History of Orthodontics

History of Orthodontics A glance at an exciting path, the oldest specialty of dentistry has treaded so far…

Basavaraj Subhashchandra Phulari BDS MDS FAGE FRSH Formerly Faculty, Department of Orthodontics and Dentofacial Orthopedics Mauras College of Dentistry, Hospital and Oral Research Institute Republic of Mauritius

Foreword US Krishna Nayak

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History of Orthodontics (A glance at an exciting path, the oldest specialty of dentistry has treaded so far…)

First Edition: 2013 ISBN 978-93-5090-471-8 Printed at Dedicated to

My Dear Parents Subhashchandra and Shivalingamma Phulari My Brothers Sangamesh BE (USA), Jagadish BE (USA) and Manjunath BE (USA) My Beloved Wife Dr Rashmi GS, Reader (Oral Pathology) and My Sons Yashas and Vrishank

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Humanity is passing through the most exciting period in the history of its existence, because of rapid technological advancement and increase in the research activities, there has been an enormous increase in the information available which has led to better understanding of the respective subjects and areas of specialization. With the contemporary understanding of orthodontics, it is more apt and important for everyone involved in the subject to be aware of how our forefathers in the subject thought, how the subject evolved in different countries, how new concepts evolved providing a trigger to each and everyone to explore deeper into the subject and make learning more exciting and enjoyable. Dr Basavaraj Subhashchandra Phulari has made sincere efforts to go into the depth of each topic providing an exhaustive insight. I am convinced that it will be a great learning experience for all the readers.

US Krishna Nayak BDS MDS (Ortho) FFPA FICD FADI FWFO Dean Academics, AB Shetty Memorial Institute of Dental Sciences Karnataka, India Past President, Indian Orthodontic Society Past President, Indian Dental Association Head Office Chairman, 8th Asia-Pacific Orthodontic Congress and 47th IOC New Delhi, India Chairman, 17th IOS PG Convention-2013 Editor, Asia Pacific, HEAL TALK-A Journal of Clinical Dentistry President Elect, International College of Dentists (India, Sri Lanka and Nepal Section) Secretary, International College of Continuing Dental Education (India Section). Immediate Past Chairman, Pierre Fauchard Academy (India Section)

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Knowledge and understanding of the history of a scientific field can enable future practioners of that field better to anticipate and respond to the challenges of rapid globalization and be better prepared to mold our future. Exposure to the history of our specialty helps us think, ask question and explore the concepts and enable us to grasp what the subject is about and how it has evolved over the years. History of Orthodontics is interesting and same time it is complex. This book is an attempt to glance and take a note of important milestones in the exciting journey of this fascinating field. It is hoped that the book would be useful to all the students of the faculty. Extensive coverage of important events in the history of orthodontics that shaped what it is today. Separate chapters dedicated to eminent inventors of the field—EH Angle, LF Andrew, James McNamara and TM Graber. Evolution of recent advances in orthodontics such as Invisalign and dental lasers are included. Evolution of orthodontic materials, model analysis, cephalometrics and orthodontic appliances are included. Exhaustive list of references is given for further reading.

Basavaraj Subhashchandra Phulari [email protected]

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Writing history of the oldest specialty of dentistry and as fascinating as orthodontics at that, was a herculean task. For writing history of any field, even it requires the author/historian to be present at that specific time and place of the event that has taken place, which is practically not possible. An event of today becomes history tomorrow. As we unravel and cherish the history of yester- years, a new history would be shaping today. In the light of this practicality, I do agree that none of the chapters in the book is directly written by me. I have drawn generously from the existing literature about the subject in the form of various books, journal articles, research papers and thesis, etc. In many of the chapters, literature about a specific event or person/researcher is kept as it appears in its original literature so as to maintain authenticity and also not to inadvertently twist the history. Many of the illustrations of the orthodontic appliances and photographs of eminent researchers used in this book are facsimiles of the pictures that appear in the existing literature about the subject. I hereby humbly acknowledge all the authors of various orthodontic books, articles, thesis, seminars, etc., whose works inspired the birth of this project. The list of the literature used for the preparation of this project is given at the end of the book under the heading of suggested reading. I also gratefully acknowledge all the professors, teachers and postgraduate students of the faculty from various dental institutions in India and abroad who have contributed directly or indirectly to this exhaustive piece of work. My special thanks to my beloved wife, Dr Rashmi GS, Reader and Postgraduate Guide, Department of Oral Pathology, Manubhai Patel Dental College and Hospital and Oral Research Institute, Vadodara, Gujarat, India, for her valuable critical comments during the preparation of the manuscript, editorial assistance and proofreading. I take this wonderful opportunity to thank Dr Rajendrasinh Rathore, Chairman of Manubhai Patel Dental College and Hospital and Oral Research Institute, Vadodara, for his inspirational support during this endeavor and throughout my career. I also thank Dr Yashraj Rathore, Trustee, Manubhai Patel Dental College and Hospital and Oral Research Institute, Vadodara, for encouraging me during this project. I owe a debt of gratitude to Professor (Dr) US Krishna Nayak, Dean Academics, AB Shetty Memorial Institute of Dental Sciences, Mangalore, Karnataka, India, for his continuous encouragement in all my endeavors and for providing foreword to this book. I am indebted to Dr Anil Shah for all the help and encouragement I have received from him during the formation of the Chapter 7—History of Dental Lasers and their Applications in Orthodontics in the book. I extend my heartfelt gratitude to Dr Padmaja Ankit Arora for helping me with important references that were required for writing the chapters on TM Graber, James McNamara and Invisalign. My heartfelt gratitude goes to Dr Poorya Naik, Assistant Professor, College of Dental Sciences, Davengere, Karnataka, Dr Ramesh GC, Assistant Professor, Sharavati Dental College, Shimoga, Karnataka, and Dr Sujay J, Assistant Professor, SJM Dental College, Chitradurga, Karnataka, who have helped immensely in this endeavor. Exceptional efforts made the production of this book possible. I extend my special thanks to Dr Hina Desai for comments and suggestions regarding chapter on Dr TM Graber’s Contribution to Orthodontics. xii History of Orthodontics

I will be failing in my duty if I do not mention the affection and support I have received from Dr Syed Zakaullah, Chairman, Al Badar Dental College and Hospital, Gulbarga, Karnataka, who has always provided that moral boost much needed during compilation of this book. My heartfelt gratitude goes to Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director) and Mr Tarun Duneja (Director-Publishing) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, whose exceptional efforts made the production of this book possible. I gratefully acknowledge the contributions made by the talented professional staff at M/s Jaypee Brothers Medical Publishers; in particular, I would like to thank Mr Venugopal V, Mr KK Raman and Mr Rajesh Sharma, for their untiring efforts in ensuring that every minute detail is taken care of. I am indebted to my dear parents for all their love and sacrifices that have made me what I am. I thank my dear sons Yashas and Vrishank for being the constant source of inspiration to set and reach new goals in life. Most of all, I thank God for all the kindness and mercy showered upon me. CCooonnnttteeennntttsss

1. History of Dentistry 1 Ancient Dentistry 2 Dentistry During the Middle Ages 6 Dentistry in the Sixteenth and Seventeenth Centuries 7 Dentistry in the Eighteenth Century 10 2. Introduction to Orthodontics 14 Definition of Orthodontics 14 What is Malocclusion? 15 Aims of Orthodontic Treatment 15 Branches of Orthodontics 16 Orthodontic Appliances 17 Timing of Orthodontic Intervention 18 Scope of Orthodontics 18 Benefits of Orthodontic Treatment 19 3. History of Orthodontics from Ancient Civilization to Twentieth Century 20 Ancient Civilization 20 Middle Ages through Seventeenth Century 21 Eighteenth Century 22 Nineteenth Century 23 Twentieth Century 24 4. History of Orthodontics in United States of America 28 Norman Williams Kingsley (1829–1913) 31 5. History of Orthodontics in Great Britain 34 The British Society for the Study of Orthodontics 37 6. History of Orthodontics in Greece and Rome 44 Middle Ages (Fifth to Fifteenth Centuries) to the Eighteenth Century 44 European Pioneers of the Early Nineteenth Century 45 7. History of Dental Lasers and their Applications in Orthodontics 47 All Laser Devices 47 Properties of Laser Beam 48 Focused Versus Defocused Beam 48 Types of Laser 49 Lasers and their Dental Applications 50 Current Clinical Use of Dental Lasers 51 Laser Use in Dentistry 51 Laser Classification 52 Applications of Lasers in Orthodontics 53 Laser Safety 58 Precautionary Measures 58 xiv History of Orthodontics

8. Angle’s Contribution to the Faculty of Orthodontics 59 Edward Hartley Angle—Dental Graduation 60 Angle‘s Dental Practice at Towanda 60 Edward Hartley Angle’s Professional Teaching Career 61 Edward Hartley Angle‘s School of Orthodontics 65 Appliance Contribution by Edward H Angle 66 Angle’s Orthodontic Material Invention 69 Case-Angle Controversy 70 Criticisms 71 9. Dr TM Graber’s Contribution to Orthodontics 76 Thomas M Graber (1917–2007) 76 TM Graber’s Contributions 77 Graber’s Other Contributions to Orthodontics 85 10. James McNamara’s Contribution to Orthodontics 88 James McNamara Analysis 88 Relating the Maxilla to the Cranial Base 89 Relating the Mandible to the Maxilla (Midface) 89 Relating the Mandible to the Cranial Base 91 Dentition Analysis 91 Airway Analysis 92 Studies on Functional Appliances 93 Studies on Rapid Maxillary Expansion 95 Studies on TMJ 96 11. Andrews’ Straight Wire Appliance 98 Why “Straight Wire”? 100 Variable Bracket Sitting Procedures: Lawrence F Andrew’s Remedy 102 Straight Wire Appliance Brackets for Different Clinical Situations 102 Straight Wire Appliance (SWA) 103 12. Evolution of Orthodontic Appliances 106 Brackets and Bands 107 Archwires 114 Properties of Archwire 117 Auxiliaries 119 History of Orthodontic Materials 120 13. History of Model Analysis 122 Carey’s Analysis 123 Pont’s Index 123 Linderharth Index 124 Korkhaus’ Analysis 124 Howe’s Analysis—1954 124 Bolton’s Analysis 125 Cast Analysis: Symmetry and Space 126 Alignment (Crowding), Space Analysis 126 Arvey Peck, Sheldon Peck—1972 127 Huckaba’s Analysis 127 Hixon and Old Father Method—1958 128 Contents xv

Marvin M Tanaka, Lystle E Johnston in 1974 128 Nance Analysis 129 Total Space Analysis—1978 130 Wylie 131 Kesling Model Analysis 131 Martinek Analysis 131 Suwannee Luppanapornlarp 131 3D Model Analysis 132 14. History of Cephalometrics 133 History Prior to the Advent of Radiography 134 Cephalometric Radiography 137 Holly B Broadbent’s Contribution 138 Other Important Contributions 139 Cephalometric Analysis 139 Evolution of Cephalometrics 140 Patient Orientation 140 X-ray Source Position 140 Film Position and Enlargement 140 Posteroanterior (Frontal) Cephalometry 141 Steiner’s Analysis: Cecil C Steiner (1896–1989) 143 15. History of Extraction in Orthodontics 145 Arch-Length Analyses 146 Second Premolar Extraction 147 Evolution of the Philosophy of Extraction in Conjunction with Orthodontic Therapy 148 Need for Extraction 150 Choice of Teeth for Extraction 150 Serial Extraction 150 Historical Perspective 151 Tweed’s Method (1966) 152 16. History of Expansion Appliances 154 Wescott’s Expansion Device 154 Angell’s Palatal Expansion Device 154 Fixed Rapid Maxillary Expansion Appliances 156 17. History of Removable Orthodontic Appliances 160 Development of Removable Orthodontic Appliances 161 Components of Removable Orthodontic Appliance 162 18. History of Fixed Orthodontic Appliances 167 E-Arch Appliance 171 Pin and Tube Appliance 171 Ribbon Arch Appliance 172 Edgewise Appliance 172 What was Orthodontics before Angle System? 173 Evolution and Development of the Edgewise Appliance 173 Evolution of Bracket 174 Evolution of Edgewise Buccal Tubes 174 The Concept of the Ideal Arch 175 The Ideal Arch Wire 176 xvi History of Orthodontics

Advantages and Disadvantages of Edgewise Appliance 178 Building Treatment into the Edgewise Appliance 178 Begg Appliance 179 Straight Wire Appliance 180 Andrews Six Keys to Optimal Occlusion 180 Limitations of Straight Wire Appliance (SWA) 182 Lingual Technique 183 19. History of Myofunctional Orthodontic Appliances 186 Activator 187 Frankel Appliance 189 Bionator 189 Class III or Reverse Bionator 190 Oral Screen (Vestibular Screen) 190 Herbst Appliance 190 Twin-Block Appliance 190 The Double Plate 191 The Tooth Positioner 191 20. History of Surgical Orthodontics 193 Pioneers 195 Mandibular Procedures 196 21. History of Cleft Lip and Cleft Palate 197 Demographic Data 199 Embryological Aspects 200 Classification 200 Etiology of Cleft Lip and Palate 201 Clinical Features 202 Cleft Lip and Palate Associated Problems 203 22. History of Malocclusion Indices 205 Index of Orthodontic Treatment Needs (IOTN) 218 Peer Assessment Rating 219 Index of Complexity, Outcome and Need 220 Dental Aesthetic Index 221 23. History of Interproximal Enamel Reduction in Orthodontics 223 History of Interproximal Enamel Reduction 223 Indications 224 Contraindications 225 24. History of Invisalign 226 Historical Perspective of Invisalign 227 What Exactly the Invisalign Means? 228 Developing the Invisalign Brand 228 Philosophy of Invisalign 229 Fabrication of Invisalign 229 Principle of Stereophotolithography 231 Summary of the Invisalign Technique 231 Indications of Invisalign 232 Advantages of Invisalign 232 Contents xvii

Disadvantages of Invisalign 232 Limitations of Invisalign 232 Procedure of Treatment with the Invisalign 232 Benefits of Invisalign 233 Care of Teeth with Invisalign 233 Study 1 233 Outcome Assessment of Invisalign and Traditional Orthodontic Treatment Compared with the American Board of Orthodontics Objective Grading System 233 Study 2 234 How Well does Invisalign Work? A Prospective Clinical Study Evaluating the Efficacy of Tooth Movement with Invisalign 234 Study 3 235 Retaining Alignment Changes with Invisalign 235 Study 4 235 Structural Conformation and Leaching from In Vitro Aged and Retrieved Invisalign Appliances 235 Study 5 235 Cytotoxicity and Estrogenicity of Invisalign Appliances 235 Study 6 236 Color Fading of the Blue Compliance Indicator Encapsulated in Removable Clear Invisalign Teen Aligners 236 Study 7 236 A Comparison of Treatment Impacts between Invisalign Aligner and Fixed Appliance Therapy during the First Week of Treatment 236 Other Studies 237 Scientific Studies 237 25. History of Molar Distalization in Orthodontics 238 History of Molar Distalization 238 Indications for Molar Distalization 239 Contraindications of Molar Distalization 239 An Ideal Intraoral Molar Distalization Appliance 240 Mechanism of Action of Distalizing Appliances 240 Pendulum Appliance 240 Pend-X Appliance 241 M-Pendulum Appliance 241 Pendulum F Appliance 243 Jones Jig 243 Intermaxillary Class II Malocclusion Correction Appliances 243 Vertical Holding Appliance 243 Removable Molar Distalization Splint 244 Symmetric Distalization with a TMA Transpalatal Arch 244 Tube Plates for Distalization of Molars 244 Cetlin Appliance 245 Anchorage Need 245 Extraoral Force 245 The Force Applied 245 The Lokar Appliance 245 K-Loop Molar Distalizer 246 The Distal Jet Appliance 246 The Crozat Appliance 247 xviii History of Orthodontics

Molar Distalization by Magnets 247 The Magnets 248 The Klapper Superspring 248 Herbst Appliance 248 The Mandibular Anterior Repositioning Appliance (MARA) 249 Saif Springs 249 The ‘Fastback’ Appliance for Molar Distalization 249 Features of Fast Back Appliance 250 Suggested Reading 251 Index 259 HHiiissstttooorrryyy oofff DDeeennntttiiissstttrrryyy 1

Ancient Dentistry Dentistry during the Middle – Nathaniel Highmore – I-Em-Hetep Ages – William Cowper – Saracens – Abulcasis – James Drake – Prof George Ebers – Garriopontus – Wilhelm Fabry – Hwang-ti – John Gaddesden – Antoni Van Leeuwenhoek – Ya-tong – Guy de Chauliac – Matthias Gottfried Purmann – Aesculapius – Giovanni Plateario Dentistry in the Eighteenth – Celius Aurelianus Dentistry in the Sixteenth and Century – Hippocrates Seventeenth Centuries – Lorenz Heister – Galen – Walter Herman Ryff – Johann Adolph Goritz – The Etruscans – Andreas Vesalius – Pierre Fauchard – Dr Guerini – Gabrielus Fallopius – Bourdet – Saint Apollonia – Bartholomeus Eustachius – Thomas Berdmore – Marshall H Saville – Ambro’ise Pare – John Hunter – Johann Stephan Strobelberger – Robert Bunon

These seems to be little doubt that dentistry in years ago, show evidence of tooth decay. The some form has been practiced from the most earliest recorded reference to oral disease is from ancient times, there seems to be but little doubt, a Sumerian text (circa 5,000 BC) that describes since considerable fragmentary evidence still “tooth worms” as a cause of dental decay. exists as to the general methods used by the ancients. If we stop to enquire who first extracted Dentistry, as a part of the medical art, was first teeth, made plates or filled carious cavities we practiced by the priests as a sort of religious rite, shall find that all such information is shrouded but later material remedies were added to aid in in the mists of antiquity along with the history effecting cures and help to maintain the prestige of the pyramids and other relics of early of the priesthood. Later the laity became interested, and surgery, including dentistry, was civilization. for a long period practiced by barbers and Oral disease has been a problem for humans travelling charlatans, who resorted to music and since the beginning of time. Skulls of the Cro- various other forms of entertainment to attract the Magnon people, who inhabited the earth 25,000 2 History of Orthodontics people. Finally, a few of the more far-seeing medical and dental practitioners became convinced of the necessity for better educated men to practice this important speciality, and thus dentistry gradually rose from about the beginning of the sixteenth century from a desultory trade or calling to the dignity of a learned profession. However, not until the latter half of the nineteenth century and the first part of the twentieth century did it really make rapid progress. It is a notable fact that many worthy dentists of modern times began their career in the laboratory or office of older practitioners. Later, however, they added to this training such scientific knowledge as was obtainable at the time and reached an honorable position among professional men. Not until 1840 was a dental Fig. 1.1: GV Black college organized to teach systematically the theory and practice of dental surgery. This, the Baltimore College of Dental Surgery, was chartered much that is considered new in medicine, dentistry February 1, 1840, opened in that year, and is still and surgery was known to Hippocrates, Fauchard, in existence. Galen and Pare. Sacerdotal Medicine, which was Perhaps it is within the last thirty-two years practiced in remote times by the priesthood, was that the greatest progress has been made by this mostly derived from the false notion prevalent young profession, during which time Dr Black among primitive peoples that the afflicted person had been stricken by the wrath of some divinity. (Fig. 1.1) introduced scientific cavity preparation The priests were always ready to treat such cases, and a balanced alloy, Drs. Callahan, Rhein, Best as they were well paid, and if the person recovered, et al gave us scientific root-canal work, and Dr their prestige was considerably increased, while if Taggart perfected and introduced the gold inlay, the patient did not improve it was because the while silicate fillings have come to occupy an supposed offender was not worthy of receiving the important place in operative work, and the desired pardon. Roentgen ray has become an indispensable aid in The first physician of record was I-Em-Hetep diagnosing pathological conditions. In 1910 Dr. (“He who cometh in peace”), who lived in the William Hunter, of London, contributed his region of King Tosher of the Third Dynasty of celebrated paper on the “Relation between Oral Egypt, about 4000 BC. He was evidently a man of Infection and Systemic Disease,” and woke the great prominence, since the Egyptians constructed dental profession to its responsibilities. Oral a pyramid at Sakkra in his honor, and as many prophylaxis has progressed to a point where statuary likenesses of him have been found, it is unclean mouths are no longer tolerated, and the evident that after his death he was worshipped prosthesis has come to our aid with removable as the Egyptian God of Medicine. That the early bridge-work and more scientific methods of Egyptian surgeons had to use great skill in the denture-making. treatment of disease is proven by the oldest book in existence, called The Instruction of Path- Hetep. ANCIENT DENTISTRY Ancient Egypt was the seat of culture and In the words of a distinguished writer, “To know learning; many students were drawn there from the history of a profession is to know the profession other lands in search of knowledge, and we are itself.” It has also been said, “There is nothing new told that during the time of Herod- Otus, about under the sun;” but be that as it may, it is a fact that 500 BC, dentistry was practiced as a specialty, so History of Dentistry 3 that “Egypt is quite full of doctors: those for the for a tooth” was a part of the law of the land, as, eyes, those for the head, and some for the teeth, also, “If a man smite out one of his servant’s teeth others for the belly or for occult maladies.” he shall let him go free.” The Saracens invaded Egypt in the seventh The Chinese boast a very ancient civilization, century, and in 642 A.D., shamefully destroyed and it is not unlikely that dentistry in some of its the great library at Alexandria. It is probable that cruder forms was known to them at a very early much valuable literature pertaining to early period in the world’s history. The Chinese “Father medicine and dentistry was thus lost, among of Medicine,” was Hwang-ti, who lived about 2700 others the writings of Herophilus and Erasistratus, BC. who, about 300 B.C., were pioneers in dissection The celebrated medical works of China refer not only of cadavers but of living men condemned to toothache, which is called “Ya-tong,” and to death by the kings of Egypt. describe nine varieties of this malady, and in Dental art among the ancient Egyptians is addition there to seven distinct diseases of the described at some length in the papyrus of Ebers a gums. Puncturing the gums as well as distant name derived from the material on which it is parts of the body for the relief of toothache and written (papyrus, a form of ancient parchment, or abscesses was practiced, this being, perhaps, one paper), and the discoverer, Prof George Ebers who of the oldest forms of dental or oral surgery. The found it at Thebes in 1872. This work, which dates same method of treatment, known as acupuncture, from 3500 to 1500 BC, gives many remedies for was applied to many other diseases as well and toothache and the so-called “Benut blisters in the the Chinese doctors chose their points of election teeth.” These remedies consisted of dough, honey, in a very scientific and learned manner, having oil, fennel seeds, incense, onions and similar altogether three hundred and eighty-eight sites ingredients used in various combinations, to be for puncturing, twenty-six of which were for the made into a plaster and applied to the aching relief of toothache. For this purpose they used gold, tooth. One prescription consists of the following: silver or steel needles and cauterized the site It is evident that dentistry in some of its cruder afterward with a cone of moxa, a sort of slow- forms must have come into being as soon as man burning vegetable wool applied through a hole in began to experience trouble with his teeth. The a coin. The moxa is compact and burns slowly, teeth are likewise largely relied upon to furnish drawing up the epidermis into a blister without diagnostic evidence in determining whether violence or excessive heat. prehistoric skulls found in excavating are of According to Dabry, the Chinese believed there human or animal origin. Prehistoric teeth do not, were worms in the teeth, and among the remedies as a rule, show evidence of caries, and if it be used therefore arsenic is said to have been made present it is said to be an evidence of considerable into pills, and one placed near the aching tooth or age, though it is difficult to understand the reason into the ear on the opposite side from the aching for this assumption, since caries is usually most organ, whereupon the pain would positively prevalent among children. Signs of abrasion are cease. Another favorite prescription used by the quite common, owing to the food habits and long Chinese read as follows: “Roast a bit of garlic and life of the subject. crush it between the teeth; mix with chopped The oldest written account of a dental horseradish seeds or saltpeter; make into a paste operation, other than extraction, is found in a with human milk; form pills and introduce one statement by Archigenes, of Rome, who advocated into the nostril on the opposite side to where the the repining of a tooth which ached without there pain is felt.” being evidence of caries, his idea being that the According to the Greeks, Aesculapius, the God pain was caused by morbid material in the interior of Medicine, is supposed to have been the son of of the tooth, which by this means could be Apollo. Cicero mentions three deities of this name, evacuated. the third of which was said to be the son of Among the ancient Hebrews neither the Bible Arsippus, who was the first to teach tooth-drawing nor the Talmud makes any mention of dental and blood-letting. The instrument used for tooth- operations, though the teeth and their beauties drawing is supposed to have been the are often extolled. “An eye for an eye and a tooth “odontagogon” of lead mentioned by Celius 4 History of Orthodontics

Aurelianus and exhibited in the temple of Apollo teeth have something to do with the sense of taste. at Delphi, sculapius, who was worshipped by the In his anatomical researches he recognized seven Greeks as one of their many Gods, was said to have pairs of cranial nerves and classified the healed the sick and to have raised the dead as well. trigeminal as the third pair. He was also of the As time elapsed there were reputed to be not only opinion that the teeth grow and thus repair the one, or, as related by Cicero, three sculapii, but wear on them, basing his opinion on the fact, no tradition gave rise to many Gods of this name to doubt, that a tooth having no opponent became whom numerous temples known as “Asklepeia” longer. In painful Dentition Galen advised were erected, among which was the famous temple rubbing the gums with the milk of a bitch or the of Cos, where Hippocrates gained most of his brains of hare.” He was, in his day, one of the knowledge of medicine. The priests or followers of most famous medical men of Rome and the Esculapius were known as “Asklepiadi.” author of many works on medicine. To Hippocrates is accorded the honorable title By this time the doctors’ shops were well of Father of Medicine, and even in those early days supplied with medicines, bandages and a great the “oath of Hippocrates” was a solemn variety of instruments, showing that the medical obligation to be taken by all who undertook the art had made considerable advancement. study or practice of medicine. Hippocrates was Dentistry had not yet become a separate born on the island of Cos about 460 BC and first profession, but was practiced by the doctors along studied medicine under his father, but later with medicine and surgery. devoted his attention to the medical books in the The Etruscans temple of Cos. Hippocrates wrote much in regard , or early Italians inhabiting that to dental maladies and their remedial measures, part of Italy known as Etruria, between the Tiber among which were considered extraction and and Arno, about 1000 to 200 BC, used bridges cauterization. He was the inventor of certain crude made of gold rings holding ox teeth, for the dental forceps and other dental instruments. He purpose of replacing lost dental organs. practiced the extraction of loose teeth and Just who these Etruscans or Toshi were, from cauterization of those that ached but were not whence they came or what became of them is not loose. He also recognized that the first teeth are definitely known, and their language is equally formed before birth by the nourishment of the fetus extinct, no code having been discovered by which in the womb. their writings can be deciphered. The Romans have also left us some specimens In speaking of fracture of the lower jaw, of bridge-work and other prosthetic appliances, Hippocrates recommended binding the teeth next which for the most part are found in tombs or in to the lesion together. He distinguished between the urns containing the ashes of those cremated. the complete and the incomplete fractures and It was said to be a custom to remove such pieces treated separately of fractures of the symphysis. If from the mouth before cremation and afterward the teeth were loosened he advised binding place them in the urn with the ashes. According several together on either side of the fracture until to the Law of the Twelve Tables, written in Rome consolidation of the bone had taken place, using about 450 BC, it was not unlawful to bury or burn for this purpose either gold wire or linen thread. corpses with the gold that was used to bind the At this time lay medicine had begun to teeth together. supplant sacerdotal medicine, and healing by the At this early period in the world’s history, priests as a religious rite was slowly giving place Rome must have had dentists, though she had as to more scientific and rational methods. yet no doctors. According to Dr. Guerini and Galen, who lived about six hundred years after others a gold crown is now in the museum of Pope Hippocrates, was an able writer and commented Julius, in Rome, which was discovered in on Hippocrates’s work. Galen was a noted excavating at Satricum, near that city. anatomist, and although he classified the teeth This would tend to prove that the Etruscans as bones, he said they were unlike other bones. not only did bridge-work, but were versed in the He was the first to recognize nerves (pulps) in art of making crowns also. The appliance found the teeth, and also erroneously believed that the at Satricum was made of two plates of gold History of Dentistry 5 stamped to represent the labial and lingual the cause of pain and decay in the teeth. As we surfaces of the lower central incisor, and were shall find later this superstition existed then soldered together to form the crown of the throughout the Middle Ages, and it was not until tooth. It is soldered to a narrow strip of gold the early part of the eighteenth century that which is contoured in such manner as to encircle Fauchard first cast doubt on their existence. As a the neighboring teeth, which act as a support for remedy for these worms, Scribonius Largus the appliance. suggested that if the seeds of hyoscyamus (henbane) be burned on charcoal and the fumes Saint Apollonia in the year 300 AD, was inhaled they would cause the worms to fall from canonized by the Church of Rome, and since then the teeth. It is a noteworthy fact that the seed buds has been the patron saint of dentistry. The ninth of henbane, when burned, form an ash that much day of February has been observed by the Church resembles worms, and as the drug has a narcotic of Rome in her commemoration. A photograph of effect that probably soothed and relieved the pain, the painting of this saint was, in 1900, presented it is no wonder that the ignorant populace of that to the Academy of Stomatology of Philadelphia, time readily gave ear to such seemingly plausible on behalf of Dr Mary H Stillwell, of Pittsburgh, by humbug. Dr C N Pierce, together with this historical sketch: Celius Aurelianus gave an account of the “Longing to obtain the grace of baptism, she odontagogon of lead found in the temple of Apollo made her way to Saint Leonine, a disciple of St. at Delphi, by which it was assumed that teeth Anthony of Egypt, and, as he baptized her, he should not be extracted unless loose enough to be bade her go to Alexandria and preach the faith. removed with a leaden instrument, though some So she went forth, and though she was only a have contended that this was only a model placed woman, young and frail, yet so eloquent were her there, probably by Esculapius, to be reproduced words, so fervent her zeal, that she made many with an iron instrument by those wishing to copy converts. About this time a tumult had been stirred it, lead being less affected by corrosion, and up in the city against the Christians and the mass therefore more lasting. He also wrote on fractures of the people were enraged at her teaching and and dislocation of the jaw, and described the came with bitter complaints to her father, who methods to be used in their reduction. gave her up to be judged by the governor. They brought her before the idol temple and Celsus gave a prescription for producing sleep in bade her worship the graven image. It is reported persons afflicted with toothache. It contained that she made a sign of the cross, and there came acorns, castoreum, cinnamon, poppy, mandrake forth from the statue an evil spirit shrieking, and pepper. When there was a large carious ‘Apollonia has driven me hence!’ This was more hollow in the tooth to be extracted, Celsus than could be borne; the people thirsted for recommended that it should first be filled either vengeance, so they tried by torture to overcome with lint or lead, in order to prevent the tooth from her constancy. She was bound and one by one her breaking under the pressure of the instrument. It teeth were drawn out, but still she did not flinch is not definitely known that he used fillings as a or fear, and on her refusal to accede to the demands means of preserving the teeth or relieving of her persecutors and renounce her faith, she was toothache. brutally clubbed about the head and face, and Marshall H Saville, according to an article in the subsequently suffered death by fire. Bulletin of the Pan- American Union, reported the “For a period of nearly fifteen hundred years finding of teeth inlaid with gold, turquoise, rock her intercession has been sought for relief from all crystal, red cement and other foreign substances pain incident to dental diseases, and her relics in skulls of the aborigines who lived in various have been and are regarded as possessing great parts of North and South America. These teeth efficacy in the cure of the same.” had been bored out with some tool and the filling Scribonius Largus, writing during the first skillfully placed in the cavity. century of the Christian era, was perhaps the first This custom was quite common in Mexico, author to give rise to the belief that worms were Central America and the province of Esmeraldas, 6 History of Orthodontics

Ecuador. In this latter province he also secured In Eastern India some of the people plane their an upper jaw from one of the natives which teeth down to an even level and dye them red by contained not only teeth inlaid with gold, but also masticating areca nuts. It is also said to be a a right lateral incisor which had been custom in New South Wales for a young man to transplanted to replace a lost central incisor, have his front teeth knocked out with a stone on showing that dentistry had reached a high stage reaching the age of virility, this being supposed to of development as a means of ornamentation at enhance his personal appearance. The natives of least. He also discovered in an excavation at the Hawaiian Islands knock out their front teeth Copan a lower jaw with a left lateral incisor that as a sacrifice to their god Eatoa. had been carved from some dark stone and implanted to take the place of one that had been DENTISTRY DURING THE MIDDLE AGES lost. In one case several teeth were found bound Abulcasis (1050–1122), an Arabian author, who together with gold bands. lived at Cordova, was one of the most able writers There are in the Peabody Museum of Harvard and surgeons of the Middle Ages. He wrote a University teeth in which had been placed inlays treatise on medicine, entitled De Chirurgia, of jade, iron pyrites and gold, some of them consisting of three volumes, the first of which was arranged symmetrically in triangles, also banded devoted entirely to the subject of cauterization, a inlays, all of which apparently were used for form of treatment much practiced at that time. His ornamentation (Dental Cosmos, 1916, Iviii, 281). method of performing this operation was to insert Among Primitive People, even at the present a red-hot cautery through a tube to protect the time, some very peculiar customs prevail which surrounding parts. have, no doubt, been a heritage from ancient times. He was especially interested at that early date Most of these people have beautiful strong teeth in prophylaxis and devoted special attention to which they ornament and embellish in various the tartar on the teeth, illustrating and describing ways for cosmetic or religious purposes, much to fourteen forms of scrapers or sealers for its removal. the detriment of these valuable organs. The He was a very religious and devout man, cautious substitution of gold teeth for missing ones has in the treatment of his patients and firmly opposed been practiced in Java from remote times, and to the needless extraction of teeth. When it became among the natives in many parts of Asia and the necessary to extract, he used one form of forceps Pacific Islands there is prevalent the custom of to loosen the tooth and another for its removal. dyeing the teeth black. In Sumatra the women file Elevators were used if the forceps failed or the their teeth down to the gums or into points, or tooth was broken. According to this author, partially remove the enamel, so as to be able to replantation was extensively practiced and apply the dye. artificial substitutes were made of ox bone to replace In Japan the married women dye their teeth teeth that had been lost. He advocated replanting black in order to distinguish them from the single teeth that had been removed by mistake or accident, women, using a dye that is made of urine, iron holding them in place with ligatures of gold or and a substance called “saki.” It is claimed that silver wire until they had again become firm. this dye is very durable and does not wear off for Garriopontus, an Arabian writer, in 1045 AD, said: many years. Dr L Ottofy, in an article on “Dentistry “On the island of Delphi a painful molar tooth, in Japan,” says, “The practice of blackening teeth, which was extracted by an inexperienced physician, as a symbol of the marital state, on the part of occasioned the death of a philosopher, for the women is becoming obsolete, yet a number still marrow of the tooth, which originates from the continue the practice.” Formerly large quantities brain, ran down into the lungs and killed that of black artificial porcelain teeth were exported philosopher.” For all we know this is the first record from America to Japan, where artificial plates for of a death resulting from the extraction of a tooth. men and single women were made with white teeth and those for married women with black John Gaddesden (1400–1450), an English doctor teeth. There are on exhibition in the Army Medical at Oxford, stated that dried cows’ dung or the fat Museum at Washington, D C, several sets of teeth of a green frog would positively cause teeth to fall of Japanese origin, carved from wood, that bear out when applied to them, and said, “If an ox, out the foregoing statement. peradventure, chewed a little frog with the grass, History of Dentistry 7 its teeth would fall out on the spot”. He is also vinegar and applied, or the juice of the rue fennel authority for the statement that “The brains of a was placed in the patient’s nostrils. This fact is of hare rubbed on the gums not only facilitate great importance, as it marks the first step in dentition but will make teeth grow again where general anesthesia and antedates Horace Wells’s they have been lost”. All of these remedies were discovery by five hundred years, though it is recommended and employed by many later doubtful if this old method was ever used writers, who claimed to have performed extensively. This author is the first to cast doubt marvellous cures by such absurd treatment. on the efficacy of the fat of green frogs for the Such statements as the foregoing seem purpose of causing the teeth to fall out. ridiculous to us, as anyone could have easily Superstition being uppermost in the lives of the satisfied himself of their falsity. The application people in those days, it took considerable courage of the cautery or arsenical compounds must have to contradict the old authorities on such a well- met with some success, as the latter is known to established belief. produce extensive necrosis. In 1308, the barbers and surgeons of London were incorporated into one guild and the name of Guy de Chauliac (1300–1368) was the most noted barber-surgeon was used to denote practitioners surgeon of the Middle Ages. He and others of that in all branches of surgery. This arrangement lasted period wrote extensively of dental ailments and until 1745 before it was finally dissolved, after operations for their relief by both physicians and which the barbers were only allowed to extract barbers. Guy followed in the foot-steps of the teeth. This should give one a fair conception of Arabians, who had made considerable progress the low repute into which surgery had fallen before him, and referred explicitly to dentators and during that period. their instruments, thus beginning the recognition The title of Doctor was first bestowed by the of dentistry as a specialty of medicine. He advised universities during the twelfth century and was that dental operations be performed for greater used to denote a learned man in any profession. security under the supervision of doctors, but had The title of Doctor of Medicine was first bestowed no criticism to make of dentators. This learned on William Gordenia by the College at Asti, in doctor used camphor, sulphur, myrrh and Italy, in 1329. Whether this title was earned or asafcetida as a filling material for carious cavities, honorary is not known. The title of Surgeon and, like his predecessors, lent belief to the Dentist was first given to Gillies and several other superstitious idea of worms in the teeth. It is men in France in 1622, though the title was not uncertain whether the worms referred to by him fully established for many years afterward. were particles of decaying food, nerves, larvae of insects or the burning henbane seed, as previously Giovanni Plateario (1450–1525), a professor at referred to, but the accepted belief was that they Pisa, was the first dentist to use the sitting posture were responsible for the pain in odontalgia. for performing operations on the teeth, others Fumigations with seeds of leek, onion and before him having used the horizontal position. henbane mixed with goats’ tallow were resorted The prevailing custom was to let the patient lie to in order to drive out the worms, after the manner prone on ground and to hold his head between first described by Scribonius Largus. operator’s knees with a vise-like grip. Guy de Chauliac also refers to medicines which DENTISTRY IN THE SIXTEENTH AND send the patient to sleep, among which are SEVENTEENTH CENTURIES decoctions of opium, hyoscyamus and lettuce. A new sponge was soaked in these medicines and Dentistry, with the other arts and sciences, made then dried, and when sleep was to be produced it its most notable advancement as a learned was wet and applied to the patient’s nostrils. This profession during the sixteenth century, for it was form of anesthesia must have been very effective, about this time that the world as we know it, made for it is related that it was used for surgical its first rapid strides forward. The invention of operations, amputations actually being performed the printing press in 1436, the taking of in this manner. To awaken the patient from this Constantinople by the Turks in 1453 and the deep slumber, another sponge was wet with discovery of America in 1492 all led to much 8 History of Orthodontics migration of peoples and the dissemination of of the development of the teeth and corrected knowledge, which constituted the beginning of a Vesalius’ error by showing that the permanent new era in which dentistry had its part. teeth do not grow from the roots of the temporary In Germany, dentistry had been practiced for teeth, but that they are generated twice over, the many centuries, as shown by artificial teeth in the first time in the uterus. He gave the first account of urns of those who had been cremated, and at this the dental follicle, and likened the teeth in their time the Germans had made considerable formation to the feathers of a bird ( De Dentibus progress. Here, as elsewhere, medicine was first Libellus, Venice, 1563). practiced as a religious rite combined with Bartholomeus Eustachius (died in 1574) was witchcraft and empirical remedies. As early as another great anatomist of the sixteenth century. 1460 Heinrich von Pfolsprundt wrote a book on After long and patient research he brought much medicine and surgery in which he described light to bear on the macroscopic (gross) anatomy wounds and fractures and the mode of their of the teeth, the number and variations of the roots, treatment. Pains of the teeth and gums were the alveoli, etc,. and gave a very clear description treated by him by the use of beverages, showing of the ligaments of the teeth and the means by his lack of skill in that direction. which they are held in the alveolus. He also gave Walter Herman Ryff (died 1570) wrote the first an account of the central cavity of the tooth, and book which treated of dentistry independently of stated that it contains blood- vessels and nerves, medicine in 1548. He is conspicuous for the fact and not marrow, as was claimed by some that his book was written in German, a living anatomists. He also investigated the embryology tongue, instead of the customary Latin, so that he of the teeth and confirmed the claim of may be looked upon as the first who attempted to Hippocrates that the first teeth are formed in the diffuse useful medical knowledge among the uterus. Eustachius is the first to deny that the teeth common people. One of the most interesting things grow during a whole lifetime, as was first claimed about his writings is that he is the first author to by Aristotle. Speaking of dental diseases, this author remarked that dental surgery was in his recognize the relation between diseases of the eyes days a most abject calling, notwithstanding its and teeth, declaring that because of their intimate having had as its initiator no less a person than relation, neither can be healthy without the other Aesculapius, the God of Medicine. being so too. While this reasoning is clearly wrong in the light of our present knowledge, it Ambro’ise Pare, born in France (1517–1592), is nevertheless marks a step in the right direction. justly entitled to the credit of being known as the According to Ryff the principal causes of dental “Father of Modern Surgery.” As an anatomist he diseases are heat, cold, traumatism and the is less accurate than either Vesalius or Eustachius, gathering of humors, and he says “The most but as a surgeon he gained great renown, having atrocious pain is when an apostema ripens in the been successively a barber, surgeon- barber, and root”. finally, in 1562, chief surgeon to the court. In his works this surgeon treated of dental maladies very Andreas Vesalius (1514–1564), who at the early thoroughly, which fact may be attributed to his age of twenty-five years became famous as an having first been a barber and consequently a anatomist, was the first who dared to correct the tooth-puller. He described fractures of the jaw and errors in Galen’s work, and gave a much more the methods of their reduction with considerable accurate description of the anatomy of the teeth thoroughness, and related some interesting cases than that given by Galen. His researches in regard which he had treated. In one instance a friend of to the teeth are incomplete, since he states that the his had his jaw broken and three teeth knocked permanent teeth grow from the roots of the out by a blow from a dagger, whereupon Pare so temporary teeth. This erroneous conclusion was skillfully treated the injury that all the teeth were due to the fact, no doubt, that the deciduous teeth successfully replaced and made of use. have no roots when shed. The Golden Tooth, in 1593 much was said in Gabrielus Fallopius (1523–1562), a pupil of Germany of a Silesian child, aged seven years, in Vesalius, carried out more fully his investigations whose mouth a golden tooth had erupted. Great History of Dentistry 9 credence was given to this story and the learned time the maxillary sinus named for him is doctors and philosophers speculated upon the accurately described), though its existence had phenomenon without the slightest doubt as to its long been known. He pointed out for the first time genuineness. Many books and papers were the anatomical relation between the teeth and written to explain the strange occurrence, and one antrum, and related a most amusing incident in writer, Jacob Horst, claimed that on the date of the connection with perforation of this sinus. A lady, child’s birth, that is, December 22, 1585, the Sun having much pain in her teeth finally had the was in conjunction with Saturn in the sign of upper canine tooth extracted, after which there Aries, and in consequence the nutritive force had was an incessant flow of humors (pus) from the developed so much that instead of osseous antrum. The patient herself wishing to learn the substance, golden matter had been secreted. It cause thereof passed a silver probe into the cavity appears that the golden tooth was nothing more its entire length, which produced the effect of its than a crown or lamina of gold let down deep into having reached the eye. Much amazed she the gum, and made by a dentist or jeweler for the stripped a long feather and passed it into it so purpose of deception, since a fee was charged for great a distance that she concluded that it had seeing the child. Balthasar Camindus, a doctor of reached her brain, not knowing that the feather Frankfort, had noted that the boy had not lent simply curled up in the cavity. He was able to himself to being examined by the learned, who allay her fears by informing her of the cavity in were likely to expose the fraud, and further relates the bone and the opening produced by the that a certain nobleman, being denied the privilege extraction of the canine tooth. of seeing the tooth, struck a dagger into the boy’s mouth and wounded him so badly that a surgeon William Cowper (1666–1709) was the first to was called and the fraud exposed. practise opening the antrum by the extraction of In the early part of the seventeenth century the the first molar. This was toward the end of the dental art was still in a pitiful state of development, seventeenth century, and he seems to be the first as shown by the literature on the subject, only to recognize antral diseases. This was something about twenty publications having appeared in like 50 years after Highmore had described the Europe during the preceding century. antrum. Johann Stephan Strobelberger, physician to the James Drake, a contemporary of Cowper, Imperial Baths at Carlsbad, published a book in operated in the same manner, and it was this 1630 in which he referred to “Gout in the teeth”, author who made known in a book entitled which included all of the diseased humors of the Anthropologia nova, published in 1707, the teeth that were supposed to fall by drops into the method of Cowper, for which reason the above- articular cavities and surrounding parts. In his mentioned proceeding is sometimes called the writings we find that many crude and worthless “Cowper-Drake operation.” remedies were still used for toothache, and the Wilhelm Fabry, better known under the Latin instruments for extraction consisted for the most name of Fabricius Hildanus (1560–1634), chief part of the pelican, named from its likeness to the doctor to the city of Berne, gave some very beak of that bird, and also some very rude forceps. interesting clinical reports on the relation between He was one of the first to cast doubt on the value dental affections and tic douloureux, and cited of fumigations with hyoscyamus seeds to cause an instance where a lady who had suffered worms to fall from the teeth, though he did not in atrociously for four years with pain in the head the least doubt the existence of the worms was completely cured by the extraction of four themselves, suggesting oil of vitriol or a decoction decayed teeth. He also gave an account of an made of a frog cooked in vinegar to kill them interesting case of rhinoplasty performed by Dr J instead. Among the remedies he suggested for Griffon, an eminent surgeon of that day, upon a odontalgia is the American tobacco plant young girl of Geneva, whose nose had been cut (Nicotiana tabacum). off by the Duke of Savoy’s soldiers in a fit of rage. Nathaniel Highmore (1613–1684) (published a Fabry testifies to the natural appearance of the treatise on anatomy in 1651, in which for the first nose even for twenty years afterward. He stated 10 History of Orthodontics that Gaspare Tagliacozzi, of the University of removing the decayed part of a tooth with a file or Bologna, was the inventor of this operation. toothpick and filling the cavity with white wax, mastic or gold or lead-foil. In this work he gave a Antoni Van Leeuwenhoek (1632–1723), a very concise description of removable prosthetic Dutchman, was the first to make high-powered pieces made of ivory or hippopotamus tusks and microscopes with which, in 1678, he made maintained in position simply by their form. discovery of the tubular structure of dentine, and Heister also refers to nasal prosthesis, which was in 1683 he discovered microorganisms in tartar then carried out by applying noses of wood or scraped from between the teeth. From a perusal of silver, properly painted. There was at this time his writings and drawings it appears that these much contention among dentists as to the bodies were bacteria rather than animalcules, as advisability of removing caries by the use of the he supposed. Both Carpenter and Beal state that file, as practised by Heister and others,because of his work was done with single lenses, as the the destruction of the enamel of the tooth. We find, compound microscope did not reach a useful however, that this was practised for a long period, stage until about 1820 to 1830. It is astonishing and was advocated in a modified form by such how much was accomplished by such primitive eminent dentists as Drs. Chapin A. Harris and means. This in all probability represents the first Robert Arthur more than a century later. step in bacteriology, which was only made Upto the eighteenth century the clumsy pelican possible by the aid of high-powered lenses. or rude forceps, used to exert lateral force on the Matthias Gottfried Purmann (1648–1721) has the tooth, was still in general use, but this was honor of being the first writer to make mention of modified about this time into what was known as wax models in connection with prosthetic work. the key of Garengeot, named after the man who Whether these models were made from molds or perfected, though he did not invent, the instrument. not is a disputed question, but the supposition is According to some writers this instrument had its that they were carved to the desired shape and origin in Germany, not in England. It was a most then passed on to a craftsman who reproduced efficient instrument for extracting teeth and was them in bone or ivory. in general use for more than a century, having Many other incidents of considerable interest been extensively used in America, and is much during the seventeenth century have to be omitted used in France and other European countries at in a history of this character, and consideration the present time. will now be given to the development of the eighteenth century. Johann Adolph Goritz, of Regensburg, writing in 1725, opposed too many extractions and also the DENTISTRY IN THE EIGHTEENTH CENTURY insertion of prosthetic pieces, because they caused In 1700, France took the lead in the dental art and the loss of the teeth to which they were attached. had recognized the importance of dentistry by This was due to their being wired to the natural requiring prospective practitioners to take an teeth, causing great strain on and consequent examination under the edict of 1699 to show their loosening of the abutments. qualifications before entering the profession. There Pierre Fauchard (born in Brittany about 1690 and is abundant evidence that the Germans had also died in Paris in 1761) was the founder of modern made considerable progress during the two dentistry. He published a work in 1728 entitled preceding Centuries and they have likewise left Le Chirurgien Dentiste, which marked a new us considerable literature upon dental surgery. epoch in the history of the dental art. This book Dentistry had already begun to flourish as a was highly commended by the leading medical distinct specialty of medicine, but it remained, as authorities of the day. It was translated into we shall see later, for Pierre Fauchard to effect the German in 1733, and a second revised French final separation. edition was issued in 1746, and a third in 1786. It consisted of two volumes in duodecimo, with 40 Lorenz Heister (1683–1758), of Frankfurt-am- full-page plates, 863 pages in all, and treated of Main, published a treatise on dentistry entitled all branches of dentistry as understood and De Dentium Dolore in 1711, in which he advised practiced at that time. According to Fauchard History of Dentistry 11 dentistry was then an important calling, as he origin, growth and anatomical parts as, body, root refers to the examination which prospective and neck. He described accurately the pulp cavity practitioners were compelled to undergo even as and root canals, and after a most thorough early as 1700, and advises that a dentist be macroscopic description, goes into the histology included in the board of examiners. He expressed of the teeth, following the writings of La Hire in himself in no uncertain terms as to the need of a 1699. Fauchard agrees with the popular idea of school of surgery in which the theory and practice his day in regard to caries, and states that it may of dental surgery could be properly taught. have its origin within the tooth as well as without. Fauchard lamented that so little was written From a passage in the fifth chapter of by able dentists who had preceded him, because Fauchard’s work one learns that tooth-brushes these men guarded their knowledge with secrecy were then already in use, but he says that those lest someone might profit at the author’s expense. made of horsehair are too rough and frequently It is a mistake to think that he created the art of have a destructive action upon the teeth. He dentistry, but that he placed it on a higher plane advised using small sponges, with which the teeth by many valuable inventions and by collecting should be rubbed up and down, inside and and publishing all of the available knowledge on outside, every morning. Before using the sponges the subject, there is no doubt. To show how they were to be dipped in tepid water or preferably concisely he wrote, it may suffice to quote the aqua vitae, “the better to fortify the gums and following account of work that may be done on render the teeth firm.” teeth : He was strong in his condemnation of elixirs “They may be cleaned; they may be straightened; and cures by magical means so much practised in they may be made shorter; caries may be removed his day, and a reference is made to the large and from them; they may be cauterized; they may be filled increasing number of Charlatans of the day, with lead; they may be separated; they may be placed wherein he exclaimed, “There will shortly be more in proper position; they may be fastened; they may be dentists than persons affected with dental removed from the jaw; they may be replaced in the diseases.” He laments over the poor quality of jaw; or they may be taken out to be placed in another work done by them, relating a case where a person’s mouth; and at last teeth are artificially deciduous tooth was extracted without roots, constructed, and may be placed instead of those that whereupon the dentist in an effort to extract the have been lost. All of these operations demand a roots removed the permanent tooth just erupting. skillful, steady and trained hand and a complete Fauchard advised seating the patient in an theory.” easy arm-chair for the purpose of performing In this work he refers to the popular idea of dental operations, and condemned the practice of worms in the teeth, which idea had existed for seating him on the ground or floor and holding more than one thousand years. He admits the his head between the operator’s knees, as was possibility of them, but states that he has never commonly done, as unskillful and unsanitary, and seen them, and that if they do exist they are not in the case of pregnant women, as capable of doing the cause of caries, but the eggs of insects may great harm. He practiced opening the tooth for have entered carious cavities and there hatched relieving abscesses by evacuating the pus. After and produced worms. three months he stopped these teeth to prevent Although Andry relates seeing very small their getting worse, but no mention of root-canal worms with a powerful glass, Fauchard states that work is made, though he placed a little cotton- he employed the same means but could not see wool in the cavity with oil of cinnamon and them. Thus he sets forever at rest this foolish allowed it to remain several weeks before filling superstition in regard to worms in the teeth as a them. cause of dental ailments so long indulged by the people of those times. Perhaps it is only as a matter Fauchard practiced orthodontia, and relates a of courtesy toward the many authors who case in which he used the file and pelican and preceded him that he admits their presence at all. put a crooked tooth in place, which operation Fauchard gave a very accurate description of required about ten minutes. The most difficult the anatomy of the teeth, their structure, position, cases he states required from three to ten days, 12 History of Orthodontics and sometimes several months, to complete. He with springs or clasps. He also practiced used gold and silver plates, which were perforated transplantation of teeth as well as the correction with holes through which he passed a silk thread of dental irregularities, and gained great renown for correcting irregularities, and when this was thereby. He used subluxation of the teeth for the not sufficient he forced them in place with the purpose of severing the dental nerve as a remedy pelican or forceps. against toothache. In 1737, Fauchard made a full upper set of Philip Pfaff, dentist to Frederick the Great, teeth for a lady of high rank, holding the same in deserves passing mention, since he was the first place with springs, and relates that the lady ate German to write a real treatise on dentistry. He is with it easily and could not get along without it. the first author who practised capping an exposed He also relates having made a full upper and lower nerve before placing a filling in the cavity, set for a gentleman, who had worn them for more Fauchard usually filling the cavity directly over than twenty-four years. When a full upper set of the exposure. He also described the construction teeth was made, Fauchard used flat springs to of artificial teeth in which he made use of not only hold the piece in place, atmospheric suction not ivory, bone and tusks of the hippopotamus and being recognized and used until the year 1800. the sea cow, but also of silver, mother of pearl and He states, however, that he has been successful in even enameled copper. His most important three cases in placing full upper sets without the contribution to science was the invention of the aid of springs. He also brought palatine prosthesis plaster model, poured in a beeswax impression. to a high degree of perfection and described five kinds of obturators, which were, however, Bourdet, dentist to the King of France, wrote a somewhat-complicated. The materials most in use book on dentistry in 1757, in which the novel idea in dental prosthesis were human teeth, was advanced of extracting carious teeth, filling hippopotamus tusks, ivory of the best quality and them with gold or lead and then replanting them. ox bone. Crowns were placed on natural roots (if If the alveolus was injured he replanted the teeth healthy) and held in place with screws or bound immediately and performed the operation of filling to neighboring teeth. afterward. He also used prosthetic pieces made The second edition of Fauchard’s work, which entirely of gold and covered them with flesh- appeared in 1746, contains (pp. 275-277) the first colored enamel on the outside, showing that some account of pyorrhea alveolaris, familiarly called dentists of olden times were even more artistic “Riggs’s disease,” after the American dentist, Dr than a large proportion of the practitioners of the John M Riggs, who, in 1876, introduced the present day who make no pretence of hiding their method of scraping the tartar from the crowns and glaring gold crowns. He also made use of roots for its cure. prosthetic pieces of hippopotamus tusk, to which In the first edition of Fauchard’s work (vol. ii, human teeth were fastened with rivets. p. 30) mention is made of a machine for preparing and drilling into teeth. This machine is illustrated Thomas Berdmore, who was dentist to George III in Siemens d’Odontologie (Jourdain, 1756, p. 207). of England and the first dentist to the English This was no doubt the beginning of the dental Royal Family, is mentioned as having instructed engine, and antedates the dental engine that the Robert Wooffendale, by many reputed to have Greenwoods made from an old spinning wheel. been the first dentist in America. Wooffen dale Summing up his writings, we may say that, emigrated to America in 1766, and though he was notwithstanding the falsity of some of his ideas, preceded by several men who practised the art, he he was far in advance of his profession and was was probably far more efficient than any who truly the founder of modern dentistry, and has preceded him. In 1768 Berdmore published an given inestimable service to suffering humanity. excellent work on dentistry which went through During the first part of the nineteenth century, many editions three English, two German and the almost all plates were fitted for the attachment of last an American edition, appearing in Baltimore, springs in case they were needed look natural. the cradle of American dentistry, in 1844, 76 years Mouton also invented a method of applying after the first edition, affording splendid proof of partial dentures by fixing them to the natural teeth its value. History of Dentistry 13

John Hunter (the celebrated English surgeon Robert Bunon (died 1749), a French dentist born (born February 13, 1728), studied under his at the beginning of the eighteenth century, was brother William, who conducted a school of one of the first to deny that the eye tooth has anatomy in London. In 1771 he published a book anything to do with the organ of sight, showing entitled Natural History of the Human Teeth, that it is supplied by the infraorbital nerve. He and in 1776 another work entitled Practical was an ardent champion of conservative dentistry Treatise on the Diseases of the Teeth. He was a and prophylaxis and succeeded in converting great lecturer and writer and kept a superb many medical men, surgeons and priests to his anatomical collection and extensive library. So views. When Fauchard’s book, Le Chirugien great did his fame become that he was made Dentiste, appeared he was disappointed to find Surgeon-General to the English Army. Hunter but little therein that interested him, and set about was a strenuous partisan of replanting and to write a book of his own. Before publishing his transplanting teeth, and described these work he entered the College of Surgery to undertake operations much more fully than had been done two years’ practice with a regularly licensed before. He experimented by transplanting a surgeon, to undergo theoretical and practical sound tooth drawn from a living person into a examinations and to take oath before the Chief cock’s comb by making an incision with a lancet. Surgeon of the Realm in accordance with the edict When, some months later, the cock was killed of May, 1699, in order to obtain the diploma of the head was injected and examined and the surgeon- dentist. He was highly eulogized by the tooth was found to be attached and circulation principal journals of the time, and by this means established as is found in the natural gums. If won much fame and many wealthy clients. we may judge from early writings, transplanting One of the chief merits of his book is that of and replanting were far more common at that having ascribed to the deciduous teeth all of the time than at present, and also profitable, as may importance that they really have. In cases of be judged by the charges of Paul Eurialius Jullion, stomatitis, Bunon advised the complete removal whose fee was five pounds five shillings for of tartar before administering other treatment. He transplanting a live tooth and two pounds two used the same measures against mercurial shillings for a dead tooth. stomatitis in the specific treatment of syphilis. IIInnntttrrroooddduuuccctttiiiooonnn tttooo OOrrrttthhhooodddooonnntttiiicccsss 2

Definition of Orthodontics – Fixed Orthodontic – Correcting Malocclusions of What is Malocclusion? Appliances Dental Origin – Functional Appliances – Correcting Malocclusions of Aims of Orthodontic – Orthopedic Appliances/ Skeletal Origin Treatment Extraoral Force Appliances – Adult Orthodontics – Functional Efficiency – Guards – Structural Balance Timing of Orthodontic – Management of Dentofacial – Esthetic Harmony Intervention – Deciduous Dentition Anomalies Branches of Orthodontics – Early Mixed Dentition Benefits of Orthodontic – Preventive Orthodontics – Late Mixed Dentition/Early Treatment – Interceptive Orthodontics Permanent Dentition – Corrective Orthodontics Scope of Orthodontics Orthodontic Appliances – Monitoring and Assessment – Removable Orthodontic of Developing Dentition Appliances

Humans have attempted to straighten teeth for chart 2.1). The term orthodontics was first coined thousands of years before orthodontics became a by Le Felon in 1839. dental specialty in the late nineteenth century. Proper alignment of teeth has long been DEFINITION OF ORTHODONTICS recognized to be an essential factor for esthetics, Knowing the definition is often an important function and overall preservation of dental health. initial step in understanding any subject. A Malposed/poorly aligned teeth may predispose number of definitions have been put forward over to a number of unfavorable sequelae such as poor oral hygiene predisposing to periodontal diseases and dental caries, poor esthetics giving rise to Box 2.1: Unfavorable sequelae of malocclusion psychosocial problems, increased risk of trauma, abnormalities of function and temporo- Poor facial appearance mandibular joint (TMJ) problems (Box 2.1). Poor oral hygiene maintenance Orthodontics is the branch of dentistry concerned Risk of dental caries with the growth of the face, development of Risk of periodontal diseases occlusion and the prevention and correction of Abnormalities of functions occlusal anomalies/abnormalities. The term Psychosocial problems “orthodontics” comes from Greek: “orthos” meaning Risk of trauma to the teeth right or correct and “odontos” meaning tooth (Flow TMJ problems. Introduction to Orthodontics 15

Flow chart 2.1: Derivation of the term orthodontics and father’s large teeth may have teeth that are too big for the jaw, causing crowding in the arch. Abnormal oral habits, such as thumb/digit sucking, lip biting and mouth breathing may also cause malocclusion by adversely affecting the normal occlusal development. Malocclusion can be presented in a number of ways. Some of the common characteristics of malocclusion include: Overcrowded teeth the years to explain what orthodontics is. Some of Spacing between the teeth the widely followed definitions are given below: Improper “bite” between maxillary and In 1911, Noyes gave the first definition of mandibular teeth orthodontics as, “The study of the relation of the Disproportion in the size and the alignment teeth to the development of the face and the correction between the maxillary and the mandibular of arrested and perverted development.” jaws. In 1922, The British Society of Orthodontists It must be appreciated that not all malocc- proposed that, “Orthodontics includes the study of lusions need treatment. Treatment of malocclus- growth and development of jaws and face ions that are mildly unesthetic and not detrimental particularly and the body generally, as to the health of the teeth and their supporting influencing the position of the teeth; the study of structures may not be needed and is not justified. action and reaction of internal and external influences on the development, and the prevention AIMS OF ORTHODONTIC TREATMENT and correction of arrested and perverted Although orthodontic treatment improves facial development.” appearance and is occasionally performed for Later, the American Board of Orthodontics cosmetic reasons, it should be aimed at restoration (ABO) and the American Association of of overall dental health. Orthodontists (AAO) stated that, “Orthodontics is Jackson has summarized the aims of that specific area of dental practice that has as its orthodontic treatment that are popularly known responsibility, the study and supervision of the as Jackson’s triad (Fig. 2.1). They are: growth and development of the dentition and its i. Functional efficiency related anatomical structures from birth to dental ii. Structural balance maturity, including all preventive and corrective iii. Esthetic harmony. procedures of dental irregularities, requiring the repositioning of teeth by functional or mechanical Functional Efficiency means to establish normal occlusion and pleasing facial contours.” The teeth along with their surrounding structures are required to perform certain significant WHAT IS MALOCCLUSION? functions such as mastication and phonation. Orthodontic treatment should increase the The term ‘malocclusion’ was first coined by efficiency of the functions performed. Guilford and it refers to any irregularities in occlusion beyond the accepted range of normal. Structural Balance Malocclusions are caused by hereditary or environmental factors or more commonly, by both Orthodontic treatment not only affects teeth but the factors acting together. One of the most also the soft tissue envelop and the associated common causes of malocclusion is a skeletal structures. The treatment should maintain disproportion in size between the jaw and the a balance between these structures and the teeth or between the maxillary and the mandibular correction of one should not affect the health of jaws. A child who inherits mother’s small jaw the other. 16 History of Orthodontics

change the normal course of events. They include the care of deciduous dentition with restoration of carious lesions that might change the arch length, monitoring of eruption and shedding timetable of teeth, early recognition and elimination of oral habits that might interfere with the normal development of the teeth and jaws; removal of retained deciduous teeth and supernumeraries which may impede eruption of permanent teeth and maintenance of space following premature loss of deciduous teeth to allow proper eruption of their successors.

