stimuli for, 96 contraindications to, 546, 546
in permanent dentition, to be treated,
Maxilla, and alveolar process, supraclusion of, history of, 542
335
and buccoclusion, 55 indications for, 542-544, 543, 544, 545
prevalence of, 211
basal arches of, 95
prevention of, before tooth eruption, 146 in nasal changes in, 551-552
bimaxillary prognathism of, 350-351, 347-349 nonparallel, 551-552, 551, 553 orthodontic
scoliosis patient(s), 370
buccoclusion of, and maxillary and alveolar procedures following, 550 records on, 546
interception of, 367-368, 371
supraclusion, 55
self-correcting, 146-147 results of, 552-554, 554
bu ttresses of, 96, 95
speech and, 101 retention following, 550 skeletal-dental
to cranial base, changes in, cephalometric
supernumerary teeth and, 119-120 reaction in, 552, 553 stabilization
analysis and, 193
thumbsucking and, 120, 227-228, 318, following, 549-550, 549
deficiency of, bilateral, 542, 543
119,153,157,227 Models, conservation of, appliance construction
unilateral, 542 and, 481-482
tongue posture and function in, ]13-115
dentition in, development of, from birth to age Molar(s), band fitting and bracket placement on,
transitional, 147-148, 147
14, 30-41 413, 413
treatment of. See Treatment
expansion of, midpalatal suture opening in. deciduous, premature loss of, 314-315, 314
in twins, 106, 104, 105, 106
See Midpalatal suture opening frontal portion and premolars, mesiodistal size of, compared.
types of, 146
of, in clefts, treatment of, 396 262, 263
Mandible, articulation of, structure of, 99 basal
growth of, 11-12, 12 changes development of, from birth to age 14, 30-41
arches of, 95
in, 196, 193,,195 height of, elongation of, biteplates and, 294-295
changes within, 196, 194
variations in, 192 extraoral force and, 303
condyle, growth of, 10, 9
mandibular relation, anteroposterior, variations first, deciduous, occlusal relation of, 46, 45
cross section of, 249
in, 192 height of, 514, 514
dentition in, development of, from birth to age
midline deviation in, 115 permanent, ectopic eruption of, 127 extraction
14, 30-41
occlusal changes in, following extraction of of, 251-253
dynamics of, examination of, 142
first molars, 117,-119 prognathic, facial occlusal changes following, 117119
posttreatment adjustment in, 621-622, 622,
skeletal patterns wi th, locking of, against deciduous second molar, 316,
623
77 318
growth of, 10-11, 27,9, 11, 12,249
protrusion of, extreme, 344-350, 345-346 loss of, occlusal changes following, 117, 117
changes in, 196, 193, 194, 195
radiography of, 168-169, 168, 169 occlusal relation of, 46-47, 48, 47, 48
with activator, 559-560, 561 favorable,
retrognathic, 81 rotation of, Crozat appliance in, case history
324-326, 324-325 functional matrix
facial skeletal patterns with, 77 sutures of, of, 534-537, 535-537
concept and, 27-28 translatory, inhibition
hyalinization in, 594, 594, 595 opening of. See
of, 164 unfavorable, 327-330, 326-327 loss of, premature, arch length loss in, 215
Midpalatal suture opening
in malposition, 98 -prernolar relationship, changes in, with change
sites of, 13
maxillary relation, anteroposterior, vari- from mixed to permanent dentition, 307
Maxillofacial triangle, Margolis', 203-204, 203
ations in, 192
midline deviation in, 115-116
movements of, 96
occlusal changes in, following extraction of first
molars, 117-118
overclosure of, 100
Index' 653
primary, ankylosis of, 240-241, 243 facial bones of, 9, 9 gums light interrupted force in, 603-604, 603
treatment of, 241-244, 243, 244 and palate of, 30 speech and, 101
resistance to force, 279 skel ton and musculature of, and adult, tongue posture and function and, 115,
second, deciduous, locking of permanent first compared,6 114
molar against, 316, 318 occlusal relation of, skull of, 7 Oral cavity, See Mouth
46, 45 submergence of, management of, 337 ormalcy, range of, 43, 45 Oral hygiene, 3
permanent, 'extraction of, 253-256, 256 occlusal orrns, growth, 43 Oral screen, 148, 148, 149
relation of, 47, 48, 47 ose, in cleft lip, 388 Orthodontic(s), for adults. scope of, 376-377 as
third, calcification of, 41-42 functional changes in, following midpalatal public health function, 628
ectopic eruption of, 127-128, 135 eruption suture opening, 551-552 in cleft palate therapy, 387-407
of, incisor recrowding and, definition of, 1
620 interceprive. definition of, American
impacted, extraction of, 256 Occlusion, adaptive individual norm in, 44 Association of Orthodontists, 211 i
impaction of, 19, 129-130, 131, 135, , centric, and centric relation, 618 nterceptive-preventive, 211-245
256,257 of mandible, 97, 98 in mandibular resection, 364-365, 369
occlusal relation of, 47, 48, 47 changes in, activator and, 558, 559 in normal in, 43-44
Monobloc. See Activator(s) deciduous dentition, 307-308 definition in occlusal rehabilitation, 381-386
Moorrees mesh diagram in cephalometric of, 44 orthopedic measures in, 145-146
analysis. See Mesh diagram, Moorrees' Mouth, development of, 43-49 practice, essentials of, 1-2
mandibular growth and, 10-11.27, guidance of, 145-166 in prepayment programs, 628-643
11 scope of, 145 principles of, 1-5
maxillary growth and, 11-12, 12 edge-to-edge, treatment of, 155 in public health programs, 1, 628-643
origin of, 10, 10 equilibration of, 623-626, 625 radiography in, 167-]75
roof of, 18 facial growth and, 19-22 scope of, 1, 2
Mouth breathing, dentofacial structures in, 19 facial profile and, 22 surgical, 365-367
malocclusion and, 112 factors determining, 44 therapy. See Treatment
test for, 112-113 guidance of, timing of procedures in, 310 Orthopedics, cleft palate, 396-403
Moyers' prediction chart in determination of ideal, 45 dentofacial, 145-146
sizes of unerupted teeth, 213:.ll4, 214t individual normal. 45 Overbite, abnormal, 155-157
Muscle(s), balance, and orthodontic therapy, 97- line of, 19 in adult, treatment of, 379-381, 380
98 mannerisms of, 620, 620, 621, 622, 623, 624 following extraction of mandibular incisor,
and relapse, 616 in mixed dentition, 321-322 treatment of, 258
facial expression and, 14-15t normal,45 deep, in adult, case report of treatment of, 377-
force of, physiologic tooth movement characteristics of, 50 378, 379
and, 592, 593 classification of, 50-74 Class I malocclusion and, 351-353, 352-354
function, jaw growth and, 19 in in deciduous dentition, 307-308 terminal. mutilated dentition and, 373
jaw movements, 98 appositive relation of de- Overjet, abnormal, 157
of mastication, 14t ciduous teeth in, 45-46, 45 appositive in adult, treatment of, 378, 381, 382
control of, 574 relation of permanent
reaction in, in activator therapy, 606- teeth in, 46-48, 47
607 patterns of, 44-45
of newborn and adult, compared, 6 soft physical variation and, 43-44 Palatal bar, 161, 159
tissue profile and, 19 plane of, functional, changes in, in treatment of Palate, cleft. See Cleft palate of
stretch reflex and, 575 Class II malocclusion with activator, 568- fetus, 30
temporalis, and coronoid process, formfunction 570, 570, 571 growth of, 12
relationship of, 25 reverse, 65 of newborn, 30
tone, effect of force on, 618 slippage of, 618 soft, muscles of, 1St
total tension in, 576 stability of dentition and, factors influencing, suture, expansion of. See Midpalatal su-
Myotatic reflex, mechanism of, 575 19-20 ture opening
regulation of, 578 terminal plane relationship in, space Panradiography, 173-175, 173-174
maintenance and, 214, 213 Parents, counselling of, in clefts, 406
tic, 620, 620, 621. 622, 623, 624 Patient(s), adolescent as, 3
traumatic, 122, 624-626, 624,. 625 adult, motivation of, 373
root resorption and, 135 child as, 2-3
variables in, 44 motivation, 1
Nailbiting, 318 Odontoma, eruption, blocked by, 139 Periodontal disease, malocclusion and, Ill,
fingers and toes in, 123, 621 Oligodontia, causes of, 126 150-152
malocclusion and, 121-122, 621 in cleft palate, 393, 403 Periodontal ligament, and tooth movability, 607
ance's method of serial extraction, 263 in ectodermal dysplasia, 115 Periodontal structures, tooth movement
Nasal cavity, 18 Oliver guideplane, advantages of, 490 and, 420-421
lateral wall of, 552 applications of, 488-490, 489 construction Pharynx, muscles of, 1St
Nasal septum, development of, 11 of, 491-493, 490-494 Openbire, 157- Photographs, in examination, 143 Plate,
Neurocranium, growth of, 16 Neutroclusion, See 159,156-161 stabilizing. See Stabilizing plate
Malocclusion, Class I complete, activator and, 565, 569 labiolingual stimulation, 401
ewborn. development of dentition of, 30-31, 30 technique in, 500-501, 501 Pletcher coil, 305
654 . Index
Pliers, White bird beak, 514 protection, of operator, 167 of Ricketts' cephalometric analysis, 202-203, 201
Plumper, 158, 158, 319 patient, 167 Rocky Mountain screw mechanism, 547
Porion, location of, in cephalogram, 178 therapeutic, effect of, on teeth, 167 Root(s), calcification of, 41-42
Posture, examination, 142 Radiogram(s), carpal, of boys and girls, from of deciduous teeth, retention of, 134-135
Prediction chart, Moyers, in determination of age 6 to age 15, 89-93 resorption, apical, 612-613
sizes of unerupted teeth, 213-214, 214t technique for making, 80, 88 asymmetric, 134
Premaxilla, floating, in clefts, treatment of, 396 cephalometric. See Cephalogram(s) in deciduous teeth, 129, 138
Premolar(s), agenetic, 335 dental, in examination, 143 initiation of, 612, 611, 613
and deciduous molars, mesiodistal size of, periapical and bitewing, uses of, 168 Tweed's and orthodontic therapy, 135-141,612 of
compared, 262, 263 diagnostic facial triangle traced permanent teeth, 135