Interceptive Orthodontics Interceptive orthodontics implies that when the action is taken, an abnormal situation (malocclusion) already exists. Certain interceptive Fig. 2.1: Aims of orthodontic treatment (Jackson’s triad) procedures are undertaken during the early manifestation of malocclusion to lessen the severity of malocclusion and sometimes to eliminate the cause. Esthetic Harmony Interceptive orthodontics is defined by the American Association of Orthodontists as “That The orthodontic treatment should enhance the phase of the science and art of orthodontics overall esthetic appeal of the individual. This employed to recognize and eliminate potential might just require the alignment of certain teeth or irregularities and malpositions in the developing movement of the complete dental arch, including dentofacial complex.” its basal bone. The aim is to get results which go Interceptive procedures include serial well with the patient’s personality and make him extraction, correction of developing anterior or her look more esthetically appealing. crossbite, control of abnormal oral habits, removal of supernumeraries and ankylosed teeth and BRANCHES OF ORTHODONTICS elimination of bony or tissue barriers to erupting The general field of orthodontics can be divided teeth. into the following three categories based on the Certain procedures undertaken may be nature and time of intervention: common to both preventive and interceptive Preventive orthodontics orthodontics. However, the timing of the services Interceptive orthodontics rendered is different. Preventive orthodontic Corrective orthodontics. procedures are carried out before the manifestation of a malocclusion, while the goal of interceptive Preventive Orthodontics orthodontics is to intercept a malocclusion that has already been developed or is developing, so Preventive orthodontics is defined as “Action taken as to restore a normal occlusion. to preserve the integrity of what appears to be the normal occlusion at a specific time.” As the name Corrective Orthodontics implies, preventive orthodontics includes actions undertaken prior to the onset of a malocclusion, Corrective orthodontics, like interceptive so as to prevent the anticipated development of a orthodontics, is also undertaken after the malocclusion. manifestation of a malocclusion. It employs Preventive orthodontics encompasses all those certain technical procedures to reduce or correct procedures that attempt to ward off untoward the malocclusion and to eliminate the possible environmental attacks or anything that would sequelae of malocclusion. Introduction to Orthodontics 17

Corrective surgical procedures may require therapy, e.g. retainers. Removable orthodontic removable or fixed mechanotherapy, functional appliances can be used in conjunction with fixed or orthopedic appliances, or in some cases an mechanotherapy. orthognathic/surgical approach. Fixed Orthodontic Appliances ORTHODONTIC APPLIANCES Fixed orthodontic appliances are so called because Today orthodontists have a wide array of they are fixed to the teeth and cannot be removed appliances in their armamentarium to treat by the patient. Fixed orthodontic therapy involves malocclusions. Success of orthodontic treatment fixation of attachments (brackets) to the teeth and depends on the appropriate selection of the application of forces by arch wires or auxiliaries appliances, the timing of the treatment, the type of via these attachments (Fig. 2.3). tooth movement and/or skeletal changes desired, Fixed appliances are indicated when multiple age of the patient and other factors. There are tooth movements are required for correction of basically four types of orthodontic appliances, malocclusion, such as rotations and bodily which can either be used singly or in combination movement of teeth. Fixed mechanotherapy allows to treat malocclusions. fine finishing and settling of occlusion. There are i. Removable orthodontic appliances a number of fixed orthodontic techniques such ii. Fixed orthodontic appliances as: Begg’s, edgewise, preadjusted edgewise, iii. Functional appliances straight wire and lingual techniques. iv. Orthopedic appliances/Extraoral force appliances. Functional Appliances Functional appliances/myofunctional appliances Removable Orthodontic Appliances are those appliances that utilize the forces of the Removable orthodontic appliances are so called circumoral musculature for their action to effect because they can be removed and fitted back into the desired changes (Fig. 2.4). They act principally the mouth by the patient (Fig. 2.2). by holding the mandible away from the normal Use of removable appliances requires careful resting position to effect growth modification of case selection for the success of the treatment. They the mandible. are ideally used when simple tipping movement Orthopedic Appliances/Extraoral of teeth is sufficient to correct a certain type of Force Appliances malocclusion. The range of malocclusions that can be treated with removable appliances alone is Orthopedic appliances use extraoral forces of high limited. They can also be used as passive magnitude (> 400 gm/side) to bring about skeletal appliances to maintain the teeth in their corrected changes. Intermittent application of such high positions after active phase of orthodontic forces in the growth period aids in correction of

Fig. 2.2: Removable orthodontic appliance Fig. 2.3: Fixed orthodontic appliance 18 History of Orthodontics

Fig. 2.4: Activator, a myofunctional orthodontic appliance skeletal malocclusions by growth modification. Orthopedic appliances like functional appliances require good patient compliance for their success, Fig. 2.5: Orthopedic appliance e.g. headgears and chin cup (Fig. 2.5).

TIMING OF ORTHODONTIC INTERVENTION Reduction or elimination of abnormal swallowing or speech problems Appropriate timing of orthodontic treatment is Growth modification using functional and essential to accomplish the desired treatment orthopedic appliances is best done in this outcome and its long-term stability. Timing of period where significant growth is taking place orthodontic intervention is related to the stage of Shortening and simplification of later dentition. orthodontic treatment Prevention of later tooth extractions Deciduous Dentition Improvements in appearance and self-esteem Orthodontic treatment during this stage mainly Parental education. includes the following: Parental education Late Mixed Dentition/Early Care of deciduous dentition Permanent Dentition Space maintenance Most corrective orthodontic treatments are carried Elimination of abnormal oral habits. out in late mixed dentition or early permanent dentition stage. Early Mixed Dentition Orthodontic treatment during this stage includes Late Treatment the monitoring of shedding timetable, serial Many types of orthodontic treatments are extraction, space maintenance and control of feasible after adolescence. However, growth abnormal oral habit. Although most corrective modification procedures to correct skeletal orthodontic procedures are performed in older malocclusion may not be feasible due to children and adolescents, it may be advantageous cessation of growth. in some cases to begin the treatment early before Surgical treatment involving orthognathic all the permanent teeth have erupted and facial surgeries are best carried out in late teens/ growth is complete. early adulthood after the cessation of growth. Advantages of early orthodontic treatment include: SCOPE OF ORTHODONTICS Correction of bite problems by guiding jaw growth and controlling the width of the upper From the era of finger pressure application to and lower dental arches invisalign treatment, the field of orthodontics has Introduction to Orthodontics 19 witnessed profound development in the form of appliance design has made orthodontic treatment newer appliance designs and techniques, which feasible in adult age as well. Orthodontic treatment have only increased the scope of orthodontics. in adults may involve the following: Adjunctive orthodontic procedures: They refer to Monitoring and Assessment limited orthodontic treatment carried out to of Developing Dentition facilitate other dental procedures. Adjunctive orthodontic procedures include uprighting of Shedding and eruption schedule is closely tilted abutment teeth prior to bridge work, monitored to ensure the normal course of space gaining for placement of implants, etc. events. Comprehensive orthodontic treatment: It is Space maintainers are given in case of usually carried out in young adults and premature loss of primary teeth to facilitate involves full fledged orthodontic treatment the eruption of successor teeth. with or without extraction of teeth. Habit breaking appliances are given to eliminate deleterious oral habits, such as thumb/digit sucking and lip biting which can Guards adversely affect the development of dentof- Mouth guard/Sports guard: Mouth guards are acial structures. often used during contact sports, such as Planned extraction of certain deciduous and/ boxing to prevent trauma to the teeth. or permanent teeth (serial extraction), done in Night guards: Night guards can be given in selected cases, can prevent future development bruxism to prevent further loss of tooth of crowding by providing adequate space for structures by attrition. the remaining teeth to erupt. Management of Dentofacial Anomalies Correcting Malocclusions of Dental Origin Dentofacial anomalies such as cleft lip and palate Malocclusions of dental origin include are usually associated with impaired facial abnormalities of intra-arch alignment and appearance, speech, hearing, mastication, interarch relationship of teeth. They can be deglutition, and dental occlusion. Thus, manag- managed by removable or fixed orthodontic ement of such patients often requires a appliances. multidisciplinary approach with a long-term treatment plan and individualized rehabilitation Correcting Malocclusions of Skeletal Origin program designed to address the treatment needs. Skeletal malocclusions include conditions where Malocclusion is usually present and orthodontic the upper and lower jaws are abnormally related therapy with or without corrective jaw surgery is to each other. frequently indicated. Growth modification: Skeletal malocclusions can be treated successfully by modifying the BENEFITS OF ORTHODONTIC TREATMENT growth of jaws during active growth period using functional or orthopedic appliances. Improved confidence. Surgical correction: Severe skeletal malocclusion Well aligned teeth that are easier to keep clean in adults can be corrected by orthognathic/ and healthy. surgical approach. Ideally positioned teeth, which lessen the chance of gingivitis and advanced gum disease. Adult Orthodontics Closed spaces to avoid the need for a bridge or Better understanding of bone cell reactions to denture. orthodontic forces and improvements in Better chewing and food digestion. HHiiissstttooorrryyy oofff OOrrrttthhhooodddooonnntttiiicccsss fffrrrooommm AAnnnccciiieeennnttt CCiiivvviiillliiizzzaaatttiiiooonnn tttooo 3 TTwwweeennntttiiieeettthhh CCeeennntttuuurrryyy

Ancient Civilization Eighteenth Century Middle Ages Through Nineteenth Century Seventeenth Century Twentieth Century

Since the beginning of human history, human orthodontists to diagnose and treat patients; and beings have understood at a very basic level that even though methods for straightening teeth, like without a proper bite, survival is very difficult. If dental braces, have dramatically changed since you cannot chew well, you cannot eat well. the early 1900s, Dr Angle’s classifications have Remains of the ancient Egyptians, Romans and stood the test of time. the Etruscans show that these societies used The history of orthodontics is interesting and various kinds of metal and ‘wires’ to straighten at the same time complex. It is the oldest speciality or adjust the teeth. of dentistry. It would be wise to follow the Many advances in dentistry and some development of this exciting field of science right pioneering efforts in teeth straightening began in from the era of ancient civilization to the current the 18th century, but it was really in the 19th century times. Prior to 1900s, the orthodontics was referred that orthodontics became a science of its own. as “Regulation of Teeth” and as “Orthodontia” Many inventors have contributed significantly up to 1930s and “Orthodontics” up to 1970s and to the fascinating science of orthodontics. The currently it is addressed as “Orthodontics and person, to whom, given the most credit for Dentofacial orthopedics” (Box 3.1). pioneering modern orthodontics is Dr Edward Angle, who is rightly honored as the “Father of ANCIENT CIVILIZATION Modern Orthodontics”. Angle developed a method for scientifically classifying, categorizing The history of orthodontics has been intimately and identifying irregular bites. His classification interwoven with the history of dentistry for more of malocclusion, also known as the Angle than 2000 years. Dentistry in turn, has its origins classifications is still being used by dentists and as a part of medicine. History of Orthodontics from Ancient Civilization to Twentieth Century 21

Box 3.1: Evolution of the term orthodontics until the Renaissance that the infallibility of his medical expertise was questioned. In his medical Orthodontics writings, he described dental anatomy and – “Regulation“ prior to 1900s embryology by specifically identifying the origin, – “Orthodontia” up to 1930s (“ia” referred to a growth, and development of the teeth and medial condition) – “Orthodontics” up to 1970s enumerating the functions of each. He believed – Currently “Orthodontics and Dentofacial the teeth to be true bones. Because dissection was orthopedics” performed on animals rather than on human beings, he erroneously applied some of his findings to human beings (e.g. the presence of an The Greek physician, Hippocrates (460–377 intermaxillary bone and the insensibility of teeth). BC), was the first to separate medicine from fancy or religion. He established a medical tradition MIDDLE AGES THROUGH SEVENTEENTH based on facts and the collected information was CENTURY gathered into a text known as the ‘Corpus Hippocraticum’. This text of the pre-Christian era There is little reference to dentition during this contains many references to the teeth and to the period. An Arabic physician Paul of Aegina tissues of the jaws as part of the medical text, which (Paulus Aegineta 625–690) wrote about includes descriptions of irregularity and crowding irregularities in the dental arches caused by of teeth. supernumerary teeth. He advised extraction of such teeth. Aristotle (384–322 BC), the Greek philosopher was the first writer who studied the teeth in a broad Ambrose Paré (1517–1590), a French surgeon, manner. In his work entitled De Partibus paid specific attention to the cleft palate. He was Animalium (On the Parts of Animals), he the first surgeon to devise an obturator for compared various dentitions of the known species treatment of cleft palate. of animals of that time. Renaissance Period Aulius Cornelius Celsus (25 BC–50 AD), the (Fourteenth to Sixteenth Century) prominent Roman author of the first century, described finger pressure to move teeth in his work During the Renaissance, one of the greatest De Re Medicina (on Medicine) (Table 3.1). geniuses of history, Leonardo da Vinci (1452– When in a child, a permanent tooth appears 1519), is remembered because he painted a smile before the fall of the milk tooth, it is necessary to on the lips of Mona Lisa. Her smile remains most dissect the gum all around the latter and extract provocative; yet the brush was only one of the it. The other tooth must then be pushed with the many tools he mastered. He was the first artist to finger, day by day, towards the place that was dissect the human body for the acquisition of occupied by the one extracted; and this is to be anatomic knowledge and the first to draw accurate continued until it reaches its proper position. pictures of these dissections. The medical art of the Romans reached its Leonardo was the first to recognize tooth form zenith under Claudius Galenus, commonly and the first to realize that each tooth was related known as Galen (AD 130–200). For 15 centuries to another tooth and to the opposing jaw as well, he dominated medical thought, and it was not thus perceiving the articulation of the teeth. He

Table 3.1: Ancient civilization Years Authors Contributions to orthodontics 460–377 BC Hippocrates Description of irregularity “Corpus Hippocraticum”. 384–322 BC Aristotle Comparison of various dentitions of different species of animals in his work “On the Parts of Animals”. 25 BC–50 AD Aulius Cornelius Celsus Described finger pressure to move teeth in his work ‘De Re Medicina (On Medicine)’. 22 History of Orthodontics described the maxillary and frontal sinuses and Bartholomaeus Eustachio (1520–1574), established their relationship to facial height. He commonly known as Eustachius, also an Italian determined and made drawings of the number of anatomist, described the minute structure of many teeth and their root formations. He noted that organs, especially the tube that connects the “those teeth that are the farthest away from the middle ear with the nasopharynx and that bears line of the temporomandibular articulation are at his name. He wrote Libellus de Dentibus (Book a mechanical disadvantage as compared with on the Teeth) in 1563, which is the first important those that are nearer.” specialized monograph on the anatomy of the Those (teeth) that act most powerfully, the teeth. In this book, he collected the writings of mascellari (molars) have broad flattened crowns various authors from Hippocrates to Vesalius, suitable for grinding the food, but not for tearing added the results of his own researches, and gave or cutting it. Those that act less powerfully, the the first accurate account of the phenomenon of incisors, are suitable for cutting the food but not the sequential development of the first and second for grinding it. The maestre (canines) are dentitions. He described the eruption and the intermediate between these two sets, their function function of the teeth, contending that there was being presumably that of tearing the food. no analogy between the deciduous and permanent dentitions. Eustachius devoted more attention to Andreas Vesalius (1514–1564), a Belgian the teeth than most anatomists, giving full physician and anatomist, set a precedent for the descriptions of the different forms, number and study of human anatomy when he personally varieties. He indicated the manner of articulation performed a dissection. It had been the custom for of the teeth and gave a somewhat ambiguous students to do the dissections while the lecturer explanation of the nature of the attachment of the described the procedure and specimen. He proved teeth to the socket and the gingival tissues, Galen wrong in many areas of anatomic comparing the latter to the attachment of the nails knowledge. His classic work, On the Fabric of to the skin. His explanation of the internal the Human Body, became the foundation that structure of the teeth differentiated the two layers reconstructed our knowledge of human anatomy and compared the enamel with the bark of trees. and thereby laid the basis for the practice of Eustachius described the dental follicle and medicine and surgery. its blood supply. He refuted the doctrine that roots In this book, he described the minute anatomy of the deciduous dentition served to form the of the teeth, particularly the dental follicle and permanent teeth. He maintained that the germs of subsequent pattern of tooth eruption: the permanent teeth are too small to be seen in the Gabriele Fallopio (1523–1562), commonly known fetus. He also mentioned that the teeth are as Fallopius, an Italian anatomist, wrote in his nourished differently than other bones, as Observationes Anatomica (Anatomic Observ- witnessed by their inability to repair when ations) a detailed description of the dental follicle. He fractured. wrote the terms hard and soft palate. The first book in the German language to have A membranous follicle is formed inside the reference to the teeth was entitled “Arzei bone furnished with two apices, one posterior (that Buchlein” (A Book of the Surgical Art) and was is to say, deeper down, more distant from the published in 1530 (author unknown). It contains gums), to which is joined a small nerve, a small the following comment. When teeth begin to drop artery and a small vein; the other anterior (that is, out push the new one every day toward the place more superficial) which terminates in a filament. where the first one was, until it sits there and fits Inside the follicle is formed a special white and among the others, for if you neglect to attend to tenacious substance, and from this the tooth itself, this, the old teeth (deciduous) will remain and the which at first is osseous only in the part nearest young ones (permanent) will be impeded from the surface, while the lower part is still soft, that growing straight. is, formed of the above mentioned substance. Each EIGHTEENTH CENTURY tooth comes out traversing and widening a narrow aperture, bare and hard; and in process of time 18th Century witnessed major events in the the formation of its deeper part is completed. development of dental science and dentistry History of Orthodontics from Ancient Civilization to Twentieth Century 23

Table 3.2: Eighteenth century Years Author Contributions to orthodontics 1772–1789 Etienne Bourdet Extraction of 1st premolars to preserve the symmetry of the jaws Extraction of the mandibular 2nd molars shortly after eruption in case of child with protruded chin 1723 Pierre Fauchard Father of modern dentistry He published his two-volume book entitled “The surgeon dentist, a treatise on the teeth” Developed first expansion appliance called “Bandlette” 1728–1793 John Hunter Natural history of teeth Growth and development of jaws Internal structure of teeth Functions of teeth

(Table 3.2) were separated. France was the leader what is probably the first orthodontic appliance. in dentistry throughout the world in the 18th It was called a Bandelette (Fig. 3.1). It was century. This was mainly due to one person; Pierre designed to expand the arch, particularly the Fauchard. No one person exerted a stronger anterior teeth and was the forerunner of the influence on the development of the profession expansion arch of modern times. than he did. In fact, he is referred to as the ‘Founder John Hunter (1728–1793), an English surgeon and of Modern Dentistry’. He created order out of a great teacher of anatomy, published his book chaos, developed a profession out of a craft and ‘The Natural History of the Human Teeth” in gave to this new branch of medicine a scientific 1771. He demonstrated the growth, development and sound basis for the future. He published his and articulation of the maxilla and mandible, and two-volume book entitled “The Surgeon Dentist, outlined the internal structure of the teeth and A Treatise on the Teeth”, which had an entire bone and their separate functions. He gave the chapter, on ways to straighten teeth. With reference basic nomenclature of dentistry incisors, to orthodontics, as early as 1723, he developed bicuspids and molars. The art of modern dentistry based on scientific foundation was first developed in Europe. It then came to the United States through the European- trained Operators for the teeth who came to America seeking fresh opportunities. Many native practitioners of America then began to “Regulate” teeth. Malocclusion was called ‘irregularities’ and their correction ‘regulation’ during this period.

NINETEENTH CENTURY Foundations were laid in the 19th century to the oldest specialty of dentistry – Orthodontics. It was in the latter part of the 19th (1880s) century that the speciality began to emerge. By the mid–19th century, basic concepts of diagnosis and treatment had begun. It was a time when each practitioner attempted treatment by devising their own method based on purely Fig. 3.1: Bandelette designed by Pierre Fauchard to expand dental arches mechanical principles. At that time, orthodontics 24 History of Orthodontics was part of prosthetic dentistry and the literature he who gave impetus to the scientific on the subject described orthodontics in the area investigations that permitted the understanding of partial or total replacement of missing teeth. of the theory and practice of orthodontics. During As early as in 1841, William Lintott, his studies, he investigated the physiologic and introduced the use of screws in his work ‘On the pathologic changes occurring in animals as the teeth’. He described premature loss of deciduous result of orthodontically induced tooth movement. teeth as a cause of malocclusion, recommended He published two volumes entitled that treatment be begun at age of 14 or 25 years “Irregularities of the Teeth and Their Correction” and also described a bite opening appliance. in 1888 and 1889. This textbook was the first great work devoted exclusively to orthodontics. Farrar JS Gunnell, in 1840, introduced the chin strap as was good at designing brace appliances and was occipital anchorage for the treatment of the first to suggest the use of mild force at timed mandibular protrusion, the principle of which is intervals to move teeth—‘in regulating the teeth, used even today. the traction must be intermittent and must not Emerson C Angel (1823–1903), in 1860 was the exceed certain fixed limits.’ first to advocate the opening of the median suture He also was the first to recommend root or to provide space in the maxillary arch, since he bodily movement of the teeth. strongly apposed extraction. This began the use Another man who also deserves much credit of arch expansion in orthodontics (Fig. 3.2). during this period of time is Norman N Kingsley (1829–1913), a prominent dentist, artist, sculptor William and Magill, developed molar bands (Fig. and orthodontist. He is known for his works on 3.3) on the teeth as early as in 1871. ”Correction of cleft palate”. As early as in 1866, It was not until the latter part of the 19th he devised a technique called ‘Jumping the bite’ century, when a few dedicated dentists gave with the use of a bite plane. He used vulcanite on special attention and importance to this phase of conjunction with ligatures, elastic bands made of dentistry, that orthodontics began to emerge as a rubber, jackscrews and the chin cap. speciality science. It was known at that time as ‘Orthodontia’, the suffix ‘ia’ referred to a medical Henry A Baker, is remembered for the condition. In the last three decades of 19th century, introduction of the so-called Baker anchorage or some great contributions were made to the the use of the intermaxillary elastics (Fig. 3.4) with speciality by the following dentists. rubber bands in 1893 (Table 3.3). John Nutting Farrar (1839 – 1913), is often referred TWENTIETH CENTURY as the “Father of American Orthodontics”. It was The most dominant, dynamic and influential figure in the specialty of orthodontics was

Fig. 3.2: Expansion appliance developed by Emerson C Angel Fig. 3.3: Molar band History of Orthodontics from Ancient Civilization to Twentieth Century 25

Table 3.3: Nineteenth century Year Author Contributions to orthodontics 1841 William Lintott Introduced the use of screws 1840 JS Gunnell Introduced chin strap 1860 Emerson C Angel First to introduce arch expansion by opening midpalatal suture “Father of expansion appliances”. 1871 William and Magill Developed molar bands 1888 and 1889 John Nutting Farrar “Father of American orthodontics” Wrote “Irregularities of the Teeth and Their Correction”. This textbook was the first great work devoted exclusively to orthodontics Laid the foundation for “Scientific orthodontics” (intermittent forces, limits to amount of tooth movements) 1829 to 1913 Norman N Kingsley “Treatise on Oral Deformities“ worked on correction of cleft palate Extraoral traction 1893 Henry A Baker Baker’s anchorage (Intermaxillary elastics)

Fig. 3.4: Baker’s anchorage (Intermaxillay elastics)

Edward H Angle (1855–1930) (Fig. 3.5). He is regarded as the “Father of Modern Orthodontics”. Fig. 3.5: Edward Hartley Angle (1855–1930) His classification of malocclusion was published in the Dental Cosmos, in 1899. Angle developed a book on orthodontics was published, and the last classification of malocclusion based on this fully revised seventh edition appeared in 1907. principle, which is still used today. He became professor of orthodontics in the year 1892. Edward Hartley Angle (1855–1930) Angle started the first school of Orthodontics Angle was born on June 1, 1855, in Herrick, in St Louis in 1900, independent from any Pennsylvania. He graduated from Pennsylvania university. From 1900 to 1928 he was the active College of Dentistry, in 1878. It was then that he head of his school, first in St Louis, later in New started his first orthodontic case on his preceptor’s London, Connecticut and finally in Pasadena, son. The problems that arose stimulated him to California. Under Angle’s aegis, the American devote the rest of his life to orthodontics. School of Orthodontists was founded in 1901. He presented his first scientific paper in 1887 Angle introduced the most universally used before the ninth International Medical Congress. classification of malocclusion, and even developed In the same year, his first paper bound edition a number of appliances such as the E-arch, the 26 History of Orthodontics pin and tube appliance, the ribbon arch appliance advocate of the relationship of malocclusion to and the edgewise appliance. facial improvement. Facial improvement was a He has been given the most credit for guide to treatment. pioneering modern orthodontics is Dr Edward Angle. Dr Angle developed a method for 1847–1923 scientifically classifying, categorizing and One of the great pioneers in orthodontics, Calvin identifying irregular bites. His malocclusion Case, was born in Jackson, Michigan, on April 24, classifications, also known as the Angle 1847. He graduated dentistry and medicine from Classifications are still used by dentists and Ohio Dental College in 1871 and University of orthodontists today to diagnose and treat patients. Michigan Medical School in 1884, respectively. And even though methods for straightening teeth, He became Professor of Prosthetics and like dental braces, have dramatically changed Orthodontics, at Chicago College of Dental since the early 1900’s, Dr. Angle’s classifications Surgery. He dropped his professorship of have stood the test of time. prosthetics in 1896 and later continued in only Although Angle died on August 11, 1930, his orthodontics throughout his life. influence is still felt very strongly in the orthodontic As a prolific writer, Case wrote 123 articles in field. The whole world still uses his classification dental literature alone on orthodontic diagnosis, of malocclusion and his excellent descriptions of orthodontic appliance, problems of tooth occlusion are hardly less important than his movement, cleft palate and associated speech classification of malocclusion. His strong problems, and prosthetic restorations of normal opposition against extraction of teeth as a part of speech and function. He was the second author orthodontic therapy has served as a balance wheel next to Angle. His textbook, the Techniques and against promiscuous tooth removal. His Principles of Dental Orthopedia, was published mechanical genius has provided some of the most in 1908. efficient appliances in use at present. Case was also a pioneer in orthodontic Another distinguished orthodontist was mechanotherapy. He was the first one to stress the Calvin S Case [(1847–1923) (Fig. 3.6)]. He importance of root movement (1892). He was one developed a classification of malocclusions that of the first to use rubber elastics in treatment (1892), included 26 divisions. Case published his major small gauge, and light resilient wires for tooth work “A practical treatise on the techniques and alignment (1917). He pioneered the use of relieves principle of dental orthopedic and prosthetic to stabilize orthodontic results. He is regarded as correction of the cleft palate”. Case was a strong the outstanding man of his time in the prosthetic aspect of rehabilitation of cleft palate deformities. Charles A Hawley (1861–1929), used a celluloid sheet containing a geometric figure that when adapted to a model determined the extent of proposed tooth movement (1905) and introduced the retainer appliance (Fig. 3.7) that bears his name (1908) (Table 3.4). In 1931, B Holly Broadbent published an article in the first issue of the new Angle Orthodontist entitled. “A New X-ray Technique and its Application to Orthodontia”. It was the introduction to the specialty and to dentistry of cephalometric roentgenography (Fig. 3.8) and, of course, cephalometric tracing and evaluation. Broadbent devised the roentgenographic cephalometer, which is the instrument that Fig. 3.6: Calvin S Case (1847–1923) accurately positions the head relative to the film History of Orthodontics from Ancient Civilization to Twentieth Century 27

Table 3.4: Twentieth century Year Author Contributions to orthodontics 1855 to 1930 Edward H Angle Father of orthodontics Classification of malocclusions E-arch appliance Pin and tube technique Edgewise technique 1847 to 1923 Calvin S Case Advocated extractions to correct facial deformities First to use elastic First to use light wires Great contribution to prosthetic correction in cleft palate patients 1861 to 1929 Charles A Hawley Hawley retainers

Fig. 3.7: Hawley’s retainer introduced Fig. 3.8: Cephalometric roentgenography (Lateral by Charles A Hawley cephalogram) and the X-ray source. His study, supported by the Changes in the area of practice include a Bolton family, consisted of a longitudinal study resurgence of treatment of the adult patient and of 3,500 school children from birth to adulthood. its concomitant expertise, as the public becomes In honor of his sponsor, Broadbent established a aware of personal dental health and esthetics. new point of reference on the skull, known as the Included also are the invasion of areas that had Bolton point. not received much attention in the past, namely, H D Kesling introduced his philosophy of tooth orthognathic surgery and the problems associated movement by using a rubber tooth positioning with the temporomandibular joint. Orthodontics device, in which the teeth were moved into a more has achieved the status of a recognized specialty ideal cuspal relationship after major correction of dentistry because of a long period of has been accomplished (1945). craftsmanship and professional expertise. HHiiissstttooorrryyy oofff OOrrrttthhhooodddooonnntttiiicccsss iiinnn UUnnniiittteeeddd SSStttaaattteeesss oofff 4 AAmmmeeerrriiicccaaa

American Orthodontics (1800– – Thomas W Evans – Alton H Thompson 1840) – Emerson C Angell – Isaac B Davenport – Benjamin James – O A Marvin – Henry A Baker – Samuel S Fitch – William E Magill – Eugene S Talbot – M Bourand American Orthodontics (1875– – Simeon H Guilford American Orthodontics (1840– 1900) – WGA Bonwill 1875) – John H Farrar – Chapin A Harris – Norman W Kingsley

In Colonial America, primitive conditions for first cutting in children” (1804). B Fendall of dental care existed for almost a century until Baltimore advertised that he “regulates the teeth European-trained operators for the teeth came of children” (1784). to this country seeking fresh opportunities. The art of dentistry in America can be said to have Leonard Koecker (1728–1850), practiced in had its origin with the importation of these Philadelphia, advertised that he supplies practitioners to the colonies. ligatures to teeth of an irregular position. He One of the most important native practi- stated this in his published articles in the medical tioners was John Greenwood (1760–1819). His press (1826): “Irregularities of the teeth is one of skills were first learned from his father, who was the chief predisposing causes of disease, and an instrument maker. He was apprenticed to Dr never fails even in the most healthy conditions Gamage, who taught him the rudiments of the to destroy, sooner or later, the strongest and best dental art. Through experience, he became set of teeth unless properly attended to. It is not proficient in the practice. only a most powerful cause of destruction of the Other practitioners include Josiah Flagg health and beauty of the teeth but also to the (1763–1816) of Boston, who advertised that he regularity of the features of the face, always “regulates teeth from their first teeth, to prevent producing, though slowly, some irregularity, but pain and fevers in children, assists nature in the frequently the most surprising and disgusting extension of the jaw, for a beautiful arrangement appearance. It is, however, a great pleasure to of a second set of teeth.” know that dental surgery is abundantly provided In 1798 CW Whitlock of Philadelphia stated with a remedy, and in most delicate subjects if that he supplies the deficiencies of nature files, placed under proper care at an early age, the regulates, and extracts teeth. John Le Tellier, also greater portion of the teeth of the permanent set of Philadelphia states, “regulates teeth from their may invariably be preserved to perfect health and History of Orthodontics in United States of America 29 regularity”. A note about his recomm-endation Other practitioners found various forms of for extraction is as follows. He advocated the treatment, such as the use of gold or silver plates “to extraction of first molars “since they are generally exert a gentle but continued pressure.” Shearjashub predisposed to disease and if these teeth be Spooner (1809–1859) wrote in his Guide to Sound extracted at any period before the age of twelve Teeth (1838), “we have to consider, first, their general years, all the anterior teeth will grow more or appearance as to regularity to the central circle; and, less backwards, and the second and third molars second, the state of preservation of each individual tooth so move toward the anterior part of the mouth to in cases where there is a predisposition to a projecting fill up the vacant space”. chin”. M Bourand from Paris observed that the parents American Orthodontics (1800–1840) should be alerted to the shedding of the deciduous teeth Irregularity of the teeth had been recognized by and any possible deformity. He stated: “Defects, dental surgeons early in the nineteenth century. sometimes, which are of such magnitude, that I have Benjamin James (1814) noted that he was “often known, in my long practice in both hemispheres, some called upon to cure irregularity, than to prevent young ladies of respectable families and of elegant it.” Levi S Parmly (1819) stated, “where features who could not observe their smiling irregularities are allowed to proceed and become countenances in a looking glass without blushing at fixed, it is often a matter of difficulty, and the irregularities of their teeth; when comparing their sometimes of impossibile to rectify them.” mouths with some of their young friends toward whom their parents had bestowed all the necessary care to Samuel S Fitch, MD, whose book entitled A System of Dental Surgery, published in 1829, is regulate their growth from childhood”. considered the first definitive work on dentistry American Orthodontics (1840–1875) in this country, devoted a significant amount of information to irregularities of the teeth. He was The correction of irregularities, however, easy in the first to classify malocclusion, what is as theory, will be found most difficult and delicate follows: in practice; not only will much skill be found ‘There are four states of this kind of irregularity. requisite, but, in equal degree, patience. The first when one central incisor is turned in, and the Thus, by the mid-nineteenth century basic under teeth come before it, whilst the other central concepts of diagnosis and treatment had begun. incisor keeps its proper place, standing before the under It was a time when each practitioner attempted teeth. The second is, when both the central incisors are treatment by devising his own method based on turned in, and go behind the under teeth; but the lateral purely mechanical principles. Orthodontics was incisors are placed properly and stand out before the part of prosthetic dentistry, and the literature on under teeth. The third variety is when the central the subject described orthodontics in the area of incisors are placed properly but the lateral incisors partial and total replacement. stand very much in; and when the mouth is shut, the under teeth project before them and keep them backward. Chapin A Harris (1806–1860), one of the most The fourth is, when all incisors of the upper are turned influential dental surgeons during this period, in, and those of the under jaw shut before them’. published the first modern classic book on His treatment consisted of applying “a force which dentistry, “The Dental Art”, in 1840. In it he gives shall act constantly upon the irregular teeth and bring much attention to various orthodontic treatment them forward; the other force to remove that obstruction procedures that were adapted from French and which the under teeth, by coming before the upper, English practitioners. His personal technique always occasion.” This is done by “application of an included the use of gold caps on molars to open instrument adapted to the arch of the mouth, fastening the bite and knobs soldered to a band for tooth a ligature on the irregular tooth and removing the rotations. resistance of the under teeth by placing some Materials generally used were cotton or silk intervening substances between the teeth of the upper ligatures, metallic wedged arches, and wooden and under jaw, so as to prevent them from completely wedges, but the discovery of vulcanite, a material closing.” used for artificial dentures, permitted the 30 History of Orthodontics construction of bite plates and other forms of report was given by E J Tucker, a respected dental removable appliances. In addition, springs that surgeon of Boston, in 1853. He condemned the were to be attached to the metal frames for use practice of early extraction of deciduous teeth and in individual tooth movement were introduced. advocated the use of rubber bands, or tubes, for As early as 1841, William Lintott introduced tooth movement. He said, “The exact position of the use of screws. They were described in the the teeth, the lines of force to be observed, and the chapter entitled “Irregularities of the Teeth”, as: tenacity of the power exerted, are all “When any one or more teeth project beyond the considerations requiring study and a careful right line, and it is desired to move them inwards, judgment.” This same society sponsored the a small hole must be drilled through the bar, over publication of the first book on orthodontics, against the most prominent point of each; a Essay on Regulating the Teeth (1841). It was screw-thread is then to be cut and a short screw written by Solymon Brown (1790–1876) of New introduced, which working through the bar, will, York, and was intended to inform parents by by a turn or two, each day, keep up such a stressing the importance of preventing continued pressure against each tooth as will irregularities. quickly force it back as desired. He described the premature loss of deciduous In 1854 Thomas W Evans (1823–1897), an teeth as a cause of malocclusion, explained that American dentist practicing in Paris, France, crowding was due to faulty growth and published the requirements for an appliance in development. He recommended that treatment the Dental Newsletter, which are as follows: should begin at the age of 14 or 15 years and also First: a firm support which shall not loosen described a bite-opening appliance, which or in any way injure the teeth to which it is consisted of a labial arch of a light bar of gold or attached; Second: a steady and sufficient silver passed around the front surfaces of the pressure; Third: great delicacy of construction teeth by means of ligatures (known as Indian that the apparatus may be a light as possible; twist), and the necks of the irregular teeth with Fourth: as a mechanism as simple as the case will pressure applied for movement. admit. In this manner, any required movement of In 1860 Emerson C Angell (1823–1903) was the teeth, inwards or outwards may be affected probably the first person to advocate the opening with great ease, and in very little time causing of the median suture to provide space in the no serious annoyance to the patient, the whole maxillary arch, since he took a strong stand apparatus being removed and cleansed every against extraction. James D White also perfected two or three days. a removable vulcanite appliance with a hinge in A modification of the screw, called the crib, a split palate (1860). was introduced by the Frenchman JMA Strange in 1841. Strange also introduced the use of the OA Marvin (1828–1907), in 1866, outlined clamp band. For retention he advised: Of use a the objectives of orthodontic treatment–first: rubber band attached to some hooks on the the preservation of correct facial expression; appliance surrounding the molars for retention.” second: the restoration of such expression; The chin strap as occipital anchorage for the Third: the proper articulation of the teeth for treatment of mandibular protrusion was better mastication; Fourth: their orderly introduced by JS Gunnell in 1840, and the arrangement, with a view to preventing principle of this may be seen today. Occipital decay. anchorage was obtained by the use of headgear As early as 1871 William E Magill (1825– devised by F Christopher Kneisel. 1896) had cemented bands on the teeth. In 1852 the American Society of Dental It may be of interest to know that in 1864 Surgeons, the first National Dental Association, George J Underwood of New York presented his established in this country (1840), committed to graduation thesis at the Pennsylvania College of a great interest in this phase of dentistry, formed Dental Surgery (Philadelphia) entitled a committee on dental irregularities. The first ”Orthodontia”. History of Orthodontics in United States of America 31

American Orthodontics (1875–1900) NORMAN WILLIAMS KINGSLEY (1829–1913) It was not until the latter part of the nineteenth Norman Williams Kingsley (Fig. 4.1) was born on century when a few dedicated dentists gave 2nd October 1829. Kingsley was one of the special attention and importance to this phase founders, who served as the first Dean of the of dentistry, that our specialty began to emerge. New York University College of Dentistry. He Known in that time as orthodontia, it required received honorary degree from Baltimore College special mechanical skills and knowledge in such of Dental Surgery in 1871. basic sciences as anatomy, physiology, and Kingsley was a prolific writer, with over 100 pathology. articles on cleft palate rehabilitation, the The period of the last three decades of the inadequacies of cleft palate surgeries, obturators, nineteenth century is studied in the framework orthodontic diagnosis, and orthodontic of individual dentists and their contributions. appliances. He was a prominent dentist, artist, Each practitioner developed his own theory and and orthodontist. As early as 1866, he practice, some to a greater degree of excellence experimented with appliances for the correction than others. Those to be discussed briefly include of cleft palate and is associated with a technique John H Farrar (1839–1913); Norman W Kingsley known as jumping the bite with the use of a bite (1829–1913); Alton H Thompson (1849–1914); plate. It was the treatment for protrusion of the Issac B Davenport (1854–1922); Henry A Baker maxilla, not necessarily with extractions, shaping (1848–1934); Eugene S Talbot (1847–1925); the dental arches to be in harmony with each Simeon H Guilford (1841–1919); and WGA other. He used vulcanite in conjunction with Bonwill (1833–1899). ligatures, elastic bands made of rubber, John H Farrar could be referred to as the Father jackscrews, and the chincap. In 1880 he published of American Orthodontics. It was he who gave A Treatise on Oral Deformities, which remained impetus to the scientific investigations that a textbook for many years. He, too, emphasized permitted the understanding of the theory and the importance of the relationship between practice of orthodontics. He began his studies in mechanics and biology as the principle on which 1875, during which time he investigated the orthodontics should be based. His book was the physiologic and pathologic changes occurring in first to recommend etiology, diagnosis, and animals as the result of orthodontically induced treatment planning. tooth movement. As a result of his studies, he published a series of articles, between 1881 and 1887, in the Dental Cosmos, one of the leading dental journals, enunciating the principle that “in regulating teeth, the traction must be intermittent and must not exceed certain fixed limits.” He also published “Irregularities of the Teeth and Their Correction” (Vol. 1 in 1888 and Vol. 2 in 1889), in which he demonstrated the many uses of the screw as the motivating attachment and the basis of what he referred to as a system of orthodontia. (Copies of these books are in the American Association of Orthodontists library in St Louis, Mo). He stressed the “importance of the observance of the physiologic law which governs tissues, during movement of the teeth, the subject being to prevent pain.” Farrar was the originator of the theory of intermittent force, and the first person to recommend root or bodily movement of the teeth. Fig. 4.1: Norman W Kingsley (1829–1913) 32 History of Orthodontics

Dr Kingsley died in 1913 in Patterson, New influence on the orthodontists. To provide a Jersey. Many of his contemporaries felt that the normal occlusion the practice of extraction of father of modern orthodontics had passed away. teeth was almost abandoned, being replaced by Calvin S Case wrote: “The longer orthodontics the expansion of the arch and the realignment of is practiced, the more respect the author has for the teeth. the general teaching.” Enunciated 40 years ago While admitting the value of extraction as a and published in his inestimable text, by that means of correction of certain irregularities of the most ingenious man of his days, Dr Norman teeth, I am forced to believe that far more Williams Kingsley, were the acceptable bases of irregularities have been caused by extractions practice, “Much success in treating irregularities than could ever have been corrected by will depend upon a correct diagnosis and extraction. prognosis.” Henry A Baker is remembered, because in 1893 Alton H Thompson was one of those forgotten he introduced the so-called Baker anchorage, or dentists who made a valuable contribution to the the use of intermaxillary elastics (Fig. 4.2) with specialty. He was recognized as an authority on rubber bands. The introduction of intermaxillary comparative dental anatomy, which is certainly elastics was interpreted by some practitioners to a basic consideration for orthodontists (He was mean the elimination of the need for extraction. a founder of the American Anthropological Clark Goddard was an early advocate of the Society). He devoted himself to research into the study and research into comparative odontology, dynamics of occlusion. This led him to the the study of skulls and teeth. This led to the following analysis: acceptance of an expansion screw for the forcible a. The construction of the temporomaxillary separation of the maxilla. He also attempted to articulation allows for lateral, anteroposterior, classify malocclusion, which included 15 vertical, and oblique movements. separate types of irregularities. b. The extent of maxillary development is Eugene S Talbot was equally proficient in reflected for the necessary support of the periodontics and orthodontics. He stressed the extensive masticating mechanism. study of the causes of malocclusion to be the key c. There is a suppression of density and to treatment. He stated that, “without the etiology diameter of the maxillary bones. of irregularities no one can successfully correct d. There is a predominance of the rotatory over deformities, as is evident in the many failures by the elevating muscles of mastication; and men who profess to make this a specialty.” He e. The special construction of the masticatory added, “Eighteen years of experience in the armature, i.e. the teeth, their vertices, parallel correction of irregularities of the teeth and a arrangement of the dental tissues, and the practical knowledge of the laws of mechanics apposition of the crushing teeth. Isaac B Davenport, as early as 1881, had created an interest in the study of occlusion. He developed a theory that the masticatory apparatus was subjected to the laws of nature, that imperfect occlusion was deleterious to the dentition, that extraction of teeth in treatment could affect the efficiency of the masticatory apparatus. He lectured before the New York Academy of Medicine in 1887. His lecture entitled “The Significance of the Natural form and Arrangement of the Dental Arches, With a consideration of the changes which occur as a result of their artificial derangement by Filing or Fig. 4.2: Baker’s anchorage (Intermaxillary by the Extraction of Teeth” has a tremendous elastic—class III elastic) History of Orthodontics in United States of America 33 have taught me not to rely on any particular with it greater possibilities for good or evil to the appliance. Frequently, though a certain patient than that of extraction”. appliance has worked well in one case it may WGA Bonwill said, “in vying with nature in not have been efficient in another case of similar matching the teeth, there must be more than mere nature. He advised that close attention to mechanics, more than being capable of filling a disproportion in the size of the maxilla and tooth or treating an abscess–we must be dental mandible, general contour and profile of the face, artists.” He developed what is known as the and the family history including hereditary Bonwill equilateral triangle. It is based on the factors important. He was one of the first to mandibular analysis of a tripod arrangement, recommend the surgical exposure of impacted extending from the center of the condyloid process canines. to the median line at the point where the In a paper presented to the Mississippi Valley mandibular central incisors touch at the cutting Association of Dental Surgeons in March 1891, edge. His measurements of more than 2,000 cases entitled “Scientific Investigation of the Cranium showed that from the center of one condyloid and Jaws,” he demonstrated intraoral process to the center of the other was four inches measurements on cast with such instruments as and that from the center to the incisor was also the registering calipers and the T-square with four inches. He used this theory in his orthodontic graduated sliding indicator. This was one of the treatment. He advocated a specialty of earliest attempts applying specific analysis of orthodontics many years before Angle: casts that reflected measurement of the jaws. “Really, in every city, someone should make Simeon H Guilford, dean of the Philadelphia of this a special practice, and the profession Dental College, was regarded as one of the finest should encourage such by sending cases for practitioners of that period. At the request of the inspection and consultation. And such a National Association of Dental Faculties, he specialist should do all he can, in return to teach wrote the first textbook for students, Orthodontia: by example and demonstrations by clinics, to Malposition of Human Teeth, Its Prevention and enlighten those who are placed so far from large Remedy, published in 1889. In this, he attempted cities that they are compelled to take such cases. to offer a classification of malocclusion. “There When we can have that understanding between are two divisions—simple irregularities or the us, then we may feel as banded brothers more malposition of few teeth with no important facial fully equipped for those hitherto difficult and disharmony, and complex irregularities, that is, thankless operations.” malposition of many teeth having corresponding The principles of resorption and deposition facial deformity” (These divisions contain eleven of alveolar bone during tooth movement were classes of malposition). discussed by LE Custer (Ohio) in March, 1888, He commented on extraction in treatments: at a meeting of the Mississippi Valley Dental “Probably no operation in the practice of Association, in a paper entitled “Intermittent orthodontia is more important, or has associated Pressure: Its Relation to Orthodontia.” HHiiissstttooorrryyy oofff OOrrrttthhhooodddooonnntttiiicccsss 5 iiinnn GGrrreeeaaattt BBrrriiitttaB aaiiinnn

Orthodontics in Britain – Sir John Russell Reynolds The British Society for the – Bell – Charles Goodyear Study of Orthodontics – Medical Act of 1858 – 1878 Dentists Act – Badcock – Tomes – JA Donaldson