eruption of, 138 on, 271 tooth movability and, 609, 609
first, extraction of, 250, 257 Radiography, central incisors, 169 trauma causing, 612, 601
case illustrating treatment following, 254-255 cephalometric. See Cephalometric(s), ra- and traumatic occlusion, 135
without orthodontic therapy, results of, 259, diographic
260 in cleft palate, 391, 393
occlusal relation of, 46, 48, 47 extraoral, 169-175 facial
-rnolar relationship, changes in, with change profile, 172, 180 in Salzmann, basal arch, 189
from mixed to permanent dentition, 307 traoral, 167-169 treatment priority index. See American
second, ectopic eruption of, 126-127,337 jaws, lateral view of, 171-172, 171, 180 of Association of Orthodontists-Salzmann
extraction of, 250 mandible, arch of, 168, 170 treatment priority index Sassouni's
impaction of, 138 body of, 169-170, 171 cephalometric analysis, 206207,205
occlusal relation of, 46, 48, 47 incisor region, 168, 168, 170 Schwarz arrowhead clasp, 298
Profile, facial. See Face, profile of of maxilla, arch of, 168-169, 169 Scoliosis, malocclusion in, 370
soft tissue, changes in, activator and, 560, 561 incisor region, 168, 16.8 interception of, 367-368, 371
muscles and, 19 in orthodontics, 167-175 temporomandibular, Screen, oral, 148, 148, 149 Screw(s),
Prognathism, alveolodental, 65, 206 172-173, 172. 173 Ramus, changes in, 196 expansion, 161-162 Hawley-Russell,
bimaxillary, 65, 350-351, 347-349 cases Reflex(es), clasp knife, mechanism of, 577 in 162
illustrating, 353-361, 355-366 anal yses control of masticator nucleus, 574 myotatic, mechanism, in midpalatal suture-opening
of, 361-364, 367t 575 appliance, 548, 547
differential diagnosis of, cases illustrating, 353- regulation of, 578 Sella-Nasion lire, 188
361 Rehabilitation, in cleft palate, 394 changes in, cephalometric analysis and, 193
facial. 197 occlusal, orthodontics in, 381-386 Serial extraction. See Extraction(s), serial
causes of, 206, 250 Relapse, in adults, 377 Skeleton, classification of, 75-94 variation of,
measurement of, 205 of causes of, 616 75-79
jaws, 65 following incisor extraction, 620 following displacement of, in midpalatal suture opening,
mandibular, in deciduous dentition, treatment tooth rotation, prevention of, 552, 551, 553
of, 313 Relapse, in adults, 377 dysplasia of, activator in, 558, 560
surgical resection of, orthodontics in, 364-365, causes of, 616 facial pattern(s) of, 75
369 following incisor extraction, 620 following cephalometric analysis and, 193-194, 191
treatment of, cases illustrating, 353-361 tooth rotation, prevention of, Class 1, 85, 87, 349-351, 352-354, 355,
Prosthesis, in cleft palate, 394-395, 401 604 357, 358, 360
Protectors, teeth, 305-306, 368-372 Protrusion, prevention of, 616-617 Class 2, 86, 87, 345-346, 347-349
bimaxillary, Direct Bonding and retention, 616-627 Class 3, 82, 83, 364-366
System in, 435-437, 436 related factors in. 620-623 and phenotypical facial appearance, in mother
maxillary, extreme, 344-350, 345-346 Resilience, definition of, 275 and son, compared, 75-79, 87
Psychodynamics, of adult patient, 373 Rest position of mandible, 97 in siblings, compared, 84-86 of
Pterygomaxillary fissure as reference line, 192 Retainer(s), acrylic, construction of, 164, 298- hand and wrist, 88
Puberty, precocious, skeletal features in, 109 299 of newborn and adult, compared, 6
Public health orthodontic programs, ad- Hawley, 162-163,294-296
proportions of, 142-143
ministration of, principles in, 628-629 criteria construction of, 300-301 tissues of, growth of, 26
for examination and acceptance of patients for, removable, 618-619
Skull, base of, anterior, registration points and
628 repair of, 164-165, 299
lines of, 190
defining handicapping malocclusion for, 629- use of, period of time fat, 623
changes in, during treatment, estimation of, 201
643 Retention, in adults, 377 following
reference lines in, 191, 191
organization of, 628 Begg technique, 459
growth of, 6-9, 7
Pulp, changes in, 611-612 following labiolingual technique in
processes in, 26
Pyknosis, 596-597, 595 openbite, 500-501, 501
stress in, 95, 96
following midpalatal suture opening, 550
structure of, 16-17
length of, 622-623
Sliding jigs, 305, 305
limits of, 623
Soldering, precious metals, 293-294
need for, 95, 617
stainless steel, 292-293, 292
and relapse, 616-627
related factors in, 620-623
of rotated teeth, 623
Rhinoplasty, facial profile and, 22, 253
Radiation, control, 167
Index' 655
Space, available, 211-213 Stress, definition of, 274 in speech and, 101
measurement of, 212-213, 212 skull, 96 swallowing and, 113
closure, coil spring force in, 280 Benninghoff's lines of stress showing, 95 treatment of, 160-161,356,159, 161
elastics in, 284 types of, 274 construction of Hawley retainer for, 300-
I labiolingual appliances in, 288 in

deciduous dentition, 316 leeway,
211, 262, 322 maintainer(s), 148-
Stretch reflex, mechanism of, 575
Strock method of surgical exposure of impacted
teeth, 340-341, 342
301
undersize, mandibular arch collapse in,
treatment of, 333-334, 332-334
149, 215 Sucking, finger. See Finger sucking lip, Tongue blade technique in crossbite, 222223,
contraindications to, 149 121, 120 218, 222
fabrication of, 215 thumb-. See Thumbsucking Tooth(Teeth), agenesis of, 126, 127, 128,
indications for, 149 tongue, 121
need for, determination of, 213-215, 213, 214t 129, 131
Supraclusion, maxillary and alveolar, and
1 types of, 215, 150, 216

mesiodistal, loss of, causes of, 117 needed,
determination of, 213-215 Moyers prediction
buccoclusion of maxilla, 55
Surgery, in clefts, 388, 396
and orthodontics, 365-367
alveolar bone and, 25
ankylosed, 130-132, 130
anomalies of, eugnathic, 55
chart in, 213-214, 214t and malocclusion, 126-141 arrangement,
Suture(s), maxillary, hyalinization in, 594, anomalies of, 141, 139, 140 as anchor for
opening, open-coil spring in, 282 594,595
orthodontic appliances, 276-277
regaining appliances, 215, 216 Spee, sites of, 13
curve of, 19 balancing of, in case of missing teeth,
opening, mid palatal. See Midpalatal suture 248
Speech, cleft palate, 403-406 opening
malocclusion and, 101 open blocked-out, resorption of, 135-141
Swallowing, tongue-thrust, 113
bite and, 101 bodily displacement of, 604-605, 605 and
tongue thrust and, 101 bones, differences between, 30
Speech appliance, in cleft palate, 402 Split- calcification of, 41-42
plate appliance, 161-162,395, 397, 400 cephalometric analysis and, 194-195,192
Tanner growth and development charts, 563-565 changes in, genetic influence on, mono-
Spring(s), auxiliary, force of, 278-279, 278
Temporomandibular articulation, 99-100 of zygous twins illustrating, 322-324,
on lingual appliance, 291, 298
child and adult, compared, 99 development 322,323
canine retraction, 283 contraction-
of, 12 treatment timing and, 330, 328-329
coil, 282
disorders, 100, 101 crowding of, 206
dislodging, for activator, 580-581, 582 flat
disturbances of, etiologic factors in, 111 deciduous, ankylosed, 316
wire, in retraction mechanism, 283 force
dysfunction, diagnosis of, 100 radiography of, appositive relation of, in normal terminal
for moving teeth, 279
172-173,172, 173 occlusion, 45-46, 45
loop-coil, bilateral continuous, in labiolingual
Tensile strength, definition of, 275 as indicator of normal permanent dentition,
techn ique, 500, 499
Test, mouth breathing, 112-113 308-309
in labiolingual technique, 499-500, 499 loop- Therapy. See Treatment
coil-loop, in labiolingual technique, 500,500 calcification of, 41
Thum bsucking, in cleft palate, 401 Class Ill malocclusion in, treatment of,
loop right-angle, in labiolingual tech- malocclusion and, 120,227-228,318,119, 153,
nique, 500, 500 310-312,311-312
157, 227
open-coil, 282 classification of, 53
therapy in, chemical, 228 mechanical,
pull-coil, 280 crossbite in, 217, 316-318,217,308,310
228-229, 228, 229
push-coil, 280 dental age and, 310
psychological, 229-230
in twinwire appliance, 462, 462 recurved. on diagnosis of, 307-320
Tissue(s), changes, in orthodontic tooth
lingual archwire in labiolingual technique, movement, 592-615 diastemas and, 316
487-488, 487, 488, 489 periodontal, hyalinization of, 594-602 cell-free effect of sequence of tooth eruption on, 315-
Stabilizing plate, construction of, 164 zones in, 594-595, 594, 595 period 316, 314, 315, 317
maxillary, 300 following, 600-602 reconstruction extraction of, indications for, 312-314,
framework for, 299 following. 596-598, 314, 315
mid palatal suture-opening appliance as, 549- 597,598 geminated, 134
550, 549 significance of, 595-596, 593, 595, 596,598 infected, 316
removable, 296-298 semihyalinization of, 594, 594 mandibular prognathism in, treatment of,313
uses of, 163 soft, of adult, 374-376 maxillary, with permanent incisors calcifying,
Steel, stainless, appliances, 292-293 cephalograms of, 178, 177~ 178 308
arch wire in labiolingual technique, 482-484, with permanent incisors developing,