Several eighteenth-century British authors, misgivings regarding the quality of much of the notably John Hunter, discussed the problems treatment on offer to “regulation cases”, as they associated with irregular dentition. However, the were then termed. first English textbook to be devoted to the subject There is not a subject connected with that matter of what would later be termed branch of practice, of which the present work orthodontics appeared in 1803. Joseph Fox’s professes to treat, which has given rise to such Natural History of the Human Teeth, subtitled, gross charlatanism, or to so much gratuitous describing the proper mode of treatment to cruelty, as that which regards the treatment or prevent irregularities of the teeth, detailed prevention of irregularity in the permanent teeth. several practical methods for altering the position Concerns of this sort were, however, not and orientation of teeth in the mouth. In 1829, uncommonly voiced with regard to many aspects Thomas Bell published The Anatomy, of dentistry at this time. The practice of dentistry Physiology and Diseases of the teeth, in which was still unregulated; there were no recognized he also discussed orthodontic problems and training programs or prerequisite educational techniques. Five years later, William Imrie, in his requirements. The better-qualified practitioners, interestingly titled Parents’ Dental Guide, such as Bell, MRCS (later FRCS) and FRS, found attributed irregularity of teeth to “intemperance much to complain about. of various kinds, combined with artificial modes In Britain, for much of the nineteenth century, of living”. James Robinson published, The dental work was undertaken by three dissimilar Surgical, Mechanical, and Medical Treatment of groups of practitioners. The members of the first teeth in 1846, which contained his ideas on group, small in number but perhaps the most etiology and treatment. It is clear, from these influential, had recognized medical qualific- texts, that procedures aimed at straightening the ations, which they had augmented by a short teeth were already part of the general dental period of training in dentistry. These men were surgeon’s repertoire by the first half of the based predominantly in London and some of the nineteenth century. larger provincial cities; most of them, like Bell, In 1829, Bell, lecturer at Guy’s Hospital on the held hospital or dispensary appointments at anatomy and diseases of the teeth, expressed some stage in their careers. The authors whose History of Orthodontics in Great Britain 35 publications have been discussed above are the Royal College of Surgeons of England began representative of this group. examining for the newly created LDS. The The second group had acquired their dental Edinburgh Dental Dispensary, run and staffed skills primarily by way of an apprenticeship, of by surgeons, was founded in 1860. In 1863, the variable length and effectiveness, to an Odontological Society of Great Britain was established dental practitioner. The number of formed, from the merger of two older, rival this category of practitioners grew as the century dental societies, under the leadership of Tomes progressed. The third group, perhaps the largest, and Samuel Cartwright, the professor of dental and the most readily available to the general surgery at King’s College Hospital. population, had little formal training and often A long political campaign achieved success combined their dental work with some other in 1878, with the passage of the first Dentists Act, occupation, such as druggist or barber. which extended the remit of the GMC to allow The forms of treatment offered by the some regulation of dental practice. The Act also different groups varied. Those who were empowered the surgical colleges of Edinburgh medically qualified tending towards a surgical and Dublin, and the Faculty of Physicians and orientation, which encompassed the whole of the Surgeons of Glasgow to offer examinations in buccal cavity. The second group, those who had dentistry similar to that of the London College. followed the apprenticeship route, generally While it would be more than a further 40 years adopted a more mechanical approach, with an before all unregulated practice was finally emphasis on the filling of teeth and the fitting of controlled, the passing of the 1878 Act was an prosthesis. They would also perform extractions. indication of the growing professional and social The activities of this group most closely status of dentistry. resembled the general dental practitioners of Generalism had been the dominant ideology today. The services offered by the third group of nineteenth-century British medicine. In 1881, were more basic, chiefly involving the extraction Sir John Russell Reynolds, later president of the of painful teeth. Royal College of Physicians and the British The Medical Act of 1858 regulated the Medical Association, maintained that practice of medicine, laying down statutory “specialism” denoted “miserable retrogression educational requirements and establishing a instead of evolution (and) the survival not of the Medical Register, which was administered by the fittest, but of the charlatan and the quack”. As General Medical Council (GMC). The Medical we shall see, similar views continued to be Act also empowered the Royal College of articulated by many, well into the twentieth Surgeons of England to award, by examination, century. However, as David Innes Williams has a License in Dental Surgery. The first diet of this pointed out, the formation of the Royal Society examination took place in 1860. Realizing the of Medicine (RSM) in 1907 signaled a new, more benefits of the Medical Act, the leading dentists, positive, attitude to specialization within many of whom were, as noted above, medically medicine itself. The RSM was organized into qualified, and urged that similar provisions be thirteen sections, rather than the traditional made for dentistry. Sir John Tomes, MRCS (later tripartite division of physic, surgery and FRCS) and FRS, was prominent in these obstetrics. The Odontological Society was campaigns. incorporated into the RSM as one of its original While Tomes and his peers were constituent sections, which represented an campaigning for the establishment of a regulated acceptance of the place of dentistry within the system of dental qualification and registration, medical establishment. they were also active in expanding dentistry’s By this time, specialization had little impact institutional base. The Dental Hospital of London within general dentistry. However, many of the was founded in 1858, and it’s associated London leading dentists, mostly members of the first School of Dental Surgery (LDS) in the following group described above, regarded dentistry as a year. The rival Metropolitan School of Dental division within medicine and themselves as Surgery (which later became the National Dental medical practitioners who had taken a special Hospital) was also established in 1858, just before interest in dentistry. The meaning of specialism 36 History of Orthodontics varied, in other words, according to whether one the production of both dentures and regulation regarded medicine or dentistry as the parent, plates. In a series of papers published in the generalist discipline. 1870s, FH Balkwill described a further Meanwhile, the demand for treatment to refinement in the use of the material, whereby correct irregularities of the teeth and jaws the vulcanite was applied directly to the working continued to grow. Earlier in the nineteenth plaster model of the teeth. This avoided the need century patients undergoing treatment to to construct a model of the appliance in wax. The straighten their teeth were described as new technique significantly improved accuracy, “regulation cases”; references to the fact that the and drastically reduced workshop time. aim of treatment was to correct what were called Balkwill’s papers demonstrate that British “irregularities of the teeth”. By the middle of dentists were actively involved uninnovation in the century, however, the term “malocclusion” the field of orthodontics in the second half of the was coming into common use. This change of nineteenth century. Although his appliances may vocabulary signaled a shift of emphasis away seem crude by modern-day standards, they from a narrow focus just on the position of the demonstrated many ingenious features, and front teeth, towards the consideration of both the appear to have been effective. Many of the relationship of teeth to each other, and to the nuances of tooth movement were, evidently, well teeth in the opposing jaw. The clinical practice appreciated at this time. Moreover, the fact that of correcting malocclusion then became known Balkwill worked in Plymouth indicates that the as “orthodontia”. Later the term “orthodontics” provision of orthodontic treatment was not was preferred. limited to the metropolis. As the nineteenth century proceeded, the Following the 1878 Dentists Act, the newly materials available to practitioners of created dental schools incorporated some “orthodontia” were improved and new methods teaching of orthodontics into their curricula. The were widely adopted. William Imrie, for 1882 “Student Supplement” of the British Journal example, made significant changes to of Dental Science listed lectures on irregularities orthodontic technique in the 1830s. He used of teeth as part of the dental surgery also plaster models of the dentition, made caps for pathology courses were offered at both the teeth, which were soldered to arches to reinforce National Dental Hospital and the Dental anchorage, and introduced gold bite plates to be Hospital of London. Orthodontic subject matter used over the palate. A treatise by Charles Gaine, appeared both in the major general textbooks and of Bath, published in 1856, is interesting in that in more specific volumes. Of the latter, James it draws on the record of successfully treated Oakley Coles’ On deformities of the mouth, congenital and acquired, and their mechanical cases. Gaine is credited with the introduction, treatment, first published in 1868, and J F simultaneously with WH Dwinelle in the USA, Colyer’s Notes on the treatment of irregularities of the jackscrew into orthodontics, an innovation in position of the teeth, are notable. Articles on that was to have a great impact on the ability to orthodontics began to appear regularly in the move individual teeth and to expand the distance dental periodical literature. The first formal between rows of teeth. Gaine also recognized the course of lectures on “what was later known as need to maintain the teeth in their corrected orthodontics” was delivered by John Henry positions for a period of time after tooth Badcock, dental surgeon to Guy’s Hospital, movement had been completed. Like Bell, he shortly after his appointment in 1900. urged that orthodontic treatment be undertaken only by those competent to do so. The JA Donaldson, in his history of The National development of a technology specific to the Dental Hospital, accurately describes the correction of irregular dentition gave its situation existing in most dental schools around practitioners a stronger claim to a distinctive skill, the turn of the century: as well as a greater sense of professional identity. There was an increasing interest in Vulcanite was patented, in 1844, by Charles orthodontics, partly as a result of lectures and Goodyear and rapidly found application in writings by practitioners who had studied in the dentistry, providing a distinct improvement in United States of America, and partly because it History of Orthodontics in Great Britain 37 was a field soon to be included in the the teaching and the practice of orthodontics in requirements of examining bodies. By 1902, this North America were more established, better led to the adoption by the National Dental organized and more sophisticated, or that Angle Hospital of “rules for regulation cases” and the was a dominant (if controversial) figure in fitting up of a room on the first floor for their American orthodontics. It is telling, for instance, treatment, but no teacher was appointed at this that Angle’s pupils from the British Isles, notably time. The treatment of each case was undertaken Chapman, Friel and Visick, came to occupy by a student under the supervision of the dental leading positions within British orthodontics. surgeon of the day. Prolific authors of research papers, all three were In other words, orthodontic theory and founder members of the BSSO, Chapman and practice were still being taught as integrated Friel serving as president. aspects of general dentistry. Angle’s teaching was predicated upon the Nevertheless, from 1903 onwards, the staff assumption that orthodontics should be a lists of the Manchester Dental Hospital contained specialty wholly independent of general the names of a number of orthodontic dentistry. Part of the rationale for a specialist demonstrators or tutors. In 1909, mention is made service, as he articulated it, was that the aim of for the first time of the existence of a separate treatment had become more ambitious. Its goal Orthodontic Department. In the same year, was now the establishment of “normal George G Campion was appointed as lecturer in occlusion”. The objective was to place all the teeth orthodontics to the Victoria University, in their correct relation, not only to their Manchester. By 1905 a “Regulation Room” had immediate neighbors, but also to their been established in the Royal Dental Hospital, antagonists in the opposite jaw, and in a staffed by the “Regulation Room House harmonious relation to the whole face. There was Surgeon”. By the beginning of the next decade, intense debate among orthodontists, in America a number of other hospitals had followed suit. and elsewhere, as to whether or not this ideal However, no formal postgraduate courses in could be achieved in all patients and, if so, how. orthodontics existed and many British dentists But the fact that this debate took place interested in the subject went to the United States demonstrates the rising technical and aesthetic for advanced training. For example, in the first aspiration of practitioners of orthodontics. decade of the twentieth century, Harold Angle’s bold assertion that orthodontics Chapman, Hubert Visick, AC Lockett, David Fyfe should be divorced from dentistry met with little and Ernest Sheldon Friel, all attended the school support in Britain. An editorial in the British run by the pre-eminent American orthodontist, Dental Journal of 1902 stated: Edward Angle, originally in St Louis. By this “Where the specialization of specialities may time, there were several full-time orthodontists lead can hardly be foreseen, and we even await in North America, most notably Angle himself, the prophesed eminent rhinologist devoted to the who had entered dedicated practice in 1892, but, left nostril. That dental speciality admits of much as yet, none at all in Britain. A pupil of Angle, division of labor without detriment is Friel, in Dublin, set up the first such practice in unquestionable, but the swing of the pendulum the British Isles in 1909. may well be too far. It appears that the Orthodontics appears to have caught the orthodontist has already arrived in America, and dental imagination in the early years of the there is a Society.” twentieth century. It is revealing, for instance, In North America, however, the trend to that the American, the British, the German, and separate orthodontics from general practice was the European orthodontic societies were all gathering pace. founded within ten years of each other. Some THE BRITISH SOCIETY FOR THE STUDY OF authorities, notably the leading historian of ORTHODONTICS orthodontics BW Weinberger, have attributed this widespread surge of interest to the impact It was from within this context of growing of Angle’s writings. There is certainly no doubt professional status and confidence, coupled with that, when compared to the situation in Britain, considerably improved technical capability, that 38 History of Orthodontics the British Society for the Study of Orthodontics similar appointment at the London Hospital sprung up. Practitioners in Britain were aware Dental School, in the founding of which he had of the increasing presence of orthodontic been closely involved. Sim Wallace, the author specialists in North America, but did not seek of the influential text Essay on the irregularities immediately to emulate them in their advocacy of the teeth (1904), was on the staff of several of a separate specialty. There was, in any case, London hospitals over the course of his career, as an editorial in the dental journal Items of while Hopson eventually became head of the Interest noted, a difference in the interpretation Dental School at Guy’s Hospital. of the word “specialist”, between England and The social and professional background of the the USA. In England, a “specialist” was often a early leaders of the BSSO is very revealing as to general practitioner having an interest and the character of the society and its aims. As Weisz expertise in a particular aspect of dentistry, has pointed out, in Britain, unlike North America whereas, in the USA, the term was used to or the rest of Europe, specialist expertise came designate someone who exclusively practiced in to be identified as the unique possession of senior that field. The English interpretation of hospital staff. It was to hospital consultants, and specialization would certainly be formative, as only hospital consultants, that general we shall see, of the first British specialist society. practitioners referred patients in need of an The driving force behind the creation of the expert opinion. What was odd and distinctively BSSO was, without doubt, George Northcroft, British about this arrangement, was that the who was a successful London dental practitioner. hospital consultants espoused an ideology of On 15 October 1907, Northcroft wrote to a gentlemanly holism and regarded themselves as number of his fellow practitioners inviting them medical generalists, albeit often with some to attend a preliminary meeting to discuss the degree of specific focus in their clinical interests. foundation of a society, the object of which would Thus, even the major beneficiaries of the process be the promotion of the study of orthodontia. of specialization within British medicine did not This meeting was held on 21 October 1907, in present themselves as specialists per se. Such was his rooms at 115 Harley Street, London. Eleven the authority and prestige of the hospital practitioners attended, in addition to North croft. consultant, especially those in the London Nine of those practiced in the West End of teaching hospitals that this model came to be the London, the other two being based in Wimbledon definitive one for specialization in Britain. As we and Eastbourne, respectively. At least seven had shall see, this pattern of specialist interest within hospital appointments. The founders of the BSSO an ostensibly generalist framework can be readily were evidently drawn from the upper strata, in identified within the agenda of the BSSO. terms of their institutional, educational and social In his address to the inaugural meeting, status, of the British dental profession. They were Badcock, as president-elected, pointed out “there the heirs of the group of practitioners who had was now sufficient demand for a society, “where campaigned to raise the professional standing of members could consult and advise each other dentistry in the second half of the nineteenth upon the problems of the already large but century. It was agreed to proceed with the plan increasingly important branch of dental surgery, of setting up a society. orthodontia”. He felt, “the proposed name for An inaugural meeting was held, by general the society should indicate that it was not the invitation, in the room of the Medical Society of intention to create a group of specialists, London, on 5 December 1907, which thirty-five practising orthodontia, but to provide an people attended. Badcock was elected president, opportunity when everybody who was with Northcroft, James Sim Wallace, and interested in both theory and practice could meet Montagu Hopson being vice presidents. All four for mutual benefit”. senior office-bearers held or had recently held, The rules of the new society were closely posts in one or other of the London hospitals. modeled upon those of the existing Odontol- As already noted, Badcock had been, until ogical Section of the Royal Society of Medicine, 1905, dental surgeon and lecturer in dental which were intended to ensure that the surgery at Guy’s Hospital. Northcroft held a organization was non-political and disengaged History of Orthodontics in Great Britain 39 from controversy. One feature of the rule book, quotation from Badcock indicates, that the very revealing of the society’s self-image, was founding figures of the BSSO evidently believed that members were to be prohibited from holding that development of the scientific and academic any commercial patents relating to dentistry. content of the subject would assist orthodontics There was also an injunction against secret in achieving a much more prominent place remedies, which were regarded as the staple of within dentistry as a whole. the “quack” specialist. One speaker at the Badcock acknowledged that anxieties had inaugural meeting thought that the prohibition been expressed that the creation of a new society, against patents would have an inhibiting effect devoted solely to one particular branch of upon the future development of dental dentistry, could be divisive within the dental technology. Nevertheless, the gentlemanly ethos profession. But he regarded this apprehension of the upper strata of London medicine, with its as being groundless. He was not, however, in pronounced antipathy to trade, prevailed and the principle against specialization in the North rule was confirmed. This was again in marked American sense. He foresaw that eventually, at contrast to American practice, where several least in the larger centers of population, only full- orthodontists had taken out patents on technical time specialists might provide an orthodontic innovations. service. In his judgment, this development would The first full meeting of the BSSO took place be beneficial. Interestingly, Badcock compared in January 1908. As president, Badcock presented the advantages to be gained from orthodontic the first official paper. He chose, as his topic, the specialization to those that would accrue from objectives of the new society and his views are the administration of anesthetics by specialist very indicative of the state of orthodontics in anesthetists, as against administration by general Britain at this time. practitioners with an interest in anesthesia, This is a very broad and inclusive remit for a which, he stated, was the usual practice at the special interest in dental or medical society, and time. In other words, Badcock was prepared, at is quite different in character from the nearest least partially, to repudiate the view, widespread North American equivalent. It is clear that, in still among medical practitioners in Britain, that offering membership to all with an interest in full-time specialization was necessarily to be orthodontics, regardless of occupational status, deplored. the BSSO did not constitute itself, at least As mentioned earlier, in the first decades of primarily, as an organization to advance the the twentieth century, North American orthod- professional interests of orthodontists. Rather ontics was riven by acrimonious controversy, than, the society defined its mission as the more relating to both the cause and the treatment of disinterested one of encouraging the malocclusion. The society’s founders were very advancement of knowledge in the field. Again anxious that these divisions should not be there are resonances here with the constitution replicated within the BSSO. With characteristic of the RSM. As Innes Williams has recently moderation, Badcock emphasized the Council’s argued, while the RSM represented the desire to include representatives from all schools acceptance of a degree of specialization within of thought. Another of the early presidents, Harry British medicine, in presenting itself as a purely Baldwin, described the society as a “model of learned society, it effectively recognized seductive humility” and was evidently proud specialties as categories of knowledge rather than that the society enjoyed a harmonious divisions of practice. While the BSSO sought to relationship with the generalist British Dental encourage the improvement of corrective Association. technique as well as the scientific understanding Some of the controversy which disturbed of normal and irregular dentition, the similarity North American orthodontics centered on of its aims with those of the RSM is noteworthy. Angle’s rigid insistence that it was bad practice To some extent, as Innes Williams notes, this to extract healthy teeth to facilitate tooth emphasis was chosen to avoid engagement in realignment. This tenet became the governing issues relating to competition in the medical principle of those full-time American marketplace. Nevertheless, it is also true, as the orthodontists who practised the Angle method. 40 History of Orthodontics

Badcock argued, however, that many potential had links with the London teaching hospitals orthodontic patients could not afford either the and/or with socially exclusive private practice, money or time for prolonged and sophisticated of the Harley Street variety. While not necessarily treatment, and for those patients extraction was or wholly antipathetic to specialist practice, most a necessary part of successful management. This of the leading members identified themselves, was, effectively, a recognition of the differences as we shall see, as generalists with a special between the British and American circumstances interest in orthodontics, rather than as specialist of orthodontic practice. Several of Badcock’s practitioners, per se. The BSSO was, in other audience would have held appointments in words, a distinctively British specialist body. voluntary hospitals where they would provide The BSSO met seven or eight times a year. economical treatment for charitable patients. Each meeting usually consisted of the Moreover, British orthodontists knew that if they presentation of a long paper and several short wished to expand the range of patients that they papers or demonstrations. Sometimes, papers treated, it was necessary to make available a shared a related theme. Approximately twenty simplified form of treatment. papers or demonstrations were subsequently On the other hand, Badcock also deplored published in the Society’s annual Transactions. those orthodontists who viewed treatment Every year its president addressed the Society, purely in empirical, mechanical terms. In his and these addresses, also published in the view, the realignment of the teeth could be Transactions, provide a valuable record of the successful, in the long-term, only if it was based opinions of the leading figures in British upon sound biological principles. He admitted orthodontics, from 1907 onwards. that the profession was still woefully ignorant It is evident from the Transactions that not in the fields of etiology, pathology and all the members of the Society were content with prophylaxis. Again the stated purpose of the the first president’s relatively relaxed attitude to Society was to be a disinterested forum, a vehicle the prospect of full-time practice. In 1910, Sim for the advancement, not merely of technique, Wallace was elected president. His presidential but of science. address reaffirmed his commitment to Badcock concluded by outlining the Council’s generalism, in terms with which many of his plans for furthering the aims of the Society. colleagues in metropolitan medicine and Future meetings would consist of the reading and dentistry would have been very familiar. The discussion of papers, casual communications and danger of specialization was, he argued, that it clinical evenings of a practical nature. A library confined its practitioners to a narrow route, and museum would be created; investigation distorting the sense of proportion and limiting committees, comprising small groups of the large and liberal outlook, which should be members, would be setup to look at selected characteristic of a learned profession. Such topics. He mentioned normal arch determin- restriction of vision was stigmatized as the curse ation, classification and orthodontic terminology of specialism. Sim Wallace emphasized that the as possible topics for the attention of these BSSO had been setup to serve the high ideal of investigating committees. the study of orthodontics and not merely to Thus, we can discern, in its first presidential improve its practice or even its teaching. The address, some of the distinctive characteristics implication was clear; full-time specialization, by of the British Society for the Study of depriving those interested in orthodontics of a Orthodontics. Its constitution emulated the broad intellectual outlook, would hinder rather gentlemanly ethos of London patrician medicine, than advance the development of their subject. with its disdain for trade and its antipathy But those presidents who concerned towards factional enthusiasm. It saw the future themselves with the quality of the British progress of orthodontics as being best achieved teaching of orthodontics frequently tended to a through the liberal ideals of the advancement of different view. This was particularly true of those knowledge and the improvement of education, who contrasted the situation in Britain with that rather than by the pursuit of specialization and in North America, to whose specialist professional organization. Many of its founders institutions, as we have seen many British History of Orthodontics in Great Britain 41 prospective practitioners travelled to receive opportunities for postgraduate training. The postgraduate training. For instance, in 1915, establishment of a dedicated clinical center in Frank Bouquet Bull, a leading member of the London would meet both needs. Samuel Society and a future president, firmly expressed proposed the Forsyth Institute in Boston as a his low opinion of the quality of the teaching of model for orthodontic education in Britain. orthodontics in Britain. He attributed this Bull’s and Samuel’s papers were both deficiency to the fact that both lectures and delivered in the second year of the First World clinical instruction in orthodontics were War. The war imposed a hiatus on British combined with dental surgery. With very few dentistry as a whole and upon the activities and exceptions, the actual teaching was still carried development of the BSSO in particular. Many out by generalists rather than specialist dentists were heavily involved in the war effort, orthodontists. Bull pointed out that the dealing with maxillofacial injuries. Orthodontic prolonged nature of orthodontic treatment made work was substantially curtailed. Even after it difficult to incorporate within the standard peace returned, orthodontic treatment remained curricula of general dentistry. Most dental available to only a very small section of the students undertook just over two years of clinical population. The vast majority of the work was instruction but this was rarely long enough to still carried out by dentists who also practised follow a single orthodontic case to conclusion. other branches of dental surgery. Even the Bull also believed that, until students had gained teachers in the orthodontic departments of the some basic knowledge of orthodontics, they dental schools were not necessarily orthodontic could not fully appreciate its value. Thus many specialists in the North American sense, although would-be practitioners, who might otherwise they would certainly have had considerable have been attracted to orthodontics, chose to expertise in the subject. However, the British remain with restorative dentistry. Islands had, as we have already noted, begun to Bull recommended that orthodontic acquire their first full-time orthodontists. The instruction should be separated from that of case for and against specialization would general dental surgery, and that it should be continue to be discussed at the meetings of the postponed until the second year of clinical Society for many years to come. But when JL studies. By this stage students would be better Payne gave his presidential address in 1921, he prepared to benefit from the teaching. In the seems to have considered that the principle of second year, a period of three months should be specialization had become accepted. S Spokes, set aside exclusively for orthodontics. Bull president in the following year, judged that the applauded the fact that the London Dental development of orthodontics as a specialty had Hospital and the Birmingham Dental School had not been detrimental to the general dental already implemented such a system. He practitioner but had benefited the profession as suggested that independent Orthodontic a whole. Departments be created, each to be under the Throughout the 1920s and 1930s, the technical direction of someone with a particular interest repertoire of the orthodontist continued to in orthodontics, preferably assisted by a improve and expand. A notable advance was the demonstrator and a specialist orthodontic house introduction of stainless steel, which was surgeon. This, he believed, would enable both employed in the construction of bands, arches patient management to be more effective, and and springs. Stainless steel was much cheaper the standard of teaching to be improved. and more clinically effective than the previous Bull was not the only eminent British metal of choice, gold. However, considerably orthodontist concerned about these matters. In more skill was required to work the new 1916, Bertram B Samuel gave a short paper material, stainless steel being difficult to weld. entitled ‘Suggestions for the formation of a Friel was a major pioneer for the introduction of London orthodontic center’. As he saw it, stainless steel, and several other British orthodontics in England had two serious orthodontists contributed to the realization of its deficiencies, the dearth of treatment facilities for clinical potential. A further important innovation less well-off children and the absence of was the adoption, with modifications, by British 42 History of Orthodontics orthodontists of Angle’s pin and tube method of in Britain. The principle of a state-funded health effecting tooth movement. This new procedure, care system seems to have been enthusiastically together with other similar techniques, again endorsed by the leadership of the BSSO. In 1942, enhanced clinical effectiveness, while the Society set up a committee to examine the demanding great precision in its construction implications of the Beveridge Report for and manipulation. orthodontics. Faced with the prospect of a need- In 1921, unregistered dental practice was driven health service, free at the point of delivery finally made illegal in Britain. There was, and presumably including orthodontics in its however, a considerable shortage of dentists, and comprehensive provision, the committee therefore little economic incentive for the considered what sort of orthodontic care could ordinary dentist to diversify his practice. From be delivered to the general population, and by the 1920s onwards, for a variety of reasons like whom. In 1945, giving the first presidential awareness of lack of knowledge and equipment, address for six years, tellingly titled ‘Our legal considerations, ready availability of other opportunity’, Norman Gray welcomed the remunerative work, many general practitioners forthcoming peacetime expansion of health care were unwilling to undertake orthodontic work. as providing the prospect of raising the standards And those who did perform such work tended of British orthodontics and increasing the to employ the cheaper and easier techniques. numbers of its practitioners. Noting that his They were inclined, for instance, to favor predecessors had expressed differing opinions removable appliances rather than the fixed ones, on the subject, Gray affirmed his belief that the which were generally more precise and powerful time for specialization had finally arrived. He but required more skill to fit and took up more envisaged that the demand for orthodontic chair time. Thus, the gap between the standards treatment would greatly increase once the of orthodontic work carried out by the general financial obstacles that had excluded poorer practitioner and that undertaken by the full-time children, were substantially removed. The specialist, or taught within the orthodontic challenge was to train sufficient numbers of departments of the dental hospitals, continued specialists to meet the orthodontic needs of the to widen. British orthodontists, meanwhile, population. looked across the Atlantic and saw that, if the In the same year, Friel also urged his fellow standard of the teaching of orthodontics in orthodontists to embrace the ideal of full-time Britain was to match its American counterpart, specialization as the only way, as he saw it, to then more specialized facilities and specialist raise British orthodontic standards to the level teachers were required. Between the wars, calls that had been achieved in the United States. Friel for the setting up of a dedicated postgraduate deprecated the fact that much treatment in center for orthodontics in London were regularly Britain was still undertaken by, as he put it, repeated. It was even suggested that it could be “skilled amateurs”. He argued that attempts to run under the auspices of the BSSO. expand the provision of treatment without the Nothing came of these plans. However, in introduction of adequate postgraduate education 1931, the Eastman Dental Clinic opened in would simply prolong this unwelcome London. This included a separate orthodontic circumstance. His choice of terms is an indication department, which provided both affordable of how far the discourse surrounding treatment and postgraduate orthodontic training. specialization in British dentistry had changed. After the Second World War, the Eastman was Whereas previously the integration of incorporated into the British Postgraduate orthodontics within the general practice of Medical Federation. Under the leadership of dentistry had been praised as conducive to a Clifford Ballard, its orthodontic department “sense of proportion” and a “large and liberal came to play a very important role in the further outlook”, it was now stigmatized as development of the subject in Britain. “amateurism”. The “curse of specialism” had The establishment of the National Health evidently been lifted. Service in 1948 created the conditions for a great The administrative structure that was chosen expansion in the provision of orthodontic care for the NHS imposed a rigid division between History of Orthodontics in Great Britain 43 hospital doctors and community-based general Society’s constitution was interpreted, by practitioners, an arrangement which was very successive meetings of its Council, as precluding conducive to the establishment of specialties. its involvement in any discussion or consultation Gradually, many more consultants were remotely political, even when orthodontic service recruited in virtually every branch of medicine provision was involved. In 1919, the Parliam- and dentistry, including orthodontics. At the same entary Health Committee invited the BSSO to time, the universities became more involved in send a report on its activities. The Secretary was orthodontic education. The first reader in instructed to decline, and reply that their orthodontics, Corisande Smyth, was appointed in activities did not extend to political affairs. When, 1951 at the Royal Dental Hospital School and the in 1920, the Federation of Medical and Allied first professor, Clifford Ballard, at the Institute of Societies invited the BSSO to affiliate, the Dental Surgery, University of London, in 1956. Secretary replied that it was not empowered by Other educational innovations were made. In its bye-laws to join. 1949, the Faculty of Physicians and Surgeons of This fastidiousness also prevented the society Glasgow awarded their first Diploma of Dental from exercising its full influence during the Orthopedics. The Royal College of Surgeons of planning and implementation of the NHS. It was England followed suit in 1954. initially reluctant, for instance, to become By the mid-1950s, it was apparent, however, involved in the consideration of specialist titles that the impact of the setting up the NHS on the within the service. The BSSO also declined to give process of specialization in orthodontics had any advice to the British Dental Association been, to an extent, paradoxical. Many more regarding charges for orthodontic appliances. In specialists were being trained but, owing to 1962, the Society was invited to submit evidence demand for treatment vastly outstripping to the Standing Dental Advisory Committee, on supply, more orthodontic work was being hospital dental services. It again refused, undertaken by general practitioners, often using expressing a wish not to become involved in limited means of treatment and under great time administrative problems. This decision was pressure. The membership of the BSSO eventually reversed, under pressure from the continued to include a substantial number of membership of the Society, but the damage had general practitioners, reflecting the dual avenues been done. Widespread dissatisfaction with the of service provision. aloofness of the BSSO from matters relating to The changes that the founding of the NHS professional interest, particularly among had set in train did not come fully into effect until members carrying out a significant amount of the 1960s, when substantial number of orthodontic treatment in practice as opposed to orthodontic specialists were appointed, either as the hospital service, led to the formation of the consultant in dental hospitals or with regional British Association of Orthodontists in 1965. The hospital boards. Oddly enough, however, this BSSO lost a number of members to the new body, expansion of the specialty was to prove fatal for whose membership was restricted to those who the BSSO. As noted above, its founders had were full-time, or nearly full-time orthodontic conceived the BSSO rather as a learned society practitioners. The British Association sought for the advancement of orthodontics than as a actively to articulate its members’ point of view professional body to speak for orthodontists. This in the political arena. Eventually, in 1994, the direction was taken partly to avoid the BSSO lost its separate identity, merging with a factionalism that had marked orthodontic number of other orthodontic groups to form the societies in North America. However, the British Orthodontic Society. HHiiissstttooorrryyy oofff OOrrrttthhhooodddooonnntttiiicccsss iiinnn 6 GGrrreeeeeeccceee aanannddd RRooommmeee

Middle Ages (Fifth to Fifteenth – Etienne Bourdet – Joachim Lefoulon Centuries) to the Eighteenth – John Hunter – Christophe-François Delabarre Century European Pioneers of the Early – JM Alexis Schange – Matthaeus Gottfried Nineteenth Century – Friedrich Christoph Kneisel Purmann – Joseph Fox – John Tomes

The earliest description of irregularities of the teeth of practicing dentistry exclusively was made by was given about 400 BC, by Hippocrates (ca 460– Pierre Dionis (1658–1718). He called dentists 377 BC). The first treatment of an irregular tooth “operators for the teeth” and stated that they could was recorded by Celsus (25 BC–AD 50), a Roman also open or widen the teeth when they are set too writer, who said, “If a second tooth should happen close together. to grow in children before the first has fallen out, Matthaeus Gottfried Purmann (1692) was the that which ought to be shed is to be drawn out first to report taking wax impressions. In 1756, and the new one daily pushed toward its place by Phillip Pfaff used plaster of Paris impressions. means of the finger until it arrives at its just Malocclusions were called “irregularities” of the proportion”. That might still be good advice, but teeth, and their correction was termed children today do not need ancient history to tell “regulating”. It remained for the enlightenment them how to goad a high canine into place. to reawaken the spirit of scientific thought Probably the first mechanical treatment was necessary to advance dentistry and other advocated by Pliny the Elder (AD 23–79), who disciplines. suggested filing elongated teeth to bring them into Beginning in the 18th century, the leading proper alignment. This method remained in country in the field of dentistry was France. This practice until the 1800s. was due, in large measure, to the efforts of one man: Pierre Fauchard (1678–1761 ) has been called MIDDLE AGES (FIFTH TO FIFTEENTH the “Father of Orthodontia”. He was the first to CENTURIES) TO THE EIGHTEENTH remove dentistry from the bonds of empiricism CENTURY and put it on a scientific foundation. In 1728, he Progress during the Middle Ages was nil. published the first general work on dentistry, a Dentistry entered a period of marked decline, as two volume opus entitled The Surgeon Dentist: A did all sciences. After the 16th century, Treatise on the Teeth. considerable progress was made, although little Fauchard described, but probably was not the was written of orthodontics during this period. first to use, the bandeau, and an expansion arch In France, students of dentistry were admitted consisting of a horseshoe-shaped strip of precious to a University, as early as 1580. The first mention metal to which the teeth were ligated. This became History of Orthodontics in Greece and Rome 45

anatomy of the teeth and jaws. His text, The Natural History of the Human Teeth (1771), presented the first clear statement of orthopedic principles. He was the first to describe normal occlusion, to attempt to classify the teeth. He established the difference between teeth and bone and gave the teeth names like cuspidati and bicuspidati. He was the first to describe the growth of the jaws, not as a hypothesis, but as a sound scientific investigation. His findings have never been successfully challenged. EUROPEAN PIONEERS OF THE EARLY NINETEENTH CENTURY Joseph Fox (1776–1816) Joseph Fox (1776–1816), a student of Hunter, was another Englishman who made notable contributions to the budding science of orthodontics. He devoted four chapters of his book, the “Natural History and Diseases of the Human Teeth” (1814), to that topic. The first to classify malocclusion (1803), he was also one of Fig. 6.1: John Hunter the first to observe that the mandible grows mainly by distal extension beyond the molars, with little or no increase in the anterior region. the basis for Angle’s E-arch, and even today its According to Weinberger, Fox was the first to principles are used in unraveling a crowded give explicit directions for correcting the dentition. He also “repositioned” teeth with a irregularities of teeth. He was particularly forceps, called “pelican” because of its interested in the judicious removal of deciduous resemblance to the beak of that bird, and ligated teeth, treatment timing, and the use of bite blocks the tooth to its neighbors until healing took place. to open the bite. His other appliances included an At that time, little attention was paid to anything expansion arch and a chin cup (about 1802). other than the alignment of teeth and then almost exclusively to the maxilla. Joachim Lefoulon

Etienne Bourdet (1722–1789) Joachim Lefoulon, a Frenchman, is probably best known for having given the science a name: Fauchard’s bandeau was refined by Etienne orthodontosie (1841), which roughly translates Bourdet (1722–1789), dentist to the king of France. into orthodontia. He was also the first to combine His was the first record of recommending serial a labial arch with a lingual arch. In the area of extraction (1757) and of extracting premolars to etiology, he arrived at factors of an entirely relieve crowding. He was also the first to practice different character from those of most authorities. “lingual orthodontics”, expanding the arch from These were based on biologic phenomena the lingual. There followed a long line of lingual controlling the growth, form, and dimension of appliances, including the jackscrew, the organs and tissues. expansion plate, and, closer to our time, the lingual arch. Christophe-François Delabarre (1787–1862) John Hunter (1728–1793) Christophe-Fraçnois Delabarre (1787–1862; Although he was not a dentist, John Hunter (Fig. French) introduced the crib and the principle of 6.1) (1728–1793) made the greatest advances in the lever and the screw (1815). He separated dentistry of his time. An English anatomist and crowded teeth by means of swelling threads or surgeon, Hunter took a particular interest in the wooden wedges placed between them. 46 History of Orthodontics

JM Alexis Schange Prussia. He was the first to use plaster models to JM Alexis Schange (1807, French) in 1841 record malocclusion (1836). That same year, when published the first work confined to orthodontics. he fitted his prognathic patient with a chin strap, He introduced a modification of the screw, the he became the first to use a removable appliance. clamp band, and, in 1842, three years after the Kneisel wrote the first French and German treatises vulcanization process had been developed, devoted exclusively to orthodontics. He and John rubber bands (actually, sections of rubber Tomes (1812–1895, English) used various tubing). He also coined the term anchorage. removable appliances to treat regularities of this. Friedrich Christoph Kneisel (1797–1847) and Tomes was also first to demonstrate bone John Tomes (1812–1895) resorption and apposition. Friedrich Christoph Kneisel (1797–1847, German), was the dentist to Prince Charles of History of Dental Lasers and their Applications in Orthodontics 47

HHiiissstttooorrryyy oofff DDeeennntttaaalll LLLaaassseeerrrsss aanannddd ttthhheeeiiirrr AAppppppllliiicccaaatttiiiooonnnsss 7 iiinnn OOrrrttthhhooodddooonnntttiiicccsss

All Laser Devices have Focused versus Defocused Laser use in Dentistry Following Components Beam Laser Classification – Laser Medium Types of Laser Applications of Lasers in – Optical Cavity or Laser Tube Lasers and Their Dental Orthodontics – Clinicians can Control Applications Several Variables of Laser Laser Safety Exposure Current Clinical use of Dental Precautionary Measures Lasers Properties of Laser Beam

Light amplification by the stimulated emission of exactly to the absorption energy. This result in two radiation. In 1956, American Physicist Townes photons of light emitted with the same wavelength, first amplified microwave frequencies by the with temporal and spatial coordination. stimulated emission process and Maser Using Einstein theory laser is produced. (Microwave Amplification by Stimulated Emission of Radiation) came into the use. In 1959, Schawlow ALL LASER DEVICES HAVE FOLLOWING and Townes discussed extending the Maser COMPONENTS principle to the optical portion of the Laser Medium electromagnetic field, laser. In 1960, Theodore Maiman, Scientist with the This can be solid, liquid or gas. This determines Hughes Aircraft Corporation developed first the wavelength of emitted light from the laser. working laser device, that emitted a deep red Optical Cavity or Laser Tube colored beam from a ruby crystal. In 1964, Patel developed CO2 laser. In 1964, Geusic developed Having two mirrors, one fully reflective and other Nd: YAG Laser. partially transmissive which are located at either Einstein, early in the 20th century described end of the optical cavity. three possible mechanisms involving proton An external mechanical, chemical or optical radiation. Absorption occurs when an atom in a power source which excites the atoms in the laser lower energy level is raised to a higher energy medium to higher energy levels. Atoms in excited level by absorbing a photon of energy. state spontaneously emit photons of light which Spontaneous emission is the process in which an bounce back and forth between the two mirrors in atom in a higher level decays to a staler lower the laser tube striking other atoms and causing energy level, releasing a photon. more stimulated emissions. Photons of energy of Stimulated emission occurs when an atom the same wavelength and frequency escape already in the excited state decays to a stale state, through the transmissive mirrors and form a laser after interaction with a photon corresponding beam. 48 History of Orthodontics

Clinicians can Control Several Variables of effectively after reflection, there is little danger of Laser Exposure damage to other parts of the mouth. It limits the amount of energy that enters the tissues. Wavelength Determines the quality or type of reaction Scattering between laser and tissue When beam is scattered within the tissue. When It is determined by composition and structure light energy bounces from molecule to molecule of active medium within the tissue. High absorption minimizes It in turn, predominantly influences whether scattering. Scattering distributes the energy over absorption occurs. a large volume of tissue, dissipating the thermal effects. Power Instant measure of energy output. Transmission Optical properties of the tissue including its Light energy can also travel beyond a given tissue water content. boundary. This is called transmission. Wave from described the manner in which Transmission irradiates surrounding tissue and laser power is delivered over time. It can be: must be quantified. – Continuous: They deliver the power output at a constant level over a prolonged period Absorption of time, generally any time span exceeding 1 sec, e.g. CO2 laser. Refers to how far beam is absorbed within the – Chopped/gated beam: It is similar to tissue or whether it is absorbed at all. continuous one except beam is alternatively released and interrupted by FOCUSED VERSUS DEFOCUSED BEAM a shutter mechanism; this chopping can Laser beam can be focused through a lens to be either a single chop or series of timed achieve a converging beam, which increases in chops. intensity to form a focal spot, the most intense Pulsed lasers: In this, energy is emitted in part of the beam. This focused beam cuts the tissue. short bursts according to a set repetitive series In defocused beam, intensity is less, beam of pulses. Between the pulses no laser energy diverges and power decreases. So a larger is emitted. circumferential area of the beam hits the tissue Because the amount of heat generated during surface causing ablation of the tissue. The laser the procedure translates directly into the tip cuts soft tissue through ‘ablation’ of tissue. This amount of collateral damage and thus means that the cellular temperature is raised postoperative discomfort – it is generally rapidly through the absorption of laser energy by recommended that the laser be used at a low the melanin in the cells and the cells virtually setting and in pulsed mode for soft tissue explode. This characteristic is useful in both procedures. cutting and contouring gingival tissues. PROPERTIES OF LASER BEAM The principal effect of laser energy is photo- thermal: This thermal effect of laser energy on Coherent: All the photon of light are in spatial tissue depends on degree of temperature rise and and temporal coherence. corresponding reaction of interstitial and Mono Chromaticity: Of one particular wavelength. intracellular water as the laser energy is absorbed, Collimation: No divergence of the beam heating occurs. Laser beam interaction with tissue: Laser beam Hyperthermia occurs when tissue is and tissue interact in four ways: elevated above normal temperature but is not destroyed at temperature of approximately Reflection 60oC. Proteins begin to denature without any A reflected light bounces off the tissue surface and vaporization of the underlying tissue. is directed toward as energy dissipates so Coagulation refers to the irreversible damage History of Dental Lasers and their Applications in Orthodontics 49 to tissue, congealing liquid into a soft semi 98% of the energy is converted to heat and solid mass. Soft tissue edges can be ‘welded’ absorbed at the tissue surface with very little together with a uniform heating to 70–80oC scatter or penetration (0.2 to 0.3 mm). where there is adherence of the layers because CO2 lasers reflect off mirrors, allowing access of stickiness due to collagen molecule. to difficult areas. Unfortunately, they reflect When the target tissue containing water is off dental instruments making accidental elevated to temperature of 100oC, vaporization of reflection to non target tissue causing concern. water occurs, process is called ablation. If the tissue CO2 laser is absorbed by optical fibers and lack o temperature is raised to about 200 C, it is of fiber optic delivery system make CO2 laser dehydrated and then burned in presence of air difficult for allows the beam to be delivered with carbon as end product. If laser energy through a flexible tube giving access to all areas continues to be applied, the surface carbonized of oral cavity. layer absorbs the incident beam, becomes a heat CO2 laser works in no contact mode with the sink and preventing normal tissue ablation. The tissue and no tactile feedback occurs. heat conduction causes a collateral thermal Depth of laser incision is proportional to the trauma to a wide area. power and duration of exposure. Laser soft tissue surgery is performed with power 5–15 TYPES OF LASER watts in either pulsed for continuous mode. It is the fastest laser in removing tissue for oral Soft Lasers use. They provide (a thermal) low energy at wavelengths believed to stimulate circulation and Nd:YAG Laser cellular activity. Used to promote healing and reduce inflammation, edema and pain, e.g. diode Developed by Geusic in 1964. Refers to laser. neodymium: yttrium-aluminium-garnet, a crystal of yttrium-aluminum-garnet doped with Hard Lasers neodymium. Lasers are in infrared range, 1.06 microns wavelength and cannot be seen. These Have been used for surgical applications, e.g., CO2 lasers use a red helium-neon laser for aiming. laser.Lasers are named according to the laser It is not well-absorbed by water but is partially medium employed: absorbed by hemoglobin and melanin. It has Solid state—e.g. ruby laser, neodymium laser an affinity for pigmented tissues. Gas state—e.g. argon laser, CO2 laser ND: YAG laser light transmits through water Semiconductor state—e.g. diode laser and penetrates wet tissue more deeply than CO2 laser. Heat build-up, scatter and depth of CO2 Laser tissue penetration by the beam remain major considerations. CO2 laser were first developed by Patel in 1964. Have a wavelength of 10.6 microns. They can be delivered by fiber optic technology. Since the beams of this laser fall into the far Their access into the mouth is unlimited. infrared range on the spectrum, they are not Laser work in either contact or noncontact visible. These lasers often use a quartz-fiber mode when working on tissue contact mode incorporating a 630 nm (Red) coaxial helium- is recommended by using pulsed rate, a coated neon laser into the device to act as an aiming sapphire tip or combination of water and air beam and thus facilitate use. cooling in contact mode, penetration depth can It received safety clearance by the U.S. Food be reduced to a point equal to CO2 . and drug administration for use in soft tissue Contact tip provide surgeon a tactile feedback. surgery in 1976. For dental use, it can deliver power up to three watts in either pulsed or nonpulsed mode. CO2 lasers have an affinity for wet tissues regardless of tissue color. Tissue pigment does Erbium– YAG Laser not affect the performance of CO2 laser. CO2 laser wavelength is readily absorbed by In 1997, FDA saftey clearance for use on hard water as soft tissue is 75%–90% water, about tissues such as enamel, cementum and bone. 50 History of Orthodontics

It consists of two wavelengths: using some combination of aluminum, indium, Erbium: yttrium-aluminum-garnet laser at gallium and arsenic. 2940 nm wavelength. Wavelength 812 nm for active medium- Erbium: chromium-yttrium-scandium- aluminum to 980 nm for active medium-indium, gallium-garnet at 2780 nm wavelength. placing them at the beginning of near infrared These lasers are delivered by a special optical portion of invisible nonionizing spectrum. fiber or hollow wave guide technology; operate The laser energy is absorbed by pigmentation in pulsed mode with an accompanying helium in the soft tissues and this makes the diode neon laser as an aiming beam, since laser an excellent haemostatic agent. wavelength is invisible. As it is used in contact mode, it provides tactile Wavelength 2940 nm, is ideal for absorption feedback during surgical procedure. by hydroxyapatite and water making it efficient It can be delivered through a flexible quartz in ablating enamel and dentin. fiber optic hand piece in continuous wave and It is essential to use a water spray to wet the gated pulses modes and is used in contact with surface during laser radiation to achieve soft tissues for surgery or out of contact for maximum efficiency of tissue removal with deeper coagulation. minimal heat generation. These lasers are poorly absorbed by tooth They have highest absorption in water and structure so that soft tissue surgery can be have shallow penetration into soft tissue of safely performed in close proximity to enamel, any wavelength. dentin and cementum. They can be used to cut soft tissue precisely It can often be used without anesthesia to due to high water content. perform very precise anterior soft tissue These lasers are well-absorbed by hard tissues; esthetic surgery or surgery in other areas of the surgeon must protect adjacent tooth the mouth without bleeding or discomfort. structures in the operative field. It is an excellent soft tissue surgical laser.

Argon Lasers LASERS AND THEIR DENTAL APPLICATIONS Argon laser light has 2 primary wavelengths, Carbon Dioxide Laser 488 and 514.5 nm. These manifest as blue and Clinical applications removal of soft tissue by green visible light. ablation. Recommended for gingivectomy, Argon is highly absorbed by hemoglobin, frenectomy and excision of soft tissue pathology strongly absorbed by melanin and poorly (both benign and malignant). Also used for laser absorbed by water. de-epithelization of flaps during and after surgery. It is absorbed well by oral soft tissue and Precautions avoid hard tissue contact by laser provides excellent hemostasis. emission, especially tooth structure. Use expanded May be well suited for selective destruction of margins when performing a laser excisional blood clots and hemangiomas with minimal biopsy to prevent fulguration of diagnostic areas. damage to adjacent tissues. Tissue penetration from laser irradiation will be It is not absorbed by hard tissue; no particular approximately 0.5 mm deep, depending on power care is needed to protect teeth during laser density; very little heat damage occurs below surgery. visual depth of wound. Travel fiber optically. Either an attenuated argon or helium neon red Neodymium:YAG Laser beam can serve as an aiming beam. Clinical applications: Removal of soft tissue by They have the ability to cure composite ablation. Recommended for gingivectomy, resins. frenectomy and excision of soft tissue pathology especially hemorrhage lesions. Also used for laser Diode Lasers subgingival curettage procedure. Diode is a solid active medium laser, Precautions: Avoid hard tissue contact by laser. manufactured from semiconductor crystals Same precautions as listed for CO2 laser. Tissue History of Dental Lasers and their Applications in Orthodontics 51 penetration from laser may cause thermal damage CURRENT CLINICAL USE OF DENTAL LASERS 2 to 4 mm below surface wound causing underlying hard tissue damage. Application CO2 Nd:YAG Ar Coagulation X X X Diode Laser Hemostasis X X X Frenectomy X X X Clinical applications: Removal of soft tissue by Gingivectomy X X X ablation. It is recommended for gingivectomy, Gingivoplasty X X X frenectomy and excision of soft tissue pathology, Vestibuloplasty X X X especially hemorrhagic lesions. Similar Incisional/excisional biopsy X X X applications as Nd:YAG laser. Used for laser- Implant recovery X X X assisted subgingival curettage and periodontal Removal of fibroma X X X pocket disinfection. Epulis X X X Precautions: Avoid contact with hard tissues. May Hyperplasia X X X Malignant lesions X X damage root cementum and bone during Oral lesion therapy X X X subgingival curettage. Tissue penetration is less Caries removal X X than comparable Nd:YAG effects, with potential Primary incisions X X for heat damage to underlying bone reduced. Gingival retraction X X X Aphthous ulcer/oral Erbium:TAG Laser lesion therapy X X X Root desensitization X X Clinical applications: Cavity preparation of Curing light-activated resins X incipient caries. Root preparation similar to acid Interproximal decay detection X etching following root planning. It has not been studied extensively for soft tissue applications. LASER USE IN DENTISTRY Precautions: Must use adequate water spray when cutting hard tissues with laser. Minimal heat Periodontics damage reported when used on dental hard tissue Initial (nonsurgical) pocket therapy at appropriate power densities. Nonosseous Gingival Surgery Potential Soft and Hard Tissue Applications Frenectomy of Laser in Dentistry Gingivectomy Soft tissue applications:Incise, excise, remove or Graft biopsy tumors and lesions such as fibromas, Periodontal Regeneration Surgery papillomas and epulides. Vaporize excess tissues, De-epithelization as in gingivoplastry, gingivectomy and maxillary Removal of granulomatous tissue or lingual frenectomy. Remove or reduce Osseous recon touring hyperplastic tissues. Remove and control hemorrhaging or vascular lesions such as Fixed Prosthetics/Cosmetics hemangiomas. Crown lengthening/soft tissue management Hard Tissue Applications around abutments Osseous crown lengthening Vaporize carious lesions. Troughing Desensitize exposed root surfaces. Formation of ovate pontic sites Endodontically: vaporize organic tissue, glaze Altered passive eruption management canal wall surfaces and fuse an apical plug Modification of sift tissue around laminates with the potential to resist fluid leakage. Bleaching Roughen tooth surfaces, in lieu of acid etching, in preparation for bonding procedures. Implantology Preventively, to treat enamel, arrest demineralization and promote remineralization. Second-stage recovery Debond ceramic orthodontic brackets. Peri-implantitis 52 History of Orthodontics

Removable Prosthetics Laser Safety Epulis fissurate 1. Precautions for patients and dental staff Denture stomatitis during laser procedures to protect non-target Residual ridge modification tissues particularly the eyes from stray beams. Tuberosity reduction 2. Reflective surfaces such as instruments, mirror Torus reduction and even polished restorations have potential Soft tissue modification to redirect laser energy. 3. Matte instruments and protective eye glasses Pediatrics/Orthodontics for patients and staff – Green safety glass– Nd: YAG laser Exposure of teeth – Amber colored glasses– Argon laser Soft tissue management of orthodontic patients – Clear glasses– CO2 laser. 4. Patients eyes should be covered with moist 2 x Oral Surgery/Oral Medicine/Oral Pathology 2 gauze pads. Biopsy 5. Non target oral tissues should be shielded with Operculectomy wet gauze, packs. Apicoectomy 6. Laser plume created when tissue vaporizes Oral soft tissue pathologies should be considered infectious. Use of an appropriate evacuation system to draw off and Operative Dentistry filter the plume is essential. 7. Extreme caution must be used when operating Deciduous teeth laser in vicinity of explosive gases such as Permanent teeth anesthetics. 8. Staff who will operate a laser or attend laser Advantages of Lasers in Soft Tissue Surgery procedures must be thoroughly trained to 1. Laser cut is more precise in tissue removal with respect this powerful tool and follow standard greater visibility since it seals off blood vessels protocol. and lymphatic leaving a clear, dry field. 9. At some operating powers of CO2 laser can cause 2. Laser sterilizes as it cuts to reduce the risk of damage to dental hard structures, clinicians blood borne transmission of disease. have emphasized need for an adequate shield 3. Minimal pain and swelling has been reported such as flat bladed instrument or silver foil after surgery. between gingival and teeth, so that beam will 4. Less postoperative infection has been reported, strike the instrument rather than the tooth. since the wound is sealed with a biological dressing. LASER CLASSIFICATION 5. There is less wound contraction during They are based chiefly on the potential of the healing and mucosal tissue does not scar. primary laser beam or reflected beam to cause 6. Less damage occurs to adjacent normal tissue. biologic damage to the eyes or skin. Higher the 7. Access is better to parts of oral cavity, classification number, greater the potential hazard. especially the mandibular, lingual, retromolar and parapharyngeal areas. Class I 8. Better patient acceptance, less operative time and fewer postoperative adverse squeal. Lasers working under normal operating 9. In treatment medically compromised patient conditions do not pose a health hazard. HIV +ve and mentally retarded patients. Devices are totally enclosed, beam does not 10. Lasers can be adjusted to cut, vaporize or exit housing, e.g. CD player. coagulate tissue, they offer greater versatility Class II than conventional instruments. 11. Pain is reduced to absent 90% of time due to Lasers emit only visible light with lower power the sealing of nerve fibers. output and do not normally pose a hazard History of Dental Lasers and their Applications in Orthodontics 53

because of normal human blinking and Frenectomy by Laser aversion reactions, e.g. supermarket bar code As permanent maxillary central incisors erupt in scanner. the oral cavity, the labial frenum shifts apically, in some instances frenum may persist even after Two Subclasses complete eruption of permanent maxillary central Class II A: Hazardous when directly viewed incisors termed as high labial frenum attachment. for longer than 1000 sec. Abnormal frenum attachment prevents Class II B: Has a dangerous viewing time of approximation of maxillary central incisors one-fourth of a sec., which is the length of time resulting in midline diastema. Frenectomy by laser of an ordinary blinking, reflected. (Fig. 7.2A) prevents recurrence and facilitates diastema closure. Patient acceptance with laser Class III a: Lasers application is very high even in condition like tongue tie, as it facilitates healing, reduces the Lasers can emit any wavelength and have discomfort and no sutures are required (Fig. 7.2B). output power less than 0.5W of visible light. It does not harm the unprotected eye. Reduction of Pain in Orthodontic Patient by These labels have a caution label on them. Application of Laser Class III b Procedures like separators placement and banding procedures are considered to be painful These lasers can produce a hazard to the in the whole course of orthodontic treatment. unprotected eye if viewed directly or viewed from reflective light for any duration. These lasers will not cause reflective hazards when using matted surfaces and do not normally produce fire hazards.

Class IV Hazardous for direct viewing and may produce hazardous diffuse reflections. Power output greater than 0.5W measured in continuous or pulsed emission. May ignite flammable objects and may create hazardous airborne contaminants. A Lasers used in dentistry: Class III b or class IV.

APPLICATIONS OF LASERS IN ORTHODONTICS Lasers have wide range of applications in dentistry. In this chapter only few important applications in orthodontics are discussed.

Exposure of Impacted Tooth by Laser Canine is the most commonly impacted tooth in the anterior segment of the dental arches due to arch length—tooth material discrepancy, this may B delay the progress of orthodontic treatment. Exposure of impacted tooth by laser facilitates Figs 7.1A and B: Exposure of impacted tooth by laser accessibility and decreases the risk of bond failure (A) Exposure of impacted canine with laser; (B) Exposed (Figs 7.1A and B). canine is bonded and ligated to the arch wire 54 History of Orthodontics

A(i) A(ii)

B(i) B(ii)

B(iii)

Figs 7.2A and B: (A) Frenectomy by laser (i) Abnormal frenum attachment prevents approximation of maxillary central incisors resulting in midline diastema. (ii) Frenectomy by laser followed by active fixed mechanotherapy; (B) Tongue tie excision by laser (i) Tongue tie (ii) Excised tongue tie with laser (iii) Nearly completion of healing

Studies proved that the application of laser in increases the efficiency of bonding especially in patient with separators reduces the level of pain uncooperative and very apprehensive patients. threshold. Laser Ablation of Surface Enamel for Application of Laser in Bonding Orthodontic Bracket Placement Orthodontic Bracket Laser ablation has been proposed as an alternative Nowadays laser is used in curing of orthodontic method to acid etching. Common problems during bracket in bonding procedure. Curing of orthodontic treatment after acid etching the enamel orthodontic bracket by laser takes approximately are demineralization and susceptibility to caries (3–5) seconds. It reduces the chair time and around brackets. Er:YAG laser ablation might History of Dental Lasers and their Applications in Orthodontics 55 overcome this drawback while offering other placement. In such cases either we have to wait benefits like reduction in clinical time, good until tooth erupts completely till the occlusal plane moisture control during bonding and bond or refer the patient to periodontist for removal of strength similar to that of acid etching. tissue to gain access for bracket placement. Either choice could add significant time to the overall Gaining Access for Bracket Placement on treatment. Partially Erupted Teeth Exposure of teeth by laser facilitates accessibility In certain cases, the orthodontic treatment is often and decreases the risk of bond failure. The patient prolonged due to incomplete or delayed eruption in the Figures 7.3A to F, the progress of orthodontic of the tooth, because the labial surface is covered treatment was delayed by thick mucosal barrier by the gingival, which hinders the bracket covering the left permanent central incisor. The

A B

C D

E F

Figs 7.3A to F: Gaining access for bracket placement on partially erupted teeth (A) Mucosal barrier covering the permanent central incisor and preventing it from erupting. (B) Exposure of permanent central incisor by laser; (C) Begg bracket bonded on the exposed permanent central incisor and ligated to the arch wire;. (D and E) Nearing the alignment of permanent central incisor; (F) Almost the permanent central incisor has brought into alignment 56 History of Orthodontics tooth is exposed by laser and then bracket is Removal of Operculae on bonded, thereby bringing it into alignment. Second Molar by Laser In some cases, second permanent molar is also Removal of Redundant Gingival Tissue by bonded to provide additional anchorage and to Laser during Orthodontic Treatment avoid excessive repair visits. If second permanent Poor oral hygiene in orthodontic patient results molar is the last tooth in the arch, it is often in swollen gingival tissue, which delays the associated with operculum. Presence of orthodontic treatment. Laser can be used in the operculum hinders the band placement. Removal removal of redundant tissue, which fastens the of operculum by soft tissue laser facilitates the progress of orthodontic treatment. exposure of tooth, later providing accessibility for band placement (Figs 7.5A and B). Management of Aphthous Ulcer by Laser during Orthodontic Treatment Use of Laser in Controlling the Growth of Facial Structure One of the most uncomfortable experiences for orthodontic patients is the formation of aphthous Orthodontics is one of the important domains with ulcer. Application of laser for aphthous ulcer (Figs interests in human growth and development with 7.4A and B) helps in reducing the pain and also the advent of “high energy lasers” (that are not promotes healing. Healing usually takes place in deleterious), it may prove that research could lead a day. Laser irradiates the surface nerve ending to the use of lasers in the practice of orthodontics and eliminates the painful stimuli. “High energy lasers” might be applied to

A A

B B

Figs 7.4A and B: Management of aphthous ulcer by laser Figs 7.5A and B: Removal of operculae on second molar (A) Aphthous ulcer on the lateral borer of the tongue; by laser (A) Showing operculum in relation to second molar; (B) Healing of the aphthous ulcer followed by laser therapy (B) Operculum has been removed with the laser History of Dental Lasers and their Applications in Orthodontics 57 manipulation of human facial growth leading to Depigmentation of Gingiva by Laser new methods to cope with problems either Gingival pigmentation gives unesthetic overgrowth or undergrowth. appearance, especially during smiling and seen more commonly in black race groups. Lasers can Caries Control during Orthodontic be used to remove gingival pigmentation and Treatment helps in restoring the lost esthetics (Figs 7.7A Development/occurrence of dental caries is not and B). an uncommon complication in orthodontic patient especially around brackets and in interproximal Crown Lengthening Procedure by Laser area after proximal stripping of teeth to gain space. (Figs 7.8A and B) Studies have demonstrated that Nd:YAG laser An excellent application of crown lengthening is irradiation with (APF) fluoride application acts when a canine is substituted for a congenitally as an effective method of caries control during missing lateral incisor. When first premolar is the orthodontic treatment. canine position, its crown height looks too short. Some clinicians recommend intrusion of the Tooth Whitening by Laser premolar and placement of a laminate veneer to Laser can be used for removal of intrinsic stains restore length. Another option, however is to (Figs 7.6A and B) and or postoperative tooth lengthen the premolar crown by laser gingivectomy. whitening to brighten the smile. Debonding of Brackets by Laser Debonding of brackets is one of the most important procedures carried out after the active fixed mechanotherapy. Debonding of ceramic bracket is difficult and often results in fracture of brackets. Studies proved that application of lasers in debonding of brackets not only helps in

B B Figs 7.6A and B: Tooth whitening by laser Figs 7.7A and B: Depigmentation of gingiva by laser (A) Before; (B) After (A) Before; (B) After 58 History of Orthodontics

Fig. 7.9: Always put on the protective eye glasses prior to the application of lasers. It is recommended to use only laser specific protective eye glasses

Figs 7.8A and B: Crown lengthening procedure by laser (A) Before; (B) After

debonding of metal brackets but also makes easy PRECAUTIONARY MEASURES of ceramic bracket debonding and prevents Following are the important precautionary fracture of enamel. measure prior to the handling and clinical applications of Lasers; LASER SAFETY 1. Always put on the protective eye glasses prior Lasers are excellent tools, but they also bear a very to the application of lasers. It is recommended high risk for high risk for severe injury and to use only laser specific protective eye glasses damage. Laser radiation mainly endangers eyes, (Fig. 7.9). the retina cornea and the lens are concerned. 2. Make sure the door of the operatory room Damage of the retina usually is permanent. Thus should always be closed. just a slight carelessness can impair your vision. 3. Use of nonreflective instrument is The second affected organ is skin although it is recommended to avoid indirect hazard. much less sensitive than eyes and damages occur 4. Cover the endotracheal tube with wet gauge only at high energies. Hence, the high risks require piece or use special stainless steel tube to avoid suitable protective measures; their strict combustion of anesthetic gases by laser beam observation is the responsibility of the clinician 5. Use of high vacuum suction or smoke and the management. evacuator for evacuations of toxic gases. AAnnngggllleee’’’sss CCooonnntttrrriiibbbuuutttiiiooonnn tttooo ttthhheee FFFaaacccuuullltttyyy oofff 8 OOrrrttthhhooodddooonnntttiiicccsss

Edward Hartley Angle –Dental Edward Hartley Angle‘s School – Edgewise Appliance Graduation of Orthodontics at Pasadena, Angle’s Orthodontic Material Angle’s Dental Practice at California USA Invention Towanda Appliance Contribution by Case-Angle Controversy Edward H Angle Edward Hartley Angle’s Criticisms Professional Teaching Career – E-arch Appliance – Pin and Tube Appliance Edward H Angle’s Publications – Ribbon Arch Appliance and Presentations

Edward H Angle is one of the most dominant, many of his qualities and quirks in adulthood. dynamic, and influential figures in the specialty From the southern boundary of District no. 1 of of orthodontics. He separated orthodontics from Herrick Township in Bradford County, you could the other branches of dentistry. Edward H almost see the deep, winding chasm of the Angle’s early years reflect elements of a classic Susquehanna River valley. This area was American success story of his era: a fiercely nicknamed “Ballibay” in the 1820s by the new determined young man of no remarkable settlers from the town of Ballybay, County heritage serendipitously finding his Monaghan, Ireland. Edward Hartley Angle was considerable aptitudes and blazing trails in born here June 1, 1855 in a modest, white wood- pursuit of his visionary goals. At various times framed house near the crest of a hill on his father’s in his letters, he expressed his admiration for a 200-acre dairy farm (Fig. 8.1). He is recorded in pantheon of archetypes with traits akin to his the 1860 Bradford County census book as own, such as the indomitable messenger in “A “Hartly”, the fifth of six children, and third son, Message to Garcia”, the popular, inspirational to Philip Casebeer Angle and Isabel Erskine short story (1899) by Elbert Hubbard, which Angle. His father’s roots were primarily Dutch became required reading for Angle’s students. and his mother was born in Ireland. From Samuel L Clemens (Mark Twain), poet- childhood, he was called “Hart” by his family storyteller James Whitcomb Riley, George and close friends. The Angles had a seventh child, Catlin, Benjamin Franklin, and Rembrandt van William, a bright lad, who died of illness at age Rijn were among his favorite heroes. All were 11. Teen-aged Hart was hurt terribly by the loss creative achievers and resolute individualists of of his younger brother Willie, his favorite sibling. humble birth and with great connection to Hart showed no enthusiasm in school or on everyday people. the farm, to the utter dismay of his Dr Angle never forgot his farm-boy life in unsympathetic father. He was always behind in northeastern Pennsylvania that helped shape his learning, especially mathematics, and he 60 History of Orthodontics

understanding mother Isabel. Recognizing his nascent mechanical skills, she secured a position for Hart with a dentist in nearby Herrick, as an office apprentice. He got on well in dentistry—it appealed instantly to his keen manual and visual senses, his love of tools and his need for orderliness. Two years later, he applied to dental colleges. His scratchy, brief letter of inquiry dated September 6, 1876, to the Baltimore Dental College is the earliest document extant from his hand. In it, he touted his proficiencies in the Fig. 8.1: Angle’s white wood-framed house where he was indispensable texts of the day: Harris’s The born Principles and Practice of Dental Surgery (1863) and avoided farm work as much as he could. He was Piggot’s Chemistry and Metallurgy, as Applied to a natural tinkerer, a whittler, a maker of things. the Study and Practice of Dental Surgery (1854). In reminiscences, his wife Anna told about his Although his English constructions and spelling heavily scarred knees, lifetime reminders of were rather crude for a schooled 21-year-old, boyhood knife slips. When his father needed a young Angle exuded the restless confidence that more efficient hay rake, 11-year-old Hart would mark his entire adult life and would win invented one. However, he did not get much him success in many adventures to come. He was appreciation for the new machine, and soon invited to enroll at Pennsylvania College of someone else applied for and was awarded the Dental Surgery in Philadelphia for their DDS patent for Hart’s instinctively clever work. It was program, then arranged in two 6-month terms an early lesson in life’s unfairness that the spaced over a nominal 2 years and located in a sensitive boy probably long remembered. building at the northwest corner of Twelfth and In Angle’s letters, we find a man who Filbert Streets. Angle alluded to his college cherished his boyhood friendships throughout experiences years later in friendly letters with life. He never lost contact with some of his classmates EL Townsend and Charles J Tibbets. Herrick chums, like Cyrus Camp, Guy Fuller, and In 1895, Angle completed his MD degree from Jerry Sanger. His correspondence with them is Marion Sims College. often in the playful tones of a kid still horsing around the farmyard. Angle peppered his letters ANGLE‘S DENTAL PRACTICE AT TOWANDA to his hometown friends with monikers After dental school graduation in 1878, Edward concocted from the names of town fathers with Angle went to the Bradford County seat, whom the boys occasionally skirted trouble. Towanda, and set-up a general practice of “Cy” Camp was sometimes referred to as “J. mechanical dentistry in the center of town. He Rufus Avery” or “Gideon Squares” in Hart’s became a boarder in the home of Towanda’s jocular letters to him. Angle also showed his self- leading physician, Dr David Shepard Pratt, a deprecating humor to old, dear friends in the good strategic decision for the bright new dentist variety of comical aliases he used in signing his in town. Young Dr Angle advertised in local letters: Alexander J Horatio, Alonzo Revellen, Big newspapers, such as The Sullivan Review, and Foot, Colossus Doc the Great, Flat-nosed Hart, appeared to be rapidly successful. Here in his Little Harty Angle, Old Man Friar, Uncle Reuben, leisure as an unmarried young professional, and sometimes simply the geometric notation“. Angle developed his first interests in mechanisms for tooth alignment or “regulation”, EDWARD HARTLEY ANGLE—DENTAL GRADUATION considered the main purpose for moving teeth at that time. In 1874, at age 18, Edward Hartley Angle was In Towanda, Angle experienced declining introduced to dentistry with coaxing from his health that was to plague him on and off for the Angle’s Contribution to the Faculty of Orthodontics 61 rest of his life. He was diagnosed with pleural pneumonia. Today, we may understand this chronic respiratory condition as a consequence of tuberculosis. One popular treatment of the day was for the sufferer to move to fresher, cleaner air—to a pristine resort set up for this purpose or to the mountains or the desert. Angle formed special bonds throughout his career with those who shared the same affliction, former student Albert “Leaf” Ketcham being the most prominent among them. After 3 years of dental practice in Towanda, in the spring of 1881, 26-year-old Dr Angle abandoned dentistry and took a train to Minneapolis, Minnesota, on a physician’s advice, in search of better health. Within a few months, his condition improved and, with his recovery, came renewed confidence and resolves to make something of himself. For his health’s sake, Angle was considering permanent retirement from dentistry in favor of work that was less confining and more outdoors. In Minneapolis, he heard that sheep farming in Montana was where the “big money” could be made. In the fall, he returned briefly to Pennsylvania to entice some of his old farm buddies from Herrick to join him in setting up a lucrative sheep-raising business. Fig. 8.2: Edward Hartley Angle They signed on excitedly, and the lot of his Ballibay cronies—including his older brother Mahlon and close friend Cy Camp—traveled Department of the Minnesota Hospital College in with the freewheeling Hart to the fresh air of the Minneapolis regarding faculty employment. Montana wilderness in search of their “pot of Impressed with what he had to offer, the college gold” (Fig. 8.2). administrators tailored a position to suit his skills Angle invested all his savings into their and their needs. In 1886, 31-year-old Edward sheep-farming venture, all to be undone by the Angle was appointed a professor of histology and great blizzard of 1882, a record-breaking deep lecturer on comparative anatomy and freeze that killed off the entire herd. The empty- orthodontia. A few years later, after the Hospital handed boys from Ballibay sullenly returned to College merged into the University of Minnesota, Pennsylvania, except for Hart. A defeated Angle, he was elevated to professor of orthodontia, a feeling physically better but mentally depleted, rare position in those days when orthodontia was hobbled in to Minneapolis by mid-1882 looking a neglected part of the prosthetics department for work—again in dentistry. at dental colleges. At the same time, he quickly ascended through the ranks to become president EDWARD HARTLEY ANGLE’S of the Minneapolis City Dental Society in 1888. PROFESSIONAL TEACHING CAREER He also was able to maintain his small private Edward Hartley Angle got back into general dental office, where he experimented more and dental practice and soon resumed the creative more with novel approaches in orthodontic thinking and tinkering with tooth-regulating mechanisms. In sum, through his resilience, appliances that he began in Towanda. Within a industriousness, and good fortune, Angle couple of years, Angle inquired at the Dental seemed to have landed on his feet 62 History of Orthodontics psychologically and financially from the Montana contemptuous treatment he received at this 1887 get-rich-quick debacle a few years earlier. Congress helped harden him for the professional His big break came in 1887 when Angle was “fights” he was to invite and encounter permitted on the speaking program of the Ninth throughout his adventurous career. To those who International Medical Congress convened in would challenge him, his style often seemed Washington, DC. On the fourth day of this abrasive, sometimes brutal; to others, those loyal important Congress, Thursday, September 8, to him and backing his causes, he was as 1887, the section on “Dental and Oral Surgery” charming and gentle as a puppy. was called to order at 11 AM in the Universalist The year 1892 was a watershed in Angle’s Church at the corner of 13th and L Streets. Thirty- professional development: he announced that he two-year-old Dr Angle was the youngest of the would be practicing orthodontia to the exclusion session’s speakers and was scheduled last on the of all other dental therapies. With this decision, day’s program. Two prominent authorities on he became the first acknowledged exclusive orthodontics directly preceded Angle: Clark specialist in orthodontics in the world. Until this Goddard, professor at University of California, moment, none of the authorities on orthodontics San Francisco, and Eugene Talbot, textbook worldwide and in history ever mustered the writer and professor from Chicago. vision and confidence to limit their dental or A confident Edward Angle presented his talk, medical practice to only this emerging type of entitled “Notes on Orthodontia with a New treatment. Angle was no longer on the faculty at System of Regulation and Retention”, using the University of Minnesota. He resigned to lantern slides—a relatively new visual aid for concentrate his energies on experimentation in lecturing. He demonstrated his classification of orthodontia and the development of marketable, tooth movements and his novel orthodontic prefabricated (“ready-made” in his vernacular), devices, such as piano wire in a soldered “pipe” new treatment appliances. He also needed time (tube) and the jackscrew and traction screw. The to work on his textbook’s third edition, his first open discussion that followed was sometimes real book, a 51-page work, 20 pages longer than acrimonious. Many well-known dentists in the his 1890 edition, which had been published as audience, including John N Farrar and Victor H an appendix in the second edition of Haskell’s Jackson, accused Angle of falsely claiming prosthetics laboratory book. He hired Anna originality. They cited others (including Hopkins, a bright young Minneapolis secretarial school graduate, to help him with his book and themselves) who earlier introduced similar practice. It was the beginning of a life-shaping appliances. Angle carefully explained how his relationship for both of them. devices were different and better, indeed “new”, but apparently, he did not prevail. The edited Angle‘S Married Life paper and subsequent inflammatory discussions were published in the Transactions of the Ninth In March 1887, Edward Hartley Angle married to International Medical Congress under an imposed, 22-year-old Florence when he was running 31 truncated, noncontroversial title, “Notes on years old. Less than 9 months later their daughter Orthodontia”. This 1887 article commonly has Florence Isabel Angle (Fig. 8.3) was born in been called the “First Edition” of his classic Minneapolis, only 3 months after her father’s textbook on the treatment of malocclusion. disastrous appearance at the Ninth International Actually, Angle considered that his first edition Medical Congress in Washington. was his 14-page chapter appended to Loomis P Angle’s correspondence a dozen years later Haskell’s new book on dental laboratory described a disintegration of this marriage from procedures published in 1887; he titled this the start. The couple was grossly mismatched, version of his Congress paper “Extracts of Notes he the ambitious idea man and she the day- on Orthodontia, with a New System by dreaming reader of romances. Angle gradually Regulation and Retention” and it did not contain lost respect for Florence “Senior”, as he referred the discrediting commentaries. to his wife in some letters, and he became by Years later, colleagues observed that the default an absentee father to their sickly daughter bitterness Angle developed from the “Florencie”. By July 1900, his personal confidence Angle’s Contribution to the Faculty of Orthodontics 63

Fig. 8.3: Angle’s daughter—Florence Isabel Angle on the left in his new directions was strong enough to prompt him to move out of their boarding-house apartment in St Louis. He had his thriving practice, his income-producing books, patents and appliances, his growing international fame, his prospering proprietary school, and perhaps most significantly, Anna Hopkins, his secretary, amanuensis, confidante, and sympathetic soul mate (Fig. 8.4). It took Angle another 9 years to Fig. 8.4: Edward Hartley Angle deliver an acceptable divorce settlement for Florence senior in May 1908. Angle’s mother had conversationalist. In addition, he was a talented died a few months earlier, and the delay and artist, not only with intricate line drawings and particular timing of his divorce may well reflect creations for clinical orthodontics, but also in the determination of a devoted son to shield his crafting gold jewelry, such as stickpins set with devout mother from the shame of his broken semiprecious stones, which he often gave as gifts marriage. On June 28, 1908, Hart and Anna were to friends. married in St Louis (at ages 53 and 36, Furthermore, Angle was an avid collector of respectively) and within 2 months the things of the world. He gladly received and newlyweds had moved to New York to begin a studied valuable arts and crafts from friends and new chapter in their lives, as retired gentry. his grateful foreign correspondents in South Africa, Japan, and elsewhere. Angle asked his Angle as an Artist well-known orthodontist-friends and mentors It should not be forgotten that Edward Hartley for photographs of themselves and other dental Angle’s personal vision was wide and deep, not celebrities, both earlier and contemporary, to add simply confined to his profession. He was keen to his lantern slide collection, which he projected observer of nature in all its forms. The preamble as a historical prelude to his lectures at various of the citation accompanying the honorary Doctor meetings. He loved American-Indian artifacts, of Science degree awarded to Dr Angle in 1915 arrowheads and tomahawk heads which he by the University of Pennsylvania acknowledged challenged his patients and friends to find and his broad intellectual base: “Lover of art and trade to him. He collected animal and human nature, intimate friend of trees and flowers, but skulls and osteological materials in plentiful preeminently founder of the science of supply from archeologists excavating the burial orthodontia….” Angle exercised his mounds around St Louis. He and Anna intellectualism with an active sociability. He was nourished for over three decades an extensive a worldly man who enjoyed people and places; collection of American-Indian weavings, he was an outgoing celebrant and beadwork, textiles, clothing, and baskets, mostly 64 History of Orthodontics

Fig. 8.5: Archeological and ethnographic collections of Angle and his wife Anna Hopkins from the tribes of the Plains and Great Basin areas of the United States (Fig. 8.5). Most of their archeological and ethnographic collections were donated to institutions and museums in their lifetimes. Almost 300 valuable objects of American–Indian ethnography were given by Anna Hopkins Angle from 1930, the year of Fig. 8.6: Anna Hopkins Edward Angle’s death, to 1959, two years after her death, to the museum of Claremont College, Dentistry at the University of Iowa from 1900 to now the Pomona College Museum of Art in Los 1902. Angle’s letters to Anna are just as colorful Angeles. It represents a living testament to the and articulate as the rest of his correspondence. broad tastes and intellectual vigor of the Angles. However, Anna did provide valuable technical skills and judgment. She knew how to craft solid, About Anna Hopkins (Angle’s Second Wife) well-spelled, grammatically correct text. She About 1908, Angle married his longtime likely served as a trusted sounding board for her secretary, Anna Hopkins (1872–1957) (Fig. 8.6), exuberant boss, and she surely must have woven who had obtained her DDS degree from the some subtle corrections and softened phrases into University of Iowa and her orthodontic training his sometimes acerbic commentaries. Dr Angle in his school. “Mother Angle” became secretary often appended his own handwritten of the American Society of Orthodontists, a corrections, notes, or comments to the final founding coeditor of the Angle Orthodontist, and typewritten letters. And to almost all addressees, honorary chair of the Angle Society executive including some close relatives, he hand-signed committee, but she would be best remembered his letters boldly as “Edward H Angle.” Only as Angle’s amanuensis, editor, foil, and buffer with old friends would he let go and sign a for many of his downtrodden students. Some creative or diminutive nickname. At rare times observers have suggested that Anna deserved during the 1899 to 1910 period, Anna would sign much of the credit for the high quality of Angle’s his letters in his absence. Her version of his written record through her significant literary signature is rather authentic looking, but still input during typing. There is absolutely no recognizably not his own. evidence to support this assertion, given the For a period in 1901–1902, when Anna admirable consistency of Angle’s literary output, Hopkins was away at the University of Iowa handwritten as well as typewritten, even during studying for her dental degree, Angle’s periods when Anna’s absence was known, such correspondence was managed by his younger as when she was attending the College of sister, Lillian, an accountant by occupation. The Angle’s Contribution to the Faculty of Orthodontics 65 technical quality of the letters that “Lillie” professional journals in the United States, Europe, attempted to transcribe during that time was and Australia between 1887 and his death in noticeably weaker and Angle knew it. He had to 1930. In addition, during his lifetime, close to 100 apologize often to his correspondents for lateness abstracts and commentaries about his work were and errors, and he resorted to handwritten published. Another 150 articles are recorded in corrections and appended notes more frequently. the indexed scientific literature about Edward Angle and his legacy, and this number continues Angle as a Writer to grow. In addition to his own writing, Angle’s letters Angle’s style of writing was largely verbal: his show that he served enthusiastically as a mentor letters (and probably his speeches) were dictated in scientific writing and editing, long before the to and transcribed by his talented secretary (and era of peer review. He generously volunteered later, second wife), Anna Hopkins. He was gifted ideas and topics for former students and with the turn of phrase, using colorful language colleagues, including one of his first four students, in original ways, and often waxing effusively in Milton T Watson, longtime friend William J Brady, a highly readable way. and brother-in-law/editor Cy Camp, who was Angle became convinced that anomalies of essential in the final editing and proofing of the molar occlusion were prime factors in the origins sixth edition (1900) of Angle’s textbook. Angle of most orthodontic problems, including dental conscripted all of them and three other colleagues crowding. Thus, he took the bold step of to write popular articles to increase public popularizing the word “mal-occlusion” in the awareness of the young specialty of orthodontia late 1890s, around the time he was creating his in the first decade of the 20th century. landmark work “Classification of Malocclusion”. Minneapolis merchants Robert Foster and Published in 1899, that article brought order out Otto Keidle remained close friends with the of chaos, simplicity from existing diagnostic Angles from their formative years there. In the complexity, transformations that Angle’s creative Angle letter archive from 1899 to 1910, “Bob and mind seemed particularly adept at seeing and Otto” (also called “White Child and Baron”) doing. Quickly, he changed the title of his received some of the most entertaining yarns and textbook from a prosaic “The Angle system of homespun dialects from Edward Angle at his regulation and retention of the teeth …” (1890– charmingly best. Angle, who no longer used his 1899) to the then ground-breaking concept, childhood name “Hart” with newly acquired “Treatment of malocclusion of the teeth …” friends, still often signed off humorously as (1900, 6th edition). “Rube” or “Reuben” or the like. In his well- Angle was a perfectionist whose painstaking written personal ramblings to friends, Angle’s exactness in his scientific thinking and writings broad and deep nonprofessional interests in became a hallmark of his lifetime of work in people, poetry, literature, history, and the world orthodontics. His detailed letters to managers through clearly. and book editors of the SS White Dental Manufacturing Company show him as a EDWARD HARTLEY ANGLE‘S SCHOOL OF polymath with a remarkable understanding of ORTHODONTICS AT PASADENA, the tasks of typesetter, illustrator, and publisher. CALIFORNIA, USA Angle edited his book six times over, modifying and adding to it every time, as his own expertise Angle’s attempts at teaching undergraduate developed and progressed, turning what began dental students at 4 schools had been frustrated as a 20-page article in 1887 into a 628-page text in by his inability to separate orthodontics from the 1907. He always seemed to be at work on an dental curriculum, although he finally address, an illustrated presentation, or established the first department of orthodontics publication. He prepared by hand many of his in a university (Marion Sims Dental College, intricate drawings and by 1900 had a library of Saint Louis, 1897). After the meeting of the over a thousand glass lantern-slides for projection. National Dental Association in 1899, several Besides his well-known textbook editions, Angle members persuaded Angle to train them in his wrote around 80 articles for publication in various office. This was the first postgraduate course in 66 History of Orthodontics orthodontics, as well as the first school devoted growth, development, and functioning of the exclusively to the specialty, and it was 3 weeks denture. He also expected the applicant to be long. In 1908, he gave up his practice in Saint reasonably familiar with history, general science, Louis and moved, first to New York, then to New and English literature. Filing, soldering, and wire London, and finally to Pasadena, Calif (1916). bending had to be mastered before the student Wherever he went, the Angle School went with was permitted to do any appliance manipulation. him. His students erected what was to become Only after surviving the rigors of discipline, the first building exclusively devoted to the theory, technique, and case analysis, the student teaching of orthodontics (1922). In 1924, the was allowed admission to the clinic. school was chartered as the Angle College of In June 1922, the members of this school Orthodontia (Fig. 8.7). founded a formal association: The Edward H After heading orthodontic departments at Angle Society of Orthodontia (commonly called several dental schools, Angle decided he could the Angle Society). The meeting of this society be more effective by teaching small, select groups in New London in 1928 was the last meeting that in his Saint Louis office. Thus was founded (1900) Angle ever attended. the first postgraduate school of orthodontics They had no acrylics, no alginates, no light (Angle School of Orthodontia, Fig. 8.8). He also wires, no model trimmers and no preformed founded the first orthodontic journal, The bands. Impressions were taken in plaster and, American Orthodontist, in 1907, but could not because undercuts prevented removing the stony prolong its publication beyond 1912. mass in one piece, the operator was obliged to Prior to admission, student was thoroughly score the material and pry it off, piece by piece. grilled in the basic sciences, either by Dr Angle he poured impression was later trimmed by hand or one of his staff. The applicant was expected to with a plane, a saw, or a huge file. know the anatomy, embryology and histology of the head and neck (exclusive of the brain), the APPLIANCE CONTRIBUTION BY EDWARD H ANGLE Edward H Angle’s correspondence and patents reveal features of the most dynamic side perhaps of this multidimensional man: the rapt and consummate inventor, a human wellspring of new ideas (Fig. 8.9). During his lifetime, Angle applied for and received 45 patents (his wife Anna obtained his 46th patent in 1934, four years after his death). Most were appliances and instruments related to clinical orthodontics, but they included laboratory equipment and a novel Fig. 8.7: Angle school of orthodontia automobile wheel. His contemporary role models were likely among the new breed of inventive, risk-taking industrialists, such as Thomas Edison, George Eastman, and Charles Kettering. America led the world by the beginning of the 20th century in technological innovation and entrepreneurship. In the first years of the 1900s, American medicine was ablaze with new light and directions for the medical and dental community. At Johns Hopkins University, William Osler initiated creative reforms in clinical education and single- handedly systematized the field of internal Fig. 8.8: Angle School of Orthodontia, first postgraduate medicine. At Northwestern University, Greene school for orthodontists Vardiman Black introduced the nomenclature of Angle’s Contribution to the Faculty of Orthodontics 67

to develop orthodontic appliances and instruments: Jacob Lowe Young, Spencer R Atkinson and Albert H Ketcham each jointly held patent rights to one or more inventions with Angle. Furthermore, trusting the biomechanical acumen of his former student Milton T Watson, Angle asked him to try out competitors’ orthodontic appliances and to conduct a comparative study and report back to Angle with his conclusions. Angle, the enterprising innovator, worked and reworked designs to develop the best appliances. As President of the E H Angle Regulating Appliance Company, incorporated in St Louis in May 1907, he kept track of the work of other inventors active in the budding field of orthodontia and maintained a folder with relevant patents filed by others. Within the 11- year record of correspondence covered by the Fig. 8.9: Edward Hartley Angle Angle letter archives, he relentlessly hounded those he perceived as idea stealers, patent tooth anatomy and the modern principles and infringers, and plagiarists—Clarence D Lukens, James N MacDowell, and Miland Knapp, and tools of operative dentistry. manufacturers Julius Aderer, Claudius Ash, and Edward Angle’s rationale for patenting his Blue Island Specialty Company. In anger, he inventions was to take legal claim of his ideas slapped some with lawsuits and inflammatory and to protect his business interests. However, defamations. many of Angle’s colleagues criticized him for the The age-old rule that brilliant inventors make zeal with which he protected his breakthrough poor business people did not apply to Edward H appliances and systems for doing “tooth Angle. He was in fact the consummate, confident regulation” and “orthodontia” more easily. businessman, maximizing income and minimizing Patent protection certainly makes sense in today’s high-stakes environment of corporate expenses. Angle was a demanding taskmaster in espionage and intellectual property rights, but his detailed letters to the machinists to whom he in Angle’s time, patenting—particularly in outsourced appliance manufacture at various medicine—was viewed in many circles as selfish times: William Hahn, the Hardinge brothers, and and mercenary. John E Canning. They were required to fabricate Angle’s enthusiasm for advancing the his devices with tight tolerances and on tight materia technica of orthodontics was so strong budgets. He held the SS White Dental that he freely mentored, encouraged, and Manufacturing Company, which by 1895 became worked with colleagues in their efforts to develop the exclusive distributor of the Angle System, to new appliances. This is seen in Angle’s letters to a rigorous Angle-controlled business relationship. Henry A Baker of Boston in which he praises the His detailed handwritten invoices from the “E H “Baker method of anchorage” and later seeks to Angle Regulating Appliance Co” show his (and protect Baker’s professional reputation as the first Anna’s) arithmetic accuracy in billing to the penny, to use inter-maxillary anchorage against equal making a lie of his schoolboy reputation of being claims made by Calvin S Case of Chicago. It is weak with numbers. also apparent in his letters to E L Townsend Angle’s Patented Orthodontic Devices, first where he encourages Townsend to write and patent in 1889 is push type jackscrew which was publish articles concerning Townsend’s idea for used to increase the width of the arches there by a prosthetic bridge appliance. Angle worked treating the malocclusions. In 1851, a lingual arch cooperatively with several of his former students soldered to bands that are cemented on teeth; 68 History of Orthodontics forcing teeth “outward and forward”. Special pliers pinched the wire increasing its length. In 1899 Edward H Angle developed the “E” (expansion) arch appliance where in the arch wire with threaded ends, extended in the tube of an anchor molar band. Nut is provided with a thread less extension that works with a friction sleeve to hold the adjustment. According to the nut’s position, the teeth could be moved either A distally or mesially. The banded teeth were attached to the arch with the help of a soft wire that allowed their tipping or aligning.

E-arch Appliance E-arch appliance was developed by Angle in early 1900. It is also referred to as Edward Angle‘s E- arch. It was the first Angle’s Orthodontic appliance developed to treat malocclusions .E- arch appliance consists of bands which are placed on molar teeth on either side of the arch of a heavy labial arch wire extended around the arch. The B ends of labial extended arch wire threaded to the buccal aspect of the molar bands allowed the arch wire to be advanced so that the arch perimeter increased. Individual teeth were ligated with the heavy labial extended arch wire with ligature wire of 0.010" (Figs 8.10A to D).

Pin and Tube Appliance Pin and tube appliance was also developed by Edward H Angle. In this pin and tube appliance, all teeth are banded. Vertical tubes were welded to the bands on the labial surface in the center of the crown for all teeth in the arch. Arch wires were secured with soldered pins that inserted into the vertical tubes (Figs 8.11A to C).Tooth movement was achieved by altering the placement of these pins. Pin and tube appliance is also used C for treating malocclusions.

Ribbon Arch Appliance Ribbon arch appliance was also developed by Edward H Angle and it is the modification of pin and tube appliance. This appliance was introduced in 1910. Ribbon arch was the 1st appliance to use a true bracket .The bracket has a vertical slot facing occlusally.The brackets were attached to the bands at the center of labial D surface of teeth (Figs 8.12A to C). Figs 8.10A to D: E-arch appliances Angle’s Contribution to the Faculty of Orthodontics 69

C B

Figs 8.11A to C: Pin and tube appliance

Edgewise Appliance In order to overcome the deficiencies encountered with his previous techniques Angle desired a metal bracket that could give a better control over individual tooth movement. The edgewise bracket has a rectangular slot facing labially, rather than occlusally or gingivally, which receives a rectangular arch wire. This unique feature of rectangular arch wire in a rectangular slot enabled control of tooth movement in all three planes of space. Furthermore, the bracket has four wings, two occlusal and two gingival, which increase C the surface of arch wire with the bracket slot and Figs 8.12A to C: Ribbon arch appliance thus give accurate control over tooth movement (Figs 8.13A to C). The term Edgewise refers to the the biological response to foreign bodies used in method by which rectangular arch wire is inserted oral environment. Reflected in many of his patents into the horizontal slotted bracket. The edgewise in which he has constantly tried to cover all appliance was developed and introduced to possibilities for adverse use or unfavorable orthodontic by Edward H Angle in the year 1925. reaction. Angle made an inventory of the available materials—gold, silver, platinum, ANGLE’S ORTHODONTIC MATERIAL platinous silver, iridio-platinum, platinoid, INVENTION aluminum, brass, copper, aluminum bronze, The highly popular Broussard bracket of the 60s steel, iron and vulcanized rubber. He found that and 70s was based on this patent. Concern about “the material most fitting was nickel silver”, a 70 History of Orthodontics

Fig. 8.14: Calvin Case

arches. In 1887 introduction in orthodontics of soldering and a “baser” alloy which contained, 60% to 70% copper, 10% to 20% zinc and10% to 15% nickel. Angle was influenced by Julius Wolff. “Wolff’s law of bone”—bone trabeculae arranged in response to stress lines on the bone. Angle had an uncompromising position against extraction. It C was his credit that “The best balance, the best Figs 8.13A to C: Edgewise appliance harmony, the best proportions of the mouth in its relation to the other features require that there shall be a full complement of teeth, and that each tooth shall brass (copper-zinc alloy) that did not have any be made to occupy its normal position, i.e. normal silver in it at all! occlusion.” He was largely self-taught, and yet he mastered complex metallurgy. In one of his publications, CASE-ANGLE CONTROVERSY he explains that pinching the arch. “Not only spreads the particles of metal, so as to increase Originally, Calvin Case (Fig. 8.14) was a genuine the length of the rod, but tempers the part subjected admirer of Angle. He advocated the Angle to the pinching action, thereby largely system at every turn and hoped to place this compensating for the reduction in the area of the system before the dental profession. In fact, he rod section at that point, and consequently gave up the general practice of dentistry because maintaining the strength and rigidity of the rod of Angle’s influence. The discord started over the under the longitudinal strain thereon.”His claim that Angle attributed the origin of the use knowledge of noble metals is witnessed also by of inter-maxillary elastics to Baker, while Case his use of gold and of platinum-iridium arches in thought that he should have received that credit. orthodontics. He was the first to use coil springs. In fact, when Angle described this procedure, he But he connected them only to nobler metal never mentioned Case. This led to charges and Angle’s Contribution to the Faculty of Orthodontics 71 countercharges between them in 1903. Case’s claim in New York City with his death in 1933. His was that in 1890 he started this procedure and influence was much felt since he was the editor of reported it at the Chicago Dental Society and also the International Journal of Orthodontia for 17 at the Columbian Dental Congress in 1893. years and also the president of the American The second point of contention was and is the one Dental Association in 1931. usually remembered the question of the extraction of certain teeth as a means of treatment. Angle’s CRITICISMS thesis was that “there shall be a full complement Bernstein of teeth, and that each tooth shall be made to occupy its normal position.” Case defended the Dr Angle did great harm to many persons, and to discreet use of extraction as a practical procedure, orthodontics, at the same time he was making his while Angle believed in non-extraction. However, many contributions. the unexpected result of this controversy was that it convinced general practitioners that they should Theodore Adler not attempt orthodontic treatment but should refer patients to the specialist. By all accounts Angle was a difficult man. He is The extraction story was continued into 1911 reputed to have harbored much of the bigotry with Martin Dewey (1881–1933) (Fig. 8.15) an and some of the xenophobia of his time. ardent champion of non-extraction. Dewey served Wuerpel as professor of Orthodontics at Kansas City Dental School, the University of Iowa Dental Department, “He did not like the Germans. He was the Chicago Dental College, and the New York broadminded but he had prejudices.” College of dentistry. He gained a wide reputation “He lost many friends, or at least he alienated as an outstanding teacher. He had started his own them”. graduate school in orthodontics in 1911 as the “If people had heard the terms he used in Kansas City School of Orthodontia and continued regard to them he would have had still more it as he traveled from one city to another, ending enemies”.

Frederick Noyes Angle “could never take criticism or argument”. When his ideas were verbally attacked, he would call his attackers “fools”.

Tom Graber Edward.Hartley.Angle. was obviously a disturbed man, and his image has been built up, far beyond what he deserved” “Approach became a classic example of cultism and dogma.” “Case was more successful as a contemporary leader than Angle. Case was on the inside leading while Angle was the maverick. He resented Calvin Case.”

Lischer “So I turned to the first special course then being offered. Unfortunately, being a resident of St. Louis, where the course was then given, I was Fig. 8.15: Martin Dewey 72 History of Orthodontics asked to sign a contract to locate elsewhere on constructing machinery, inclu- completion of the instruction. Angle added: ‘You ding a hay rake (at age 11); at- know, Lischer, I can pick the flowers in my garden tends high school in Canton, myself.‘ Pennsylvania. 1874–1876 Apprentices with a local dentist Robert Rubin in Herrick. Angle possessed many of the personality qualities Fall 1876– Attends the Pennsylvania seen in geniuses. They can be difficult, demanding, February 1878 College of Dental Surgery in and unforgiving. They tend to be so devoted to Philadelphia, receiving DDS their field that they fail to develop other aspects of degree on February 28, 1878; their lives. Angle seems to fit that category.” beings practicing dentistry in Towanda, the county seat of Wuerpel Bradford County, Pennsylva- nia. Here he develops an inter- It (orthodontics) was his religion and his god. He est in orthodontia. would sacrifice everything for its sake. He could Spring 1881 Develops a chronic respiratory only see his life and his work and his devotion in ailment, called pleural pneu- terms of orthodontia.” monia, probably tuberculosis. Autumn 1881 Moves to Minneapolis, Min- Edward H Angle’s Publications and nesota, for health reasons. Presentations Within months, his health re- Though Angle died 1930, his influence is still felt covers and he returns to Penn- strongly in orthodontics. Even his enemies sylvania briefly to join his older recognized the many contributions made by brother Mahlon and friends in Edward Hartley Angle. His pioneer efforts in planning a sheep-raising ven- orthodontic education, his contribution to ture in Montana. orthodontic literature, and his developments of Late 1881 Moves to Montana with associ- innumerable instruments and appliances are not ates to enter the sheep-ranching the accomplishments for which he will be business. remembered. Long after these have faded into Early 1882 The severe winter of 1882 kills history, Angle’s name will be associated with the their sheep flock and dooms the onward march of biologic science and it will be venture financially. realized how perceptive was the mind that could 1882–1883 Relocates to Minneapolis and penetrate the empiricism of his day and proclaim resumes the private practice of the significance of normal occlusion. This dentistry; continues his interest established orthodontia as a science and it will in orthodontia. remain Angle’s greatest monument. Characteristic 1886 Accepts position as professor of of the man was a remark made shortly before he histology and lecturer on com- died: “I have finished my work. It is as perfect as I parative anatomy and orth- can make it.” odontia in the Dental Depart- ment of the Minnesota Hospital Date Event College in Minneapolis. Two June 1, 1855 Eward Hartley Angle born to year later, it becomes part of the Philip Casebeer Angle (1820– University of Minnesota, and he 1907) and Isabel Erskine Angle is elevated to professor of orth- (1824–1908) in district 1 odontia. Maintains his part-time “Ballibay”, Herrick Township, private practice of dentistry. Bardford County, Pennsylva- March 1887 Marries florence A Canning of nia. The fifth of seven children. Minneapolis, sister of his ma- Demonstrates early talent for chinist Hohn E Canning. using tools and devising and September 8, Present of his first major address Angle’s Contribution to the Faculty of Orthodontics 73

1887 describing aspects of the Angle 1895 Fourth american edition is pub- System of Regulating Appli- lished, a 112-page hard-cover ances before the 9th Interna- book now titled. The Angle Sys- tional Medical Congress in tem of Regulation and Reten- Washington, DC. Angle’s origi- tion of the Teeth and Treatment nality is challenged in the of Fractures of the Maxillae. heated discussion that ensues. 1895 Relocates to St Louis, Missouri Angle later considers a 14 page (with his wife Florence, his extract of this paper, published daughter florence Isabel, and his without discussion in an 1887 secretary-assistant Anna textbook by Loomis P Haskell, Hopkins; sets up a private prac- as the “first edition” of the Seren tice there limited to orthodontia. American editions of his famous 1896–1899 Professor of orthodontia in the book. Dental Department of Marion- December 3, Daughter Florence Isabel Angle Sims College of Medicine, St 1887 is born in Minneapolis. (She Louis. died in 1970 in Morganton, 1897–1898 Teaches in the Dental Depart- North Carolina.) ment of Washington University, 1888 Elected president of the Minne- St Louis. apolis City Dental Society. 1897 Fifth American edition is pub- March 5, 1889 Patents a jack-screw lished by SS White, machinism, the first of 46 pat- philadelphia; also a German ents held by angle. translation of his fourth (1895) 1890 “Second edition” of his book is American edition is published published, as a 30-page appe- by SS White Co, Berlin. ndix to the second edition of a 1897 Is awarded MD degree from dental laboratory handbook by Marion-Sims College of Medi- Loomis P Haskell. cine. 1892 Resigns from the faculty at the 1899 Dental Cosmos publishes University of Minnesota; limits Angle’s “Classification of Mal- his practice exclusively to orth- occlusion”, his most important odontia, thus becoing ostensibly journal article to date. the world’s first specialist in 1899 Claudius Ash publishes orthodontia. Gustave Darin’s French trans- 1892 Hires Anna Hopkins (1872– lation of Angle’s book under the 1957) of Minneapolis as his sec- title Methode du Professeur retary and office assistant. Angle Pour la Regularisation et 1892 Publishes third edition, a 51- le Traitement des Dents et Pour page pamphlet entitled, The le Traitement des Fractures des Angle System of Regulation and Maxillaires. Retention of the Teeth. June 6, 1899 Patents the E-Arch, his expan- 1892–1898 Professor of orthodontia at the sion archwire mechanism. American College of Dental Sur- August 1899 Angle’s paper on orthodontia gery (later merging into North- prepared for presentation at the western University School of National Dental Association Dentistry) in Chicago. meeting at Niagara Falls is by- 1894 Appointed surgeon to the Great passed at the last minute by pro- Northern Railroad for the treat- gram officials. This personal ment of fractures of the maxil- slight fuels Angle’s desire to lae. found a postgraduate school of 74 History of Orthodontics

orthodontia and a professional 1905 Contributes chapter on orth- society devoted to orthodontia. odontia in Edward C Kirk’s November 1899Teaches a postgraduate course American Textbook of Oper- on orthodontia in his office in ative Dentistry (also in 1911 the Olivia Building, St Louis. edition, revised). Attending are thomas B mercer, Spring 1906 Resigns membership in Ameri- Henry E Lindas, Herbert A can Society of Orthodontists; Pullen, and Milton T Watson. encourages establishment of The December 8, Resigns his appointment of Alumni Society of the Angle 1899 Marion Sims college of medi- School of Orthodontia (Earliest cine. Forer-unner of the Edward H 1900 Founds the Angle School of Angle Society of orthodontists). Orthodontia; first 5-week course Winter 1906– Retires from practice of is held from May 1 through early 1907 orthodontia in St Louis; june 1900 in the odeon Build- focuses on writing seventh ing, St Louis. American edition of Treatment July 1900 Separates from wife Florence of Malocclusion of the Teeth, Canning Angle. Angle’s System (628 pages). October 1900 Publishes sixth edition, a 315- 1907 Father Philips Casesbeer Angle page work, Treatment of dies, age 87. Malocclusion of the Teeth and May 1907 Incorporates the EH Angle Fractures of the Maxillae. Regulating Appliance co in St Angle’s System. Louis, Missouri. Early 1901 Founds the Society of Orthod- June 1907 Founds The American Orth- ontists (antecedent of the Ameri- odontist, the first journal in the can Association of Ortho- world devoted exclusively to dontists) and serves as its first orthodontics (discontinued in president. 1912); it is the forerunner of The Early 1901 Founds the Society of Dental Angle Orthodontist. Science of St Louis. 1908 Mother Isable Erskine Angle July 1901 First meeting of the Society of dies, age 84. Orthodontists (renamed in 1902, May 1908 Divorces Florence Canning The American Society of Orth- Angle in Minneapolis, Minne- odontists) is held in St Louis, sota. Missouri. June 27, 1908 Marries Anna Hopkins in St 1902 With Angle’s encouragement, Louis, Missouri. Anna Hopkins graduates from Summer 1908 Moves from St Louis with wife the University of lowa with a Anna H Angle to Larchmont, DDS degree. New York. December Offered the editorship of orth September 15– The Angle School of orthodontia 1902 odontia of the international October 31, is in New York City for a 6-week Dental Journal; Angle declines 1908 course, in an office building at the offer. rhe corner of West 72nd Street August 29– Chairman of Section VI and Broadway. September 3, (Orthodontia) of the fourth Fall 1908 Hemann Muesser publishes 1904 International Dental Congress, Josef Grunberg’s German trans- St Louis. lation of Angle’s sixth (1900) 1904 German translation of his fifth American edition under the title (1895) American edition is pub- Behandlung der Okklusions- lished by SS white Co Berlin. anomalien der Zahne. Angle’s Contribution to the Faculty of Orthodontics 75

April 1909 Purchases home at 58 Bellevue nia by graduates of the Angle Place, New London, Connecti- School of Orthodontia. cut. 1922–1923 Grateful students fund con- July 1909 Wins patent infringement suit struction of a building in Pasa- against appliance manufacturer dena for the Angle School of Julius Aderer. Orthodontia at 550 Jackson October – The Angle School of Orthodontia Street, next to Angle’s home; it December 1909 moves to New London, conn- is dedicated on January 8, 1923. ecticut; course session length- 1924 The Angle College of Orthodon- ened to 9 weeks, given in the tia and Infirmary is chartered by Munsey Building. California. No tuition is charged July– Second (final) course session in for the college’s 12-month pro- September New London at the Harbor gram (which is followed with 1911 School, after which Angle closes periodic faculty supervision Angle School of Orthodontia due to his declining health. during the first year of private 1913 Revised and expanded German practice). All patients were edition of Angle’s book (1907 treated free of charge. American edition) is published September 15, Patents the edgewise arch with new chapters by Josef 1925 mechanism. Grunberg and Albin Late 1927 The Angle College of Orthodon- Oppenheim (778 pages). tia closes unofficially due to February 22, Awarded Honorary ScD degree Angle’s deteriorating health. 1915 by the University of Penns- August 11, Edward H Angle dies in Santa ylvania. 1930 Monica, California, at age 75 Late 1916 Angle moves to southern from heart failure; burial at Califomia for health reason; Mountain View Cemetery, purchases home at 1025 North Altadena, California. Madison Avenue, Pasadena. November 17, The Angle Orthodontist, a 1917 At request of Hames C Angle (no 1930 scientific journal devoted exclu- relation), he reopens the Angle sively to orthodontics, is School of Orthodontia at his founded in chicago in Dr home in Pasadena. Angle’s memory by the newly 1922 Edward H Angle Society of orth- reorganized Edward H Angle odontists is started in Califor- Society of Orthodontia. 76 History of Orthodontics

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Thomas M Graber (1917–2007) Graber’s Other Contributions TM Graber’s Contributions to Orthodontics

THOMAS M GRABER (1917–2007) 1969–1982, where he was the head of the Section of Orthodontics; and at the University of Illinois Dr TM Graber as an Orthodontist, at Chicago College of Dentistry from 1994 until Researcher, and Dental Educator his death. He also served as a visiting professor Dr Thomas M. “Tom” Graber, known inter- on the faculties of the University of Michigan. The nationally as an orthodontist, researcher, and University of Freiburg, Germany, and the dental educator, born in St Louis on May 27, 1917 University of Gothenburg, Sweden. A natural and died on June 26 at age 90, in Evanston, Illinois. teacher, he was “one of those people who could Dr Thomas M Graber was certainly a pioneer take complex subjects and explain them clearly to amongst men. His complete devotion and love for students,” said his wife, Doris, a professor of the specialty of orthodontics is reflected in his political science at the University of Illinois at extensive works on a myriad of topics, spanning Chicago. over a period of nearly six decades. As Dr Graber’s A pioneer in orthodontics and craniofacial family friend and colleague Dr Jim McNamara biology, Dr Graber did research on craniofacial noted, “Tom’s energy and enthusiasm for our anomalies, cleft palate, cleft lip, temporomandi- profession make him a wonderful role model for bular joint anatomy and disturbances, orthopedic future generations of orthodontists.” The passing growth guidance of the dentofacial complex, and of Dr Thomas M Graber marks the end of an era in the use of magnetic forces in orthodontics and orthodontics. dentofacial orthopedics. His 60 years of research have added to our knowledge in these fields and Dr TM Graber’s Dental Graduation changed the way they are taught around the world. Dr Graber earned a DMD degree in dentistry He gave more than 475 continuing education (Washington University, 1940), an MSD in courses around the world and was on the orthodontics (Northwestern University, 1946), American Association of Orthodontists Annual and a PhD in anatomy (Northwestern University, Session program more than any other person in 1950). AAO history. Beginning in 1951, he made annual lecture tours to university departments and Dr TM Graber’s Working Experience medical and dental societies around the world. Dr TM Graber served as a captain in the United He wrote 28 books on orthodontics and dental States Army Dental Corps from 1941–1945. He anatomy and contributed chapters to 20 other was on the faculty of Northwestern University books. He wrote more than 175 scientific articles from 1946–1958 at the University of Chicago from in refereed dental and medical journals, not to Dr TM Graber’s Contribution to Orthodontics 77 mention hundreds of book and journal article Michigan and contributed to the University of reviews and abstracts. Illinois at Chicago College of Dentistry as well. From 1985 to 2000, he served as editor-in-chief Dr Graber enjoyed travel, visiting countries of the American Journal of Orthodontics and around the world and even the North Pole and Dentofacial Orthopedics. He went on to found the Antarctica. He enjoyed photography; he skied, World Journal of Orthodontics, and he continued played tennis, bicycled, swam, went scuba diving, as editor-in-chief of that publication until his death. and sailed—pursuing many of these activities well Dr Graber’s contributions to organized into his 80s. orthodontics and orthodontic education were He is survived by his wife of 66 years, Dr Doris unsurpassed. He served on the AAO Council on Graber; sons Dr Lee W Graber, Dr Thomas W Orthodontic Education from 1962 to 1973; Graber, Jack D Graber, and Dr Jim M Graber; founded the Audiovisual Council of the AAO in daughter Dr Susan Graber; and 14 grandchildren. 1962; was general chairman of the AAO Annual Session twice; founded the Kenilworth Dental TM GRABER’S CONTRIBUTIONS Research Foundation; was director of Continuing TM Graber’s contribution are listed and explained Education for the G. V. Black Institute since 1967; below; was director of Dental Continuing Education for the University of Chicago Center for Continuing Physiology of Occlusion Education from 1971 to 1981; founded the Northwestern University Cleft Lip and Palate Normal Occlusion Institute and the Orthodontic Section at the — TM Graber (DCNA, 1968) University of Chicago Medical School; was a In this paper, Dr Graber states that any definition founding member of the Illinois Society of of normal occlusion cannot be static and merely Orthodontists; and was a former president of the descriptive of tooth relationships. Normal Chicago Society of Orthodontists, the Midwest occlusion involves not only the teeth, but also the Component of the Edward H. Angle Society, and investing tissues, the contiguous and motivating the Illinois Society of Orthodontists. musculature, curve of Spee, inter-occlusal Dr Graber held appointments at Children’s clearance, and the TMJ morphology and function. Memorial Hospital and Wyler Children’s Hospital He has organized the historical progress in the in Chicago. He received honorary doctoral degrees development of current concepts of occlusion into from the University of Gothenburg, Sweden, 1989; three periods: Washington University, St Louis, 1991; the Fictional period (before 1900) University of Michigan, 1994; Kunming Medical Hypothetical period (1900–1930) University, China, 1996; and Aristotle University Factual period (1930 – present). of Thessaloniki, Greece, 2005. His honorary- degrees from Washington University and the Fictional Period University of Michigan were the first and only ones ever given to a dentist. Concepts were developed from inductive Dr Graber received awards too numerous to analysis. list. He was quite proud to be the first non-Japanese Terminology was loose and reflected the person to be inducted as a member of the Japan personal preferences of the authors. Orthodontic Society in 1997, and he received the Authors talked about dental antagonisms, Emperor of Japan’s Order of the Sacred Treasure, “meeting” or “gliding” of teeth. the highest Japanese award ever bestowed upon Good descriptions of the morphologic nature a noncitizen of Japan, in 2003. of individual teeth existed, but an appreciation Active in his community, Dr Graber was a of the functioning dentition as a whole was member of the Sons of the American Revolution, lacking. Fort Dearborn Chapter; and had been a leader in Hypothetical Period the Boy Scouts of America where all four sons became Eagle Scouts. It was EH Angle who organized the existing He was a generous philanthropist, having concepts of occlusion at the time and formulated endowed a professorship at the University of definite principles of diagnosis in treatment. 78 History of Orthodontics

He gave the ‘key of occlusion’ based on the configuration in Class I, Class II, and Class III position of the upper first molar. malocclusions. Angle described normal occlusion using a “Whenever there is a struggle between muscle skull that he called ‘Old Glory’. and bone, bone yields.” Muscle function can Calvin Case developed the concept of “apical be adaptive to morphogenetic pattern. base”. He also called attention to the effect of A change in muscle function can initiate the nose and chin button on the profile. morphologic variation in the normal In 1908, Bennett suggested the functional configuration of the teeth and supporting bone, analysis or the dynamic approach to occlusion or it can enhance an already existing for the first time. He noted that the mandible malocclusion. had a resting position (depended on In the latter instance, the inherent structural musculature) and a functional position mal-relationship calls for compensatory or (depended on the teeth in maximum contact). adaptive muscle activity to perform the daily functions. Factual Period The structural abnormality is increased by compensatory muscle activity to the extent that With the introduction of biometric procedures a balance is reached between pattern, and scientific methodology, this period saw a environment, and physiology. trend toward the dynamic and a de-emphasis It is imperative that the orthodontist appraise on the static. muscle activity and that he conduct his In 1931, B. Holly Broadbent introduced orthodontic therapy in such a manner that the radiographic cephalometry. finished result reflects a balance between the Occlusion now meant inter-digitation of teeth structural changes obtained and the functional plus the influence of the musculature as well forces acting on the teeth and investing tissues as that of the temperomandibular joint. at that time.