profile of, changes in, activator and, 560,561
484, 485, 486 307
muscles and, 19
soldering of, 292-293, 292 normal occlusion in, 307-308
tolerance, in adult therapy, 373-376
wire force, 277-279 occlusal relation in, 51 over-
Tongue, development of, 11
Stimulation plate, 401 retention of, 314
muscles of, 14t
Stomatognathic complex, force-linked, 9596 and permanent, arrangement of, compared,47
posture, and function, malocclusion and, 113-
Stomatognathic dynamics, 95-102 115 to permanent, occlusal changes from, 53,52
Strain, definition of, 274 and open bite, 158, 157, 158, 160, 161 premature loss of, 314-315
types of, 274 sucking, 121 prolonged retention of, 131-132, 132, 136
thrust, examination in, 159-160 resorption of roots of, 129, 138
genetic reference in, 114, 161
656 . Index
Tooth (Teeth), deciduous - (Cont.) changes in, favorable, 324-326,324-325 impaction of, 335-344 incomplete,
retention of roots of, 134-135 genetic influence on, 322-324, 322, 323 management of, 335
spacing of. 316 unfavorable, 327-330, 326-327 loss of, shifting of adjacent teeth following,
thumb- and finger sucking and, 318 crossbite in, 217, 217, 2J8 crowding 117-119, 117
treatment in, 307-320 in, treatment of, 321 diagnosis in, through caries, 316
contraindications to, 310 321-334 malformed, 335
indications for, 309-310 occlusal relation in, 46, 47 treatment in, 335-372
dental age and, 143, 310 development treatment in, 321-334 position of, changes in, following orthodontic
of. at birth, 30-31, 30 at age 1 year, 31 indications for, 321 prognostic therapy, causes of, 616 stomatognathic
-32 factors in, 331 -333 scope of, complex and, 95 irregularities of, 146
at age 2 years, 32 321 tooth movability and, 608, 608 posterior,
at age 3 years, 34-35, 31 two-stage, 330-331, 331, 332 mobility of, in elongation of. biteplates and, 294-295
at age 4 years, 35, 32 posthyalinization period, 600 extraoral force and, 303
at age 5 years, 35-36, 33 of modern man, 54 primary, overretained, diagnosis of, 240241,
at age 6 years, 36, 34 movability, fractured roots and, 610-611, 610, 242, 243
at age 7 years, 36, 35 611 extraction of. cas s requiring, 239240,242
at age 8 years, 36, 36, 37 at hypercementosis and, 609-6JO, 609, treatment of, 241-244, 243, 244
age 9 years, 36-37, 37 at 610 protectors, 305-306, 368-372
age 10 years, 38-40, 38 at impacted teeth and, 608-609, 609 re-enclosure of, in jaws, 131, 241, 243
age I I years, 40, 39 lamina dura and, 607, 595, 607 relation of, to facial skeleton, in Downs'
at age 12 years, 40, 39 local disturbances and, 608, 607, 608 analysis, 200-201, 200-201
at age 13 years, 40-41 periodontal Iigam nt and, 607 systemic replantation of, 342
at age 14 years, 41, 40 factors in, 607-608, 593, 603 tooth resorption of, internal, 135 roots
at age 17 years, 41 position and, 608, 608 of, calcification of, 41-42
engulfed, 131. 241. 243 movement of. archwire in, 414, 416 fractured, tooth movability and, 610611,
eruption of, 29-42. See also Eruption control biteplane in, 162, 163, 294 biteplate 610, 611
of, activator in, 558-559, 565, 560,570 in, 162-163 types of, 610
prevention before, 146 bodily, 604-605, 605 resorption of. See Root(s), resorption
wi th Class II activator, 581, 572-573, 582,583 direction of, with extraoral appliance, 301- rotated, reten tion of, 623
with Class II1 activator, 581-582, 584 303 rotation of, 604, 603
exfoliation of, premature, 132-134 edgewise appliance in, 408, 408-409, edgewise appliance in, 408-409, 409, 411
extraction of, shifting following, 116 410
lingual appliances and, 288-289
fusion of, 128 force variation in, 602-604 separating of, for banding, 292, 289
grinding of, 122- 123 interrupted, 602-603, 602 shifting, extraction and, 116 stability of,
growth of, changes in, 196, 194 labial and lingual appliances in, 220 factors influencing, 276
impacted, 128-130, 131, 135 orthodontic, methods of, 602-605 following orthodontic correction, factors
locating of, 337-339, 340, 341, 342 tooth in posthyalinization period, 602 tissue responsible for, 97
movability and, 608-609, 609 intrusion of, changes in, 592-615 periodontal and occlusion, factors influencing, 1920
activator and, 560 structures and, 420-421 physiologic, submerged, 131, 241. 243 supernumerary,
loss of, condi tions resulting from, 12lt 592, 593 appearance of, 230, 230 causes of, 126
malposition of, Lischer method of desig- reciprocal, and anchorage, 419-420, 419, 420, in cleft palate, 395
nating, 50 421 detection of, 119-120, 230-231, 231,
rnalposrtioned, artificial eruption of, 335-336 tipping, 602, 597 232, 233
diagnosis of, 337 vertical, activator and, 560-561, 560, 561, effects of, 232, 233
mandibular, changes in, analysis of, 195- 562 location of, 230, 230
196,194, 195 mutilated, crowded out of arch, treat- problems associated with, 132, 133, 139, 315
crowding of, in adult, treatment of, 379 ment of, 377
treatment of, 232-235, 234
deciduous arrangement of, in normal terminal and malocclusion, treatment of, 375 types of. 126 supplemental,
occlusion, 46, 45 permanent, arrangement of, treatment of. 342-344, 343 232, 234
in normal terminal occlusion, 47-48, 47, 48 with severe overbite, 373
surgical exposure of, 238-239, 240, 241
maxillary, changes in, analysis of, 195, 194, ncnvital, treatment of, ili adults, 376-377
195 in impaction, 340-342, 342
numerical variations of, 126 surgical movement of, 342
deciduous, arrangement of, in normal peg, 133, 139
terminal occlusion, 45-46, 45 permanent, therapeutic radiation and, 167
permanent, ankylosed, 335 torsion of, immediate, 341-342
arrangement of, in normal terminal appositive relation of, in normal terminal
occlusion, 46-47, 47, 48 missing, balancing transversion of, 141,139, 140
occlusion, 46-48, 47 calcification of, 42 traumatized, 122, 134
of teeth in case of, 248
and deciduous arrangement of. compared,47 unerupted, permanent, determination of sizes
mixed, anteroposterior occlusal changes in,
deciduous dentition as indicator of normality of, 213-214, 2141
321-322
of, 308-309
diagnosis in, 335-372
ectopy of, 335-344
Index' 657
space maintenance for, type of occlusion with twinwire appliance, 469, 474 Class II, of microglossia and mandibular arch collapse,
influencing, 214, 213 supernumerary teeth Division 2, Subdivision malocclusion, with 333-334, 332-334
interfering with, 132 Crozat appliance, 531-534, 532-534 in mixed dentition, 321-334
Torque, buccal, in treatment of Class II1 with twinwire appliance, 469, 476 Class Il indications for, 321 prognostic
malocclusion, 280 malocclusion, with activator, functional factors in, 331-333 scope of, 321
definition of, 275 occlusal plane changes in, 568-570, 570, 571 two-stage, 330-331,331, 332
directions of, 279-280 with mutilated dentition, with twinwire of mutilated dentition, 342-344,343, 373,
la bial root, 281 lingual appliance, 469, 472-473 375,377 need
root, 281 orders of, Class III malocclusion, early, 310-3)2, 311- for, 211
280, 280 312 of nonvital teeth, of adults, 376-377 of
Trajectories, Benninghoff's lines of, profile of in permanent dentition, 358, 360-361, 354, overbite, 258
skull showing, 95 358-360, 364-366 in adult, 379-381,380
Transversion, 141, 139, 140 stages of, 354 case report of, 377-378,379
Trauma, causing root resorption, 612, 601 with activator, 559-560, 588-590, 561, 589 of overjet, in adult, 378, 381. 382 overretained
occlusal, 122, 624-626, 624, 625 in clefts of lip and palate, 389-396 primary teeth, 241-244,243,
of tooth, 122, 134 of crossbite, in cleft palate, 399-400, 403 244
Treatment, adolescent as patient, 3 of early, labiolingual technique in, 480, 506-512, patient motivation and, 1
adult(s), 373-386 481, 509-511 periodontal, 150-152
case report of, 377-378, 379 fixed appliances in, 223-224, 223, 224, 225 in permanent dentition, 335-372 plans,
age factor in, 146, 147 fixed-removable appliances in, 226227, 227 reevaluation of, 145 response to,
appliances. See Appliance(s) removable appliances in, 224-226, 226 differences in, 146-148 results of,
of arch collapse, mandibular, 333-334, tongue blade technique in, 222-223, 218, desirable, 618