The Developing Occlusion—Orthodontic The Role of Upper Second Molar Extraction Considerations for the Handicapped in Orthodontic Treatment — Owen, Graber (DCNA, 1974). — TM Graber (AJO, 1955) The authors state that the nature and severity In Class II treatment, the greatest change of the handicap in a child may totally dominate produced by the orthodontic appliances is in the dental diagnostic and treatment the maxilla. Distal adjustment of tooth position considerations. in the maxilla alone, or in conjunction with They have described the type of care to be mandibular growth, is the basis for correction. rendered according to the severity of the If space required for the tooth adjustment is handicap – mild, moderate, severe. gained in the second molar area, only as much Timing, case selection and management are space as required need be used, with the the main factors in treating or not treating the subsequent mesio-vertical eruption of the handicapped patient. maxillary third molars filling the gap. It is important to weigh the possible benefits Maxillary 2nd molar removal expedites to the child with the individual’s physical and correction of Class II division 1 malocclusion, dental status as affected by his ability to provided that: comprehend and cope with orthodontic There is excessive labial inclination of the procedures. maxillary incisors, with no spacing. Overbite is minimal. The “Three M’s”: Muscles, Malformation 3rd molars are present in the maxilla, in good and Malocclusion position and of proper shape. — TM Graber (AJO, 1963) The cases offering the poorest prognosis for In this classic article, Dr Graber has analyzed maxillary 2nd molar extraction are severe muscles and their relationship to structural basal dysplasias with vertically inclined Dr TM Graber’s Contribution to Orthodontics 79

maxillary incisors, no spacing, and severe Possible unilateral response in correction of overbite. class II relationship, and Difficulty in the control of excessive overbite. Maxillary Second Molar Extraction in Class II Malocclusion Dentofacial Orthopedics versus Orthodontics — TM Graber (AJO, 1969) — Graber, Chung, Aoba (JADA, 1967) In this paper, Dr Graber has again dwelled In this paper, the authors have reported that upon the removal of upper 2nd molars as a orthopedic therapeutic measures with heavy therapeutic means for correction of Class II and interrupted force against the bone may be malocclusion. used successfully in orthodontics. He recommends the extraction of maxillary Greater use of this type of extraoral force is 2nd molars in those instances in which there recommended because of its superior ability are good maxillary 3rd molars and where there to correct basal jaw anteroposterior mal- is a significant Class II/1 malocclusion and relationships. involvement of all 4 tissue systems – teeth, bone, In addition, there is greater stability, a lower muscle and nerve. percentage of tooth extractions, minimal use A fixed lingual arch is used to prevent the of intra-oral appliances, less attendant mandibular 2nd molars from over-erupting. orthogenic damage (decalcification, root The results appear to be stable over a long resorption), minimal chair time, and longer period of time. intervals between appointments. The iatrogenic reaction is minimal or non- An occipital base of anchorage is more existent. satisfactory for correction of Class III mandibular prognathism. Extraoral Force—Facts and Fallacies In cases of open bite, the direction of restrictive — TM Graber (AJO, 1955) force must be as vertical as the design of the Dr Graber studied 150 cases of Class II/1 cranial cap will permit. malocclusion treated with extra-oral force In Class II/1 malocclusion, a cervical source using the same type of appliance. of anchorage is satisfactory. The appliance consisted of molar bands, a .045 Heavy Intermittent Cervical Traction in inch stainless steel labial arch wire with Class II Treatment: A Longitudinal vertical spring loops at the lateral-canine Cephalometric Assessment embrasure to receive the cervical gear. This was — Mills, Holman, Graber (AJO, 1978) a metal tube with a continuous spring inside to provide distal motivating force. Investigated the changes brought about in the He concluded that: dentofacial complex as a result of the use of Class II/1 malocclusions are amenable to heavy cervical traction forces applied correction by the use of extraoral force. Marked intermittently in the maxilla in growing Class II improvement in the basal relations can be division 1 patients, and compared with obtained; overbite and overjet problems can untreated controls. be helped greatly. Their findings showed that there was: Coordination of treatment with the pubertal A stable reduction in the ANB angle is seen. growth spurt ensures a greater likelihood of SNA did not move downward during success [10–12 years in girls; 12–17 years in boys]. treatment; no significant tipping of PP Certain untoward sequale may be seen in the occurred. use of extraoral force. These include: Less forward progress of point B and Pog Incomplete correction of tooth malrelationship, occurred in treated group. Thus, SNB was Excessive distal tipping of maxillary 1st molars, constant. Possible impaction of maxillary 2nd or 3rd Mandible was rotated downward and molars, backward—slight increase in SN-MP angle. Possible excessive lingual tipping of maxillary Significant decrease in overbite occurred incisors, during treatment. 80 History of Orthodontics

U1-SN decreased during treatment, but are older than 10 years of age, and that increased during follow-up. protraction in combination with an initial Treatment had marked withholding effect on period of expansion may provide more normal downward and forward eruption of significant skeletal effects. maxillary 1st molars. However, in post- treatment period, these teeth erupted more than Craniofacial Features of Patients with in controls, losing some of the treatment effect. Class III Abnormalities: Growth-related Distal tipping of upper molars occurred during Changes and Effects of Short-term and treatment, but relapsed after appliance Long-term Chin-cup Therapy removal. — Deguchi, Kuroda, Minoshima and Graber Distal uprighting of lower molars and incisors (AJODO, 2002) occurred during treatment. Molar position was The craniofacial features of patients with stable, but incisors relapsed following Class III abnormalities, including growth- treatment. related changes and effects of short-term and Sagittal arch length decreased significantly long-term chin-cup therapy, were studied. during treatment. This effect was stable. Twenty female subjects were treated with chin- Both the downs OP and functional OP tipped cups and an orthopedic force of 500 g for 31 downward anteriorly as a result of treatment, months (short-term treatment group). Another and relapsed insignificantly following 36 female patients were treated with chin-cups treatment. and a force of 250 to 300 g for 86 months (long- Anterior facial height increased more than term treatment group). normally as a result of treatment. Most of this Cross-sectional lateral films of 562 skeletal change took place in the lower facial height. Class III girls served as controls. Their results showed that: The Effectiveness of Protraction Face Mask Short-term treatment resulted in a slight Therapy: A Meta-analysis improvement in ANB angle and Wits — Kim, Viana, Graber, Omerza and BeGole appraisal, while long-term treatment resulted (AJODO, 1999) in a significant improvement in ANB angle This study examined the effectiveness of maxillary and Wits appraisal. protraction with orthopedic appliances in Such treatment also resulted in a significant Class III patients. A meta-analysis of relevant inhibition of the growth of the ramus (2.2 mm) literature was performed to determine whether a and body length (3.6 mm) of the mandible, a consensus exists regarding controversial issues backward rotation of the mandible, and a such as the timing of treatment and the use of reduction (8.2°) of the gonial angle. adjunctive intra-oral appliances. However, there was no alteration of any The results showed that there was: parameter of the maxilla and the cranial base, No distinct difference between the palatal except the length of S-N and N-S-Ar in the long- expansion group and non-expansion group term treatment group. except for 1 variable, upper incisor angulations, which increased to a greater Long-term Application of Chin-cup Force degree in the non-expansion group. This Alters the Morphology of the Dolichofacial finding implies that more skeletal effect and Class III Mandible less dental change are produced in the — Deguchi, Kuroda, Hunt and Graber (AJODO, 1999) expansion appliance group. Investigated the immediate and long-term Examination of the effects of age revealed effects of prolonged use (mean, 7 years 2 greater treatment changes in the younger months) of chin-cup appliances in subjects group. with dolichofacial Class III mandibles. Results indicate that protraction face mask Thirty six female subjects with severe skeletal therapy is effective in patients who are Class III malocclusions, associated with large growing, but to a lesser degree in patients who gonial angles, were studied. Dr TM Graber’s Contribution to Orthodontics 81

At post-treatment (T1, 65 months duration) and Magnetic versus Mechanical Expansion with post-retention (T2, 56 months after T1), Ar-Me Different Force Thresholds and Points of and Wits appraisal cephalometric parameters Force Application were significantly different between patients —Vardimon, Graber, Voss and Verrusio (AJODO, 1987) and control subjects (n = 230). Studied the effects of force magnitude (high vs The Go-Me parameter in treated subjects was low) and point of force application (tooth vs direct longer than that of the controls at T0 but palatal endosseous pins) on palatal expansion became significantly shorter at T2. treatment in 4 Macaca fascicularis monkeys. Ar-Go parameter increased less than the controls at T2. Animal 1 (IS) Results indicate that long-term use of the chin-cup appliance (>5 years) is effective in Received an upper acrylic appliance with an subjects with severe skeletal Class III expansion screw. abnormality. The appliance was bonded bilaterally from canine to 1st molar. Rare Earth Magnets and Impaction Thus, high forces (2033 g) were transmitted — Vardimon, Graber, Drescher and Bourauel (AJO, 1991) indirectly to the mid-palatal suture via the abutment teeth. Introduced a new, magnetic attraction system, with a magnetic bracket bonded to an impacted Animal 2 (IM) tooth and an intra-oral magnet linked to a Hawley-type retainer for stimulating the natural Received two permanent SmCo5 magnets in eruption of an impacted tooth into the oral repelling configuration. cavity. The appliance was bonded to the abutment The magnetic system consisted of a magnetic teeth (canine and 1st molar). bracket and an intra-oral magnet. It transmitted low forces (258 g) indirectly to A miniaturized prism-shaped Nd2Fe14B the mid-palatal suture. magnetic alloy in an un-magnetized form was Sliding (A) and stationary (B) acrylic housings ground down (width = 2.20 mm × height = to receive the magnets. (C) Acrylic occlusal 2.59 mm × depth = 2.02 mm) to fit into an extensions to be bonded to dental arch. (D) enlarged intra-bracket space, i.e. into the space Horizontal tubes to receive the U-shaped bar (E) created between two machined down-tie Vertical holes (F) to retain the reactivation holders wings of a twin bracket. (G) Teflon rings (H) to serve as barriers in the Vertical and horizontal magnetic brackets reactivation process. were designed, with the magnetic axis magnetized parallel and perpendicular to the Animal 3 (DM) base of the bracket, respectively. Received a magnetic unit linked to a plate The vertical type is used for impacted incisors attached to the palate via 4 endosseous pins. and canines. It transmitted low forces (258 g) directly to the Horizontal magnetic bracket is applied for palatal shelves. impacted premolars and molars. Animal 4 (control): received a passive sham Rare Earth Magnets appliance bonded to abutment teeth. Graber described the potential for the clinical Their results showed that: utilization of rare earth magnets for the following Treatment time was longer in the low force, purposes: magnetically-induced appliances groups – 33 Space control (space closure/opening) days in IS, 135 days in IM and 95 days in DM Open bite therapy (intrusion of posterior teeth) groups. Palatal expansion In animal IS, a diastema developed between Growth guidance (functional appliances) the incisors and the force was directed supero- De-impaction of canines and molars. laterally and then transmedially, thus causing 82 History of Orthodontics

fractures in the nasal complex and other Magnetic Strength and Corrosion of iatrogenic sequelae. Rare Earth Magnets In the magnetically-induced appliances, the — Ahmad, Drummond, Graber, BeGole (AJODO, 2006) force radiated supero-laterally, dissipating in Evaluated several magnet coatings and their the zygomatico-frontal suture, and the overjet effects on magnetic flux density. significantly increased due to marked Sixty neodymium-iron-boron magnets were widening of incisive and transverse sutures. divided into 6 equal groups—polytetra- The palatally pinned magnetic appliance fluoroethylene-coated (PTFE), parylene- produced bodily tooth movement, the greatest coated, and noncoated. increase in inter-molar distance, and a They were subjected to 4 weeks of aging in superior positioning of the maxillo-palatine saline solution, ball milling, and corrosion region. testing. Their results suggested reduction of Their results showed a significant decrease in conventional forces for palatal expansion by magnet flux density after applying a protective up to eight-fold, through the use of rare earth layer of parylene, whereas a slight decrease magnets. was found after applying a protective layer of PTFE. Stability of Magnetic versus Mechanical After 4 weeks of aging, the coated magnets Palatal Expansion were superior to the non-coated magnets in — Vardimon, Graber and Voss (EJO, 1989) retaining magnetism. Spatial stability following palatal expansion (PE) The corrosion-behavior test showed no treatment was studied longitudinally on 8 significant difference between the 2 types of Macaca fascicular is monkeys. coated magnets, and considerable amounts of The sample was divided into short-term and iron-leached ions were seen in all groups. long-term groups. The authors concluded that throughout the The 4 animals in each group received: processes of coating, soaking, ball milling, and An indirect screw (IS) PE appliance (F = 2035 g). corrosion testing, PTFE was a better coating An indirect magnetic (IM) PE appliance (F = material than parylene for preserving magnet 258 g and 360 g). flux density. However, corrosion testing A direct magnetic (DM) PE appliance (F = 258 g showed significant metal leaching in all and 360 g). groups. A sham appliance. Direct force transmission was via pinning to Functional Orthopedic Magnetic Appliance the palatal shelves, indirect transmission was (FOMA) II—Modus Operandi via abutment teeth. — Vardimon, Stutzmann, Graber, Voss, Petrovic This study indicated that: (AJODO, 1989) Transverse stability was greatest in the Introduced a new functional appliance (FA) skeletally borne appliance. to correct Class II dentoskeletal malocclusions. Inter-canine distance relapse was 53% for IS The FOMA II uses upper and lower attracting and 23% for DM groups. magnets (Nd2Fe14B) to constrain the lower jaw Inter-molar expansion was more stable than in an advanced sagittal posture. inter-canine expansion due to selective activity In vitro, a special gauge transducer measured of circummaxillary sutures and root the magnetic attractive path and forces. configuration. In vivo, 13 prepubertal female Macaca Sagittal advancement and vertical superior fascicularis monkeys received facial implants translation were greater in the magnetic and were treated for 4 months with the appliances with low force PE regimen. following appliances: Clinical implication – low force PE regimen – Conventional FA (4 subjects) can be of substantial benefit in young skeletal – FOMA II (5 subjects) Class III patients with transverse maxillary – Combined FOMA II + FA (2 subjects) deficiency. – Sham (control) appliance (2 subjects). Dr TM Graber’s Contribution to Orthodontics 83

1. The FOMA II consisted of upper and lower malocclusions that exhibit midface sagittal magnetic plates. deficiency with or without mandibular excess. Buccal (solid line) and lingual (dashed The FOMA III consists of upper and lower line) 0.035-inch stainless steel arch wires acrylic plates with a permanent magnet formed the metal substructure. incorporated into each plate. The two arch wires were linked together The upper magnet is linked to a retraction by acrylic overlaying the incisor and molar screw and is retracted periodically (e.g. crowns. monthly) to stimulate maxillary advancement The FOMA II was designed with a and mandibular retardation. magnetic inclined plane (25°). The upper plate of a FOMA III consists of a 2. The conventional FA (feedback plates) guided 0.031-inch stainless steel arch wire forming the mandible to a forward position by using a the metal substructure. The arch wire bypasses slanted guide bar attached to the upper plate the premolar-canine segment to permit and a lower oblique plane of the lower plate. eruption and crosses the occlusal plane at the 3. The combined FOMA II + FA appliance M1-M2 embrasure (a). consisted of a labial magnetic unit and a The upper magnetic housing (b) is linked to a lingual prong system. retraction screw (c). 4. The sham appliance with its passive upper The magnetic unit (b + c) is positioned along and lower plates. the midpalatal line. The screw housing is linked to the plate at the The in vitro results showed the following: M1-M2 level (d). Vertico-sagittally displaced upper and lower Two guiding bars (e), attached to the plate magnets attracted ultimately along an oblique (lingually to the central incisors and laterally line with a terminal horizonal slide to become to the screw housing), and restrains the fully superimposed. magnetic unit from vertical deflection via The functional performance improved when guiding tubes (f). the magnetic interface acted as a magnetic inclined plane. Upper Plate of a FOMA III in The magnetic force was able to guide and an Experimental Animal constrain the mandible toward the constructive protrusive closure position. The attractive mode neodymium magnets used The in vivo results demonstrated the following: in their study produced a horizontal force of Functional performance increased in FOMA 98 g and a vertical force of 371 g. II (22%) and in the combined FOMA II + FA The ratio of horizontal to vertical force vectors (28%) over the conventional FA. is dictated by inclination of magnetic interface Mandibular length increased significantly in in the sagittal plane. the treated animals over the control animals. The more perpendicular the magnetic interface Incisor proclination was lower in magnetic is to the occlusal plane (sin 90° = 1), the greater appliances than in the conventional FA. is the horizontal force vector. Mandibular elongation and condylar posterior The interaction between sutural and condylar inclination resulted from posterosuperior growth sites appeared biphasic, characterized by endochondral growth and by bony an immediate and rapid excitation of the remodeling of the condylar neck. circummaxillary sutures followed by a delayed No anterior displacement of the post-glenoid and slow suppression of the condylar cartilage. spine nor the articular eminence was found. Maxilla The Functional Orthopedic Magnetic 1. The target area of the protractive force was Appliance (FOMA) III found to be localized in the pterygomaxillary — Vardimon AD, Graber TM, Voss LR, Muller fissure. (AJODO, 1990) 2. Three-dimensionally, the separation of the Developed an intraoral inter-maxillary sutures at the PMF was found to diminish in appliance for the treatment of Class III inferosuperior and lateromedial directions. 84 History of Orthodontics

Mandible The impairment/repair dynamics were found to be dominated by 3 principles: ERR level of The fact that no pathologic change was found in irreversibility, delayed resorption response the condylar cartilage encourages a long-term use and jiggling. of the FOMA III appliance, initiating treatment at an early skeletal age. Repair of Orthodontically Induced Root A later radiographic and histologic study by Resorption by Ultrasound in Humans Vardimon, Graber et al (AJODO, 1994), again — El-Baily, El-Shamy and Graber (AJODO, 2004) on nine Macaca fascicularis monkeys who were treated for 4 months with FOMA III revealed This study evaluated the effect of low-intensity the following data: pulsed ultrasound (LIPUS) on the healing 1. The growth pattern of the cranial base process of orthodontically induced tooth-root (saddle angle) was not altered. resorption in humans. 2. Midfacial protraction occured along a Twelve orthodontic patients who were seeking recumbent hyperbolic curve with a orthodontic treatment that necessitated horizontal maxillary displacement and an extracting the first premolars before anterosuperior premaxillary rotation. mechanotherapy participated in this study. 3. Cumulative protraction of the maxillary For each patient, buccally activated springs complex was initiated at the pterygom- were used to tip the maxillary first premolars axillary fissure with an additional buccally, with an initial force level of 50 g. contribution provided by other A short period of LIPUS was applied to 1 side circummaxillary sutures (zygomaticom- of each patient’s mouth, with the other side axillary s., transverse s., premaxillary s.). used as a control. 4. Inhibition of mandibular length was After 4 weeks, the experimental premolars of minimal, but a tendency toward a vertical all patients were extracted, and the premolars condylar growth pattern was observed. of 6 patients were studied by scanning electron microscopy (SEM); the premolars of the other Determinants Controlling Iatrogenic 6 patients were studied histologically. External Root Resorption and Repair The SEM study showed a statistically During and After Palatal Expansion significant decrease in the areas of resorption —Vardimon, Graber, Voss, Lenke (AO, 1991) and the number of resorption lacunae in the In this study, the mechanisms controlling LIPUS-exposed premolars. external root resorption (ERR) and repair were Histologic examination showed healing of the studied on 8 Macaca fascicularis monkeys. resorbed root surface by hypercementosis. The animals were treated with jackscrew, The results of this study provide a non- magnetic and sham palatal expansion screws. invasive method for reducing root resorption They were divided into short- and long-term in humans. groups. SEM morphometric analysis found major Repair Process of External Root Resorption evidence of ERR in the tooth-borne jackscrew Subsequent to Palatal Expansion Treatment appliance, in the long-term group, in the —Vardimon, Graber and Pitaru (AJODO, 1993) maxillary premolars, on the buccal and The repair process of external root resorption furcation root surfaces, on the mesio-buccal (ERR) and the role of retention mechanics in root and in the apical zone. enhancing ERR repair were studied on eight Correspondingly, the ERR mechanism is Macaca fascicularis monkeys that were divided controlled by impulse (F. Δt) and the critical equally into short- and long-term groups. Six barrier of the PDL as primary determinants monkeys received palatal expansion and by the environment density as the appliances, and 2 received sham appliances. secondary determinant. The short-term group received active ERR is initially regulated by the force treatment. component of the impulse and, with increased The long-term group received additional duration, by the time component. retention (4 months) and relapse (2 months) Dr TM Graber’s Contribution to Orthodontics 85

treatment periods with biweekly injections of There is an abnormally large contribution of individual vital dye per phase, i.e. procion red upper face height to total face height when the H-8B and violet H-3R (80 mg/kg B.W.), teeth are in occlusion, due to vertical maxillary respectively. deficiency. Their results showed that: There is markedly larger inter-maxillary The short-term group demonstrated penetrated clearance or freeway space in CP individuals resorption with pulp exposure at sites with when compared to normal. This suggests that initial deficiency of the protecting odontoblastic while there is a bony insufficiency, the general layer (apical zone, nutrition canal). musculature attempts to maintain a normal The long-term group showed two forms of ERR developmental pattern and relation of parts. repair: Mandibular growth on the whole appears 1. Non-functional retarded repair cementum, normal. Values taken with the teeth in comprised of overlapped incremental lines occlusion indicate over closure. and deprived of extrinsic fibers, was There is excessive lingual axial inclination of delineated in severe pulp exposure. the lower incisors to the mandibular plane. The pulp/dentin complex showed intense The maxillary 1st molar tends towards a distal incorporation of procion dye in the position with reference to craniometric dentinal tubuli, conceivably related to a measurements outside the maxilla. defense response in the form of sclerotic Surgical correction can limit the growth dentin. potential of the maxillary denture. 2. Functional rapid repair cementum, The clinical results of orthodontic treatment, comprised of discriminated incremental while improving the tooth-to-tooth lines mainly of mixed cellular cementum, relationship in some cases, does not with a consistent pattern of five sequential necessarily stimulate basal bone development. phases: the lag phase (14–28 days), the Therapeutic results are often unstable and incipient phase (14 days), the peak phase have to be maintained indefinitely. (14–28 days), the steady phase (42–56 days) and the retreating phase (70 days). A Functional Study of the Palatal and Sharpey’s fibers at functional ERR sites Pharyngeal Structures were scarce, never emerging from the — Graber, Bzoch, Aoba (AO, 1959) dentinocemental junction, and not Using high speed roentgenographic developing into principal fibers. The pulp/ equipment, the soft tissue morphology of dentin complex showed an increase in normal subjects was studied during the instant pulp stones but no formation of tertiary of production of various consonant sounds dentin. The apical area responded by (p, b, f, w, m). hypercementosis in the form of apical Biometric analysis was made. occlusion and a displaced pulp canal. Following conclusions were drawn: Soft palate increases significantly in length GRABER’S OTHER CONTRIBUTIONS TO from the rest to functional position. ORTHODONTICS The greatest extent of the upward and A Cephalometric Analysis of the backward movement of the palate takes place Developmental Pattern and Facial at the midpoint of the posterior superior Morphology in Cleft Palate surface of the palate (mean = 16 mm). — TM Graber (AO, 1949) The velopharyngeal valve is consistently closed for all the consonant sounds during Thirty three cleft palate patients (22 males, 11 normal speech production. females) were studied cephalometrically. Slight anterior movement of the posterior It was found that: pharyngeal wall is seen in 50% of normal The maxilla in Cleft palate patient’s cases is cases. deficient in antero-posterior, lateral, as well The authors concluded that the orthodontist, as vertical growth. as well as the prosthodontist and speech 86 History of Orthodontics

therapist, should profit from a better correct a variety of developmental jaw appreciation of normal speech physiology. deformities, whether they are hereditary or traumatic in origin. Postmortems in Post-treatment Adjustment The patient is best served by this teamwork, — TM Graber (AJO, 1966) not only during the actual mechanical and In this classic article, Dr Graber stresses the operative phases, but also during the initial need for a longer period of orthodontic diagnostic and treatment planning phases, management in many cases. that are every bit as important. He says that, with the orthodontists’ Proper diagnosis requires a thorough dependence on pattern and growth and knowledge of growth and development, of development, it is essential to keep patients cephalometric analysis, of occlusion and under observation longer and observe the proper jaw relationships, and of surgical and status of the stomatognathic system in its orthodontic techniques to correct these biologic continuum. deformities. The concept of treating the malocclusion once Here, the orthodontist, because of his training and then considering it finished is un- and experience in these aspects, can be physiologic. Thus, the philosophy of a longer invaluable to the surgeon. orthodontic management and responsibility, with two or three shorter periods of orthodontic Post-pharyngeal Lymphoid Tissue in Angle mechanotherapy, is more appropriate. Class I and Class II Malocclusions — Sosa, Graber and Muller (AJO, 1982) Serial Extraction: A Continuous Diagnostic Studied the relationship between the adenoid and Decisional Process tissue and type of malocclusion. — TM Graber (AJO, 1971) Xeroradiographic lateral cephalograms were Serial extraction is a guided, progressive made of 80 Class I and 64 Class II/I removal of deciduous teeth ahead of the time malocclusions. they would normally be shed, to enlist the The epipharyngeal lymphoid tissue, fundamental phenomena of adaptability and nasopharyngeal airway, nasopharynx and adjustment. certain cephalometric landmarks were Dr Graber states that the technique is measured. biologically sound, proven, and should not be Their results showed that: considered a compromise. There is no clear-cut relationship between In almost all instances of serial extractions, either Class I or Class II/I malocclusions and conventional orthodontic therapy is required the total nasopharyngeal area. to complete the alignment of teeth, to parallel Sexual dimorphism was seen: the roots, to eliminate overbite and to effect – Class I males: widening of antero-posterior residual space closure. However, the duration dimension of nasopharynx is associated of such mechanotherapy is significantly with anterior rotation of the mandible, shorter, is likely to produce less damage, and longer maxillas, larger SNB angles, the results are more stable. opening of cranial base angle, and increased distance from sella to PNS. Thus, Orthosurgical Teamwork these patients have more anteriorly — Olson, Mincey and Graber (JADA, 1975) positioned maxilla and mandible. Using the examples of 6 patients with different – No association was present at all for Class malocclusions, the authors have reported on II/I males. the combined orthodontic-surgical approach – Class II/I females: larger nasopharyngeal towards treatment. area is associated with longer maxillae and They state that surgery and orthodontics can smaller palatal plane angles, and anterior separately, but surely better in combination, rotation of mandible. Dr TM Graber’s Contribution to Orthodontics 87

Orthodontics and Temporomandibular They received therapeutic US on one side of Disorder: A Meta-analysis the mandible for 20 minutes/day for four — Kim, Graber and Viana (AJODO, 2002) weeks. In this meta-analysis, the relationship between Anthropometrical and histological evaluations traditional orthodontic treatment, including revealed that US enhances mandibular growth the specific type of appliance used and by condylar endochondreal bone growth and whether extractions were performed, and the consequently mandibular ramus growth. prevalence of temporomandibular disorders It thus increases the mandibular condylar, (TMD) were investigated. ramal, and total mandibular heights in Their data indicated that traditional growing rabbits. orthodontic treatment did not increase the Dr Thomas M Graber was certainly a prevalence of TMD. pioneer amongst men. His complete devotion and love for the specialty of orthodontics is Growth Modification of the Rabbit reflected in his extensive works on a myriad of Mandible Using Therapeutic Ultrasound: topics, spanning over a period of nearly six Is it Possible to Enhance Functional decades. Appliance Results? As Dr Graber’s family friend and — El-Bialy, El-Shamy, Graber (AO, 2003) colleague, Dr Jim McNamara noted, “Tom’s The objective of this study was to evaluate the energy and enthusiasm for our profession effect of therapeutic US on condylar and make him a wonderful role model for future mandibular growth in the rabbit model. generations of orthodontists.” The passing of Eight growing New Zealand male rabbits were Dr Thomas M Graber marks the end of an era chosen for this study. in orthodontics. 88 History of Orthodontics

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James McNamara Analysis Relating Mandible to Cranial Studies on Functional Relating the Maxilla to the Base Appliances Cranial Base Dentition Analysis Studies on Rapid Maxillary Relating the Mandible to the Airway Analysis Expansion Maxilla (Midface) Studies on TMJ

Dr McNamara received his dental and of Michigan Elementary and Secondary School orthodontic education at the University of Growth Study, one of the largest longitudinal California, San Francisco, and a Doctorate in studies of untreated individuals in the world. Anatomy from the University of Michigan. He This unique collection allows the study of facial serves as the Thomas M and Doris Graber development from the early juvenile period to endowed Professor of Dentistry in the middle age in the same group of untreated Department of Orthodontics and Pediatric subjects, providing a basis of comparison for Dentistry, Professor of Cell and Developmental ongoing clinical investigations. Biology in the University of Michigan Medical School and Scientist at the Center for Human JAMES McNAMARA ANALYSIS Growth and Development. He is the author Presented by Dr James A McNamara as an (with artist William L Brudon) of the new text, original article in the December 1984 issue of the Orthodontics and Dentofacial Orthopedics. He American Journal of orthodontics. has maintained a private practice in Ann Arbor He asserts that his analysis method is since 1971. He is a Diplomate of the American presented as a language, which can be used Board of Orthodontics and a Fellow of the by the clinician to better identify and describe American College of Dentists. In addition, Dr the structural relationships of the jaws, as well McNamara is editor-in-chief of the 40 volume as to communicate easily with other clinicians Craniofacial Growth Monograph Series as well as lay persons. published through the University of Michigan. This method of analysis is derived in part from He has published over 180 scientific articles in the principles of the Ricketts’ and Harvold refereed journals, has written, edited or analyses. contributed to 53 books, and has presented The James McNamara analysis is useful in courses and lectures in 30 countries. More diagnosis and treatment planning of the recently, McNamara has focused on clinical individual patient when values derived from studies of the effects of orthodontic, orthopedic the tracing of the patients’ head film are and surgical interventions on the growth of the compared to established norms; the norms face. He serves as the curator of The University from three groups have been derived: James McNamara's Contribution to Orthodontics 89

– The Bolton study Normative Standards in McNamara Analysis are – The Ann Arbor sample (200 adults) listed below (Table 10.1). – The Burlington sample. Table 10.1: Normative Standards in McNamara This analysis consists of five major sections: Analysis – Relating maxilla to cranial base Midfacial Mandibular Lower anterior – Relating maxilla to mandible length (mm) length (mm) facial height (mm) – Relating mandible to cranial base (Co-point A) (Co-Gn) (ANS-Me) – The dentition – Airway analysis. 80 97–100 57–58 81 99–102 57–58 I. RELATING THE MAXILLA TO THE 82 101–104 58–59 CRANIAL BASE (FIG. 10.1) 83 103–106 58–59 84 104–107 59–60 Soft Tissue Evaluation 85 105–108 60–62 The nasolabial angle and cant of upper lip should 86 107–110 60–62 be examined both clinically and cephalometrically. 87 109–112 61–63 The nasolabial angle is formed by the intersection of 88 111–114 61–63 a line tangent to the base of the nose with a line 89 112–115 62–64 tangent to the upper lip. Norms for nasolabial angle 90 113–116 63–64 according to: Ann Arbor adult sample = 102 ± 8°. 91 115–118 63–64 An acute nasolabial angle can be a reflection of 92 117–120 64–65 dentoalveolar protrusion, but it can also occur 93 119–122 65–66 because of the orientation of the base of the nose. 94 121–124 66–67 The cant of the upper lip should be evaluated relative 95 122–124 66–67 96 124–127 67–69 to the vertical orientation of the face. The upper lip to 97 126–129 68–70 nasion perpendicular angle should be: 98 128–131 68–70 ± 14° 8.2° in females 99 129–132 69–71 8.4° ± 7.8° in males. 100 130–133 70–74 101 132–135 71–75 Hard Tissue Evaluation 102 134–137 72–76 103 136–139 73–77 In an evaluation of the position of the maxilla 104 137–140 74–78 relative to the cranial base, two factors are 105 138–141 75–79 considered: The skeletal relationship of point A to the nasion perpendicular. Nasion Perpendicular to Point A The first measurement to be made is the linear distance from point A to the nasion perpendicular. In the composite norms for adults of both sexes in this analysis, point A is 1 mm ahead of the nasion perpendicular line.

II. RELATING THE MANDIBLE TO THE MAXILLA (MIDFACE) The lengths of the mandible and the maxilla (midfacial region) are related. The effective maxillary length—line from condylion to point A. The effective mandibular length—line from Fig. 10.1: Relating the Maxilla to the cranial base condylion to anatomic gnathion. 90 History of Orthodontics

A geometric relationship exists between the mandibular length and are not directly related effective length of the midface and that of the to the age or sex of the individual subject. mandible. Any given effective midfacial length Once the effective length of the midface is corresponds to a given effective mandibular known, the effective mandibular length can length. be estimated. If the effective midfacial length is subtracted from the mandibular length, the maxillo- Vertical Relationship (Fig. 10.2) mandibular differential can be determined. Lower anterior facial height. It is measured Ideally this differential is 20 mm for small- from ANS to Me. sized persons, 25–27 mm for medium-sized In well-balanced faces the vertical dimension persons and 30–33 mm for large-sized persons. correlates with the effective length of the Composite norms have been extrapolated from midface. the values derived from the Bolton and Mandibular plane angle(Fig. 10.3): Angle Burlington samples, as well as from the Ann between F-H plane and Go-Me. Arbor sample. – Normal Value: 22°+/–4° These norms represent a geometric relationship – Higher Value: Excessive lower facial between effective midfacial length and effective height

A B

Figs 10.2A and B: (A) Vertical maxillary excess results in downward and backward positioning of the mandible creating excessive anterior facial height (ANS-M); (B) Vertical maxillary dentoalveolar deficiency causing an upward and forward positioning of the mandible and deficient lower anterior facial height (ANS-M)

A B

Figs 10.3A and B: (A) Mandibular plane angle of 22 degrees to Frankfort horizontal in average normal individual; (B) High mandibular plane angle suggestive of excessive lower facial height James McNamara's Contribution to Orthodontics 91

– Lower Value: Deficiency in lower facial Relating the Lower Incisor to the Mandible height Anteroposterior position of Lower Incisor: Determined Facial axis angle: Angle between Postero- by using a traditional version of the Ricketts superior aspect of pterygomaxillary fissure to measurement of the facial surface of the lower gnathion and Line joining Basion to Nasion. incisor to the A-Pog line. – Balanced Face = 90° Bolton study Norms: – Excessive vertical development, less than 1.5 mm anterior to the A-Pog Line. 90°(negative value) Ann Arbor Norms: – Deficient vertical development, higher 2.3–2.7 mm anterior to the A-Pog Line. than 90°(positive value).

III. RELATING MANDIBLE TO CRANIAL BASE (FIG. 10.4) The relationship of the mandible to the cranial base is determined by measuring the distance of the pogonion to the Nasion perpendicular. According to the composite norms: – In a mixed dentition (balanced face) pog lies 8 mm to 6 mm (posterior) with respect to Nasion perpendicular and moves forward with growth. – In adult male the chin position is usually –2 mm to +2, relative to Nasion perpendicular.

IV. DENTITION ANALYSIS Relating Upper Incisor to Maxilla (Fig. 10.5 and 10.6) A vertcal line is drawn through point A parallel to Fig. 10.5: Method of determining position of upper incisor relative to point A. NP = nasion perpendicular; PNP = point A nasion. The distance from point A to the facial vertical constructed parallel to nasion perpendicular through surface of Upper incisor is measured → A-P position point A; D anteroposterior distance from upper incisor to of Upper incisor Norms = 4–6 mm (Adults). point A (should be 4–6 mm)

A B

Figs 10.4A and B: Mandible to cranial base measured from pogonion to nasion perpendicular. Tracing (A) shows normal mandible to cranial base relationship in an adult woman. Tracing (B) shows serverly retrusive mandible (–31 mm) and mildly retrusive maxilla (–3 mm) 92 History of Orthodontics

Upper Pharynx The upper pharyngeal width is measured from a point on the posterior outline of the soft palate to the closest point on the posterior pharyngeal wall (Fig. 10.7A and B). This measurement is taken on the anterior half of the soft palate outline because the area immediately adjacent to the posterior opening of the nose is critical in determining upper respiratory patency. Apparent airway obstruction, as indicated by an opening of 5 mm or less in the upper pharyngeal measurement, is used only as an indicator of possible airway impairment. A more accurate diagnosis can be made only Fig. 10.6: Severely protrusive upper incisors (11 mm) in a by an ENT specialist. protrusive maxilla Lower Pharynx Vertical Position of Lower Incisors Lower pharyngeal width is measured from the Evaluated on basis of existing lower anterior facial intersection of the posterior border of the height. First, the lower incisor tip is related to the tongue and the inferior border of the mandible functional occlusal plane. to the closest point on the posterior pharyngeal If curve of Spee is excessive: lower incisor is to be wall (Fig. 10.7A). intruded (if LAFH is normal/excess) OR lower Average measurement is 11–14 mm molar is allowed to erupt and lower incisor independent of the age. extruded (when LAFH is inadequate). According to the measures derived from the Ann Arbor sample, the average value for this V. AIRWAY ANALYSIS measurement is 10–12 mm and does not change appreciably with age (Fig. 10.8). Two measurements are used to examine the possibility of airway impairment.

A B

Figs 10.7A and B: (A) Average normal upper pharyngeal airway space A, in this instance 15 mm. Lower pharyngeal airway space B measurement is 11 mm; (B) Possible upper airway obstruction; measurement A is approximately 2 mm James McNamara's Contribution to Orthodontics 93

functional appliance than in those wearing the tissue-borne appliance.

Treatment and Post-treatment Effects of Acrylic Splint Herbst Appliance Therapy —Franchi L, Baccetti T, McNamara JA Jr. AJO 1999 This study evaluated the skeletal and dentoalveolar changes induced by acrylic splint Herbst therapy of Class II malocclusion. The study showed that two-thirds of the achieved occlusal correction was due to skeletal effects and only one-third to dentoalveolar adaptations. Both skeletal and dentoalveolar effects were mainly due to changes in mandibular structures. A significant amount of relapse in Fig. 10.8: A patient with a normal lower pharyngeal measurement molar relationship occurred during the post- treatment period, and this change could be ascribed to the mesial movement of the upper molars. Obstruction of the lower pharyngeal area because of a posterior positioning of the tongue Linda Ratner Toth, James A McNamara Jr. against the pharyngeal wall is rare. AJO 1999 A greater than average pharyngeal width on the other hand suggests a possible anterior Twin-block and FR II compared with untreated positioning of the tongue either due to habitual class II. posture or due to tonsillar enlargement. Mandibular length increase in Twin-block- Clinical conditions that can be associated with 3 mm a forward tongue position and/or enlarged Mandibular length increase in FR II- 1.9 mm. tonsils: The present study suggests, that Class II – Mandibular prognathism correction with the Twin-block appliance is – Dentoalveolar anterior crossbite achieved through normal growth in addition – Bialveolar protrusion of the teeth. to mandibular skeletal and dentoalveolar changes. STUDIES ON FUNCTIONAL APPLIANCES Class II correction with the FR-2 is more —James A McNamara Jr, Raymond P Howe, skeletal in nature, with less dentoalveolar Terry G Dischinger. AJO 1990 changes noted. The present study suggests, therefore, that This study investigated the treatment effects Class II correction can be achieved with either produced by the tooth-borne (Herbst appliance system evaluated here. The FR-2 appliance) and one primarily tissue-borne appliance appears to have primarily a skeletal (FR-2). effect, whereas, the Twin-block appliance The results of this study indicated that both produces both skeletal and dentoalveolar appliances had influenced the growth of the adaptations. craniofacial complex in treated persons. Significant skeletal changes were noted in both Tiziano Baccetti, Lorenzo Franchi, Linda treatment groups, with both groups showing Ratner Toth, James A McNamara Jr. AJO 2000 an increase in mandibular length and in lower facial height, as compared with controls. The findings of this short-term cephalometric Greater dentoalveolar treatment effects were study indicate that optimal timing for the noted in the group wearing the tooth-borne orthodontics treatment. 94 History of Orthodontics

Cephalometric parameter used in McNamara analysis are summarized in this below table along with their respective normative value (Table 10.2).

Table 10.2: McNamara Analysis Name of Patient ______Age ______Sex ______

Normal Patient Comment 1. Maxilla to Cranial Base Nasolobial angle 14 (±8) ______8 (±8) ______No. Perp. to point A 0–1 mm ______

2. Maxilla to Mandible* Anteroposterior Mand. length (Co-Gn) ______Max. length (Co-Point A) ______Max./mand. differential Small 20–23 mm ______Med. 27–30 mm ______Large 30–33 mm ______Vertical L. ant. fac. ht. (ANS-Menton) Small 60–62 mm ______Med. 65–67 mm ______Large 70–73 mm ______Mand. PL (FH-Go-Menton) 22 (±4) ______Facial axis (Ba-N) = (PTM-Gn) 0 (±3.5) ______

3. Mand. to Cranial Base (Pog-Na Perp.) Small –8 to –6 mm ______Med. –4 to 0 mm ______Large –2 to +2 mm ______

4. Dentition 1 to Point A 4–6 mm ______1 to A-Po 1–3 mm ______

5. Airway Upper pharynx 15–20 mm ______Lower pharynx 11–14 mm ______

Summary Conclusion

Twin-block therapy of Class II disharmony is The Importance of the Assessment of during or slightly after the onset of the pubertal Skeletal Maturity and the Onset of the peak in growth velocity. Pubertal Growth Spurt in Individual Patients When compared with treatment performed has to be Emphasized as a Fundamental before the peak, late Twin-block treatment Diagnostic and Decision-making Tool in produces more favorable effects that include Treatment Planning for Class II Malocclusion – Greater skeletal contribution to molar — Faltin KJ, Faltin RM, Baccetti T, Franchi L, correction Ghiozzi B, McNamara JA Jr. AO 2003 – Larger increments in total mandibular The findings of the present study on Bionator length and in ramus height therapy followed by fixed appliances indicate – More posterior direction of condylar that this treatment protocol is more effective growth, leading to enhanced mandibular and stable when it is performed during the lengthening. pubertal growth spurt. James McNamara's Contribution to Orthodontics 95

Optimal timing to start treatment with the STUDIES ON RAPID MAXILLARY EXPANSION Bionator is when a concavity appears at the Joyce Y Chang, James A McNamara lower borders of the second and the third Jr,Thomas A Herberger. AJO 1997 cervical vertebrae (CVMS II). In the long-term, the amount of significant supplementary The purpose of this investigation was to elongation of the mandible in subjects treated examine the long-term effect of the Haas-type during the pubertal peak is 5.1 mm more than in RME on bite opening and on the antero- the controls, and it is associated with a posterior position of the maxilla. backward direction of condylar growth. There was no significant difference among Significant increments in mandibular ramus groups receiving rapid maxillary expansion, height also were recorded. followed by edgewise treatment (RME), standard edgewise therapy alone (SET), or no de Almeida MR, Henriques JF, de Almeida treatment (CTRL). RR, Weber U, McNamara JA Jr Angle. The current investigation of long-term Orthod 2005 treatment effects concludes therefore that RME therapy used in the treatment of patients with The results indicated that the treatment effects Class I and Class II malocclusions does not of Herbst produced in the mixed dentition have a significant long-term effect on either patients were primarily dentoalveolar in the vertical or the anteroposterior dimensions nature. of the face. The mandibular incisors were tipped labially, and the maxillary incisors were retruded; a McNamara JA Jr, Baccetti T, Franchi L, significant increase in mandibular posterior Herberger TA. AO 2003 RME Followed by dentoalveolar height occurred, and there was Fixed Appliances a restriction in the vertical development of the maxillary molars. In comparison with controls, a net gain of 6 mm There was no difference in the forward growth was achieved in the maxillary arch perimeter, of the maxilla between the two groups. whereas a net gain of 4.5 mm was found for the In comparison with the controls, however, the mandibular arch perimeter. Herbst treatment produced a modest but The amount of correction in both maxillary statistically significant increase in total and mandibular intermolar widths equaled mandibular length. two-thirds of the initial discrepancy, whereas treatment eliminated the initial deficiency in Paola Cozza, Tiziano Baccetti, Lorenzo maxillary and mandibular intercanine widths. Franchi, Laura De Toffol, and James A The amount of correction for the deficiency in McNamara, Jr. AJO 2006 maxillary arch perimeter was about 80%, whereas in the mandible a full correction was Two-thirds of the samples in the 22 studies achieved. reported a clinically significant supplementary elongation in total mandibular length (a change Geran RG, McNamara JA Jr, Baccetti T, greater than 2.0 mm ) as a result of overall active Franchi L, Shapiro LM. AJO 2006 treatment with functional appliances. The amount of supplementary mandibular growth appears to Treatment with an acrylic splint RME followed be significantly larger if the functional treatment by fixed appliances produced significantly is performed at the pubertal peak in skeletal favorable short-term and long-term changes maturation. The Herbst appliance showed the highest in almost all maxillary and mandibular arch coefficient of efficiency (0.28 mm per month) followed measurements. by the Twin-block (0.23 mm per month). The The amount of change in both maxillary and coefficient for the bionator 0.17 m per month). For mandibular intermolar and intercanine widths the activator, it was slightly lower (0.12 mm per fully corrected the initial discrepancies. month). The coefficient of efficiency for the Fränkel Approximately 4 mm of long-term relative increase appliance, was the lowest (0.09 mm per month). in maxillary arch perimeter, and 2.5 mm additional 96 History of Orthodontics

maintenance of mandibular arch perimeter were Pre-chondroblastic – chondroblastic layer observed in the TG compared with the CG. showed responses. These results suggest that this protocol is Initial adaptations along the posterior border effective and stable for the treatment of of the condyle followed by changes in the constricted maxillary arches, and can relieve posterosuperior region. modest deficiencies in arch perimeter. This study demonstrated that significant adaptive responses can occur in the Cozza P, Baccetti T, Franchi L, McNamara mandibular condyle of the juvenile rhesus JA Jr. Am J Orthod Dentofacial Orthop. 2006 monkey following alteration in the functional position of the mandible. The aim of this study was to investigate the And that the condyle is highly responsive to effectiveness of a quad-helix/crib (Q-H/C) changes in the biomechanical and biophysical appliance in a group of growing subjects with environment of the TMJ region during growth. thumb-sucking habits and both dental and skeletal open bites. Kristine S West and James A McNamara, Jr. The Q-H/C appliance was effective in AJO 1999 correcting the dental open bite in 90% of growing subjects with thumb-sucking habits The purpose of the present study was to evaluate and dentoskeletal open bites. cephalometrically the craniofacial growth The average increase in overbite during Q-H/ changes and adjustments that occur from late C therapy (3.6 mm more), the maxillary and adolescence to mid adulthood in persons who mandibular incisors had significantly greater had no previous history of orthodontic lingual inclinations (about 4.0 degrees) treatment. Mandibular and midfacial lengths as associated with greater extrusion (1.4 and 1.0 well as posterior and lower anterior facial heights mm, respectively) in the Q-H/C group. had increased significantly for males and The Q-H/C protocol produced a clinically females over both time intervals. significant improvement in the vertical skeletal The pattern of expression of these changes was relationships because of downward rotation different in the two genders: males showed an of the palatal plane. Neuromuscular and anterior rotation of the mandible, whereas skeletal adaptations to altered function in the females demonstrated a posterior rotation of orofacial region. the mandible. Soft tissue changes also were somewhat James A McNamara, Jr. AJO 1973 different between genders. In males, the nose and chin grew downward and forward, with The nature of intrinsic musculoskeletal the lips generally moving straight adaptations resulting from experimental downward. alterations of the orofacial environment. In contrast, females had nasal growth that Neuromuscular adaptations. progressed downward and forward, and there Mandibular adaptations – changes in the was a slight retrusion of the lips over time. growth pattern of the condylar head and Continued tooth eruption was noted in both compensatory migration of the dentition. genders as well. (depending on the maturational level). Maxillary adaptations – changes in the extent STUDIES ON TMJ and vector of growth of the skeletal components. McNamara, Jr. OOO 1997 James A McNamara, Jr and Carlson DS. The relationship between orthodontic AJO 1979 treatment and TMDs has long been of interest TMJ adaptations to protrusive function. to the practicing orthodontist. Significant adaptive responses can occur in The interest in orthodontics and TMD in part the mandibular condyle of the juvenile rhesus was prompted in the late 1980‘s after litigation monkey following alteration in the functional that alleged that orthodontic treatment was the position of the mandible. proximal cause of TMD in orthodontic patients. James McNamara's Contribution to Orthodontics 97

This resulted in an increased understanding specific gnathologic ideal occlusion does not of the need for risk management as well as for result in signs and symptoms of TMD. methodologically sound clinical studies. Thus far there is little evidence that The findings of current research investigating orthodontic treatment prevents TMD, the relation of orthodontic treatment and TMD although the role of posterior unilateral are as follows: crossbite correction in children may warrant further investigation. Signs and Symptoms of TMD May Occur in Healthy Persons Conclusion Signs and symptoms of TMD increase with The overall goal of McNamara’s research age, particularly during adolescence, until is to provide a sound biological basis for menopause and so TMD s that originate understanding how the face normally during treatment may not be related to the grows and how facial growth can be altered treatment. by experimental and therapeutic interven- Treatment performed during adolescence does tion. not increase or decrease the chances of TMD His past research involved studies of both later in life. normal and experimental alterations in the Extraction of teeth as a part of treatment plan growth of the facial region in a non-human does not increase the risk of TMD. primate, using the rhesus monkey as a model There is no increased risk of TMD associated of human craniofacial development. with any particular type of orthodontic More recently, McNamara has focused on mechanics. clinical studies of the effects of orthodontic, Although a stable occlusion is a reasonable orthopedic and surgical interventions on the orthodontic treatment goal, not achieving a growth of the face. AAnnndddrrreeewwwsss’’’ SSStttrrraaaiiiggghhhttt WWiiirrreee AAppppppllliiiaaannnccceee 11

Why “Straight Wire”? Overcome in the ‘Straight Straight Wire Appliance Deficiencies in the Wire Brackets’ Brackets for Different Clinical Conventional Edgewise Bracket Variable Bracket Sitting Situations Design, and How they are Procedures: Lawrence F Straight Wire Appliance (SWA) Andrew’s Remedy

The ‘straight wire’ appliance is an example of examiners appointed at these prestigious what a motivated person could achieve with societies, and yet they differed considerably. determination and perseverance. It is a Therefore, Lawrence F Andrews concluded that fascinating story of a man fully engaged in the then existing criteria for measuring the practice that carried out outstanding research extending into numerous projects and culminated in the development of an appliance that has profoundly affected the practice of orthodontics. After his graduation in 1959, Laurence F Andrews (Fig. 11.1) was looking for a topic to write a thesis that was required for certification by the American Board of Orthodontics. The theme that he chosed was the prevalent quality of American orthodontic practice with respect to static occlusion. He started an assessment of post- treatment orthodontic study models exhibited at the meetings of American Board of Orthodontics, Angle Society and Tweed Foundation. Although the records indicated that the patients’ occlusion had shown remarkable improvement over the original condition, and there were few common findings (such as class I molar occlusion, normal overjet, absence of cross bites and incisor rotations), many other features like angulations and inclinations of various teeth and curve of Spee were quite disparate. These cases had been judged as the outcome of excellent treatment by Fig. 11.1: Lawrence F Andrew Andrews’ Straight Wire Appliance 99 quality of finishing were ill defined and needed Andrews later stated in his interview that he to be revised. considered finding the facial axis of clinical He rightly decided that the answer to his crown as his most significant contribution to question rested in the nature’s ideal cases. Thus orthodontics, because it can be used for both started his tryst with the normal, which he latter angulations and inclination. Also it has a reliable on called optimal occlusion. He collected correlation with planes of crown at all times and orthodontic study models of 120 non-treated with the mid-transverse planes of all the crowns individuals whose occlusion was considered to in an arch when the teeth are correctly be ideal by him and his peers. With a keen eye positioned. “Without it there would have been and logical mind, he picked out the six consistent no six keys and no straight wire appliance.” features related to the clinical crowns, which Andrews reexamined the treated cases were common to all the study models. He named applying the criteria of the six keys. This study these as the six keys to normal occlusion. They revealed that most of them failed to attain many, describe the characteristics of best static natural if not all, keys. The failures were, in a descending occlusion as related to molar relation, angulations order of occurrence, errant angulations of the and inclinations of the teeth and stipulate that teeth; interarch relations, inclinations of the teeth, there should be no rotations and spaces, and the rotations of remaining teeth, excess curve of Spee curve of Spee should be flat. He published his and persistent spaces. results in the American Journal of Orthodontics Lawrence F Andrew started analyzing the in the year 1972. The article since has attained causes for the above short comings and came to the status of mandatory reading for anyone the conclusion that the standard edgewise aspiring to become an orthodontist. appliance had too many deficiencies to obtain The uniqueness of Andrews’ study was that consistent results. These were in the following the tooth positions were referenced from form: clinically visible teeth crowns (or, more 1. Variability in wire bending from operator to specifically, the labial and buccal surfaces of operator and even with the same operator. clinical crowns) and not from the long axis of 2. Deficiencies in the standard edgewise bracket the teeth, which can be judged only from the design. radiographs. Further, the referents selected were 3. Variations in the bracket sitting procedures. such that optimal occlusion based on them Lawrence F Andrew’s next study was aimed obviated the need to use articulating paper to at exploring the conceptual feasibility of check the interfacing of occlusal surfaces or view developing an appliance, which would facilitate the occlusion from the lingual side. The most obtaining the six keys consistently in treated important of the referents was the facial axis of cases. It consisted of numerous measurements clinical crown, formerly termed long axis of the on the plaster casts of non-orthodontic normal clinical crown. For all the teeth other than the occlusion. These ascertained the natural molars, it is the most prominent ridge on the anatomic similarities (earlier named ‘tendencies’ crown’s face; while for the molars it is the by Wheeler) in human dentitions. Specifically, dominant groove on the crown’s face. From the they were related to constancy of position and facial perspective it appears as a straight line. shape within each tooth type, and consistency From the mesial or distal perspective it is of relative size of crowns within an arch. The perceived as a straight line tangent to the conclusions from this study were: midpoint of the crown’s face. The midpoint of 1. Most individuals have normal teeth facial axis of clinical crown is named as the facial regardless of whether they have normal axis point (FA point), which is formerly termed occlusion or malocclusion. Abnormally long axis point. It is used for assessing the shaped crowns in the rest of the persons are positions of the teeth as also for placing the generally amenable to restorative procedures brackets accurately on the teeth. When all the to normalize them before orthodontic teeth are correctly positioned, the plane joining treatment is started. the FA points of all the teeth is named as 2. Each normal tooth type (such as the central Andrews’ plane. incisors, lateral incisors, cuspids, etc.) is 100 History of Orthodontics

similar in shape from one individual to is built in the brackets instead of depending another. on the wire bends, more consistent results 3. All the teeth in any individual’s mouth are could be obtained. generally proportionate though they may 2. Other wire bends (secondary bends) are vary in size from person to person, i.e. all the required for compensating for faulty teeth tend to be large, medium or small. placement of the brackets or the deficiencies 4. The size of normal crowns within a dentition in the bracket design. One example is the has no effect on the relative prominence of buccal root torque in the posterior region of their facial surfaces, or the curvatures both the archwire that is needed in the vertical and horizontal of the labiabuccal conventional edgewise treatment, which is surfaces on which the brackets will be placed, given not to effect any torquing movement or on the location of contacts between two but to avoid unintentional torque. Standard teeth types. Also, optimal crown angulation edgewise brackets placed on the curved or inclination as well as interarch relation are buccal surfaces of the posterior teeth, on not related to the size of the crowns and hence receiving a flat (untorqued) archwire, would are attainable, whatever may be the size of create an unintended torque on the teeth in a the crowns. crown buccalroot lingual fashion that is 5. When the upper and lower jaws are generally undesirable. Buccal root torque in proportionate and properly related, it is the archwire prevents this from happening. always possible for the teeth to be brought in These wire bends are needed in all the optimal occlusion. successive archwires and in almost all the The study thus paved the way for creating a patients. This repetitive wire bending could new appliance by taking advantage of the be eliminated if the bracket design anatomic similarities in the human dentition, and shortcomings are corrected by suitable by recognizing the fact that similarities exist in modifications (for example, by having built- the positions of the normal teeth when they are in torque in the brackets itself to remedy the optimally occluded. Andrews developed his above mentioned situation). appliance to address all the above mentioned 3. Even for the same operator, the bends placed problems with respect to variability in wire in the successive archwires are likely to vary. bending, deficiency in bracket design and They will certainly be different for different variable bracket sitting procedures. operators. Since every bend in the archwire not only causes some action but also has a WHY “STRAIGHT WIRE”? reaction, the results from such differing bends The term straight wire in the present context are unpredictable and often lead to undesired refers to an archwire that is given the arch form tooth movements. Additional secondary wire and often the curvature to open the bite, but bends will be required for overcoming them. which is free from the first, second or third order 4. Some of the bends influence the actions of bends. It is a ‘formed’ but ‘unbent’ archwire. other bends, e.g. torque in the anterior section Lawrence F Andrew’s endeavor to develop an of the archwire negates the tip by a ratio of appliance that would permit the use of such an 1:4 (wagon-wheel effect). Accurate wire archwire by transferring most of the tooth bending to negate such ill effects is extremely guidance functions from the archwires to the difficult but provision could be made in the brackets (by modifying the bracket design), was bracket design to overcome them to a large based on the following reasoning: extent. 1. Some of the bends in an archwire are needed However, it should be noted that in only few for effecting first, second and third order cases, the entire treatment could be completed tooth movements (Lawrence F Andrews using ‘straight’ archwires. Andrews stated that termed these as the primary bends). It is straight wires in progressively larger dimensions difficult to make these bends precisely for take the treatment close to the treatment affecting the exact amount of tooth objectives, but in many cases would require some movement. Hence, if precise tooth guidance wire bending in the final archwires to fine tune Andrews’ Straight Wire Appliance 101 the results. The analogy he gave was of reaching (which he described as fully programmed some destination far away. You need not walk brackets) had the following features: all the distance. The straight wire appliance is 1. Every tooth type had a specifically designed like an airplane that takes you to the nearest bracket, which had precisely builtin airport quickly and effortlessly. Final wire angulations and inclinations to eliminate the bending is like walking the last few kilometers. second and third order bends. The magnitude Deficiencies in the conventional edgewise of angulations and inclinations for different bracket design, and how they are overcome in teeth (‘prescription’ values in degrees) were the ‘straight wire brackets’ derived from his study of normal occlusion. The conventional edgewise brackets are 2. Unlike in the conventional edgewise brackets, identical for all the teeth except some mesiodistal in which the slots are perpendicular to the width differences. However, different teeth have vertical edges of the bracket, the slots were different relative prominences, angulations and cut at an angle to the vertical edges for inclinations. This necessitates giving first, second attaining the built-in angulation in the and third order bends in the archwire. bracket. This obviated the need to rotate the 1. Bracket base is perpendicular to the brackets for angulating them. faciolingual axis, and the slot is cut parallel 3. The bases of the brackets were inclined (the to the facio-lingual axis. This leads to angle of inclination precisely matching the targeting the bracket slots to different inclination of the facial plane of the respective inclinations and occlusogingival levels. When crown at the FA point) in order to effect the placed on different teeth with varying torque needed for the particular tooth type; curvatures, the latter may result in functional the bracket slots were not torqued within the interferences. bracket body. In other words, the torque was 2. Because the bracket bases are not contoured built in the bracket bases and not in the face occlusiogingivally, they can rock on the of the bracket. This made it possible to make curved crown facial surfaces, which further the mid-transverse planes of each crown and affect the slot inclination and occlusogingival bracket stem and slot, coincide, and also to positions. Similarly, lack of mesiodistal base align the mid-transverse planes of all the contour could lead to rocking of the brackets, crowns and bracket slots so that they which will affect the rotational control. coincided with Andrews’ plane when the 3. Because the brackets are not angulated, teeth were correctly positioned. second order bends in the archwire become 4. The thickness of the brackets stem was varied necessary. Angulating the brackets according to the facial prominence of each themselves does not solve the problem tooth, thus eliminating the need for the first because of rocking potential of the bracket order bends. The bracket bases were made base. such that the slot in every bracket was 4. Stems of equal prominence necessitate the perpendicular to the mid-sagittal plane of the first order bends such as the bends required crown. This necessitated a built-in offset in between the upper central and lateral incisors. the maxillary molar tubes or brackets. Similarly, because the molar tubes or brackets 5. The bracket bases were contoured both have no offset built-in, first order bends occlusogingivally and mesiodistally, become necessary mesial to the molars. (compound contouring) according to the Andrews rightly observed that what stands facial surface anatomy of each tooth type to between the orthodontist and the teeth are the eliminate rocking of the brackets on the teeth; brackets, and therefore the brackets should be since bracket rocking in the occlusogingival designed and affixed on the teeth such that their direction would affect the built-in torque, and planes should reflect the planes of the teeth bracket rocking in the mesiodistal direction crowns. Hence he set about designing a new would affect the rotational control. system of edgewise brackets (and a more precise Thus it became possible to use flat unbent way of attaching them on the teeth. His brackets archwires in the appliance through most part of 102 History of Orthodontics the treatment. The treatment could be started with distance from the incisal edge or the cusp tip would small diameter wires, which would flex in the cause variation of slot inclination depending on brackets on malpositioned teeth. The resilient the crown heights of the same type but different wires, while regaining their original shape and size teeth. form, would correct the malpositions to some Lawrence F Andrews emphasized that the extent. As one gradually moves to bigger accurate placement of the brackets was an diameter archwires, they would progressively integral part of the straight wire appliance. He align the teeth till a full size ‘straight’ archwire, suggested a bracket sitting procedure, which was could passively fit in all the brackets. aimed at targeting the slot within two degrees Two types of bracket configuration were and 0.5 mm of the precise placement over the originally made available. The vertical edges slot site (This is the area on a tooth that would were always parallel to the facial axis of clinical accept the bracket such that the bracket slot crown, while the horizontal edges were would receive a ‘straight’ archwire passively perpendicular to the vertical edges in the square when the tooth gets optimally positioned). He type brackets and at a different angle in the demonstrated that most of the people are able to rhomboid shaped or so-called ‘diamond’ - mark the midpoint of a line about 10 mm in brackets. The latter type bracket became more length (a figure close to the length of facial axis popular since the horizontal edges could be well of clinical crown of a maxillary central incisor) aligned with the incisal edges. to the accuracy of within 0.5 mm. Further, they Some other features called the convenience can also judge the parallelism of two or more features meant for increasing the ease of the lines within the accuracy of two degrees. Hence operator such as marking on the brackets to he reasoned that it should be possible for anyone identify them, and gingival tie wings on the with average skill to draw with a pencil the facial posterior teeth extended laterally for ease of axis of clinical crown of all the teeth, mark their ligation were added to the brackets. Similarly, midpoints and align the midpoint of the base of for comfort of the patients some features were each bracket with the facial axis point in such a incorporated, as for example, the facial aspects way that the sides of the brackets are parallel with of the incisor and canine brackets being curved the facial axis of clinical crown. This is done by and parallel to the crown’s facial surface so as to placing the brackets on the crowns straddling the reduce irritation to the lips. Some more features facial axis of clinical crown with the vertical named auxiliary features such as power arms, components of the brackets (viz. the vertical hooks, face-bow tubes, tubes for utility arches edges of brackets and the tie wings) parallel to and rotation arms were also added. the facial axis of clinical crown and the horizontal midpoint of the brackets equidistant from the end VARIABLE BRACKET SITTING points of the facial axis of clinical crown. This PROCEDURES: LAWRENCE F ANDREW’S would provide the accuracy needed in using the REMEDY full potential of the fully programmed brackets. Many authors earlier had suggested different STRAIGHT WIRE APPLIANCE BRACKETS landmarks for bracket locations on the teeth. FOR DIFFERENT CLINICAL SITUATIONS Lawrence F Andrews felt that the traditional referents for angulation (long axis of the crown Andrews initially introduced brackets for the or the tooth, incisal edges for incisors and cusp treatment of non-extraction cases, with an ANB tips for other teeth, marginal ridges, contact differential of less than five degrees, which he points, etc.) were neither reliable nor practical. referred to as the standard brackets. Similarly, inclination referents viz. long axis of Subsequently he developed brackets for crowns or teeth were unsatisfactory. extraction cases. Additionally, the inclination of the bracket slots There was one standard (non-extraction) at varying heights on these axis would vary bracket for every tooth except for the incisors, because of the curvature of the facial surface. that had three, and the maxillary molars, that had Thus, a location of the landmark at a specified two. The differing features were built-in Andrews’ Straight Wire Appliance 103 inclination for the incisor brackets and counter rotation and counter mesiodistal tip) to angulations, and offset angles for the molars. All neutralize the buccal crown-tipping tendency. other features remained the same. The upper and The additional (negative) inclination was four, lower incisor inclinations were different for five and six degrees for minimum, moderate and different skeletal types. For skeletal class I, class maximum translation. For mandibular molars, II and class III, the upper central incisor only counter rotation and counter-mesio-distal inclinations were 7, 2, and 12 degrees, the upper tip were added. lateral incisor inclinations were 3, -2 and 8 The canine, premolar and molar brackets degrees, and for all mandibular incisors the tubes acquired attached ‘power arms’ to move inclinations were –1, 4 and –6 degrees, them in a bodily manner instead of permitting respectively. For maxillary first molars, the any tipping (The usage of these was originally angulation and offset were 5 and 10 degrees, for envisaged and the term originally coined by class I molar finish occlusion, while these were 0 Calvin Case. Andrews retained the name in his and 0 degree for class II molar finish occlusion. honor). The length of power arm was adjusted The brackets for extraction cases were such that the amount of moment generated from developed in a more elaborate fashion. Series of it, when added to the moment created by the brackets were developed for different built-in angulation for counter tip, would equal combinations of extractions, ANB differentials, the moment arising from application of the and anchorage requirements. As the teeth are mesially or distally directed force on the tooth, translated, they tend to tip mesiodistally and thus nullifying the latter. rotate into the extraction sites since the force acts All these modifications were bound to create at the brackets away from the center of resistance, an impression of the necessity of keeping a very both in the lateral as well as occlusal perspectives. large inventory of brackets. However, Andrews In addition to these tendencies, the maxillary argued that there are only 12 treatment plan molars during translation also tend to tip during possibilities for each arch, which are met by a translation on account of the drag created by the mixture of some standard and some translation prominent lingual root. Hence the relevant brackets. Hence depending on one’s practice existing features of the brackets were altered or requirements, one could keep the standard and new features were added to counter these effects commonly required translation brackets in stock to an extent that would overcorrect them. and order for the remaining as and when Depending on the amount of translation required. required, the built-in angulation for the canines and premolars was varied. For teeth undergoing STRAIGHT WIRE APPLIANCE (SWA) distal or mesial translation, 2, 3 and 4 degrees Lawrence F Andrews made some interesting were added to or subtracted from the remarks when he introduced the straight wire corresponding angulations of the standard appliance to the profession. He was candid to brackets for minimum (up to 2 mm), moderate (2 to 4 mm) and maximum (4 to 6 mm) retraction admit that he did not consider the appliance as respectively. This was meant for giving the the ultimate one (“Will there ever be one?”). He counter mesiodistal tip. further emphasized that although he had his own Anti rotation adjustments were built in the treatment philosophy and mechanics, his extraction series to prevent the teeth from appliance was not meant to serve only his way rotating into the extraction site. This was in the of treatment, but was for universal use to suit form of deviation of the mesiodistal axis of the any philosophy and mechanics employing slot from its normal (perpendicular to the edgewise brackets. He felt that his appliance midsagittal plane) position by 2, 4 and 6 degrees could successfully treat about 90 percent of cases respectively for minimum (less than 2 mm), leaving out the 10 percent of extreme cases moderate (2 to 4 mm) and maximum (4 to 6 mm) (which would need surgical orthodontics). retraction. As was mentioned earlier, the SWA did not For maxillary molars needing translation, the gain universal acceptance instantly. Although inclination values were altered (in addition to majority of the edgewise practitioners changed 104 History of Orthodontics over to some form of pre-adjusted edgewise as facial axis point). This is also not accepted by appliance by eighties, there were some who these authors. Dellinger found it erratic and voiced serious misgivings. Further, many inconsistent. Germane et al also questioned researchers critically examined the concept of the Andrews’ contention that the facial surface SWA, and found several flaws in the concept contour is more consistent when long axis. point itself. The comments/observations of some of the is used to locate the brackets and that the prominent critics is summarized below. clinicians can place the brackets within an error The main drawback of the SWA is that it of ± 2 degrees torque. overlooks biological variation in the anatomy of The colum angle, i.e. the angle between the teeth of different individuals (this criticism long axis of crown and the long axis of root differs would hold true for other versions of pre- from tooth to tooth and also for the same tooth adjusted edgewise appliances also). Dellinger, in different persons. In class II division 2 cases Vardiman, Lamberts, Germane and other have the central incisors have a more acute collum discussed this aspect. They used more angle than that seen in class II division 1 cases. sophisticated gadgets to study the crown surface Hence, even when crowns are correctly curvatures (‘profile’) of different teeth. Dellinger positioned (which is difficult on account of earlier used an optical comparator. Germane et al used mentioned reason) root placement will vary. magnified projections of the X-ray pictures of Teeth with more acute collum angle will be extracted teeth for making the measurements. placed closer to the palatal cortical plate in some Dellinger argued that the basic data should have cases even pressing against it. What effect the been collected from individuals having variation in root placement will have on the malocclusion and not from ideal occlusion casts health of the teeth or stability of the results is not as was done by Andrews. known yet. One of the important features of SWA (and Different vertical growth patterns have other pre-adjusted edgewise appliance) is the different inclines of occlusal plane with respect torque built in the brackets, which ideally should to the cranium. The inclination value of the eliminate third order bends in the archwire. A maxillary incisors are preadjusted with respect uniform torque value in the bracket slots for any to the occlusal plane. While the angle of U1 to given tooth of all the patients is based on the SN remains almost same in all groups, that premise that individual teeth of any given type between U1 to OP varies in high, average or low (e.g. right upper central incisors or left mandibular plane angle cases. Hence, a uniform mandibular second premolars, etc.) in all the built-in torque value for all the patients would patients would exhibit identical curvatures of place the upper incisors in positions other that facial surfaces. Only then, at a particular height optimum in high or low angle case. The upper on any type of tooth (e.g. at the facial axis point) incisors would be placed more upright or more brackets with properly contoured bases would proclined respectively in these cases. Such cases fit in identical manner. The above mentioned would require different torque values for correct authors have challenged this axiom. According placement of these teeth. to them this curvature could vary by as much as Dellinger made a scathing attack on SWA. He 5.2 0 to 10.40 for teeth with low variation and stated, “Clinicians are being saved not by what 12.80 to 25.60 for teeth with high variations. Such the SWA does but by what it does not do” (since variations are bound to affect the torque values less than full size wires are used). And further in most of the individuals. Therefore, use of “If full sized unbent archwires are placed in the prescribed bracket torque value may improve mouth and are allowed to totally work out, the care in some patients but not the others. results would be erratic, inconsistent and Treatment must be tailored to the biologic clinically unacceptable”. variation presented by each patient. This implies There is at least some truth in this comment that the third order bends will be often required because Andrews stated, in his interview in most of the patients. published few years later after the above criticism Andrews had laid great stress on the appeared, that his preference is for 0.022 brackets consistency of the long axis point (later renamed and that the largest wire he uses in these brackets Andrews’ Straight Wire Appliance 105 is 0.018" X 0.025" (He does not use full size wires, article of Ross et al that summed up neatly the not even the NiTi wires). place of SWA in modern orthodontics. “The Schudy also made comments similar to straight wire appliance should not be Dillinger- “Placing a lot of torque in the upper considered an inappropriate tool. It is an incisor brackets and then never using it by not important step forward in orthodontic filling the brackets is an admission that it is not mechanotherapy that has maximum right for some of the patients”. He also pointed effectiveness on average or good skeletal out the possibility of abuse of the appliance by patterns. It is clear that the concept of ‘one the general dentists. “It (the SWA) does not place appliance fits all’ defies normal biologic the teeth in their proper position automatically variation among orthodontic patients. Hence, as it allegedly is supposed to do. It provides an skilled orthodontic care is still needed in spite easy way for the general dentist to try to do of technologic advances”. orthodontics, believing that it automatically Whatever inventions have occurred from his produces good results” (JCO Aug 92). time to till date in orthodontics is purely on the Perhaps a balanced view of the basis of Andrews Angle’s keys to normal contradictory opinions can be found in the occlusion. EEEvvvooollluuutttiiiooonnn oofff OOrrrttthhhooodddooonnntttiiiccc AAppppppllliiiaaannnccceeesss 12

Brackets – Lewis Bracket Manufacturing of Archwire – Metal Brackets – Steiner Bracket Methods of Straightening of – Plastic Brackets – Broussard Bracket Orthodontic Wires – Ceramic Brackets – Lang Brackets Properties of Archwire – Weldable Brackets – Jaraback – 1963 – Pseudoelastic Effect – Bondable Brackets – Roth – 1976 – Thermoelastic Effect – Ribbon Arch Brackets Bands – Strength of the Wire – Modified Ribbon Arch/ History of Archwires – Formability Brackets in Begg Technique – Gold – Solubility And Weldability – Tip Edge Brackets – Stainless Steel – Friction – Edgewise Brackets – Nickel–Titanium Alloys – Environmental Stability – Preadjusted Edgewise – Beta–Titanium or TMA or Can – Shape Memory Effect Brackets Wire – Lingual Brackets Auxiliaries – Cobalt-Chrome-Nickel Alloy – Self-ligating Brackets History of Orthodontic Materials – Optiflex Archwire – Single Width Bracket – Use in Dentistry – Multistrand Archwires – Twin Brackets – Uses in Orthodontics

Man has long enhanced his appearance. Evidence Despite all this evidence and experimentation, dates back some 3000 years. Archaeologists have until the 1700s the most aesthetic though not discovered mummified remains with crude metal effective appliance remained the finger. The bands wrapped around individual teeth with French surgeon, Pierre Fauchard the “Founder of catgut thought to have been used to apply forces. Modern Dentistry” described procedures for Later in 400-500 BC, Hippocrates and Aristotle aligning the teeth, including: filing them, both considered ways to straighten teeth. The manipulating them with forceps, and then tying Etruscans were using appliances to maintain them with thread to a silver or gold “bandeau”. space and prevent collapse of the dentition; while A contemporary of Fauchard, Etienne Bourdet, in a Roman tomb in Egypt, a researcher found a dentist to the King of France, went a step further number of teeth bound with a gold wire, the and recommended the extraction of first premolars original ligature wire. At the time of Christ, to maintain symmetry of the jaws. He also used Aurelius Cornelius Celsus first recorded the the first and more aesthetic lingual appliances. treatment of malaligned teeth using finger The discovery of vulcanite, when combined pressure. with gold wire springs and screws, allowed the Evolution of Orthodontic Appliances 107 use of removable appliances to induce individual 1. Weldable brackets tooth movement. By 1937, the discovery of acrylic 2. Bondable brackets had allowed translucent acrylic plates to replace III. Depending on technique for which they are black vulcanite. used 1. Ribbon arch brackets Edward H Angle (1855–1930), the “Father of 2. Begg modified ribbon arch brackets Modern Orthodontics” developed the first 3. Tip-edge bracket widely adopted system for correcting 4. Edgewise brackets malocclusions using brackets soldered to the 5. Pre-adjusted edgewise brackets labial of metal bands. Thus the Edgewise system 6. Lingual brackets was born. BRACKETS AND BANDS Metal Brackets Until the early 20th century, 14 to 18 carat gold Metal brackets (Fig. 12.1) are routinely used in was the principle metal used for constructing orthodontic practice of which steel brackets orthodontic brackets and bands. However, with are the most frequently used. the metallurgical developments of World Wars I Titanium brackets are recently introduced and II appropriate forms of stainless steel became and have high biocompatibility and low available. The introduction of stainless steel friction. allowed the development of progressively smaller appliances. The road to smaller Advantages of Metal Brackets appliances had begun and it was significantly accelerated with Buonocore’s direct bonding of a. They can be sterilised. resin to enamel and Newman’s use of epoxy resin b. They can be recycled. in 1965 to directly bond brackets to the labial c. They resist deformation and fracture. surface of teeth. d. Exhibit less friction with the arch wire. e. They are comparatively less expensive. BRACKETS Brackets are passive components which Disadvantages provide a means of transferring tooth-moving a. Easily noticeable, metallic brackets are forces from archwires, elastics and other aesthetically not pleasant. active components of fixed orthodontic b. They may corrode and cause staining of the appliance. teeth. They can be welded to the bands which are then cemented onto the teeth (weldable Plastic Brackets brackets). Bondable brackets being increasingly used in recent years, although Plastic brackets (Fig. 12.2) initially made from weldable ones have to be opted in some cases. acrylic and later from injection moulded poly- Brackets manufactured from a variety of carbonate, were introduced in the 1970s. They materials are available and they can be of promised significantly enhanced aesthetics; various designs suitable for different orthodontic techniques. Brackets can be classified in a number of ways as listed below: I. Depending on material used for manufacture 1. Metal brackets a. Gold b. Stainless steel c. Titanium 2. Plastic brackets 3. Ceramic brackets II. Depending on mode of attachment Fig. 12.1: Metal brackets 108 History of Orthodontics

Fig. 12.2: Plastic brackets A unfortunately, problems of staining, odour, time- dependent creep, and breakage soon became apparent. Permanent deformation, or creep, occurs when a material is subjected to a constant load over an extended period. It is particularly important for thermoplastic materials such as polycarbonate and polyurethane resins. Compensation for the lack of strength and rigidity is reinforcement with ceramic or fiberglass fillers and/or metal. This has improved their popularity. B Plastic brackets made of polycarbonate and Figs 12.3A and B: Ceramic brackets other related materials were introduced to improve aesthetics. However, they are not preferred as they have a number of difficulty in debonding the brackets. These disadvantages such as: problems are being overcome and the brackets 1. They tend to get discolored easily especially now offer quite an aesthetic alternative to in patients who smoke or drink coffee, tea, stainless steel. Transparent and opaque tooth etc. colored ceramic brackets are available and are 2. They have poor dimensional stability generally made of alumina or zirconium based 3. Their slots tend to distort products. 4. There is a high amount of friction between plastic bracket and metal archwire. Advantages 1. They are highly a esthetic not easily Ceramic Brackets noticeable. Ceramic brackets (Figs 12.3A and B) were first 2. Resist discoloration unlike plastic brackets introduced in the 1980s. There are two basic forms; 3. Dimensionally stable, do not distort in oral monocrystalline, which is almost transparent; cavity and polycrystalline which is tooth colored. Disadvantages Offering better aesthetics than either stainless steel or polycarbonate; they also exhibit good 1. They are very brittle and thus tend to fracture resistance to wear and deformation, as well as easily during active treatment and also while color stability. However, they have problems debonding. when compared to stainless steel brackets 2. Exhibit greater friction at wire/bracket including greater frictional resistance, bracket interface than metallic brackets breakage, iatrogenic enamel damage, and 3. High cost of material. Evolution of Orthodontic Appliances 109

Fig. 12.5: Bondable brackets

Figs 12.4A and B: Weldable bracket

Weldable Brackets (Figs 12.4A and B) They are either welded or soldered to the band which is then cemented over. The weldable brackets have metal flanges on the base to facilitate welding. Bondable Brackets (Fig. 12.5) They are directly bonded onto the teeth using Fig. 12.6: Ribbon arch brackets bonding adhesives Base of these brackets generally exhibit meshwork or indentations to facilitate bonding with the adhesive material. Ribbon Arch Brackets (Fig. 12.6) Ribbon arch brackets had a simple design with occlusally facing vertical slot in it They were used in ribbon arch technique.

Modified Ribbon Arch/Brackets in Begg Technique (Fig. 12.7) Begg technique uses modified ribbon arch brackets in which the vertical is facing gingivally rather than occlusally This modification allowed easy tipping of the Fig. 12.7: Modified ribbon arch/brackets in Begg teeth. technique 110 History of Orthodontics

Fig. 12.10: Preadjusted edgewise brackets

Fig. 12.8: Tip edge bracket

Fig. 12.11: Lingual brackets

Fig. 12.9: Edgewise brackets

Tip Edge Brackets (Fig. 12.8) Preadjusted Edgewise Brackets (Fig. 12.10) They are used in tip-edge technique. The bracket They are modified edgewise brackets with in-built design is a modification of the conventional tip, torque angulations incorporated in their Edgewise bracket where two diagonally opposite design. corners of the conventional edgewise bracket slot are removed and a vertical rectangular slot is also Lingual Brackets (Fig. 12.11) added. Lingual brackets are arguably the most aesthetic, appliance of all as they are placed on Edgewise Brackets (Fig. 12.9) the lingual aspect of the teeth. Despite being Edgewise brackets and their modifications becomes made of stainless steel they are virtually the mainstay in orthodontic practice today. They invisible to the casual observer. Unfortunately are employed in edgewise technique. Most these appliances are generally considered to be Edgewise brackets have rectangular horizontal slot more time consuming to both place and adjust, with four wings, two gingival and two occlusal. and therefore attract a significant premium in The rings help securing archwire in the slot and cost over conventional labial brackets and are brackets may also have hooks for attaching initially more uncomfortable than labial auxiliaries such as elastics. They are available as a brackets. Consequently fewer patients are set of different brackets for different teeth. attracted to them. Evolution of Orthodontic Appliances 111

Fig. 12.13: Vertical Slot Lewis bracket Fig. 12.12: Self-ligating brackets

Self-ligating Brackets (Fig. 12.12) Self-ligating brackets were first popularized in the 1980s, one of the earliest being the speed system. They are more aesthetic as they have a much smaller labial “footprint” than other stainless steel brackets of the day and no longer require the use of either steel or elastomeric ligature ties. Stainless steel self-ligating brackets have been Fig. 12.14: Tooth that is badly rotated, the wing in the direction of the rotation can be removed. The bracket can then be shown, in-vitro, to have the lowest static and positioned properly, with the remaining wing serving to rotate kinetic frictional forces. Polycarbonate self- the tooth into proper position ligating brackets generate significantly greater static and kinetic frictional forces than stainless steel self-ligating brackets but are comparable to conventional stainless steel brackets. Decreased amount of archwire, Interbracket span and resiliency Single Width Bracket Closing loop archwires Narrow width - ineffective tooth rotation. Second order bends Angle - gold eyelets - on the orthodontic bands. Lewis Bracket Two brackets - single tooth. Lewis bracket is wedge shaped bracket, which Twin Brackets places the tie wing close to the tooth occlusally and further away gingivally. Two edgewise brackets on a common base. ‘Siamese twin bracket’ by Swain Vertical Slot Lewis Bracket (Fig. 12.13) Space between two brackets is 0.050 inch, A vertical slot 0.020 × 0.020 inch. which 0 equal to the width of one bracket. Uprighting springs - correct axial inclinations Advantages Additional Benefit Rotational control : mainly by deflection of arch wire For tooth that is badly rotated, the wing in the Positive control direction of the rotation can be removed (Fig. 12.14). The bracket can then be positioned Disadvantages properly, with the remaining wing serving to 10 percent play of archwire rotate the tooth into proper position 112 History of Orthodontics

Fig. 12.17: Joseph Johnson introduced twin arch appliance

Fig. 12.15: When a Lewis or Steiner bracket is completely tied into a cuspid, there is a tendency to flatten the curvature of the archwire

Fig. 12.18: Oren A Oliver introduced labiolingual appliance

Lang Brackets (Fig. 12.16) By Dr Howard Lang Placed in large, round surfaced teeth- Fig. 12.16: A Lang bracket avoids this effect, while maxillary and mandibular cuspids. retaining the rotation wing capability Contoured so that bracket fits beautifully on most cuspids. When a Lewis or Steiner bracket is completely Steiner Bracket (Fig. 12.15) tied into a cuspid, there is a tendency to flatten Flexible rotation arm. the curvature of the archwire. The flexibility arms gives a rotational effect . A Lang bracket avoids this effect, while retaining the rotation wing capability. Broussard Bracket Later Modifications Graffard Broussard modified edgewise bracket 0.0185 × 0.046 inch vertical slot Burstone modified canine bracket - a vertical II accept a doubled 0.018 inch auxiliary wire tube - retraction assemblies. Evolution of Orthodontic Appliances 113

Edgelock bracket and Hanson speed appliance bracket: These brackets eliminate the need for ligature ties as they possess self-ligating mechanism. In 1938 Joseph Johnson introduced twin arch appliance (Fig. 12.17) In 1940 Oren A Oliver introduced labiolingual appliance (Fig. 12.18)

Holdaway – 1952 Fig. 12.19: Self-ligating bracket Angulated brackets on the teeth adjacent to extraction spaces aid in: paralleling the roots . setting up posterior anchorage. obtaining correct axial inclinations or ‘artistic positioning’ of the teeth.

John J Stifter – 1958 U S patent - designing an edgewise bracket comprising a male and female component Ivan Lee – 1960 Torqued slots - regional and basic edgewise bracket. To eliminate - adding torque - anterior portion of the upper archwire. Manufacturers – 1960: raised the base of lateral incisor. Raised bases eliminated the need for lateral offset bends. Fig. 12.20: Peter C Kesling Jaraback – 1963 Appliance in position. It is impossible to Described the use of torqued brackets position the teeth precisely into occlusion. Andrews Straight Wire Appliance - 1970 After appliance removal, the teeth will shift Two varieties. slightly. The standard prescription for non extraction cases and ‘Translation series’ for extraction Self-ligating Brackets cases . Self-ligating brackets (Fig. 12.19) don’t need Limitations of conventional Straight Wire tie wires or elastic ligatures to hold the bracket archwire onto the bracket. They are held on Moving teeth apex first generates maximum by a “trap door” built into each bracket. anchorage resistance As early as 1935, the idea of a self-ligating Torque control - unwanted reciprocal torque brackets began to take shape. reaction in adjacent teeth Over the years many designs were patented, Full expression of torque not achieved- but few were commercially available until “Torque slop” due to play between bracket Ormco created the edgelock system in 1972. and arch wire Nowadays, we have a number of self-ligating Roth – 1976 choices, such as Orec’s speed braces, Ormco’s Damon system, GAC’s In-Ovation, and Bracket set up containing modifications of tip, Adenta’s Evolution. torque and rotations. Purpose of Roth - over corrected tooth Peter C Kesling (Fig. 12.20) decided to combine positioning. both the techniques. He modified a straight wire 114 History of Orthodontics bracket, to create tip edge bracket and differential Table 12.1: The stainless steel strips are available in force technique. In this technique initial crown different widths and thickness to suit different teeth tipping was done followed by controlled root Teeth Band Thickness Band Width Figure uprighting with straight arch wires (differential (Inches) tooth movement with straight arch wires). Therefore it is known as the “differential straight Incisor 0.003 0.125 arch technique”. Archwire slot permits initial Canine 0.003 0.150 Premolar 0.003 0.150 crown tipping mesially or distally and faces Molar 0.0050.006 0.0180.018 horizontally, the slot and bracket are termed

Kesling determined that: It orients the archwire slot to relative to the It is necessary for each tooth to tip either facial surface of each tooth on the model. mesially or distally but not in both directions All teeth tip distally except those distal to the BANDS extraction sites, which tip mesially Anchor molars should remain upright Bands (Fig. 12.21) are passive components that throughout Rx. provide space for fixing various attachments onto Diagonally opposite corner were removed the teeth. They are generally made of soft stainless Permits desired distal crown tipping steel. The stainless steel strips are available in Preadjusted in three dimensions- different widths and thickness to suit different tip, torque, in and out built in teeth (table 12.1). Weldable brackets, buccal tubes Slot size - 0.022" × 0.028 and other auxiliary attachments are soldered or welded over the bands, which are then cemented Alexander – 1983 around the intended teeth.

Vari–simplex discipline: Availability Vary - variety of bracket types used; Simplex - KISS principle (Keep it Simple Sir) 1. Custom-made bands are fabricated using band Discipline was chosen rather than the materials which are available in the form of appliance. spools. Based on edgewise philosophy 2. Preformed seamless bands are available in different sizes which can be directly cemented Creekmore – 1993 around the tooth. Preformed bands are increasingly being used in recent years. Slot machine onies solution to the Inaccuracies of bracket placement, ARCHWIRES Anatomic and biologic variations, over correction for tissue rebound and relapse and History of Archwires Mechanical differences of preadjusted By the 1960s, gold as an archwire had largely been edgewise orthodontic appliance replaced. It gave way to thinner, more resilient stainless steel wires such as Wilcox’s Australian wire. However, in 1974, Unitek patented its nitinol (Nickel Titanium Naval Ordnance Laboratory) wire having the lowest modulus of elasticity and most extensive deactivation range of any equivalent cross sectional wire of the time. This allowed the application of light forces over a protracted range. By 1986, “superelastic” alloy wires that undergo stress induced change in their crystal form had been developed. These offered significant advantages over nitinol. The range of Fig. 12.21: Bands wires available to orthodontist has been futher Evolution of Orthodontic Appliances 115 extended by the addition of various other elements temperature. At the annealing temperature, (Table 12.2) including cobalt-chromimum. Beta- atoms become mobile enough to move about titanium and, in 1994 copper. Copper NiTi and thereby get relieved of some of the internal changes its crystal form at a specific temperature. stresses, which had been introduced during Most recently, a nickel free wire, titanium-niobium rolling. When the metal cools down, the grain has been introduced. With these new wires, structure is seen to be uniform. especially the super elastic wires, it is no longer 3. Drawing: This is the final step, wherein this necessary to incorporate multiple loops, small cross section wire is further drawn into significantly enhancing aesthetics as well as its final size. This is a more precise step in comfort. which the wire is pulled through a small hole A number of manufacturers now offer NiTi in a die. The hole is slightly smaller than the and stainless steel archwires coated with tooth starting diameter of the wire; so that the wall colored material to enhance their aesthetics, is squeezed uniformly from all sides as it especially when combined with ceramic brackets. passes through. The cross section of the wires Unfortunately, these coatings tend to wear away are the same as the die. with time; however, further research should see Methods of Straightening of Orthodontic Wires this resolved. The search for improved aesthetics is leading Following are the two methods of straightening us down the road of fiber reinforced composites. of wires; These materials are not yet clinically useful as 1. Spinner straightening. archwires; however, they have been incorporated 2. Pulse straightening. into bis-GMA ribbons and bonded, as strips, to 1. Spinner straightening: In this type of multiple teeth, to provide retention and also straightening, the wire is pulled through a anchorage, reducing the number of conventional bronze roller, which torsionally twist the brackets required. wires. However, this mode does not produce wires as mechanically efficient as the the ones Manufacturing produced by ‘pulse straightening’. Disadvantages: Disadvantages of spinner The manufacture of metal alloy wires involves straightening are as listed below making an ingot followed by rolling and drawing: Deformation 1. Making the Ingot: This involves pouring of Decreased yield stress value. molten metal into a mold. The result obtained 2. Pulse straightening: This is a recent and more is the cast wire to produce an ingot. A accepted method of straightening of wires, magnified view of this ingot shows crystals or which employs special machines to straighten grains; it is mainly this grain structure, which wires which lead to: ultimately controls the significant mechanical Maintenance of the yield strength properties of the final wire. Grain formation Smooth finish, which would be also, depends on the rate of cooling and the size of beneficial as it produces less friction. the ingot. Pulse straightened wires have superior 2. Rolling: The formed ingot is rolled into a long qualities in comparison to spinner straightened bar. This is done with the help of a device wires as shall be discussed in the following section termed as the roller. During rolling, the on stainless steel. individual grains retain their identity throughout this process. Each grain gets Basic metallurgy: At this juncture, it is mandatory elongated proportional to the ingot. The to understand briefly the metallurgical properties. squeezing and massaging actions of roller 1. Metal: According to the Metals Handbook increases the strength by causing the grains to (1992); a metal is defined as ‘an opaque mesh and interlock. The rolling procedure is lustrous chemical substance that is a good continued till the crystals are so locked that conductor of heat and electricity and, when they can no longer adjust. At this point, the polished is a good reflector of light’. rolling is interrupted and the metal structure 2. Alloy: An alloy is defined as ‘a metal containing is annealed by heating it to a suitable two or more elements, at least one of which is 116 History of Orthodontics

a metal, and all of which are mutually soluble Because of this, the strength values could be in the molten state’. altered by the phenomenon of either work 3. Alloy system: ‘An alloy system is an aggregate hardening or heat treatment. This could be either of two or more metals in all possible beneficial (for example: the formation of ‘dead’ combinations’. ligature wires) or could be deleterious (properties of a wire may be lost during soldering Metallic Bonds and Crystalline Structure procedures) and should be kept in mind. Metallic bonds imply the primary ionic interaction, Solidification of Metals which holds the metal structure. Atoms with free Liquid state: The liquid or ‘molten state’ represents valence electrons as the metal atoms are able to a multitude of random atoms or molecules lose their outer shell (valence) electrons and form surrounding numerous unstable atomic a positive ion. The free electrons are able to move aggregates. This can be seen in the solidification about in the metal space lattice and they are termed curve as shown in the: as an ‘electron cloud’. The electrostatic attraction If a metal is allowed to cool, it first cools down between the positive ions and the electron cloud uniformly (as shown by the portion A-B). After this forms the ‘metallic bond’. there is a gradual increase in temperature (till B), It is this metallic bond that is responsible for also known as the latent heat of solidification. The luster, conductivity properties and ability of the portion below the fusion temperature (B-B’) is metal to deform plastically. termed as super cooling. It is during this period A regular crystalline configuration is typical that the crystallization of the metal begins. This for metals. This is referred to as ‘space lattice’ or takes place around ‘nuclei’; also termed as embryos. ‘crystal’ (grain). B-B1 → Super cooling The common lattice configurations are: → Tf Fusion temperature 1. Simple cubic. 2. Body-centered cubic or ‘BCC’, e.g. austenite This nucleus formation can either be homog- NiTi. enous or heterogeneous. This eventually leads to 3. Face-centered cubic or ‘FCC’, e.g. austenite ‘grain’ or crystal formation. It is at the Grain bound- SS. ary that the areas of lattice imperfections can exist. 4. Body-centered Tetragonal ‘BCT’, e.g. Lattice Imperfections and Dislocations martenisitc SS. As would have been seen in the solidification of 5. Close packed Hexagonal, e.g. martensitic metals: NiTi. Crystallization does not occur in a uniform It can be inferred from the above examples that manner and some lattice positions may be the lattice configurations (in turn, the grain ‘vacant’ or ‘overcrowded’. These are termed structure and their orientation) play a significant as “lattice imperfections”. Dislocations are role in determining the ultimate mechanical defects along a particular path in a properties. polycrystalline structure. e.g. edge dislocation. Cast versus Wrought Metals Dislocations tend to build up at grain Generally, all metals and their alloys originate boundaries, greater stress is required to from castings. A cast metal which is produce greater slip. Thus, the material plastically deformed, either by machining or becomes stronger, harder and less ductile. This working, is termed as a wrought metal. is termed as the phenomenon of ‘strain Cast structures are close to equilibrium hardening’ or ‘work hardening’. conditions and are incorporated in some The ultimate result of strain hardening is dental applications. However, the orthodontic fracture. wires are in the wrought form. Wrought metals Heat Treatment have a fibrous structure with extremely elongated crystals. Also this structure exhibits Heat treatment is the thermal processing of an enhanced mechanical properties like increased alloy for a length of time above room temperature tensile strength and hardness. but below its solidus temperature. Evolution of Orthodontic Appliances 117

Quenching: A process wherein the metal is cooled through the medium of brackets and welded rapidly from an elevated temperature. buccal tube on the palatal aspect of the molar The Heat treatment procedures are carried out bands. for the following reasons: Gold a. Preservation of a phase at room temperature, which is stable usually at higher Before 1950’s, gold and other precious alloy temperatures. combinations like platinum and palladium with b. Rapidly terminate a process that only occurs gold and copper were routinely used for at elevated temperature. orthodontic purposes. Gold and gold alloy archwire exhibit excellent formability, Types of Heat Treatment environmental stability and biocompatibility. 1. Stress relief: This refers to a ‘low’ temperature Angle’s Ribbon arch appliance utilized a gold heat treatment to relieve the stresses due to platinum alloy combination as the ‘archwire’. strain hardening. Cobalt-chromium alloy is However, their popularity lost ground due to two very responsive to stress relief. It also, improves main reasons: ductility. a. The marginal properties and cost factor 2. Annealing heat treatment: This employs a involved. heat treatment at a substantially higher b. Advent of stainless steel or the ‘rust free’ alloys. temperature as compared to the stress relief. Consists of three phases: Stainless Steel i. Recovery. Stainless steel (Fig. 12.22) was introduced by ii. Recrystallization. Wilkinson in 1929. Stainless steel archwire (Table iii. Grain growth. 12.2) exhibit adequate strength, high resilience, 3. Age hardening heat treatment: It is a long term formability, high stiffness, biocompatibility and process in which the temperature is slightly economic feasibility. lesser than the anneal temperature. The metal The drawback of these archwires includes is then cooled rapidly by quenching. high modulus of elasticity; more frequent PROPERTIES OF ARCHWIRE activations are required to maintain the same force level. Different types of archwire, right from gold to till date invention in archwire, are explained below Nickel-titanium Alloys (Fig. 12.23) with their properties. Archwires are one of the active components of Nickel titanium alloyl also known as nitinol, fixed orthodontic appliances, which when used (Nickel titanium Naval Ordnance Laboratory) bring about various tooth movements (tipping, was invented by William R Buchler at Naval bodily, torque, rotational and vertical movements) Ordnance Laboratory. The main advantage of this

Table 12.2: Classification of archwires I. Based on material used 1. Gold and gold alloys 2. Stainless steel 3. Nickel-titanium alloys 4. Beta-titanium 5. Cobalt–chromium- nickel alloys 6. Optiflex archwires II. Based on cross-section 1. Round 2. Square 3. Rectangular 4. Multistranded Fig. 12.22: Stainless steel 118 History of Orthodontics

braided or twisted and may have three strands or six strands. The main advantage of these arch wires is that they exhibit increased flexibility.

Physical Properties of Wire The first group of properties is concerned with the elastic behavior which represents the internal stress/strain in the wire. This is produced by an external force deflecting the wire, the stress being the internal load and the strain the internal distortion.

1. Stiffness/Springiness Fig. 12.23: Nickel-titanium alloy i. Pseudoelastic effect: When an austenitic wire is placed in the mouth and deformed by alloy over others is the high elasticity and shape forcing it into the misaligned brackets, the back memory. The drawback of these archwires is pseudoelastic effect is induced. This that they cannot be neither welded nor soldered, transforms the austenitic alloy into a and cannot receive bends or loops or helices. martenstic state which, as the teeth align, Various phases of NiTi, like the austenitic-active, gradually reverses to the austenitic state. with pseudoelasticity and the latest being ii. Thermoelastic effect: Martensitic-active alloys superelastic Cu-NieTi were brought out. Other are stable at room temperature, but when varieties like martensitic active alloy or raised to mouth temperature, the material thermoelastic NiTi alloy also evolved. The credit changes into an austenitic state which exhibits for introducing the superelastic NiTi goes to Fujio shape memory. Miura and to Dr Rohit Sachdeva for introducing iii. Martensitic stabilized alloy (e.g Unitek’s original Cu-NieTi. nitinol): The alloy, introduced in 1970 by Beta-titanium or TMA or Can Wire Andreasen. It is stabilized by introducing a certain amount Goldberg and CJ Burrstone invented beta-titanium of work hardening during processing and does and it is also known by TMA or CAN wire. The not show true memory shape properties. main advantage of these arch wires include high Austenitic-active Alloy: “Active “ means that it range of action, high spring back, receive bends, exhibits the shape memory, in this case of the loops and helices, and they can be welded or soldered. pseudoelastic type, the shape memory effect being induced by stress distorting the arch Cobalt-chrome-nickel Alloy wire in malaligned teeth. Examples of Cobalt- chrome-nickel alloy is also known as superelastic Niti are Titanol from Forestadent elgiloy. These wires exhibit excellent formability, and Nitinol SE from Unitek. joinability, spring back and biocompatibility. Martensitic-active Alloy: Again this exhibits shape memory, but of the thermally activated Optiflex Archwire variety. This alloy is stable at low temperatures Optiflex archwire was invented by MF Talass in but when is placed in the mouth, and the 1992. Optiflex archwires are composed of clear temperature increased to mouth temperature, optical fibers and are therefore highly aesthetic. it exhibits the shape memory effect. Examples The drawback of these archwire is that they cannot of thermally activated Niti are Neo Sentalloy receive sharp bends. from GAC and Nitinol XL from Unitek. Multistrand Archwires 2. Range of Deflection – Spring Back Multistranded archwires are made up of number The range of wire is the distance it will bend of thinner wires. They can be round or rectangular, elastically before permanent deformation occurs. Evolution of Orthodontic Appliances 119

If the wire is deflected beyond its yield point, it b. Heat, as in the thermoelastic effect in the will not return to its original shape. Martensitic-active alloy where the transition 3. Strength of the Wire temperature is between room and mouth temperatures. The strength of a wire is important because it determines the maximum force it can deliver. AUXILIARIES The above three properties are related by the formula: strength = stiffness X range. Brass wire was initially used to ligate the arch wire to the band/bracket combination. However, 4. Formability by the 1960s, the thinner and more aesthetic This is the amount of permanent deformation a stainless steel had replaced it as the ligature tie of wire can withstand before it breaks. choice. The advent of polyurethane materials has 5. Solubility and Weldability seen the introduction of aesthetic colored elastomeric modules to ligate the arch wire to the Stainless steel can be soldered and welded, but bracket. While offering good aesthetics when NiTi cannot. Miura recently reported a method initially placed these modules are prone to of soldering nickel-titanium wires. TMA is discoloration and breakdown over time and so weldable as described by Burrstone. must be regularly replaced. They also tend to 6. Friction increase the friction between the bracket and the archwire. Nevertheless, their ease of placement The laboratory understanding of friction is not relevant to the clinical situation. Because every and appeal to younger patients has ensured their time the patient bites together, the tooth is liable general use. to move a small distance in all three planes of The latest innovation to the orthodontist’s space. More important is the concept that the two aesthetic armamentarium is the sequential clear components, bracket and wire, may damage each plastic aligner. The principles of this process were other as they moved across their surfaces. This is actually developed by kesling in 1945. However,it borne out by the fact that it is difficult to slide did not achieve more widespread use until teeth with ceramic brackets along a wire, as the invisalign combined the technique with 3D abrasiveness of the ceramic notches the surface computer graphic and CAD/CAM technology to of the metal. allow phased movement of multiple teeth to correct 7. Environmental Stability mid to moderate malocclusions. Since invisalign appeared a number of other companies have Any material used for the construction of wire released similar products, including an must be stable in the oral environment. This has Australian company, Clear Smile. Unfortunately, been one of the limitation aesthetic. these appliances are not suitable for treating all 8. Shape Memory Effect malocclusions. Those with significant crowding or spacing, and/or interarch discrepancies (such The shape memory effect exhibited by the more as Class II and III relationships) often cannot be recent nickel-titanium wires has revolutionized the selection of wires for appropriate tooth treated properly with these systems alone. movement. The wires manufactured for Similarly, individuals with very short crowns and orthodontic purposes are composed of an alloy younger adolescents where teeth are not fully of nearly equal parts of nickel and titanium. The erupted are generally not suitable. Although some shape memory effect is brought about by a change extraction treatments are being carried out they are in the internal crystal formation from the not normally as suitable as non-extraction cases. martensitic phase with a hexagonal crystal Precise alignment and finishing with these systems structure to or from the austenitic phase with a can be more difficult compared to traditional fixed cuboids crystal structure (Kusy, AJO Sep 1991). appliances so that a compromise result may need The shape in crystalline structure can be to be accepted. Further, they are still somewhat brought about by either: visible on the labial surface and over the incisal a. Stress, as in the pseudoelastic effect in the edges. However, clear aligners are considerably Austenitic Active Alloy. more aesthetic than traditional braces. 120 History of Orthodontics

HISTORY OF ORTHODONTIC MATERIALS chemists worldwide try to find a substitute for this natural polymer of isoprene (C H ) . Success Baptized with a name resulting from the 5 8 n occurred in 1910 when Karl Dietrich Harries, in contraction of the words “elastic” and Germany, polymerized with the help of sodium “polymer”, elastomer is an umbrella term which (Na), 2,3 dimethyl Butadiene. This rubber encompasses materials which resist distortion substitute, which received the name Buna, was and resume their original shape or volume. followed by the invention of Buna-S (S standing Classified according to their chemical structure, for styrene) by K Ziegler in 1927. In the U S, a however, materials which are not necessarily sulfur-substituted elastomer was invented by J C flexible are still called elastomers. Patrick in 1930, and produced under the name Their resilience has been exploited since anti- Thiokol. The next year, a chlorine-substituted one, quity. A century and a half after Fauchard’s use invented by F J A Nieuwland and W H Carothers, of silk, the first elastomer, rubber, allowed the was launched by Dupont Company under the upgrade of simple ties to gradual movements. name Duprene (name changed today to This started for rubber a career which was not Chloroprene or Neoprene). challenged for another century. Otto Bayer invented polyurethanes, in Returning from Columbus’ second voyage, Germany, in 1937. While the latter may not Michele de Cuneo reported in 1495 the strange represent a major category of elastomers for the custom “Indians” have to milk trees (latex means general use, these most interesting for milk in Latin). In 1521, Hernando Cortes reported orthodontics. In the recent years, polyurethanes that Aztecs use this coagulated and dried milk have become increasingly important due to to make balls for game and to waterproof textiles. advances in telechelic polymers (from tele, In 1750, Francois Fresneau was the first to describe distance, and chele, claw, in Greek). These the tree which is now known as Hevea brasiliensis. polymers (especially polyols) contain reactive The tree was called by the indigenes caa (tears) end groups which can be used to further increase ochu (wood), i.e. the tree which sheds tears. This their molecular weight (mw), or to generate other gave in French its current name, “caoutchouc”. copolymers with a wide range of properties. Its name in English came from the famous scientist Usually, as the molecular weight). Increases, the Joseph Priestley who described the material in more valuable are the polymers. 1770 as “excellently adapted for wiping from The above series of discoveries has led to a paper the marks of a black lead pencil”, in other diminished share of consumption for natural words, a good ”rubber”. A similar product is gutta rubber (only 35% among all elastomers). Not only percha, extracted from another tree, Pallaquium that the plantations in Southeast Asia are both gutta, which grows in Southeast Asia. expensive to maintain and subject to weather The first attempt to commercialize the new conditions, but the substitutes prove to be better material were deterred because it softened when and by far more versatile. heated and was partially soluble in water. It was not until 1839 when Charles Goodyear Use in Dentistry accidentally discovered “sulfur cross-linking” that rubber became a substitute for the omnipresent While maxillofacial prostheses were described by plastics. Ambroise Pare’ (1517-1590), their massive use Soon, rubber became precious, and Brazil was was determined by the two world wars. While the fast to monopolize it. Henry Wickham elastomers used years ago were mainly vinyl succeeded, however, in smuggling the nuts of the plastisols (plasticized polyvinyl chloride), today tree to England. Starting 1976, England developed polyurethanes, as such or modified with acrylics, large rubber plantations in Ceylon (Sri Lanka) and and silicone rubbers (HTV, high temperature Malaya (Malaysia, Indonesia). An invention with vulcanized) are preferred. important consequences was that of J Dunlop After minor uses of elastomer, in the making who, in 1888, invented the pneumatic tires for of dams, cups, points, special filling materials bicycles. The extension of this idea by the (gutta percha), a major impact was prompted by burgeoning industry of automobiles made the spread of AIDS. This has led to a new Evolution of Orthodontic Appliances 121 assessment of the cross-infection procedures, in impressions have a limited life, even if kept in which gloves were essential. Their routine wearing “humidors”. during treatment became mandatory in the U S Elastics, elastomeric auxiliaries recalled by the following OSHA’s regulations and FDA’s alert of famous Case-Angle controversy (Angle attributed March 1991. their first use to Baker, instead of Case), the first Among the elastomeric impression materials use of intermaxillary elastics has been used in large amount are the polysulfides, the documented to date as early as 1880. Initially used “addition” and “condensation” polysiloxanes, to exert interarch forces, today elastics are used to and the polyethers. All of these are identified by close spaces within the arches, hold archwires in the American Dental Association (Specification brackets and act as force-delivery systems for 19) as “non-aqueous elastomeric dental retraction, protraction, tipping, intrusion, impression materials”. extrusion and rotation. The advantage of these elastomers is related Natural rubber, the first elastomer used for to their hydrophobicity, which renders them both such purposes, has lost considerable ground in accurace and physically and chemically stable. the last years. Due to proprietary “secrets”, it is Polyethers are less water repellent and therefore difficult to make a correct estimate. The chemical less dimensionally stable in the presence of nature of the elastomers used is often withheld, humidity. This reflects also on their as are some characteristics like the thermal biocompatibility, since these are not inert and can lead to tissue irritations whenever the material is behavior (thermoset vs thermoplastic). At the left in the sulcus. Likewise, “condensation” recent A A O Annual convention in Denver, none polysiloxanes are less accurate due to reasons of the exhibitors selling gloves knew the material which we will examine later. these were made of (the alternative was “latex” or “non-latex”). Uses in Orthodontics Polyurethanes are now preferred due to their superior properties such as biocompatibility, better In addition to the elastomers generally used in dentistry, some particular uses and tensile and tear strength, and higher elasticity developments are specific to orthodontics. Thus, modulus and abra-sion resistance than the best while water-based alginates are used in dentistry natural rubber. A review of their properties has for study and record models, in orthodontics these been recently published. Unfortunately, all are the preferred impression materials. A similar elastomers lose 50 to 70 percent of their initial force during their first day of application, and after case is that of composites, which are used in 6 dentistry as restoratives, filling materials, onlays three weeks, only 30 to 40 percent of it is left . To and inlays, while in orthodontics, as adhesives. compensate for this diminished force, stronger Alginates the insoluble salts rather than elastics have to be used. To prevent possible polymers, alginates are of low cost, convenient damage, these are prestressed in advance to 50 to and enough accurate for most orthodontic 100 percent of their length. Unfortunately, this operations. Their advantage resides in a gel leads to a lack of certitude when it comes to know structure which can resume its shape when the the force applied. impression is made over undercuts. Succeeding Functional appliances used as early as 1902 the agar-agar impression materials (colloidal for Robins’ monobloc, Vulcanized rubber was for suspensions in water which can be reused), long time the only material available for functional alginates is commonly classified as “irreversible appliances. Tooth positioners, bite planes, chin hydrocolloids”. Both before and after gelation, cups, oral screens, wedges, cushions and elastic alginates are altered by heat and water: in water straps can all be made of elastomers. As it will be presence, these materials expand: in its absence, shown, that some feels soft or hard is just a matter they contract (syneresis). As a result, alginate of cross-linking which is adjustable as needed. HHiiissstttooorrryyy oofff MMooodddeeelll AAnnnaaalllyyysssiiisss 13

Carey’s Analysis Alignment (Crowding), Space – Long Method – Procedure Analysis – Problems – Inference – Principles of Space Analysis Total Space Analysis—1978 Pont’s Index Arvey Peck, Sheldon Peck— – Anterior Area – Drawback of Pont’s Analysis 1972 – Middle Area Linderharth Index Huckaba’s Analysis – Posterior Area Korkhaus’ Analysis Hixon and Old Father Wylie Howe’s Analysis—1954 Method—1958 – Commenting on Model – The Procedure Marvin M Tanaka, Lystle E Analysis Bolton’s Analysis Johnston in 1974 Kesling Model Analysis – Procedure – Short Method—Tanaka- Martinek Analysis – Determination of Overall Johnson – Comparative Analysis of Ratio – Procedure in the Maxillary Arch Howes, Rees, Kesling and – Determination of Anterior – Modifications Strayer Ratio Nance Analysis Suwannee Luppanapornlarp Cast Analysis: Symmetry and – Procedure for Mandibular 3d Model Analysis Space Arch—1976