251, 332-334 222 undesirable, 618, 618
Begg technique in. See Begg technique of crowding, in adult, 379 in surgical, 365-367
bimaxillary prognathism, 351, 347-349 mixed dentition, 321 of thumbsucking, 228-230, 228, 229 timing,
biomechanics in, 274-287 in deciduous dentition, 307-320 influence of, on dentofacial
bone and, 9-10 contraindications to, 310 changes, 330, 328-329
of bruxism, 123, 381 indications for, 309-310 dental, twinwire appliance in, cases illustrating, 463-
changes in, evaluation of growth and, 195-196 preliminary, 3-4 477, 463-479
child as patient, 2-3 of diasternas, in adults, 374, 384 two-stage, in mixed dentition. 330-331, 331, 332
Class I malocclusion(s), in permanent Direct Bonding System in. See Direct types of, 145
dentition, 356,359,355-357,361-363 with Bonding System without extraction, case histories of, 264-270,
bimaxiUary alveolodental prognathism, with early, advantages of, 146, 617-618 266-267. 268-269
twin wire appliance, 477, 478 in Class III malocclusion, 310-312, 311312 Trisomy 18, malformations in, 387, 390 Tubes,
with bimaxillary protrusion, with twinwire contraindications to, 146 half-round, for labiolingual appliance, 480,
appliance, 477, 478-479 with overbite, extraction. See Extraction(s) 495,482, 495
352,352-354 of finger sucking, 228-230, 228 Tweed's, diagnostic facial triangle, 248, 270-
with twinwire appliance, 463-465, 463469 fluoridation, 3 271, 252
without extraction, 264-270, 266-267, 268-269 and growth changes, 21-22 as extraction and, 248
Class II, Division 1 malocclusion, 56-57 in influence, 352, 352-354 tracing of, on lateral radiogram, 271, 270, 271
monovular twins, 322-323, 323 favorable, case history of, 324-326, facial types, 271-272, 270. 271
in permanent dentition, 344-350, 351, 336, 345- 324-325 ' method of establishing required and available
346, 347-349 unfavorable, case history of, 327-330, 326- arch length, 272
and unfavorable growth changes, 327330, 326- 327 orthodontic guidance, 270
327 in impaction, orthodontic, 339-340 serial extraction sequence, 270
with activator, 558, 563-565, 556, 557, 558, surgical, 340-342,342 Twins, heterozygous, clefts of lip and palate in,
560, 562, 568, 569. 570 of incisors, axial position of, 399-400 387, 390
with Crozat appliance, 527-531, 537, 528-530, in edge-to-edge occluslon, 377-378, 379,383 monozygous, clefts of lip and palate in, 387, 390
538-541 lateral, maxillary, missing, 375 interceptive- dentition of, 106
with labiolingual technique, 501-503, 502-505 preventive, clinical techniques in, 211-215 and facial outlines of, 104 dentofacial
with twinwire appliance, 469, 470-471, 475 labiolingual technique in, case reports of, changes in, genetic influence on, case
Class Il, Division 1, Subdivision malocclusion, 501-502, 502-511 history of, 322-324, 322,323
with twin wire appliance, 469-477, 477 of mandibular prognathism in deciduous mirror, dentition and facial outlines of, 105
Class II, Division 2 malocclusion, in dentition, 313 Twinwire appliance, 460-479 anterior
permanent dentition, 351, 349-350 with of maxilla, in clefts, 396 bands of, 461-462, 461
labiolingual technique, 503-506, 506-508 in maxillary protrusion, 344-350, 345346 in cases involving extraction, 462
coil-springs with, 462, 462
construction of, 460-462
headgear attachment in, 462
658 . Index
Twinwire appliance- (Coni.) labial Ll.S, Children's Bureau, on orthodontics as gauges of, 292
arch, 460-461, 460 public health function, 628 rectangular, 278
malocclusions treated with, cases illustrating, sizes, conversion table for, 483
463-477, 463-479 Vestibular screen. 148, 148, 149 stainless steel, 292
molar appliance of, 461, 460, 461 Wrist(s), radiograms of, technique for making,
Water jets, 3 80, 88
Welding, spot, stainless steel, 293 radiographic comparison of, of boys and
University of Washington cephalometric White bird beak pliers, 514 girls, from age 6 to age 15, 89-93 skeletal
standards, 202t Wirers), for labial and lingual appliances, components of, 88
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Contributors