Orthodontic diagnosis and treatment planning is diagnostic aids such as cephalogram and OPG done by taking into consideration the tooth and hence diagnostic value of such independent material, skeletal and muscle balance and growth model analysis is questionable. potential. Among the various decisions taken, an Model analysis provides us with valuable important decision is the one taken for or against information and when it is correlated with other extraction of certain teeth to achieve the desired diagnostic aids will help us in diagnosing and results. Model analysis is one of the essential planning treatment for a case. Among other diagnostic aids. Study models help us to benefits, model analysis provides a means of visualize the patient’s occlusion from all aspects evaluating the amount of space required for and also help us in making the necessary proper alignment of teeth; by allowing accurate measurements of the teeth and the dental arches assessment of Arch length—Tooth material and basal bone. Most of the model analysis discrepancy. Various methods of model analysis suggested by various authors does not correlate have been described and appropriate analysis the findings of model analysis with their must be selected for a given case. History of Model Analysis 123

CAREY’S ANALYSIS material excess, which can be managed by proximal stripping. Arch length—Tooth material discrepancy is one 2. Extraction of second premolar: If the discrepancy of the important causative factors of is 2.5–5 mm. second premolar may need be malocclusion. Carey’s analysis is aimed at extracted. determining the extent of the discrepancy. 3. Extraction first Premolar: If the discrepancy is Carey’s analysis is performed on the mandibular more than 5 mm, then extraction of first cast. If the same analysis carried out on the premolar is advised. maxillary arch, then it is called as Arch Perimeter Analysis. PONT’S INDEX

Procedure Pont in 1909, proposed a method of predetermining the ideal arch width which has 1. Determination of arch length: The arch length become to be known as Pont’s index. However, anterior to the mandibular first molars is he felt that the method of measuring teeth to measured using a 0.012 inch soft round brass determine arch width was not the only factor to wire which adapted to the model of the consider in orthodontic treatment planning. He mandibular arch so that one end engaged first also stressed the assessment of facial profile, permanent lower near the marginal ridge. determination of Angle classification, The wire is next passed over the buccal cusps relationship of upper and lower jaws to one of the premolars, then over the normal cuspal another and the midline as important essentials position of the cuspid, then over the anterior to be considered. teeth at ridge center and finally around the Pont devised a method of predetermining an same course on the opposite side, ending in “ideal” arch width based on the mesiodistal the mesiobuccal line angle of the lower first width of the crowns of the maxillary incisors. permanent molar of the other side. The wire Pont suggested that the ratio of combined is cut at this point and straightened, and the incisor to transverse arch width (as measured length is recorded. from the center of the occlusal surface of the In case of proclined anteriors, the soft teeth) was ideally 0.8 in the bicuspid area and round brass wire is passed along the 0.64 in the first molar area. He also suggested cingulum of anterior teeth. that the maxillary arch can be expanded 1 to 2 In case of retroclined anteriors the soft mm more during treatment than the ideal to round brass wire is passed labial to the allow for relapse. In recent years there has been anterior teeth. an unfortunate revival of the use of the Pont’s In case of well aligned anterior teeth, the index in a most sloppy manner. Its only occlusal guide Researchers at the University of wire passes over the incisal edges of the Washington applied the pont’s index to patients anterior teeth. who had undergone complete orthodontic 2. Determination of arch width/tooth material: treatment and were out of retention for at least Tooth material is determined by measuring 10 years. No permanent teeth had been the mesiodistal width of the teeth anterior to extracted in any of the patients. They found very the first permanent molars (incisors, canines poor correlations between the combined and premolars) at the maximum contour maxillary incisor width and the ultimate arch using bow divider. width in the bicuspid and molar areas, and 3. Determination of the discrepancy: The concluded that measuring the mesiodistal width discrepancy refers to the difference between of incisors to predetermine maxillary bi-molar the arch length and tooth material. and inter bicuspid width is of no value. Inference Mandibular arch form and mandibular intercanine diameter have been repeatedly found to 1. Non-extraction case: If the discrepancy is 2.5 be more reasonable treatment guides for both mm or less, it indicates minimal tooth mandibular and maxillary ultimate arch width 124 History of Orthodontics than the Pont’s index. It’s of little use in rational shaped dental arches. He concluded that due treatment planning. consideration must be given to the shape of the In an interesting prelude to the index itself, Pont skull in assessment of arch form and width. noted that the mesiodistal width of the maxillary central and lateral incisors could be used to predict LINDERHARTH INDEX the mesiodistal width of the maxillary canines in Linder Harth G in 1961, on a study on Rhineland normal dental arches. He sugested that half the population proposed index values of 85 and 64 mesiodistal diameter of central plus the mesiodistal rather than Pont’s values of 80 and 64. diameter of lateral would generally, equal the mesiodistal width of the canine. Pont did not KORKHAUS’ ANALYSIS indicate the size of the sample used to determine the proposed index, but did state that they were of Korkhaus used Linder Hart’s measurements and French nationality only. introduced a third measurement from the For each normal dental arch, he suggested midpoint of the inter premolar line of upper arch that a constant relationship existed between the to a point incision between the incisal edges of width of four upper anterior teeth and the width upper central incisors. For a particular width of of the dental arch in premolar and molar area. incisors there is a specific value of the distance All his measurements and predictions were from the incision to the interpremolar line related to the maxillary arch and did not include according to Korkhaus. an assessment of the mandibular arch. If the perpendicular distance from Pont determined a constant ratio between interpremolar line is more than ideal, then the 1. The width of the four maxillary incisors anterior teeth are proclined, if it lesser than the 2. The width of the maxillary arch as measured ideal then the teeth are retroclined. from the center of the occlusal surface of the first premolars and first molars. In the ideal HOWE’S ANALYSIS—1954 dental arch he concluded that the ratio of Howe devised a formula for determining whether combined incisors width to transverse arch the apical bases could accommodate the patient’s width was 0.8 in the premolar area and 0.64 teeth. in the molar area. In orthodontic procedure Pont suggested that The Procedure the maxillary dental arch should be expanded one or two millimeters more than that found in Tooth material (TM) equals the sum of the normal occlusion to allow for relapse. mesiodistal width of the teeth from the first permanent molar forward. Premolar diameter Drawback of Pont’s Analysis (PMD) is the arch width measured at the top of the buccal cusps of the first premolars. Premolar JA Stifter in 1958, tested Pont’s analysis in ideal diameter to tooth material ratio (PMD:TM) is and normal class I dentitions. Cases with slightly slipped contacts, minor rotations and obtained by dividing the premolar diameter by insignificant deviations from perfect occlusion the sum of the width of the 12 teeth. were used, but were considered in a group Premolar basal arch width (PMBAW) is separately from ideal sample, a significant obtained by measuring, with the bowed end of correlation existed between the combined the boley Gauge, the diameter of the apical base maxillary incisors widths and the inter molar on the casts at the apical of the first premolars. and inter premolar width. No corresponding The ratio of the premolar basal arch width to correlation was found for normal group. The tooth material (PMBAW:TM) is obtained by sample consisted of French nationalities. Hence dividing the premolar basal arch width by the Pont’s index universal validity is questionable sum of the width of the 12 teeth. and analysis does not taken into consideration Basal arch length (BAL) is measured at the and the alignment of teeth. midline from the estimated anterior limits of the Hotz in 1961, suggested that deviations from apical base to a perpendicular that is tangent to Pont’s index may be related to long and narrowly the distal surface of 2nd molar. The ratio of BAL History of Model Analysis 125 to tooth material (BAL:TM) is obtained by dividing second permanent molars are measured and the arch length by the sum of the width of the 12 summed up. teeth. 2. Sum of maxillary 12 teeth: The mesiodistal Howe’s believed that the premolar, basal arch width of all the teeth mesial to the maxillary width (he called it the canine fossa diameter) second permanent molars are measured and should equal approximately 44% of the summed up. mesiodistal width of the 12 teeth in the maxilla 3. Sum of mandibular 6 teeth (anteriors): The if it is to be sufficiently large to accommodate all mesiodistal width of all the teeth mesial to the teeth. When the ratio between basal arch the mandibular first permanent premolars width and tooth material is less than 37%. are measured and summed up. Howe’s considered that to be a basal arch 4. Sum of maxillary 6 teeth (anterior): The deficiency necessitating extraction of premolars. mesiodistal width of all the teeth mesial to If the premolar basal width is greater than the the maxillary first permanent premolars that premolar coronal arch width, expansion of the is maxillary anteriors are measured and premolars may be undertaken safely. summed up. Since this method was introduced, rapid palatal expansion has came into more common Determination of Overall Ratio use and clinicians have more opportunity to alter According to Bolton’s study, the sum of the apical base itself. mesiodistal width of the mandibular teeth Howe’s analysis is useful in planning anterior to second permanent molars is 91.3% of treatment of problems with suspected apical base the mesiodistal width of maxillary teeth anterior deficiencies and dividing whether to 1) extract to the second permanent molar. teeth 2) Widen the dental arch or 3) expand rapidly the palate. Sum of mandibular12 100 Overall Ratio = Mandibular apical base distance is more Sum of maxillary12 critical than that of maxillary. In the authors opinion Howe’s analysis is more logical and Inferences superior to the pont’s Index because the Howe’s analysis is applicable to each arch and has been If the ratio is less than 91.3%, then it indicates represented as an aid to thoughtful diagnosis and maxillary tooth material excess. planning while the Pont’s index is often used as Amount of maxillary excess is determined by the a rigid rule and an illogical excuse for not formula, extracting. Sum of mandibular 12 × by 100 Sum of maxillary 12 = BOLTON’S ANALYSIS 91.3 If the ratio is more than 91.3%, then it indicates Bolton’s analysis gives significance to tooth size. mandibular tooth material excess. According to Bolton, there exists a ratio between Amount of mandibular excess is determined by the mesiodistal widths of maxillary and the formula, mandibular teeth. Malocclusion occurs when Sum of mandibular 12 × 91.3 there is disparity between the mesiodistal Sum of mandibular 12 = dimensions of maxillary and mandibular teeth. 100 Bolton’s analysis helps in determining disproportion in size between maxillary and Determination of Anterior Ratio mandibular teeth. According to Bolton’s study, the sum of mesiodistal widths of mandibular anteriors should be Procedure 77.2% of the mesiodistal width of maxillary 1. Sum of mandibular 12 teeth: The mesiodistal anteriors. The anterior ratio is obtained by the width of all the teeth mesial to the mandibular formula, 126 History of Orthodontics

Sum of mandibular 6 × 100 analysis using the dental casts is required for this Anterior Ratio = purpose. Sum of maxillary 6 Principles of Space Analysis Inferences Since malaligned and crowded teeth usually result If the ratio is less than 77.2%, then it indicates from lack of space, thus analysis is primarily of maxillary tooth material excess. space within the arches. Space analysis requires Amount of maxillary excess is determined by the a comparison between the amounts of space formula, required to align them properly. Sum of mandibular 6 × 100 Analysis can be done either directly on the Sum of maxillary 6 = dental casts or by computer after appropriate 77.2 digitization of the arch and tooth dimensions. If the ratio is more than 77.2%, then it indicates Dental cast analysis is two dimensional. mandibular tooth material excess. If a computer method is preferred, it is easier Amount of mandibular excess is determined by and more practical to use an office copying the formula, machine to obtain a 2-D usage of the occlusal Sum of mandibular 6 × 77.2 view of the dental casts, then digitize from that. Sum of maxillary 6 = 100 A readable and surprisingly accurate image can be obtained by simply placing the casts CAST ANALYSIS: SYMMETRY AND SPACE on the center of the copying machine, avoiding the edges of its image area, where An asymmetric position of an entire arch should distortions often appear. have been detected already in the facial/esthetic Whether done manually or computerized, the examination. An asymmetry of arch form also first step in space analysis is calculation of may be present even if the face looks asymmetric. space available. This is accomplished by A transparent ruled grid placed over the measuring arch perimeter from the 1st molar upper dental arch and oriented to the palatal to the other over the contact points of raphe can make it easier to see a distortion of posterior teeth and incisal edge of anteriors. arch form. Asymmetry within dental arch, but There are two ways to accomplish this. with symmetric arch form, also can occur. It 1. By dividing the dental arch into segments that usually results either from lateral drift of incisor can be measured as straight line approxim- or from drift of posterior teeth unilaterally. The ations of the arch. ruled grid also helps in seeing where drift of teeth 2. Or by contouring a piece of wire (or a curved has occurred. Lateral drift of incisors occurs line on computerize screen) to the line of frequently in patients with severe crowding, occlusion and then straightening it out for particularly if a primary canine was lost measurement. The 1st method is preferred for prematurely on one side. This often results in manual calculation because of its greater the permanent canine being locked out of the reliability. arch while the other canine is nearly in its normal Second step is to calculate the amount of position with all the incisors shifted laterally. space required for alignment of teeth. This is Drift of posterior teeth is usually caused by early done by measuring the mesiodistal width of each loss of a primary molar, but sometimes develops tooth from contact point to contact point and then even when primary teeth were exfoliated on a summing the width of the individual teeth. If normal schedule. the sum of the widths of the permanent teeth is greater than the amount of space available, there ALIGNMENT (CROWDING), SPACE ANALYSIS is an arch perimeter space deficiency and It’s important to quantify the amount of crowding would occur. If available space is larger crowding the arches, because treatment varies than the space required (excess space), gaps depending in the severity of crowding. Space between some teeth would be expected. History of Model Analysis 127

Space analysis carried out in way is based on The primary sources of facio lingual tooth size two important assumptions data for the incisors have been skeletal material 1. Anteroposterior of the incisors is correct. (i.e. and extracted teeth and not plaster casts. incisors are neither excessively protrusive nor The index proposed for clinical orthodontics retrusive. utilizes an MD/FL ratio. It’s constructed in the 2. The space available will not change because following manner. of growth; neither assumption can be taken MD crown diameter in mm for granted. Index = × 100 It must be remembered that incisor protrusion is FL crown diameter in mm relatively common and that retrusion though Mandibular incisors of two groups of young uncommon, does occur. There is an interaction female Caucasian adults from North eastern between crowding of tooth and protrusion of region, i.e. Boston were studied. retrusion. One group was designated as group with If the incisors are positioned lingually, this perfect mandibular incisors alignment, while accentuates crowding but if the incisors the other was designated as the “Control protrude, the potential crowding will be at population group”. The members of both least partially alleviated. sample were all within same age range If there is not enough room to properly align (17-27 years). the teeth, the result can be crowding, For each subject in both groups, the protrusion or some contribution of the two. maximum mesiodistal (MD) crown diameter For this reason, information about how much and the maximum FL crown diameter were the incisors protrude must be available from measured directly in the mouth. The clinical examination to evaluate the results of mandibular central incisors of the group with space analysis. perfect alignment has a mean MD/FL index The second assumption, that space available will of 88.4 with a SD of 4.3 not change during growth is valid for adults but The mandibular lateral incisors of the groups may not be for children. In a child with a well with perfect alignment had a mean MD/FL proportioned face, there is little or no tendency for the dentition to the displaced relative to the index of 90.4 with a standard deviation of 4.8. jaw during growth, but the teeth often shift Take the lower incisor measurements in a anteriorly or posteriorly in a child with a jaw sequence beginning with the four MD discrepancy. For this reason, space analysis is less measurements, right lateral incisor to left lateral accurate and less useful for children with skeletal incisor followed by four FL measurements, problems (Class II, Class III, long and short face) left lateral incisor to left lateral incisor. than in those with good facial proportions. Male-female differences in MD/FL indices Even in children with well proportioned for the mandibular incisors appear to the faces, the position of the permanent molars below clinical significance. changes when primarly molars are replaced by premolars. If space analysis is done in the mixed HUCKABA’S ANALYSIS dentition it is necessary to adjust the space It uses both study casts and radiographs for available measurement to reflect the shift in determining the width of unerupted tooth. molar position that can be anticipated. It is necessary to compensate for enlargement ARVEY PECK, SHELDON PECK—1972 of radiographic image. This can be done by measuring an object than can be seen both in It has been shown that naturally well aligned radiograph and on the cast. A simple propor- mandibular incisors possess distinctive dimensional tional relationship can then be established as characteristics; these teeth are significantly smaller follows; mesiodistally and significantly larger facial- lingually when compared with average population Actual width of primary molar (X1) = tooth dimensions. Apparent width of primaryyy molars (X2) 128 History of Orthodontics

combined width of the maxillary cuspid and Actual width of unerupted premolar (Y1) bicuspids. Apparent width of unnnerupted premolar (Y2) c. Compute the amount of spee to left in the arch for molar adjustment by subtracting the X1 × Y1 OR Y 1= estimated cuspid and bicuspid size from the X2 measured space available in the arch after This can be used for both arch groups. alignment of the incisors. Record these values HIXON AND OLD FATHER METHOD—1958 for each side. From all the values now recorded, a complete assessment of the space They examined the dental casts and periapical situation in the mandible is possible. radiographs of 41 children in the mixed dentition and the casts of the same children taken Procedure in the Maxillary Arch following the eruption of canines and premolars. Utilizing a 16 inch target film distance they found The procedure is similar to that for the lower a weak correlation between the mesiodistal arch, with two exceptions: 1) A different widths of the primary and permanent teeth. The probability chart is used for predicting the upper correlation coefficient between the sum of the cuspid and bicuspid sum. 2) Allowance must be widths of mandibular permanent incisors and made for overjet correction when measuring the that of mandibular permanent canines and space to be occupied by the aligned incisors. premolars measured on the casts, was similar to Remember width of the lower incisors is used to reported by other authors. The strongest predict upper cuspid and bicuspid widths. correlation was between, on the one hand, the It is good practice to study the radiographs sum of the width of the central and lateral when mixed dentition analysis is done in order incisors in one quadrants, measured on the casts to note absence of permanent teeth, unusual added to the sum of the width of the two malpositions of development, or abnormalities premolars in the same quadrant, measured on of crown form. For example, mandibular 2nd radiographs and on the other, the sum of the premolars sometimes have two lingual cusps, width of the canines and premolars after their when they are so formed, the crown is larger than eruption. From these results the authors devised might be expected from the probability chart; a table for prediction of mesiodistal width of therefore a higher predicator value is used. unerupted canines and premolars. Modifications MARVIN M TANAKA, LYSTLE E JOHNSTON IN 1974 A technique for mixed dental analysis that compensates nicely for radiographic Dental casts of 506 orthodontic patients in enlargement of tooth images in periapical films Cleveland area were obtained from the is available. Its based on the assumption that Orthodontic Department of Case Western the degree of magnification for a primary tooth Reserve University School of Dentistry. To be will be the same as that for its underlying included in the study, patients had to be of permanent successor on the same film. probable European ancestry and less than 20 1. Measure the width of the primary tooth on years old. the X-ray film (Y1) and the width of its underlying permanent successors (X1) on the Short Method—Tanaka-Johnson X-ray film. A shorter but less precise method has been 2. Measure the primary tooth (Y) directly in the developed which is of merit, but does not allow mouth or on the dental cast. The width of for sexual dimorphism with equal accuracy. the unerupted permanent totoh (X) can then a. Add the width of the mandibular incisors and be calculated by simple mathematical divide by two. proportion b. To the value obtained add 10.5 mm to predict X : X1 = Y : Y1 or X = X1Y / Y1 the combined widths of mandibular cuspid X/X1 = Y/Y1 and bicuspids and 11.0 mm to predict the X = X1Y/ Y1 History of Model Analysis 129

Inaccuracy in radiographic tooth size 3. Many have presumed than to have an measurements is not dentist fault. It occurs accuracy that is not present in any of the because the developing tooth are not always methods yet developed. placed exactly at right angles to the central ray, None of Mixed Dentition Analysis are as precise therefore, the radiographic image of the tooth, as one might like, and all must be used with when slightly rotated or tipped, is significantly judgment and knowledge of development. larger than the actual size of the tooth. Mandibular incisors have been chosen for Ballard and Wylie 1947, conducted an measuring since they are erupted into the mouth investigation to evaluate the assumption that early in the mixed dentition, easily measured there is harmony in tooth size in any one accurately and are directly in the midst of most individual that is, if the incisors are larger than space management problems. average, the canines and premolars and molars Maxillary incisors are not used in any of the are also correspondingly larger than average. predictive procedures, since they show too much They examined the casts of 441 individuals variability in size and their correlations with who had permanent incisors, canines, premolars other groups of teeth are of lower predictive and 1st molars fully erupted. value. Therefore, the lower incisors are measured They developed a predictive formula. to predict the size of upper as well as lower X = 9.41 + 0.527Y and Which X = sum of mesiodistal width of posterior teeth. canines and premolars and Y = Sum of Procedure for Mandibular Arch—1976 mesiodistal width of mandibular incisors. 1. Measure with tooth measuring gauge, the NANCE ANALYSIS greatest mesiodistal width of each of the four Determined the space available in the arch mandibular incisors and record the values in for unerrupted canines and premolars by mixed dentition analysis form. measuring the mesiodistal width of primary 2. Determine the amount of space needed for molars and canine as dental casts, and determined alignment of the incisors. Set the Boley gauge the space required by measuring the mesiodistal to a value equal to the sum of the width of width of the unerupted teeth on radiographs. the left central incisors and left lateral incisors. He claimed that this assessment was accurate in Place the point of the gauge at the midline of most cases. He also measured total arch length the alveolar crest between the central incisors from mesial surface of one permanent first molar and set the other point along the line of the to the other and showed that, in transition from dental arch on the left side. Mark on the tooth mixed to permanent dentition, molar move or the cast the precise point where the distal mesially on average 1.7 m in lower arch and 0.9 surface of the lateral incisors will be when m in upper arch. aligned. Repeat this on the right side of the Clinical judgment: arch. If the cephalometric evaluations show It’s not time consuming the mandibular incisors to be too far labially, It requires no special equipment or the Boley guage tip is placed at the midline radiographic projections but moved lingually a significant amount to Although best done an dental casts, it can be simulate the expected uprighting of the done with reasonable accuracy in the mouth. incisors as dictated by the cephalometric It may be used for both dental arches. evaluation. Mixed Dentition Analysis have been misused in 3. Compute the amount of space available after several ways: incisor alignment. To do this, measure the 1. They have been applied mechanically distance from the point marked in the line of without proper regard for biologic dynamics the arch. To the mesial surface of the first of a critical stage is dentitional development. permanent molar. This distance is the space 2. Naive assumptions have been made (e.g. A available for the cuspid and 2 bicuspids and universal 1.7 mm late mesial shaft). for any necessary molar adjustment after the 130 History of Orthodontics

incisors have been aligned. Record data for the arch perimeter need to be prevented for both sides. molar adjustment and all the space can be 4. Predict the size of the combined widths of the made available for incisors, cuspids and mandibular cuspid and bicuspids. bicuspids. Perhaps the most severe termination of mixed Long Method dentition analyzes is their inability to reflect the position of the incisors with respect to the skeletal Experienced clinicians may choose to use the 50% profile. There are a number of crude rules of prediction since it is a more precise estimate. thumb for determining how much arch Those who are inexperienced or without the use perimeter deduction occurs for each degree or of cephalometrics and a precision appliance millimeter the incisor edge is changed in the method would do well to proceed more conservatively (i.e. use 75% level of prediction). cephalometric visualization of treatment. For Prediction of the combined width of cuspid, example, one degree of tipping or 1 mm of lingual first bicuspid and second bicuspid is done by use displacement of the mandibular incisal edge is of probability charts. said to be equal to 1 mm of arch shortening on The tables used herein are based on size each side. variations and relationships in teeth. North American whites and may or may not be valid TOTAL SPACE ANALYSIS—1978 for other ethnic groups. This analysis is developed by Levern Merrifield. This method has divided the lower dental arch Problems into 3 areas. Anterior middle and posterior to A problem arises when considering the space left analyze the space requirement in the lower arch. for molar adjustment. If this value in the chart is Measurement from study casts and cephalograms negative, that is, the predicted sizes of 3, 4, and 5 are used in this analysis are greater than the space left after the alignment Anterior Area of the incisors, then crowding will occur in the arch even without any forward molar adjustment Space Required when the first permanent molars are in an end to end relationship (i.e. a flush terminal plane of Measure width of mandibular incisors on the the second primary molars, approximately 3.5 models and width of canine from radiographs. mm of space (one half a cusp width) is required Cephalometric correction for incisor position to convert to a class I molars relationship. This is calculated according to Tweeds method. needed 3.5 mm might be acquired, without FMIA is taken into consideration. The incisors orthodontic intervention, in any of three ways are then repositioned and the difference is the 1. 3.5 mm more late mesial shift of the actual and proposed FMIA is determined. mandibular first permanent molar than the The difference in angulations is multiplied by maxillary. 0.8 mm to get difference in multi meters. 2. At least 3.5 mm more forward growth of the Soft tissue modification: Upper lip is measured mandible than the maxilla. from vermilion border of upper lip to greatest 3. Some combination of dental adjustment and curvature of labial surface of central incisor. differential skeletal growth. Since we cannot The total chin thickness is measured from soft yet predict accurately the amongst of tissue chin point to NB Line. differential skeletal growth that will occur, If lip thickness is greater than chin thickness treatment planning must be based on dental the difference is determined and multiplied adjustment factors. If differential skeletal by 2 and added to the space required. If less growth occurs during this period, in the no modification is necessary. molar relationship will result and the mixed Measure Z angle of Merrifield and add the dentition analysis prediction must be altered cephalometric correction to it. If corrected accordingly. When there is class I molar angle is greater than 80°, the mandibular relationships in mixed dentition, no part of incisor angulations is modified is necessary. History of Model Analysis 131

If the correlate angle is less than 75° additional b. Estimated increase: The increase is 3 mm per uprighting of mandibular incisor is necessary. year, i.e. 1.5 on either side until 14 years of age in girls and 16 years in boys. Space Available Total space deficit: This is arrived by comparing the space required and space available in Measure space availability by using brass wire anterior, middle and posterior. Thus we can from mesiobuccal line angle of first primary know where the discrepancy is present. molar of one side to another. WYLIE Middle Area Commenting on Model Analysis Space Required In the year 1959, Commenting on model analysis Measure mesiodistal width of first premolar methods point out “first of all, it is next to as the cast and measure width of the impossible to measure bone dimension from unerupted premolar from the radiographs. even the best plaster cast.”Teeth, yes with great Curve of occlusion: A flat object is placed on accuracy. But no one can arrive a reliable ratio the occlusal surface of mandibular teeth without measuring the both components containing the incisors and first molar. The accurately. As a matter of fact, only the procedure deepest position between the flat surface is of Howe’s Pretends to measure anything but measured and occlusal surface of primary tooth-size and between teeth. Second, one over molars was measured on both side. simplifies the problem when he Presumes that Depth on right side + depth of left side + 0.5 mm crowding can be analyzed completely. When he 2mm knows the size of teeth basal bone. But admits that we cannot ignore the abundant Empirical Space Available evidence that such procedures work, because through trial and error, we have discovered the Using brass wire measure from mesiobuccal line dimensions which we should accept as timing angle of first primary molar to the distal buccal factor. line angle of first permanent molar on either side. KESLING MODEL ANALYSIS Posterior Area In the year 1945, he reported his analysis. Kesling Space Required gave a method of analysis, which was so-called a. Mesiodistal width of II and III molars is “diagnostic setup”. Aim of this analysis is to obtained from radiographs as they might be determine the needs of reducing tooth material. unerupted. If not visible Wheelers method is MARTINEK ANALYSIS used for calculation Comparative Analysis of Howes, Rees, X = Y-X1/Y1 Kesling and Strayer X = Estimated width of 3rd molar Y = Actual size if premolar 1 mandibular molar Martinek, in the year 1957, presented an X’ = Wheelers value for 3 molars. interesting paper on comparing the analysis of Y’ = Wheelers value for 1 molars. Howes, Rees, Kesling, Strayer on five treated cases. Space Available SUWANNEE LUPPANAPORNLARP Amount of space available consists of space presently available on casts and estimated In the year 1993, Suwannee luppanapornlarp, increase. studied the long-term comparative effects of a. Space presently available; obtained by premolar extraction in clear-cut extraction and measuring the distance on occlusal plane to non extraction class-2 patients. He concluded that distal surface of I molar to anterior border of premolar extraction produced a significantly ramus on lateral cephalogram greater reduction in hard and soft tissue protrusion 132 History of Orthodontics both treatments produced the mandibular mesial breakthroughs for tried and true practices. The displacement—extraction significantly more than first time 3D modeling technologies were applied non-extraction. However, at recall the two groups to the dental industry was in 1987 by Dr Mormann. did not differ with respect to signs and symptoms The 3D modeling technology, at this point and of dysfunction. time, allowed Dr Mormann to revolutionize the reconstructive dental industry. Over the years, 3D MODEL ANALYSIS as 3D modeling technologies improved, the In the current age, where today’s technological application became ever more revolutionary. Here barrier is tomorrow’s technological breakthrough, is a partial list of currently available treatments we are continuously reinventing industries, designed with the aid of 3D modeling software: manufacturing and design practices and finding Bending ART system Invisalign® treatment, innovative applications of new technological Suresmile process Orthocad, E-models, etc. History of Cephalometrics 133

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History Prior to the Advent of - Broca Other Important Contributions Radiography - Paul Topinard – Allan G Brodie – Classifying Physiques - Ihering – Thompson and Brodie – Measurements and Cephalometric Radiography – Margolis Proportions – Wilhelm Conrad Roentgen – Wylie – Renaissance to the – Wilhem Koening and Dr Otto Cephalometric Analysis Twentieth Century Walkhoff Evolution of Cephalometrics - Leonardo da Vinci – Van Loon Patient Orientation - Albrecht Durer – AJPacini and Carrera X-ray Source Position - Spigel – Atkinson Film Position and Enlargement - Pieter Camper – Simpson Posteroanterior (Frontal) - Deschamps – Dewey and Riesner Cephalometry - Johann Friedrich Holly B Broadbent’s – Down’s Analysis Blumenbach Contribution – Steiner Analysis - Anders Retzius – Paul Simon – Tweed’s Triangle - Thomas Huxley – Charles Bingham Bolton – Wit’s Appraisal

Ever since God created man in his image, man Cephalometry had its beginning in has been trying to change man into his image. craniometry. Craniometry is defined in the Attempts to change facial appearance are Edinburgh encyclopedia of 1813 as “the art of recounted throughout recorded history. The measuring skulls of animals so as to discover their question of what is a normal face, as that of what specific differences”. For many years, anatomists constitutes beauty, will probably never be and anthropologists were confined to measuring answered in a free society. craniofacial dimensions using the skull of dead Orthodontists, in their attempts to change individuals. Although precise measurements facio-orodental deviations from accepted norms, were possible, craniometry has the disadvantage have adopted cephalometric measurement, a for growth studies. method long employed in physical anthropology. Cephalometry is concerned with measuring With the introduction of roentgenography, it was the head inclusive of soft tissues, be it living or inevitable that this procedure should be employed dead. However, this procedure had its limitations as a medium for the purpose of roentgenographic owing to the inaccuracies that resulted from cephalometrics. Cephalometric radiography was having to measure the skulls through varying introduced into orthodontics during the 1930s. thickness of soft tissues. 134 History of Orthodontics

With the discovery of X-rays by Roentgen in Sheldon’s temperamental components, 1895, radiographic cephalometry came into viscerotonia, somatotonia, and cerebrotonia, being. It was defined as the measurement of head convey behavioral traits commonly associated from bony and soft tissue landmarks on the with physique. With a seven-point scale for each radiographic image (Krogman and Sassouni 1957). somatotype component, there is a wide This approach combines the advantages of distribution in the dense midrange around the craniometry and anthropometry. The disadv- 4-4-4 type; a close relation between somatotype antage is that it produces two-dimensional image and temperament becomes tenuous. of a three-dimensional structure. Nonetheless, common knowledge suffices to recognize dominant behavioral trait in many HISTORY PRIOR TO THE ADVENT OF instances, and that information can be revealing RADIOGRAPHY about the people in general. It may also give some Classifying Physiques clues relating to the orthodontic treatment by providing an insight to the character of the History prior to the advent of radiography patients—their expectations concerning the should begin with the mention of attempt of the treatment’s contribution to their well being, even scientists to classify the human physiques. In 500 their understanding and willingness to accept the BC, the Greek physician and Father of medicine, discipline of cooperation needed for successful Hippocrates, designated two physical types — conclusion of therapy. habitus phithicus with a long thin body subject to tuberculosis, and habitus applecticus— a short Measurements and Proportions thick individual susceptible to vascular diseases Early History—the Canons and apoplexy. The search was continued by Aristotle, Galen (200 AD) and Rostan (1828). Portrayal of human form demands not only Rostan was the first to include muscle mass as a artistic talent and technical ability but also component of physique. Viola’s (1909) disciplined and consistent style. To ensure these morphological index recognizes three stipulations when images of royalty and deity morphological types. Kretschmer (1921) adhered were commissioned and executed, the ancient to the three Greek terms: the pyknic (compact), Egyptians developed an intricate quantitative aesthetic (without strength), and athletic. system that defined the proportions of the human Kretshmer also included dysplastic physique body. It became known as the Canon. The theory which was taken up by Sheldon again in 1940. of proportions according to Panofsky is a system The long historic thread extended into the of establishing the mathematical relations twentieth century when Sheldon introduced his between the various members of the living method of somatotyping, based on three creature, in particular of the human being. The components of physiques, each rated on a seven mathematical relation can be expressed by the point scale and expressed as a three digit number division of a whole as well as by the called somatotype. It also included a rating of multiplication of the unit; the effort to determine dysplasia in the five regions of the body. them could be guided by the desire for beauty as “Dysplasia is literally bad shape or form. In well as interest in the norms, or finally by the somatotyping, it refers to disharmony or uneven need for establishing a convention. distribution of a component or components in Initially the canons were enclosed in a grid different parts of the body,” according to Carter system of equalized squares with 18 horizontal and Heath. lines, line 18 drawn through hairline. Later it was Moreover their definition of a somatotype included in a grid system of 22 horizontal lines, quantifies relative fatness or endomorphy, relative line 21 drawn through the upper eyelid. musculoskeletal robustness or mesomorphy and After the outline of the human figure, was relative linearity or ectomorphy. The somatotype drafted on papyrus leaves the iconographic then stands as a “measuring of overall appraisal norms or canon, served to insert the figure into a of body shape and composition, an anthropological network of equal squares. The image could be identification tag and a useful description of transferred to any required size by first drawing human physique.” a coordinate system to proper size; into this History of Cephalometrics 135 system the image can then be drawn readily and Using strictly geometrical methods, he accurately for displaying in a tomb or on a wall. provided a proportionate analysis of the This procedure is still universally used to enlarge leptoprosopic (long) face and euryprosopic or reduce any kind of illustration. (broad) face in coordinate system, where the Indian econometric studied extensively by horizontal and the vertical lines were drawn Ruelius, was transmitted through sanskrit through the same landmarks or facial features. literature and extensively reviewed in Indian His drawings attest continuous efforts to define texts of architecture. The proportional canons of variations in the facial morphology. One of this that system were already detailed in older is significant as the key to cephalometric analysis. sources and did not materially change with time. In the difference between the retroclined and the Face height was used as the module of both the proclined, facial profile is shown by a change of Sariputra and Alekhyalakshana proportional angle between the vertical and the horizontal system, which closely reflected the natural axes of a rectangular coordinate system to relation of the parts of the body with each other. characterize the facial configuration of each The Sariputra system, dated 1200 AD are known subject. for the sculptures honoring the God Buddha. Sixteenth century saw the first truly scientific attempt in cranial measurement and the Renaissance to the Twentieth Century introduction by Spigel (1578–1625 AD) of the “lineae cephalometricae”. Spigel’s linear Fifteenth century saw the advent of specific cephalometricae consisted of four lines: the facial, measurements being made to compare the occipital, frontal and sincipital lines. He features of different skulls and heads. Leonardo described these lines as follows: da vinci (1452–1519 AD) was probably one of Facial: from the most inferior point of the chin the earliest people of note to apply the theory of to the most superior point on the forehead. head measurement to good effect in practice. Occipital: from the crown of the head to the He used a variety of lines related to specific atlas. structures in the head to assist in his study of the Frontal: from one temple to the other. human form. His drawings included a study of Sincipital: from the lowest part of the ear, in facial proportions in natural head position. the region of the mastoid process, to the According to the notes, the profile was divided highest part of the sinciput, sinciput being the into seven parts by eight horizontal lines. anterior part of the head or skull from Subdivision is made with vertical lines. In his forehead to the crown. study of horse and horse men, he used a scheme According to him, in a well proportioned of facial measurement within a grid system with skull, these lines should all be equal. five horizontal and six vertical lines and the The Dutchman Pieter Camper (1722–1789 subject in natural head position. The joining of AD) was credited with the introduction of facial the lower lip and the chin and the tip of the jaw angle and for famous publication “Dissertation and the upper tip of the ear with the temple forms sur les varietes naturelles de la physionomie” a perfect square; and each face is half a head. which appeared posthumously in 1791. The key Albrecht Durer (1471–1528 AC) was a to his methodology was to orient crania in space, brilliant, unusually productive and an exuberant horizontal from the middle of the porus artist of great virtuosity. He published a treatise acusticus to a point below the nose. Camper’s in 1528 on cranial measurements which horizontal became the reference line for the comprised “Vier Bucher von menschlicher angular measurements used to characterize Proportion” dealing with the proper proportion evolutionary trends in studies of facial of human form in the first two books, the morphology and aging. proportions according to mathematical rules in The facial angle as he described, was formed third book, the human figure in motion in the by the intersection of a facial line and a horizontal fourth book. Durer’s four books mark a climax, plane. The facial line was a line tangential to the which the theory of proportions had never most prominent part of the frontal bone and to reached before or was to reach ever after. the slight convexity anterior to the upper teeth. 136 History of Orthodontics

The horizontal plane passes through the lower distance. The second line passes from the posterior part of the nasal aperture, backwards along the margin of the foramen magnum to the tip of the line of the zygomatic arch and through the center nasal spine. Broca’s occipital angle was formed of the external auditory meatus. by two different lines giving alternative angles, Camper’s facial angle was readily accepted originating from the posterior and anterior as standard measurement in craniology. The margins of the foramen magnum and passing terms prognathic and orthognathic introduced anteriorly through the junction of frontal and nasal by Retzius are tied to Camper’s illustrations of bones. The magnitude of occipital angle decreases facial form in man and primates. As a result, the as the habitual posture of the animal tend more angle between a horizontal line and the line from towards upright. nasion to prosthion became the time-honored An antagonist of Camper, Johann Friedrich anthropological method to determine the facial Blumenbach (1752–1840 AD) rejected the type. The term prognathism refers to the method of lines and angles as a test of national prominence of the face or jaws, relative to the characteristics and proposed a minute survey of forehead, and a straight facial profile became the skull particularly the frontal and maxillary labeled as orthognathous. bones. In 1795, he described a method of The drawbacks of Camper’s facial angle were: positioning the cranium which has to be It ignores the contribution made by the lower measured in a standard reproducible manner. jaw to facial forms. His method was simple, consisting of resting the He did not adhere strictly to his location of skull on its base and looking down vertically posterior reference point for the horizontal upon its vault. The points to be noted were, the plane. projection of the maxilla anterior to the frontal The direct comparison of skull of different arch, the direction, of the jaws and cheek bones ages was not possible because the locating (outward, forward, etc.) and the proportional point might alter in position relevant to other breadth or narrowness of the head. bony structures with advancing age. Anders Retzius (1796–1860 AD) correlated Shortly after this, Deschamps (1740–1824 the two schemes, i.e. of Camper and Blumenbach, AD) introduced the cephalic triangle made up thereby providing a basis for the methods of of facial, occipital, and coronal angles. The facial craniology used today. He is also credited with angle was the lesser angle formed by the the introduction of cephalic index, the ratio of intersection of a horizontal line that passes from breadth to length of the skull expressed as a the external auditory meatus to the base of the percentage. nose, which crossed a profile line. This is similar Nineteenth century produced three great to Camper’s facial angle. Fortunately, the use of men in the history of craniology: Huxley, Broca external auditory meatus as a reference point and Topinard. enabled a rough comparison to be made between Thomas Huxley (1825–1895 AD) wrote in different skulls. 1876, “the so-called facial angle, in the fact, does In the same period as Camper, there was a not simply express the development of jaws in French man, Daubenton who was very relation to face, but is the product of two factors, concerned with the relative position of the facial and cranial, which vary independently. The foramen magnum in man and lower animals. He face remaining the same, prognathism may be made use of new angles, including the occipital indefinitely increased or diminished, by rotation angle to make measurements. Although his of the frontal region of the skull, backward or measurements were not very reliable, a similar forward, upon the anterior end of the basicranial angle was later used by another craniologist, axes”. He also introduced two new angles, the Pierre Broca. sphenomaxillary and sphenoethmoidal angles. Daubenton’s occipital angle is formed by two He preferred the sphenomaxillary angle to lines, the first line passes along the level of Camper’s angle when comparing the degree of opening of the foramen magnum, from the initial prognathism in different skulls. This angle is edge of the foramen along the surface of the formed by the two lines drawn from basion and occipital condyles and anteriorly for short prosthion to prosphenion. The other angle, History of Cephalometrics 137 sphenoethmoidal tends to be less than 180° in center of each auditory meatus to the lower point man. on the inferior margin of each orbit by Von Broca (1824–1880 AD) who is the founder of Ihering (1850–1930). The Frankfurt agreement the Paris society of anthropology believed that modified Von Ihering’s definition such that the the great variability of the cranial form plane passes through the upper border of the constituted a principal difficulty for the bony meatus vertically above their centers. craniologist. He was the first craniologist to However, the reproducibility of this plane on an institute a precise and accurate technique which intact skull is less than Broca’s condyloalveolar could be used to compare crania so that it was plane. Subsequent to the agreement, the made possible to discriminate between the definition of the horizontal plane has been variation in racial types among human skulls. altered so that it is now taken as passing through He introduced a base line “plan alveolo- the right and left porion and left orbitale. condylien” which passes through the alveolar Thereby, reducing the problems incurred by point and tangential to the inferior surfaces of asymmetrical skulls. the two occipital condyles. He also developed a craniostat, mainly constructed of wood for CEPHALOMETRIC RADIOGRAPHY positioning the skull. In 1895, Professor Wilhelm Conrad Roentgen It was generally accepted at this time that the made a remarkable contribution in the field of angles were best determined on projected science with the discovery of x-rays. On December drawings of the skull. Broca devised a simple 28, 1895, he submitted a paper “On a new kind method to trace the outline of the skull on to a of rays, A Preliminary Communication” to the piece of paper by fixing the skull in the craniostat Wurzburg Physical Medical Society for publication and positioning a drawing board with paper in its journal. attached to it parallel to the midsagittal plane and Professor Wilhem Koening and Dr Otto a pencil held in a frame perpendicular to the Walkhoff simultaneously made the first dental paper. The resultant tracing was equivalent to a radiograph in 1896. It was clear that the use of tracing of the peripheral, as depicted on a lateral X-rays provided the means of obtaining a skull radiograph. different perspective on the arrangement and Paul Topinard (1830–1912 AD) used a similar relation of bones, thus expanding the horizons craniostat with some additional modifications. of craniometry and cephalometry. Topinard wrote in 1890 “the craniometer The evolution of cephalometry in the substitutes the mathematical data for the twentieth century is universally linked to uncertain data founded on judgment and Edward Hartlay Angle’s publication of his opinion. Moreover it studies the skeleton of the classification of malocclusion. But the dogmatic ensemble, the cranium and the face separately inferences of the new school were criticized for and each of the plates as well”. failing to include differential diagnosis of facial During nineteenth century, the need for profile in patients with class III and class II standardization of methods used in craniometry malocclusion. became an important issue and since then, many Van Loon was probably the first to introduce bodies have met to better define those points and cephalometry to orthodontics, when he applied planes in use. The most important meeting as far anthropometric procedures in analyzing facial as the dental profession is concerned was held growth by making plaster casts of face into which in Frankfurt-am-Main in August 1882. This was he inserted oriented casts of the dentition. the 13th General congress of the german Hellman used cephalometric techniques and anthropological society and it is to this congress described their value beginning with 1920s. that the Frankfurt horizontal plane owes its The first X-ray picture of skull in the standard name. lateral view was taken by AJ Pacini and Carrera Earlier in 1859, a horizontal plane following in 1922. Pacini received a research award from the zygomatic arches was suggested by a Russian the American Roentgen Ray Society for a thesis craniologist, Von Baer. Later, the plane was entitled “Roentgen ray anthropometry of the defined more precisely as line drawn from the skull”. Pacini introduced a teleroentgenographic 138 History of Orthodontics technique for standardized lateral head This development enabled orthodontists to radiography and thereby opened a way, which capture the field of cephalometry from the proved to become a tremendous advance in anatomists and anthropologists who had cephalometry, as well as in measuring the monopolized craniometric studies, particularly growth and development of face. His method, in nineteenth century. which was rather primitive, involved a large fixed distance from the X-ray source to the HOLLY B BROADBENT’S CONTRIBUTION cassette. The head of the subject, placed adjacent to a standard holding the cassette, was Broadbent’s interest in craniofacial growth began immobilized with a gauze bandage wrapped with his orthodontic education under E H Angle around both the face and the cassette after the in 1920. He continued to pursue that interest patient’s midsagittal plane was carefully oriented along with his orthodontic practice, working parallel to the cassette. with a leading anatomist J Wingate Todd. He identified the following anthropometric The idea of diagnosing dental deformities by landmarks on the roentgenogram: gonion, means of planes and angles was first proposed pogonion, nasion, and anterior nasal spine. He in 1922 by Paul Simon of Germany in his book, also located the center of the sella turcica and “Fundamental principles of a systematic the external auditory meatus. He measured the diagnosis of dental anomalies”. Although his gonion angle and the degree of maxillary “Law of the canines” was later disproved by protrusion. Broadbent, his theories stimulated the latter to Atkinson in 1922 advocated the use of apply the principles of craniometry to living roentgenograms in locating the ‘key ridge’ and the subjects. soft tissue relations to the face and jaws. In 1923 The uncertainty of locating landmarks in the McCowen reported on profile roentgenograms that skull of the living child by approaching through he used for orthodontic purposes to visualize the skin and soft tissues led him to search for a means relationship between the hard and soft tissues and of recording craniometric landmarks on the to note the changes in profile which occur during living child accurately as done with a craniostat treatment. in measuring the dead skull. Simpson presented a method for obtaining During 1920’s, Broadbent refined the profile roentgenograms in 1923 before American craniostat into craniometer by the addition of 1927, Ralph Waldron Society of Orthodontists. In metric scales. This proved to be the first step in of Newark, NJ made mention of measuring the the evolution of craniostat into a radiographic gonion angle from a roentgenogram taken at 90o cephalostat. It did not take him much longer to to the facial profile. Waldron was the first to convert the direct measuring instrument into a construct a cephalometer, which differed little radiographic craniometer. from those used today. Meanwhile, the course of Broadbent’s In 1928, Dewey and Riesner published an orthodontic practice corrected the malocclusion article, “A Radiographic study of facial deformity”. Dewey and Riesner immobilized the of Charles Bingham Bolton, son of Chester and patients head in a head clamp and placed the Francis P Bolton. His discussions of facial growth cassette against the patient’s face. They took with Congress woman, Bolton led to the addition profile roentgenograms by aligning the eye to ear of Bolton study of facial growth to the long list plane by a right angle leveling technique. They of Bolton philanthropies. As Charles grew to used a target distance of three feet. adulthood, this study became a major personal In 1931, the methodology of cephalometric as well as financial commitment. radiography came into full function when B Cephalometrics was neither developed as a Holly Broadbent in USA and H Hofrath in technique looking for an application nor was it Germany simultaneously published methods to developed as a diagnostic tool. Broadbent’s single obtain standardized head radiographs in the goal was the study of craniofacial growth. The angle orthodontist (A new X-ray technique and Broadbent’s technique for cephalometric its application to orthodontia) and in radiography was one of the tools which he Fortschritte der Orthodontie, respectively. developed for the implementation of that study. History of Cephalometrics 139

The technique and apparatus perfected for the and the pattern once attained at an early age, Bolton fund study of the normal developmental did not change. growth of the face, eliminated practically all of Thompson and Brodie (1942) in a report on the technical difficulties encountered in previous the rest position of the mandible, concluded methods of recording dentofacial changes, and that: proved to be a convenient as well as scientific 1. Morphogenetic pattern of the head was method of measuring orthodontic procedures. established ata early age and did not According to Broadbent, the patient’s head change, was centered in the cephalostat with the superior 2. Presence or absence of teeth has little bearing borders of the external auditory meatus resting on the rest position of the mandible and on the upper parts the two ear rods. The lowest 3. Vertical facial proportions are constant point on the inferior bony border of the left orbit, throughout life. indicated by the orbital marker, was at the level Margolis (1943) wrote on the relationship of the upper parts of the ear rods. The nose clamp between the inclination of the lower incisor and was fixed at the root of the nose to support the the incisor-mandibular plane angle and was the upper part of the face. The focus film distance first to corroborate Tweed’s clinical observation was set at five feet (152.4 cm) and the subject film that, in normal occlusions, the lower incisors are distance could be measured to calculate image 90° to the mandibular basal bone. magnification. With the two X-ray tubes at right In 1947, Wylie produced a method of angles to each other in the same horizontal plane, assessing anteroposterior dysplasias and that two images (lateral and posteroanterior) could same year, Margolis contributed his maxillo- be simultaneously produced. facial triangle. Germany’s Hofrath’s technique differed from CEPHALOMETRIC ANALYSIS Broadbent’s technique in this way of the central ray was not fixed in relation to the head and no The major use of radiographic cephalometry is in plan was suggested for super-positioning characterizing the patient’s dental and skeletal subsequent X-rays. relationships. This led to the development of a number of cephalometric analyzes to compare a OTHER IMPORTANT CONTRIBUTIONS patient to his or her peers, using population In 1937, using serial records of twins; Broadbent standards. William B Downs (Fig. 14.1 ) in 1948 showed how growth or its lack was the greatest limiting factor in clinical success. In 1943, he stipulated that, eruption of the third molars had no ill effect on the denture, particularly the lower incisors. In 1938, Allan G Brodie at the University of Illinois presented a cephalometric appraisal of orthodontic results: 1. The use of elastic causes a disturbance in the Bolton plane-occlusal plane angle; 2. Axial inclinations of orthodontically- moved teeth tend to return to their original inclinations. 3. Bone changes during treatment are restricted to the alveolar process. Brodie, in a landmark study (1941) used for his PhD in anatomy, corroborated Broadbent’s contention that the growth pattern of the normal child’s face develops in an orderly fashion downward and forward Fig. 14.1: William B Downs (1899–1996) 140 History of Orthodontics

2. The landmarks to locate the FH plane, orbitale and porion, especially the latter, are difficult to identify on a cephalogram. An alternative to overcome this problem was to use a functionally derived NHP. According to Morrees and Kean, it was obtained by asking the subject to look at the image of their eyes in the mirror located at eye level. A frame of reference was originally intended as a reliable procedure for orienting facial profiles so that, same orientation could be established on different occasion by different investigators. Although the functionally derived NHP was Fig. 14.2: Herbert I Margolis (1900–1984) more accurate, its reproducibility was less than FHP (anatomic approximation of NHP). Lateral and posteroanterior views perpendicular to each developed the first cephalometric analysis. Its other in the horizontal plane were specified for significance was that, it presented an objective three-dimensional analyses. method of portraying many factors underlying Bjork’s studies of facial prognathism malocclusion and there could be a variety of illustrated the unreliability of intracranial causes of malocclusion exclusive to teeth. This reference lines in cephalograms. was followed by another analyzes by Cecil C Kroagman and Sassouni (1957) conducted an Steiner (1953), CH Tweed (1953) , RM Ricketts exhaustive survey of roentgenographic (1958), V Sassouni (1969), HD Enlow (1969), JR cephalometry in which the FHP (Frankfort Jaraback (1970), Alex Jacobson (1975), etc. horizontal plane) coincided with the physiologic or true horizontal. EVOLUTION OF CEPHALOMETRICS Sassouni made an attempt to standardize the The thoroughness of Broadbent’s approach to the orientation of cephalograms by means of an design of the cephalometric method is evident optical plane advocated in 1862 by Broca, who from the fact that the basic technique has stated that “when a man is standing and when survived almost unchanged for over seventy his visual axis is horizontal, his head is in natural years. position”. In about two decades time, the instrumentation had evolved to a form more suitable for X-RAY SOURCE POSITION the individual practitioner through the pioneering efforts of Margolis (Fig. 14.2), Higley The X-ray source is positioned five feet (152.4 cm) and others. from the subject’s midsagittal plane. A change to 150 cm has been adopted by some as a PATIENT ORIENTATION conveniently round metric number, but the difference is negligible. A major improvement The ears were established as the basis for in lateral cephalostats is, the capability of taking orientation and fixation in the beam axis. lateral and posteroanterior views with a single Frankfurt plane was adopted for horizontal X-ray source instead of two. orientation with nasion for stabilization. The Frankfort horizontal plane (FHP) was chosen FILM POSITION AND ENLARGEMENT because this was approximate the natural head position (NHP). But the FHP also had its The other significant change from the original drawbacks and those were: technique is adjustability of film position. The 1. Some individuals show a variation of their original cephalostat was based on the design of FHP to the true horizontal to an extent of ± the anthropometric craniometer and cassettes were 10°. attached to these mechanisms. The disadvantage History of Cephalometrics 141 of this very efficient mechanical design is that it since it requires rather large equipment with two makes cassette position and resultant enlargement X-ray sources. depended on head size. Evaluation of serial Modern equipment uses one X-ray source. changes by direct superimposition is made Therefore, following lateral cephalometric unreliable by this variable enlargement. registration, the patient must be repositioned if The relative immunity of angular a posteroanterior cephalogram has to be measurements to enlargement distortions led produced. A head holder or cephalostat that can many researchers to opt for angular over linear be rotated 90° is used, so that the central X-ray values whenever possible. Also newer instruments beam penetrates the skull of the patient in a have been developed that can over come this posteroanterior direction and bisects the drawback of variable enlargement by providing transmeatal axis perpendicularly. Maintaining independent adjustments for head holding the identical horizontal orientation from lateral mechanisms and cassette. to the posteroanterior projection is critical when comparative measurements are made on each POSTEROANTERIOR (FRONTAL) other (Moyers et al, 1988). CEPHALOMETRY In using natural head position for posteroanterior cephalometric registrations, some Since the introduction of a standardized method practical problems are encountered. The patient’s for obtaining skull radiographs, cephalometrics head is facing the cassette; which makes it has become one of the major diagnostic tools in difficult for the patient to look into a mirror to orthodontics. The posteroanterior cephalogram register natural head position (Solow and contains diagnostic information not readily Tallgren, 1977). Furthermore, space problems available from other sources. This information make it impossible to place a nose piece in front allows the practitioner to evaluate the width and of nasion to establish support in a vertical plane. angulation of the dental arches in relation to their For better evaluation of patients with osseous bases in the transverse plane; evaluate craniofacial anomalies that require special the width and transverse positions of the maxilla attention to the upper face, the patient head and mandible, evaluate the relative vertical should be positioned with the tip of the nose and dimensions of bilateral osseous and dental forehead lightly touching the cassette holder. structures; assess nasal cavity width, and analyze (Chierci, 1981) vertical and/or transverse facial asymmetries. In cases of suspected significant mandibular Malocclusions and dentofacial deformities displacement, the posteroanterior cephalogram constitute three-dimensional conditions or should be taken with the mouth of the patient pathologies. Although all orthodontic patients slightly open in order to differentiate between deserve an equally comprehensive three functional mandibular displacements and dimensional diagnostic examinations, dentoskeletal facial asymmetry (Faber, 1985). As assessment of posteroanterior cephalometric far as exposure conditions and considerations are views are of particular importance in cases of: considered, more exposure is needed for postero- 1. Dentoalveolar and facial asymmetries anterior cephalograms than lateral views (Enlow, 2. Dental and skeletal cross bites 1982). 3. Functional mandibular displacements. Cephalometric radiography, which came into The same equipment that is used for the widespread use after the Second World War, lateral cephalometric projections is utilized. The enabled orthodontist to measure the changes in initial unit described by Broadbent consisted of tooth and jaw positions produced by growth and a set up in which two X-ray sources with two treatment. Among other findings, these radiog- cassettes were simultaneously used, so that raphs revealed that many class II and Class III lateral and frontal cephalograms were taken at malocclusions resulted from faulty jaw relation- the same time. Although precise-three- ships, not just malposed teeth. By the use of cephal- dimensional evaluations are possible using this ometrics, it was also possible to see that jaw growth technique, it has now been almost abandoned could be altered by orthodontic treatment. 142 History of Orthodontics

According to Salzmann, cephalometric skeletal ossification, have proven to be more radiograph can show following features; accurate. 1. Show dimensional relationship of the The standard method to evaluate skeletal craniofacial components. maturity has been the use of hand-wrist 2. Reveal manifestations of growth and radiographs, matching the overall pattern of the developmental abnormalities. subject’s maturation to a set of reference patterns, 3. Helps in treatment planning. available in an atlas. Skeletal maturation is 4. Helps in diagnosing the patient, especially of generally determined by evaluating either the skeletal origin. stage of ossification of bones of the hand and 5. Helps in evaluating the dentofacial growth wrist, due to the large number of different types changes during and after the orthodontic of bones available in these areas, or the treatment. ossification onset of the ulnar sesamoid. The goal of cephalometric analysis is to However, to avoid taking additional radiographs, estimate the relationship, in all three planes that the cervical vertebrae, as seen on routine lateral is in anteroposterior, vertical and transverse cephalograms, have been used to determine the relationship of the jaws to the cranial base and skeletal maturity. to other, the relationship of the teeth to their It is well known that the lateral view of supporting bone, and the effect of the teeth on cervical vertebral bodies change with growth. In the profile. 1972, Lamparski stated that the cervical In the 16th century, artists Durer and Da Vinci vertebrae were as statistically and clinically sketched a series of human faces with straight reliable in assessing skeletal age as the hand-wrist lines joining homologous anatomic structures. technique. In recent years, evaluation of cervical Variations in these lines highlighted the structural vertebrae has been increasingly used to difference among the faces. These facial determine skeletal maturation. Several authors proportions were basically an artist’s attempt, have reported a high correlation between cervical with beauty and harmony as the guiding vertebrae maturation and skeletal maturation of principles, to quantify the basic structures of the the hand-wrist. It has been found that cervical human face. vertebrae could offer an alternative method for Much later, the anthropologists invented an assessing maturity without the need of hand- instrument—the craniostat, which helped in wrist radiographs. However, cervical vertebrae orienting dry skulls and facilitating standardized were used to evaluate growth in a subjective measurement. This improved the art of manner because the method consisted of a comparisons as the instrument improved qualitative comparison between the patient reproducibility but this also did not allow the radiographs and the images contained in the study of skulls of living humans. The discovery atlas. of the X-rays in 1895 by Sir William Conrad Mito et al (2002) established a new method Roentgen, proved to be a boon in this direction. for objectively evaluating skeletal maturation on Orthodontic diagnosis and treatment cephalometric radiographs. A regression formula planning for growth children must involve was determined to obtain cervical vertebral bone growth prediction. The pubertal growth spurt is age based on ratios of measurements of the third considered to be an advantageous period for and fourth cervical vertebral bodies. However, certain types of orthodontic treatment and the population used to derive the formula should be taken into account together with consisted of Japanese girls only. orthodontic treatment planning. The study of facial form as revealed in the Because of the wide individual variation in analysis of lateral skull radiographs. In addition the timing of the pubertal growth spurt, to clinical examination, analysis of a lateral chronological age is an unreliable guide for cephalogram permits a more detailed evaluation assessment of children development status. of facial and dentoskeletal structures to aid Other parameters such as, growth velocity, diagnosis and treatment planning, especially in secondary sex changes, dental development and cases with a skeletal discrepancy. Also provides History of Cephalometrics 143 baseline measurements to monitor the effects of growth and development. Lucien De Coster: Lucien De Coster of Belgium in the year 1939, was the first to publish an analysis based on proportional relationships in the face conforming to the principles used in antiquity. Wits analysis: The Wits analysis (1967) gets its name from the University of Witwatersrand in South Africa; it was brought stateside by Alexander Jackobson of the University of Alabama. Rejecting dependence on the ANB angle, Jacobson relates A and B linearly by Fig. 14.3: Tweed’s triangle verticals from the occlusal plane. Like the Harvold analysis, the Wits analysis concentrates on the skeletal discrepancy between the jaws. It determines the magnitude of the jaw discrepancy by relying on the linear difference between points A, B and the occlusal plane. The wits take into account, the horizontal and vertical relationship of the jaws, but its weakness is that it is influenced by the dentition and therefore skews the analysis from indicating the true skeletal discrepancies between the jaws.