R. William McNeill, D.D.S., M.S. H. K. Terry, D.M.D.

Fujio Miura, D.D.S., M.S.

Earl B. Shepard, D.D.S. D. G. Woodside, D.D.S., M.5c.

Library of Congress Catalog Card Number 73-22136

Printed in the United States of America

Library of Congress Cataloging in Publication Data

Incidence of the Various Malocclusions .............. . 6

6. Classification of Normal Occlusion 12. Guidance of Occlusal Development .. .. .. ..................... 145

The Age Factor in Treatment of 17. Interceptive-Preventive Orthodontics

29. The Begg Technique Skeletal-Dental Reaction ............................. : .... 552

Illustrative Case Histories .................................. 442 Possibilities and Limitations ...............................558

31. Labiolingual Technique 35. Tissue Changes in Orthodontic Tooth

37. Orthodontics in Public Health and Defining Handicapping Malocclusion .................629

The psychic effect of a dentofacial defect can be of

The growing skull does not balloon out at an equal rate

Figure 2-1. The body proportions change

&rth & Adult A

Fig. 2-4. Structural details

Periosteum @. Periosteum and compact

ing the stage of development and the timing and plan of

ROLE OF BONE IN ORTHODONTIC THERAPY

Types of Bone Formation

Fig. 2-6. (a) The diameter of the nar-

Fig. 2-7. (Top) Head of human embryo of about 33 days,

Growth of the Maxilla . 11

Fig. 2-9. Growth additions

Fig. 2-10. The distribution of re-

Growth of the Palate

Fig. 2-12. Outlines of skulls showing

Fig. 2-13. (A) Front view of skull

fig. 2-14. The sites of the maxillary sutures

TABLE 2-1. FACIAL EXPRESSION

Muscle Origin Insertion Innervation and Action

3. Muscles of the Tongue, the Pharynx, and the Soft Palate

Muscle Origin Insertion Innervation and Action

Fig. 2-16. (A) The skull is an ovoid

Posterior n"5al ~Plne G-reQrer pCllohne f"romen 7 -

Fig. 2-17. Section of head showing nasal

r ' . Humulus or p'er'J'l.0id ."

Fig. 2-18. Sagittal section of the

Fig. 2-19. (Top left) Transverse section of the

Fig. 2-20. In the left column are

Fig. 2-21. This boy's growth was un-

DENTAL OCCLUSION AND THE FACIAL CRANIOFACIAL ABNORMALITIES

BIBLIOGRAPHY Baume, L. J. and Holz, J.: Ontogenesis of the human

I Enlow, D. H., and Hunter, W. 5.: A differential analysis of sutural

Fig. 4-1. From V. O. Hurme and Forsyth

' MEAN AGES OF TOOTH EMERGENCE

DIFFERENCES BETWEEN TEETH AND BONES 8. Maxillary second molars

ORDER OF TOOTH ERUPTION DEVELOPMENT OF DENTITION FROM BIRTH TO

Fig. 4-2. (Left) Gums and palate of a fetus 18

Fig. 4-3. Unerupted teeth at birth. (Courtesy Dr. David Marshall)

(B) Permanent first molars are in the process of calcification.

Fig. 4-4(A). Occlusal radiograms of a child of 3 years

Fig. 4-5. Anterior and lateral views of the skull of a 4year-old

tion. The deciduous first molar crowns are approaching the

Fig. 4-6. (Left) Occlusal ro-

Fig. 4-7. (Left) Occlusal