Tweed’s Triangle Tweed in the year 1954 based on the hypothesis that, in the normal occlusion, the mandibular incisors are upright over the basal bone, constructed a triangle formed by the lower central incisor, mandibular plane, and Frankfort Fig. 14.4: Richard A Riedel (1922–1994) horizontal plane. The Tweed’s triangle (Fig. 14.3) makes use of three planes that form a diagnostic studies at the University of Washington of long- triangle called Tweed’s triangle. Following are range treatment stability have left us an the planes of Tweed’s triangle: unsurpassed legacy. 1. Frankfort mandibular plane angle (FMPA) The ANB angle is defined as the mutual 2. Incisor mandibular plane angle (IMPA) relationship, in sagittal plane, of the maxillary 3. Frankfort-mandibular incisor plane angle and mandibular bases. (FMIA) STEINER’S ANALYSIS: CECIL C STEINER ANB Angle (1896–1989) Richard A Riedel (1922–1994) (Fig. 14.4), Cecil C Steiner was Angle’s second student at introduced ANB angle before completing his the Pasadena school. He was initially rebuffed Master’s degree at Northwestern University in because he did not know who Charles Darwin United States of America. Nowadays this is most was. Later with mother Angle’s encouragement, widely used diagnostic cephalometric angle. The he not only got the admission but also carved ANB angle represents the anteroposterior his name in the orthodontics. The Steiner relationship of the maxilla with the mandible. In analysis, published in 1953, offered specific addition to his cephalometric research Riedel’s guides for the use of cephalometric measurements 144 History of Orthodontics in treatment planning, based on what to determine, for example, if extractions were compromised incisor positions would be necessary. Through this step-by step approach, necessary to achieve normal occlusion when the the Steiner analysis has been instrumental in ANB angle was not ideal. It I also incorporated “popularizing“ cephalometrics. At one time, arch length and other considerations, such as the southern California was known cephalomtrically profile, enabling even the neophyte orthodontist as Steiner Territory”. History of Extraction in Orthodontics 145

HHiiissstttooorrryyy oofff EEExxxtttrrraaaccctttiiiooonnn iiinnn OOrrrttthhhooodddooonnntttiiicccsss 15

Arch-Length Analyses – Case or Angle Controversy Historieal Perspective Second Premolar Extraction Need for Extraction – Dewel’s Method 1978 – Tweed’s Method (1966) Evolution of the Philosophy of Choice of Teeth for Extraction – Nance Method Extraction in Conjunction with Serial Extraction – Grewe’s Method Orthodontic Therapy

Extraction of one or more teeth is sometimes described euphemistically as “reduction in the necessary to establish normal functional total number of dental units”. According to occlusion, especially when jaws are not large Lischer, “The extraction of one or more enough to accommodate all the teeth. Tooth permanent teeth to facilitate an orthodontic extraction may also be needed to correct the treatment dates back at least to Fauchard (1728), anteroposterior dental arch relationships. The and has been resorted to ever since. . . . The space gained by extraction is utilized to relieve narrow, orthodox view that extraction of a tooth crowding or to retract the proclined anteriors. is never justified is being discarded. . . . The profile The decision of extraction should always be of a growing child must never be regarded as a based on sound judgment, taking patient’s age, fixed line, but one in which further changes will development and amount of space needed for continue to take place.” As early as 1920, George tooth alignment into consideration. The decision W Grieve (1870–1950, Angle School, 1907; Fig. to opt for extraction should be made only after 15.1), considered the dean of Canadian careful clinical evaluation, cephalometric and orthodontists, recommended the removal of model analysis to assess the need and outcome of permanent teeth. However, the increase in such extraction. First premolars are most extractions that took place in the mid-1940s was frequently extracted as a part of orthodontic due, in large part, to the influence of Charles treatment followed by the second premolars. Tweed, whose teachings had become widely Injudicious extractions may lead to undesirable accepted. He advocated positioning the consequences such as arch collapse, deep overbite, mandibular incisors upright over basal bone spacing and tissue damage. (approximately 90° to the mandibular plane By the 1930s, the relatively common extraction angle) and argued that expansion of dental units practices of the late 19th century, dictated largely off this bone led to instability. Extractions in the by technique limitations, had given way to permanent dentition rapidly became the most Angle’s non-extraction dogma. Although a more common treatment strategy for the correction of tempered position continued to be held by Case Class I and II malocclusions, and, as Allan Brodie and others, the word “extraction” had become ruefully remarked, “soon the air was filled with all but unmentionable. Thus, when it was bicuspids”. The prevalence of extractions soared mentioned in the literature, it was frequently from a modest 30% in 1953 to 76% in 1968. 146 History of Orthodontics

prominent lips. Abraham Goldstein studied patients 21 years after retention and found that non-extraction patients looked better. Lack of incisor prominence. Narrowed maxillary arch. Desire to avoid extended treatment. The increased fear of malpractice litigation. In the 1980s, claims were made that temporomandibular disorder problems could be attributed to the removal of maxillary premolars. But there were also some positive factors. Increased use of extraoral traction and functional appliances to take advantage of growth. More arch length gained by the use of bonded brackets. Better understanding of retention. Reproximation (e.g. air-rotor stripping, “slenderizing”). Increased use of removable appliances (which rely mainly on a full complement Fig. 15.1: George W Grieve of teeth). Revival of “arch development”14 (lateral Tweed did not extract indiscriminately, but, in expansion, rotation or distalization of too many patients, practitioners looked on the molars, and controlled proclination of removal of 4 premolars as the easy way out of an mandibular incisors). By 1993, the arch-length problem. Conservative leaders, prevalence of extraction had returned to although acknowledging that extraction had its 1950s levels (28%). Proffit and Fields place, were reluctant to endorse it publicly, out believe that nonextraction is once again of fear that it would lead to abuses. Brodie, who being carried to an extreme. became Angle’s torchbearer, said, “If I say it’s OK to extract, the first thing you know, ARCH-LENGTH ANALYSES everybody’s going to be extracting instead of making a proper diagnosis. Doctor Angle told In the 1950s, to a considerable extent a result of me that and it’s true”. Silas J Kloehn’s (1902–85, Fig. 15.2) revival of By the 1980s, the pendulum had swung back cervical traction and Nance’s arch-length analysis, toward non-extraction as orthodontists began there was increased interest in mixed-dentition using new appliances and technologies to treatment and serial extraction. Perceiving a need increase arch length and width, making it easier for improvement in mixed-dentition tooth-size to treat crowded dentitions without extractions. measurement, Hixon and Oldfather in 1958 Several other factors were responsible for this developed an analysis based on the widths of the shift, including some negative ones. mandibular permanent incisors and the X-ray Relapses (including the return of rotations measurements of the unerupted canines and and overbite) and the reopening of extraction premolars, using a 16-in cone. This contribution spaces. proved to be the most popular of its kind to date; Gingival depressions at extraction sites. however, it was later revised because it was learned The finding that extraction is no guarantee that this analysis often under predicted the widths of stability. of unerupted teeth. Moyers’ analysis (1973), based Flattened lips—”aged” look. The general on linear regression equations and the widths of public often prefers fuller and more the mandibular incisors, achieved widespread History of Extraction in Orthodontics 147

extreme cases, a mandibular incisor might require extraction.

SECOND PREMOLAR EXTRACTION A borderline patient presents the dilemma of extracting first premolars when the amount of crowding does not warrant the 14 or 15 mm per arch thus gained, or the alternative of non- extraction, which might be equally undesirable for reasons of esthetics or stability. The idea of extracting teeth other than the first premolars must have occurred to early clinicians, and some might very well have done so. Surely, many had to deal with congenitally missing second premolars. But it was well into the 20th century before it is mentioned the literature. One of the first authors to spell it out was Clarence W (Clu) Carey (1904–2003, Fig. 15.3). Carey was an innovator whose many contributions to orthodontics include laminated arches, the Bi-Po toothbrush, and the tooth-size dental calculator. He was nevertheless more cautious when he advocated (1947) extracting 4 second premolars if the discrepancy is more than 2.5 mm and if the Fig. 15.2: Silas J Kloehn operator is willing to accept a compromised result. In 1949, Nance spoke of removing the second rather than the first premolars to keep clinical acceptance because of its simplicity and the incisors over basal bone. Perhaps the most ease of application. Offering insight into why some definitive description of second-premolar occlusions did not “fit”, Wayne Bolton devised extraction procedures during those years was an analysis based on average measurements to written by B F (Tod) Dewel (1902–99, Fig. 15.4 ), determine tooth-size discrepancies between the who emphasized that closure of extraction spaces maxillary and mandibular arches. This analysis requires “a delicate balance . . . between anterior made it possible to determine whether the anchorage and posterior resistance”. He maxillary or the mandibular teeth (commonly, reminded us that “extraction of second premolars the 6 anterior teeth) have deficient or excessive decreases by 2 teeth the resistance the buccal mesiodistal diameters. His analysis immediately segments present when the spaces are being became a standard part of the complete diagnostic closed”. In 1964, Ricketts (1920–2003) advocated analysis of malocclusion, although, in 2000, Smith placing the mandibular incisors within 1 et al, examining the validity of Bolton’s ratios for standard deviation of the Point A-pogonion various ethnic groups, concluded that the ratios plane. That same year, Schoppe suggested that a apply only to white women and should not be discrepancy of 7.5 mm or less should be the used arbitrarily for white men, Hispanics, or blacks. criterion for considering second premolar Peck and Peck, believing that tooth shape (rather removal, if there is no need for incisor retraction. than tooth width) might be a factor in determining He offered these advantages for the option: whether crowding of the mandibular incisors Permits more rapid mesial movement of would occur, devised an index based on the ratio molars. between the mesiodistal and faciolingual widths. Permits less lingual movement of incisors. With this and Bolton’s ratios, it became possible Is probably the best means of gaining space to determine the need for re-proximation. In when a minimum of space is necessary. 148 History of Orthodontics

Tends to alter the profile less. Tends to hasten closure of the extraction space. Reminiscent of Tweed’s “100 cases”, Logan showed 100 case records of patients treated with second premolar extractions at the 1970 annual Pacific Coast Society of Orthodontists’ meeting. In a 1973 article, he listed these advantages of second-premolar extraction, over and above those proffered by Schoppe. Eliminates problems of rotated, tipped, or late-erupting second premolars. Facilitates closure of anterior open bite by reducing posterior vertical dimension. Eliminates need to bond mandibular second premolars, which are less-than-ideal candidates for bonding. Gains additional space for second and third molars. Makes it easier to control rotations, axial inclinations, and anterior torque. Requires less Class II elastic force and headgear. Fig. 15.3: Clarence W (Clu) Carey Produces fewer end-to-end bites because of the comparative widths of maxillary and mandibular premolars. Maintains the maxillary first premolar, which is usually stronger than the second premolar.

EVOLUTION OF THE PHILOSOPHY OF EXTRACTION IN CONJUNCTION WITH ORTHODONTIC THERAPY The role of extractions in orthodontic treatment has been a matter of controversy for years. Although John Hunter recognized the role of extraction as early as 1771 in his book Natural history of the teeth, it was not until mid 20th century that extraction of teeth in conjunction with orthodontic therapy became more acceptable.

Case-Angle Controversy Originally, Calvin Case (Fig. 15.5) was a genuine admirer of Angle. He advocated the Angle system at every turn and hoped to place this system before the dental profession. In fact, he gave up the general practice of dentistry because of Angle’s influence. The discord started over the claim that Angle attributed the origin of the use Fig. 15.4: BF Dewel of inter-maxillary elastics to Baker, while Case History of Extraction in Orthodontics 149

Fig. 15.5: Calvin Case Fig. 15.6: Martin Dewey thought that he should have received that credit. Department, the Chicago Dental College, and the In fact, when Angle described this procedure, he New York College of dentistry. He gained a wide never mentioned Case. This led to charges and reputation as an outstanding teacher. He had counter charges between them in 1903. Case’s started his own graduate school in orthodontics claim was that in 1890 he started this procedure in 1911 as the Kansas City School of Orthodontia and reported it at the Chicago Dental Society and and continued it as he traveled from one city to also at the Columbian Dental Congress in 1893. another, ending in New York City with his death The second point of contention was—and is in 1933. His influence was much felt since he was the one usually remembered—the question of the the editor of the International Journal of extraction of certain teeth as a means of Orthodontia for 17 years and also the president treatment. Angle’s thesis was that “there shall of the American Dental Association in 1931. be a full complement of teeth, and that each tooth The climax of this conflict was a debate in shall be made to occupy its normal position”. 1911 at the annual meeting of the National Dental Case defended the discreet use of extraction as a Association (former name of the ADA). Bitterness practical procedure, while Angle believed in non- and animosity were rampant. It took many years extraction. However, the unexpected result of after this episode for the problem to become a this controversy was that it convinced general matter of calm and objective evaluation and practitioners that they should not attempt respectful appreciation of various points of view, orthodontic treatment but should refer patients each of which has made its contribution to to the specialist. orthodontics. The extraction story was continued into 1911 The first decade of the twentieth century was with Martin Dewey (1881–1933) (Fig. 15.6) an an era of the manufacture of standardized ardent champion of non-extraction. Dewey appliances. These appliances were made as sets served as professor of Orthodontics at Kansas of various kinds mounted on cards and sold by City Dental School, the University of Iowa Dental dental supply companies. By the use of a few 150 History of Orthodontics simple soldering techniques, the dentist could the diagnosis of “mouth breathing”, which took make a required “fitting”, as it was called. on special meaning (1907). William J Brady (Iowa City) advertised as a In 1907 Benno Lischer (1876–1959)(Figure consulting specialist in orthodontia: 14.7), dean and professor of dental orthopedics at Advice by mail upon regulating cases of all Washington University Dental School in St. Louis, kinds. Appliances fitted to models with full founded the International School of Orthodontia, instructions for handling from beginning to end. and in 1912, he published Principles and Methods Instructions: send good models of both upper of Orthodontia. He was an advocate of early and lower, with thin wax bite. Give age and sex. treatment. Lischer wrote: “It is my firm belief that Pack carefully. After examination, an estimate irreparable damage is done by oft repeated advice to of the cost of instructions of appliance will be wait until the permanent teeth are all erupted before submitted free of charge. If satisfactory, remit the beginning operations for correction of malocclusion.” amount by bank draft or money order. Other publications included the first separate George C Ainsworth patented a regulating journal entitled American Orthodontist, which appliance that used vertical tubes and the started in 1907 and ceased publication in 1912. In principle of the loop wire in 1904.Varney Barnes 1909 CN Johnson (Chicago) edited a work entitled patented the so-called Barnes posterior tube A Textbook of Operative dentistry, which consisting of a soldered band that held several contained a chapter, “Orthodontia”, written by teeth together, with vertical tubing applying root Herbert A Pullen covering over 275 pages of text. pressure to individual teeth. It contained not only etiology, diagnosis, and Many innovative ideas and procedures were treatment modalities but also instruction in introduced. Victor H Jackson (1850–1929) was laboratory procedures. experienced in mechanics and devised a specially designed appliance known as the Jackson crib, NEED FOR EXTRACTION which incorporated the use of an auxiliary spring Extraction of teeth in orthodontic treatment is (finger) as an aid in tooth movement. His appliance necessary in two main circumstances: was one of the first “systems” of treatment to 1. For the relief of crowding caused by arch influence the development of modern lengthtooth material discrepancy orthodontics. Jackson published Orthodontia and 2. For the correction of anteroposterior dental Orthopaedia of the Face in 1904. In it, he claimed arch relationship. that with his method a large number of patients could be cared for as contrasted to the highly CHOICE OF TEETH FOR EXTRACTION sophisticated techniques in vogue at the time that The choice of teeth for extraction should be limited the number of patients. carefully made with consideration to the Another contribution was reintroduction of following factors: the maxillary suture opening by Herbert A The amount of tooth material excess in Pullen (1874–1938) in 1902. Charles A Hawley relation to arch length, degree and site of (1861–1929) used a celluloid sheet containing a crowding. geometric figure that, when adapted to a model The anteroposterior inter-arch relationship. determined the extent of proposed tooth Profile of the patient. movement (1905) and introduced the retainer Age of the patient and his/her dental appliance that bears his name (1908). developmental status. Scientific studies included research in dental The direction of jaw growth. histology, particularly by Frederick B Noyes Carious status of the teeth. (1904); the influence of heredity and environment General health status of the dentition. on dental structures (1905); emphasis on rhinology, which brought the medical fraternity SERIAL EXTRACTION into cooperation (1907); the study of the deciduous dentition vis-a-vis nasodental growth, Serial extraction is an interceptive orthodontic especially by Edward A. Bogue (1838–1921); and procedure undertaken in the (early) mixed History of Extraction in Orthodontics 151 dentition period that involves planned removal Although popular, the term “serial extraction” of certain primary and permanent teeth in a does not stress the importance of thorough programmed sequence, so as to relieve crowding knowledge of growth and development, compre- in the arches and to guide the remaining erupting hensive analysis based on investigative records permanent teeth into a more favorable position. required to execute the procedure properly and A thorough understanding of the dynamics of thus may be misleading. orofacial growth and development and that of the Hotz (1970) recommended the term “guidance stomatognatic system is essential for the success of eruption”. It is also sometimes referred to as of serial extraction procedures. When executed “guided extraction”, while other authors prefer properly in carefully selected patients with the to call the procedure “Guidance of Occlusion”. proper assessment, skilled timing and careful monitoring, programmed serial extraction Dewel’s Method 1978 procedures can produce best possible and most Dewel’s has proposed a three step serial extraction stable results with minimal or in some cases no procedure in 1978 (Table 15.2). further need of corrective mechanotherapy at a Step 1: In this step the deciduous canines are later stage when all permanent teeth erupt. extracted to create space for the alignment of the Although occasionally used to intercept Class incisors (Fig. 15.7A). The main objective of II and Class III malocclusions, serial extraction extracting primary canines is to establish the procedure is mainly used to intercept and/or integrity of upper and lower incisors. This treat Class I malocclusions with crowding prevents development of lingual cross bite of resulting from severe tooth size arch length maxillary laterals and resultant mesial migration discrepancy. of maxillary canines. Step 2: In this step deciduous first molars are Definition extracted at 8-9 years of age. The objective of

Tweed: Serial extraction as ‘the planned and Table 15.1: Authors and their inventions sequential removal of the primary and permanent teeth to intercept and reduce Authors Diseases of teeth dental crowding problems.’ Robert Bunon (1743) First reference to extraction Iondon: The correctly timed, planned of primary teeth to facilitate removal of certain deciduous and permanent alignment of permanent teeth in mixed dentition cases with teeth dentoalveolar disproportion. Kjellgren (1929) First coined the term Serial Extraction Nance (1940s) Popularized the procedure HISTORICAL PERSPECTIVE considered father of serial Robert Bunon in the early 1743 advised extraction extraction technique of primary teeth to achieve a better alignment of Hotz (1970) Argued against the term serial extraction to call it permanent teeth in his diseases of teeth (Table guidance of eruption 15.1). Later several authors like Bourdet (1757), Table 15.2: Dewel’s method Hunter (1771), Robinson (1846) and Harris (1855) advocated removal of primary canines and Steps Tooth extracted Purpose the premolars when permanent incisors Step 1 Extraction of Alignment of crowded. deciduous canines incisors The term “serial extraction” was first coined Step 2 Extraction of To facilitate the eruption by Kjellgren in 1929. However it was Nance who deciduous first of first premolars ahead popularized the procedure in 1940’s in England molars of permanent canines Step 3 Extraction of first To facilitate eruption and is considered as the Father of Serial premolars of permanent canines Extraction technique practiced today. 152 History of Orthodontics

A B C

D E

Figs 15.7A to E: Dewel’s method of serial extraction: (A) Deciduous canines are extracted to create space for the alignment of the incisors; (B) Deciduous first molars are extracted to facilitate eruption of first premolars; (C) First premolars are extracted to facilitate the eruption of permanent canines; (D) Favorable eruptin of canines after removal of first premolars; (E) Proper occlusion after minimal period of fixed orthodontic mechanotherapy deciduous first molar extraction is to accelerate of proper intercuspation usually requires eruption of first premolars. This ensures that the orthodontic mechanotherapy of minimal duration first premolars emerge into oral cavity ahead of (Fig. 15.7E), although it may not be necessary in the permanent canines (Fig. 15.7B). rare cases. Step 3: In this step first premolars are extracted to facilitate the eruption of permanent canines TWEED’S METHOD (1966) (Fig. 15.7C). After serial extraction procedure, the teeth are This method involves the extraction of the fairly aligned (Fig. 15.7D). However, establishment deciduous first molars at 8 years of age. This is History of Extraction in Orthodontics 153 followed by the extraction of the first premolars molar is delayed. The first premolars should and the deciduous canines simultaneously. be extracted as they emerge. 2. Class 1 malocclusion with severe mandibular Nance Method anterior crowding. Deciduous Canines are extracted when there Nance method of serial extraction is a is arch length deficiency and more than 5 mm modification of Tweed’s method which involves per quadrant. The deciduous first molars are the extraction of the deciduous first molars extracted next on completion of at least half of followed by the extraction of the first premolars first premolar root formation and the extraction and the deciduous canines. of first premolars follow as the erupt into the oral cavity. Grewe’s Method 3. Class 1 malocclusion where minimal Grewe’s method of serial extraction is based on mandibular anterior crowding is 6–10 mm the planning of extraction sequence for different arch deficiency. clinical conditions. In such conditions the first premolars are 1. Class 1 malocclusion with premature loss of extracted. The deciduous first molars are a mandibular deciduous canine. extracted when the roots of the premolars are Class 1 malocclusion with premature loss of a more than half formed, as this would in turn mandibular deciduous canine will result in result in premature loss or eruption of the first midline shift, when the arch length premolar as soon as the first premolars erupt discrepancy is 5–10 mm/arch, then the into the oral cavity; these are extracted followed remaining deciduous canines should be by deciduous canines. If this is bound to be extracted the deciduous first molars are eruption of permanent canines before that of extracted next, if the first premolar have their first premolar, then the deciduous canine is roots more than half formed. If the roots of the extracted first followed by the extraction of the first premolars are not developed more than deciduous first molar and encleation of the half then extractions of the deciduous first first premolar. HHiiissstttooorrryyy oofff EExExxpppaaannnsssiiiooonnn AAppppppllliiiaaannnccceeesss 16

Wescott’s Expansion Device – Kingsley’s Incline Plane Angell’s Palatal Expansion Device – Herbst’s Retention-Joint Appliance – Goddard Expansion Device – Coffin Appliance – Kingsley’s Extraoral Traction Fixed Rapid Maxillary Expansion Appliance Appliances

WESCOTT’S EXPANSION DEVICE ANGELL’S PALATAL EXPANSION DEVICE Wescott first reported the placement of mechanical A year later, Angell’s performed a similar forces on the bones of the maxilla, in 1859. He procedure with a differentially threaded used two double-clasps separated by a telescopic jackscrew connected across the palate to both bar to correct a cross bite in a 15-year-old girl. One bicuspids on one side and the second bicuspid double clasp was soldered to the tube and the on the other (Fig. 16.2). The patient was given a other was soldered to a screw that fit into the tube, key to turn the screw and instructed to keep it thereby allowing lengthening of the screw to uniformly firm. Upon her return, 2 weeks later widen the palate. Adjustable spurs were also she had developed a space between her central attached perpendicular to the telescopic bar to incisors, which Angell claimed “showed allow forward repositioning of the incisors (Fig. conclusively that the maxillary bones had 16.1). separated”. Goddard, in 1893, further standardized the palatal expansion protocol. He activated the device twice a day for 3 weeks, followed by a consolidation period to allow the deposition of “osseous material” in the created gap. The description of his appliance is similar to Hyrax appliance, being attached to the first bicuspids and second molars bilaterally. In addition to palatal expansion, two other orthodontic techniques utilized traction for the correction of craniofacial skeletal deformities. In 1866, Kingsley first applied extraoral traction to correct the protrusion of the maxilla. His appliance consisted of a gold frame that covered the incisors and a head cap, which was connected to the frame Fig. 16.1: Wescott’s expansion device by elastic ligatures (Figs 16.3A and B). History of Expansion Appliances 155

Nine years later, Potpeschnigg described a “Tooth Regulating Machine” that consisted of a head cap connected to a steel rod, that was secured to the tooth by means of an elastic ring. Traction was applied to the tooth by tightening the elastic band between the head cap and metal rod (Fig. 16.4). In 1892, Kingsley successfully used principles of traction to treat mandibular retrognathia, with a functional appliance. He developed an inclined plane attached to the upper arch to force the entire mandible forward as the patient closed his mouth. Thirteen years later, Herbst demonstrated his “retention-joint appliance” which consisted of two telescoping rods attached to the teeth (Fig. Fig. 16.2: Angell’s palatal expansion device 16.5). As the patient closed his mouth, the placed on the maxillary teeth mandible was forced forward into a normal position.

A B Figs 16.3A and B: Kingsley’s extraoral traction appliance (A) and Potpeschnigg’s “tooth regulating machine” (B)

Fig. 16.4: Kingsley’s incline plane

Fig. 16.5: Herbst’s “retention-joint appliance” 156 History of Orthodontics

Arch expansion is one of the methods of orthodontic community at that time. Later in 1956, gaining space in orthodontics. The concept of arch this expansion device was reintroduced to expansion was explained for the first time by orthodontics by Andrew Hass, in the United States Emerson C Angel. Hence, he is considered as of America. father of expansion appliances. Arch expansion Removable expansion appliance may be a can be slow or rapid, removable or fixed. Slow simple expansion appliance with incorporated arch expansion brings about mainly dentoalveolar jackscrew or Coffin appliance. Fixed arch expansion whereas rapid maxillary expansion expansion appliances are toothborne expansion brings about both skeletal as well as dentoalveolar appliance (Hyrax, Isacson) or tooth and tissue expansion. borne expansion appliance (Derichsweiler Haas Rapid maxillary expansion appliances are the expansion appliance). How much to expand and best appliances of the orthopedic expansion. In when to expand are evaluated by model analysis. this, changes are produced mainly in the underlying skeletal structures rather than by the FIXED RAPID MAXILLARY EXPANSION movement of teeth through the alveolar bone. APPLIANCES Rapid maxillary expansion not only separates the Fixed rapid maxillary expansion appliances are midpalatal suture but also affects the circum- fixed expanders and cannot be removed by the zygomatic and circummaxillary sutural systems. patient. These fixed expanders can be classified Rapid maxillary expansion is also called into tooth and tooth tissue-borne appliances. palatal expansion or split palate. Rapid maxillary Tooth and tissue borne appliances are: expansion is a skeletal type of expansion, which Derichsweiler type produces skeletal changes by separation of mid Haas type. palatal suture. Most commonly used fixed expander of tooth Rapid maxillary expansion device was first borne appliances are: used by Emerson C Angel in the year 1860. He Hyrax type used a jackscrew type of rapid maxillary Isaacson type. expansion device between two premolars in maxillary arch on palatal side in a 14-year-old Derichsweiler-type expander: Derichsweiler girl and achieved arch expansion by ¼ inch in 14 expansion appliance consists of molar bands on days. For this significant valuable contribution to right and left permanent first molars and first the expansion in orthodontics, he is considered premolars with wire tags soldered into the palatal as the Father of rapid maxillary expansion. surface of all molar and premolar bands. The outer Walter Coffin in 1877, developed a spring for free ends of wire tags are inserted into split palatal the purpose of arch expansion which has come to acrylic incorporating a jack expansion screw in be known as Coffin spring. This spring also its center (Fig. 16.6). produces arch expansion by separation of mid Haas-type expander: Haas expander was palatal suture, when used in young patients. This designed and popularized by Andrew Hass in expansion device was of gained popularity by the year 1961. This appliance consist of molar bands on right and left permanent molars and premolars. A jackscrew is incorporated in the midline into the two acrylic pads that closely contact the palatal mucosa. Support wires also extend anteriorly from the molars along the buccal and lingual surface of the posterior teeth, to add rigidity to the appliance (Fig. 16.7). Haas states that, more bodily movement and less dental tipping is produced when acrylic palatal coverage is added to support the appliance thus permitting the forces to be generalized not only against the teeth but also against the Fig. 16.6: Derichsweiler type expander underlying soft and hard palatal tissues History of Expansion Appliances 157

Fig. 16.8: Hyrax expander Fig. 16.7: Hass expander

Hyrax–type expander: The more commonly used type of banded RME appliance is the Hyrax–type expander. This type of expander is made entirely from stainless steel. Bands are placed on the maxillary first molars and first premolars. The expansion screw is localized in the palate in close proximity to the palatal contour. Buccal and lingual wires may be added for rigidity (Fig. 16.8). Isaacson expansion appliance: It is a fixed tooth borne appliance without acrylic covering. This appliance consists of molar bands on first right and left, permanent molars and premolar bands on right and left permanent premolars. Metal Fig. 16.9: Isaacson expansion appliances flanges are soldered into the molar and premolar bands (14, 16, 24, and 26) on buccal and palatal sides (Fig. 16.9). A spring loaded expansion screw (Minne) expander having a nut which can compress the spring and is made to extend between palatal metal flanges. Activation: It is activated by closing the nut, so that the spring gets compressed. Bonded rapid maxillary expansion: These appliances consist of an acrylic splint covering variable number of teeth on either side in the maxillary arch, to which a jack screw is attached. Splint can be either cast cap made of silver copper alloy or acrylic splint made of polymethyl methacrylate (Fig. 16.10). A wire framework may be adapted around the teeth to reinforce the acrylic. Fig. 16.10: Bonded rapid maxillary expansion appliances

Expansion Screw A typical expansion screw (Figs 16.11A to D) halves. Each half has a threaded inner side that consists of an oblong body, divided into two receives one end of a double ended screw. The 158 History of Orthodontics

A B

C D

Figs 16.11A to D: Different types of expansion serews

A B

Figs 16.12A and B: (A) Expansion screw key; (B) Showing activation of expansion screw by placing the key in the hole screw has central bossing with four holes. These Various types of expansion screws are holes receive a key called expansion screw key available to carry out different types of expansion (Figs 16.12A and B) which is used to turn the screw. as enumerated in Table 16.1. History of Expansion Appliances 159

Table 16.1: Different types of expansion screws Table 16.2: Timm’s schedule of activation of expansion screw Expansion screw type Use Age of the patient Degree of Number of Symmetrical bilateral Bilateral expansion activation activation in a day expansion screw o Traction screw Closing spaces Up to 15 years 90 2 times in a day o Expansion screw with Separate expansion of More than 45 4 times in a day split activator maxilla or mandible 15 years Three-dimensional Anterior and bilateral screw expansion Table 16.3: Expansion orthodontic appliances Expansion Screw Activation Schedule Author Contributions to Schedule by Timms orthodontics S.No. Type of expansion appliance Developed by See Table 16.2. 1 Derichweiler expansion Derichweiler appliance Expansion Orthodontic Appliances 2 Isaacson’s expansion Isaacson Expansion orthodontic appliances (Table 16.3) appliances are used to relieve crowding in cases of arch 3 Haas expansion appliance Haas 4 Coffin spring Walter coffin length—tooth material discrepancy. Following are 5 Jack expansion screw Jack the researchers involved in the development of various type of expansion appliances. HHiiissstttooorrryyy oofff RReeemmmooovvvaaabbbllleee OOrrrttthhhooodddooonnntttiiiccc AAppppppllliiiaaannnccceeesss 17

Development of Removable – Contraindications Orthodontic Appliances – Advantages – Victor Hugo Jackson – Disadvantages – George Crozat Components of Removable – Robin Orthodontic Appliances – Andersen – Retentive Components – Adam – Active Components – Martin Schwartz – Base Plate – Indications

Removable orthodontic appliances are so-called type of malocclusion. The range of malocclusions because they are designed to be fitted and that can be treated with removable appliance removed by the patient. Removable orthodontic alone is limited. They can also be used as passive appliances are limited to tipping and simple appliances to maintain teeth in their corrected rotatory movements of teeth, which are sufficient positions after active phases of orthodontic for many orthodontic treatments. They depend therapy, e.g. retainers. Removable orthodontic on cooperation and a certain degree of skill on appliance is often used in conjunction with fixed the part of patient. Removable orthodontic mechanotherapy. appliances may be active or passive. The most familiar removable device is the The use of removable orthodontic appliances retainer, specifically the Hawley or Begg device. was always more popular in Europe than the Its function, however, is retention—keeping teeth United States, but even there, the use of fixed in their place after the desired tooth-movement appliances [using (generally metal) bands and has been achieved. brackets] has largely become the primary method The main drawback of removable orthodontic of treatment. Nevertheless, as the authors of appliances is that they can only apply a tipping Removable Orthodontic Appliances point out, force (whereas fixed appliances can also apply a removable appliances are often an effective rotating force), this means they are not suitable means of addressing many patients’ needs and for the complete treatment of some cases in some cases have considerable advantages over (specifically, serious class II and III cases). Among fixed appliances. the big advantages of removable orthodontic Use of removable appliances also requires appliances are in the area of anchorage (since the careful case selection for, success of the treatment. palatal area is also used for this), significant since They are ideally used when simple tipping fixed appliances must generally rely on adjacent movement of teeth is sufficient to correct a certain teeth (As the authors note, the use of removable History of Removable Orthodontic Appliances 161 appliances generally involves the upper arch; that is still used occasionally. Crozat appliance lower arch treatment with them is limited by consists of: difficulties with retention and bulk, as well as – Modified Jackson’s clasp. the limited space available for active components – Heavy gold wire framework. on the appliances themselves). – Lighter gold finger springs to produce desired tooth movement. DEVELOPMENT OF REMOVABLE ORTHODONTIC APPLIANCES Robin Removable orthodontic appliances begin with a In the year 1900, forerunner of all functional brief general introduction, and then discusses the appliances, the monobloc was developed by ‘Biomechanics of tooth movement’, various Robin. active components that can be utilized, and how they function and are integrated into devices, Andersen including a variety of springs, bows, and screws. The next survey ‘Appliance retention’, ‘The In the 1920s, andersen developed activator in baseplate’, and ‘Anchorage’, discussing the Norway. He was the first person to develop factors that should be taken into consideration functional appliance. which designing the device, both generally (going so far as to note: “Removable appliances Adam should ideally be fitted within two weeks of the In the 1921s, Adam developed a clasp called impression being taken”) and also in tailoring it Adam’s clasp. to the individual case. Anchorage issues, in particular, must be closely monitored from visit Martin Schwartz to visit, and as the authors point out: “if space is critical, it may be wise to plan for extraoral anchorage He developed split plate appliance. from the start”. Clearly, the use of extraoral anchorage headgear, which in the case of Indications of Removable Orthodontic removable appliances cannot be cervical (since Appliances the pull must be upwards so as not to displace Use of removable orthodontic appliances the appliance) allows for much greater flexibility requires careful selection. They should not be in treatment, as headgear can be used as the sole used in circumstances where fixed orthodontic source of anchorage or to reinforce intraoral appliance therapy would be more appropriate. anchorage, as well as extraoral traction be an May be used as an adjunct to fixed orthodontic active component for tooth movement. appliance treatment.

Victor Hugo Jackson Contraindications of Removable Victor Hugo Jackson is from United States of Orthodontic Appliances America. He was the chief proponent of Removable orthodontic appliances are removable appliances. contraindicated in case, where bodily movement At that time, neither the modern plastics for is required. base plate material nor stainless steel wire- clasp, springs were available. Advantages of Removable Appliances Appliances are fabricated with bases and Advantages of removable orthodontic appliances precious metal or nickel silver wires. are listed below: In early 20th centuries. 1. Removable appliances permit easy cleaning. George Crozat 2. They need less chair side time. 3. They are good for overbite reduction. In early 1900s, Crozat developed a removable 4. They can tip the teeth efficiently. appliance fabricated entirely of precious metal 5. They eliminate occlusal interferences. 162 History of Orthodontics

Disadvantages of Removable Retentive Components Orthodontic Appliances Evolution of Clasp Design Disadvantages of removable orthodontic Jackson describes the construction of a crib appliances are listed below: clasp which has a square form and is designed 1. Removable orthodontic appliances can bring not only to grasp the tooth buccally but, by about only a limited type of tooth movement. running forward and backward and turning 2. Anchorage of tooth movement is sometimes sharply at a right angle, to grasp the tooth difficult, since anchor teeth cannot be anteroposteriorly. The next real advance in prevented from tilting. clasp design was the introduction of the 3. Retention with removable orthodontic arrowhead type of clasp, usually attributed appliance is more difficult than with fixed to Schwarz and introduced in England by appliances. Tischler. 4. A high degree of cooperation and a certain The arrowheads depend on the use of the amount of skill is required from the patient, spaces below the point of contact between who has to remove, clean and replace the two teeth. Several arrowheads are usually appliance at frequent interval. embodied in a clasp. 5. Limited scope on lower arch. The modified arrowhead clasp, introduced by 6. They affect speech. Adam in 1949 and today widely referred to as the Adam clasp, makes use of the mesial Advantages of Removable Appliances and distal undercuts of a single tooth only a. They are removable and therefore easier to and can in practice be applied to any tooth, clean. deciduous or permanent. The success of a removable orthodontic b. They can provide increased vertical and appliance mainly depends upon good retention horizontal anchorage due to palatal coverage. of the appliance. Adequate retention of a c. They can produce efficient over-bite removable orthodontic appliance is achieved by reduction in a growing child. incorporating certain wire components, got d. They can transmit forces to blocks of teeth. engaged the undercuts on the teeth. These wire Disadvantages of Removable Appliances components that help in retention of a removable appliance are called clasps. Following are the a. The appliances can be left out. different type of clasps which aids in retention b. Only tilting movements are possible. to the appliance: c. They affect speech. i. ‘C’clasp or Circumferential clasp d. A technician’s input is required to make the ii. Jackson’s clasp or Full clasp appliances. iii. Adam’s clasp e. Intermaxillary traction is more difficult. iv. Schwartz clasp f. They are inefficient for multiple tooth v. Crozat clasp movements. vi. Triangular clasp g. Lower removable appliances are more vii. Ball end clasp difficult to tolerate. viii. Resta clasp ix. Eyelet clasp COMPONENTS OF REMOVABLE x. Southend clasp. ORTHODONTIC APPLIANCE Modifications of Adam’s Clasp and its Use Removable orthodontic appliance consists of following three components: Adam’s clasp offers a unique feature that, its 1. Retentive components design can be modified in a number of ways suit 2. Active components varies clinical requirements. The following are 3. Base plate. some of the modifications of Adam’s clasp. History of Removable Orthodontic Appliances 163

1. Adam’s clasp with incorporated helix They can also be used for space closure in the Use: For the attachment of elastics. anterior segment as well as space distal to 2. Adam’s clasp with soldered hook canines. The following are some of the routinely Use: For attachment of elastics. used design of labial bows (Table 17.1): 3. Adam’s clasp with traction hook 1. Short labial bow Use: For attachment of elastics. 2. Long labial bow 4. Adam’s clasp with additional arrowhead 3. Split labial bow Use: For additional retention. 4. Modified split labial bow 5. Adam’s clasp with single arrowhead 5. Reverse labial bow Use: For partially erupted teeth. 6. Robert’s retractor 6. Adam’s clasp with soldered buccal tube 7. Mill’s retractor Use: For attachment of face bow. 8. High labial bow 7. Double Adam’s clasp on maxillary central 9. Fitted labial bow. incisor Use: For additional retention. Springs 8. Adam’s clasp with distal extension Use: For attachment of elastic and additional Springs are active components of removable retention. orthodontic appliances which are used to bring about tooth movement. There are different types Active Components of springs (Table 17.2) which can be used according to the need. The basic principle behind Bows using springs is that, when a wire is deflected, it Bows are one of the active components of tries to regain its prefabricated original shape and removable orthodontic appliance. They are while trying to do so, the springs move the teeth usually used for overjet retraction of anteriors. along their path.

Table 17.1: Different types of labial bows Type of labial bow Wire used for Description of Activation Flexibility Indications fabrication the bow Short labial bow 23 gauge hard It extends from Reduction of Less flexible Minor overjet round stainless permanent lingual palatal than any other reduction steel or 0.7 mm canine to canine acrylic of type of labial (upto 3.5 mm) anteriors bows Mild space closure Compression in the anterior of both U loops segment Long labial bow 23 gauge hard It extends from Reduction of More flexible Minor overjet round stainless first permanent lingual palatal than short reduction steel or 0.7 mm premolar to acrylic of labial bow Minor anterior premolar anteriors space closure Compression Closure of space of both U loops distal to canine Split labial bow 23 gauge hard The bow is split Reduction of More flexible Anterior retraction round stainless in midline lingual palatal than short steel or 0.7 mm acrylic of labial bow anteriors Compression of both U loops

Contd... 164 History of Orthodontics

Contd... Type of labial bow Wire used for Description of Activation Flexibility Indications fabrication the bow Modified split 23 gauge hard The bow is Reduction of More flexible Mainly used for labial bow round stainless modified to lingual palatal than short, closure of midline steel or 0.7 mm engage the acrylic of long and diastema opposite central anteriors split labial incisors Compression bow For example, of both right bowwill U loops engage left central incisor below the contact point and vice versa Reverse labial 23 gauge hard It extends from Reduction of More flexible Overjet reduction bow round stainless permanent lingual palatal than short, (5 to 7 mm) steel or 0.7 mm canine to canine acrylic of long, split, or permanent anteriors modified split premolar to Opening the labial bow premolar loop resulting in The bow is lowering the reversed bow incisally and compensatory bend is given to maintain proper level of bow Robert’s 23 gauge hard It extends from Reduction of More than Increased overjet retractor round stainless permanent lingual palatal short, long, (7 to 9 mm) steel or 0.5 mm canine to canine acrylic of split, modified It incorporates anteriors split and an helix on Closing both reverse labial either side the helices bow The diameter of both helix should be 3 mm Mill’s retractor 23 gauge hard Bow having Reduction of More than Large overjet round stainless extensive lingual palatal short, long, split, (more than 9 mm) steel or 0.7 mm looping acrylic of modified split, anteriors reverse labial Compression bow and Robert’s of looping retractor High labial 21 gauge hard Extends in Activated only Apron spring is Proclined incisors bow with round stainless buccal by apron spring highly flexible apron spring steel or 0.9 mm vestibule Apron sping is because it is Apron spring Apron springs activated by fabricated with fabricated with are made to bending it thinner gauge wire 0.4 mm rest on incisors toward the teeth Fitted labial 23 gauge hard It is made to be It is not Least as Mainly used for bow round stainless fitted in the activated compared to retention after steel or 0.7 mm contour of all all other types completion of or 21 gauge anteriors of bows fixed orthodontic hard round therapy stainless steel or 0.9 mm History of Removable Orthodontic Appliances 165

Table 17.2: Different types of springs and their activation and indications Type of spring Wire used for Description of Activation Indication fabrication the spring Finger spring 0.5 mm or 0.6 mm Consist of active Closing the helix Closure of midline stainless steel wire arm, helix and and moving active diastema retentive arm arm towards the Closure of minor Helix is of 3 mm tooth to be moved anterior space in diameter and should rest on the long axis of root of the tooth to be moved Retentive arm is of 4-5 mm in length and is made to get embedded in acrylic base Z spring 0.5 mm or 0.6 mm Consists of two Activation depends Correction of stainless steel or helixes arranged on its indication minor rotation in pattern of Z For correction of Labial movement that’s why also minor rotation then of incisors known as double only one upper helix Labial movement cantilever spring is activated by of tooth in case of opening the helix single or segmental For labial move- cross bite ment of incisors the spring is activated by opening both the helixes T spring 0.5 mm or 0.6 It consists of Pulling the free end Buccal movement mm stainless T shaped arm of T towards the of premolars steel wire intended direction of tooth movement Mattress spring 0.6 mm round It is shaped like a —— Labial movement of stainless steel wire mattress with ‘U’ upper teeth in cross bite loops extending up to the retentive Helical coil 0.6 mm round Free-ended spring —— Regain the lost space spring stainless steel wire with two helixes formed on different arms

Canine Retractors removable orthodontic appliance with canine retractor can be efficiently used only when the Canine retractors are springs that are used to move canine is mesially angulated. When used on canines in a distal direction. upright or canines, the removable canine They can be classified in a number of ways retractors can worsen the situation. Thus fixed (Table 17.3). orthodontic appliances with greater control over Usefulness of canine retractors depends on tooth movement are preferred over removable the angulations of the canine to be retracted. The canine retractors. 166 History of Orthodontics

Table 17.3: Classification of canine retractors Base Plate According to their location, canine retractors can be Base plate has a greater percentage of bulk in classified as: removable orthodontic appliance than other Buccal placed buccally components. The design of base plate varies with Palatal placed palatally the type of removable orthodontic appliance. Self According to presence of helix or loop: cure or auto polymerizing acrylic resins are used a. Helical canine retractor for the fabrication of base plate. It joins all other b. Looped canine retractor (active and retentive) components of removable According to their mode of action: orthodontic appliance together into a single a. Push type functional unit. b. Pull type The following are some of the commonly used canine retractors (Table 17.4) 1. ‘U’ loop canine retractor 2. Helical canine retractor 3. Palatal canine retractor 4. Buccal self-supported retractor

Table 17.4: Different types of canine retractors and their activation and indications Type of canine Wire used for Description of Activation Indication retractor fabrication canine retractor (in mm) U loop canine 0.6 or 0.7 It consists of U Closing the loops For canine retraction retractor loop, active arm 1 to 2 mm or and retentive arm cutting the free which is distal ends of active arm by 2 mm and readapting it Helical canine 0.6 or 0.7 It consists of a coil Opening the helix For shallow sulcus retractor of 3 mm diameter by 1 mm or by in mandibular arch and active arm cutting 1 mm of (towards the tissue) free ends and and retentive arm readapting it Palatal canine 0.6 or 0.7 It consists of a coil Opening the helix For retraction of retractor of 3 mm diameter, 2 mm at a time palatally placed active arm and canine guide arm Buccal canine 0.6 or 0.7 It consists of a coil Opening the helix For retraction of retractor of 3 mm diameter, or closing the helix buccally placed active arm (away 2 mm at a time canine from the tissue) and retentive arm Buccal self- 0.6 or 0.7 It consists of a coil Activation by For retraction of supported canine of 3 mm diameter, closing helix buccally placed retractor active arm (away 1 mm at a time canine from tissue) and retentive arm HHiiissstttooorrryyy oofff FFFiiixxxeeeddd OOrrrttthhhooodddooonnntttiiiccc AAppppppllliiiaaannnccceeesss 18

E-arch Appliance The Concept of the Ideal Arch Building Treatment into the Pin and Tube Appliance – Comparison of Architectural Edgewise Appliance Ribbon Arch Appliance and Dental Arches History of Begg Appliance Edgewise Appliance – Cause for Collapse of Arches Straight Wire Appliance What was Orthodontics before – Ideal Arch Form Andrews’s Six Keys to Optimal Angle System? The Ideal Arch Wire Occlusion Evolution and Development of – Characteristics of an Ideal Limitations of Straight Wire the Edgewise Appliance Arch Wire Appliance – Arch Wire Bends Evolution of Bracket History of Lingual Technique Advantages and Disadvantages Evolution of Edgewise Buccal of Edge- wise Appliance Tubes

For the first third of this past century, orthodontics found itself dominated by one man, Edward H Angle (Fig. 18.1), with the resultant intellectual stagnation that arises from such monomaniacal control. This recognition in no way detracts from Angle’s contributions—notably his clear and simple classification system along with the edgewise bracket. Both of these inventions have endured for a century, and that is no mean achievement in any scientific discipline. Nevertheless, orthodontists’ unquestioning acceptance of his limited diagnostic and treatment planning regimens hindered the advancement of this discipline more than it helped, and the last half of this past century was spent trying to overcome the stupor of the first half. Angle’s influence continued until an apostate student of his, Charles H Tweed, had enough courage and objectivity to challenge Angle’s non- extraction scheme. It was not a tremendous leap of intellectual power. Tweed simply and honestly Fig. 18.1: Edward H Angle 168 History of Orthodontics recognized that when 100 percent of your patients that bore his name was too immense to permit relapsed, there might be something wrong with such hubris from a young upstart. But as the diagnosis and/or treatment planning. Samuelson, the MIT economist, once noted: Dr Tweed (Fig. 18.2) acted appropriately in “Science progresses slowly—funeral by the face of this challenge—quite unlike the ancient funeral.” And so it was and is in orthodontics. dentist who chided a young colleague who was describing his meticulous technique of Non-extraction Philosophy endodontic filling to the monthly assembly of Aside from the edgewise bracket and the dentists. The old man explained his own classification system, Angle’s most enduring technique that used a simple matchstick legacy has been his belief in non-extraction sharpened with a pocketknife and then jammed therapy. Angle had unsuccessfully experimented into the canal. When the young dentist asked if with premolar extractions while using his ribbon a lot of these root canal fillings did not arch appliance, but he never solved the problem subsequently fail, the older man replied, “Every of paralleling the roots to prevent the extraction damn time!” spaces from opening. If he could not do it, then, Tweed tired of those orthodontic abscesses ergo, no one else could, and this resulted in a and, unlike his peers, sought to correct the virulent opposition to any extractions and an deficiencies he saw in Angle’s philosophy. Some insistence upon enlarging the arches to would say that he overcorrected, but that said, accommodate all of the teeth. we must pay homage to anyone who has the skill This dogma stayed dominant for several and temerity to successfully challenge a mentor decades until Tweed advocated the extraction of and his minions. Tweed’s success brings to mind premolars based on his diagnostic triangle, which the remark of C S Lewis, who said, “No genius is was the first systematic treatment planning so fortunate as he who has the skill and ability to stratagem orthodontists had. Tweed received do well that which others have been doing corroboration simultaneously from another poorly”. former Angle protégé in Australia, Raymond Nevertheless, I do not think that Tweed would Begg, who had studied aborigines and concluded have ever been able to deliver his paper that nature intended for enamel to wear. He describing his extraction technique if Angle had decided that orthodontists could mimic nature still been alive. Angle’s influence over the society by extracting teeth prior to orthodontic therapy. The Tweed and Begg extraction philosophies eventually prevailed and remained uncontested for some time. Several years passed before Holdaway, published his articles that suggested the soft tissue as the determining feature of diagnosis. This disputed Tweed’s narrow diagnostic regimen that focused on the mandibular incisor and totally neglected the soft tissue. Tweed’s triangle set in motion a trend that emphasized more prudence in the extraction of teeth. Soon others added their discoveries regarding soft tissue and the maxillary incisors as main determinants of diagnosis and treatment planning. From the inception of this specialty, with Angle, diagnosis never had too much importance because everyone received the same non-extraction treatment with the same expansive appliance. The marvel of it is all that the collection of orthodontic Fig. 18.2: Dr Tweed records never became important. A few months History of Fixed Orthodontic Appliances 169 ago an orthodontist boasted that since invoking a introduced the E arch, i.e. expansion arch that different treatment regimen, he was treating 98 used a labial wire supported by clamp bands on percent of his patient non-extraction using the molar teeth which ligated to the other teeth. treatment. One was tempted to ask if he still took Metallurgical developments by the early 20th records because with diagnostic certainty such century allowed clinicians to encase all of the as that, records are clearly redundant. teeth with bands and solder attachments that Orthodontists should not waste patients’ time could control the horizontal rotations. Angle and money taking impressions, cephalometric developed a popular attachment known as the X-rays or doing treatment simulations, if all pin and tube attachment in 1911, and it satisfied treatment plans are essentially the same. One does many of the requirements of clinicians; but this not need orthodontic records to come to such a demanded unusual dexterity, patience and skill, preconceived conclusion. so dental clinicians evolved to a ribbon-arch Obviously, this one-size-fits-all treatment bracket, which Angle introduced in 1918. It planning did not benefit patients a hundred years provided good control in two-dimensions and ago, and it does not in our own age, but such became popular quickly. The ribbon arch simplicity continues to hold enormous appeal for attachment also marked the first time orthodontic attachments gained the name bracket. many orthodontists. Orthodontists pride When Angle launched the ribbon-arch bracket, themselves in being scientists, and without doubt he had already started work on the edgewise they receive good training in the scientific method; bracket primarily as a supplement to his ribbon- but it takes very little anecdotal information to arch appliance. Nevertheless, the edgewise eclipse the scientific judgment of many in the bracket did not suddenly spring full-grown from profession. Albert Szent-Györgyi was probably Angle’s fertile mind, but slowly evolved with more right than he knew when he said, “The brain several iterations. When Angle realized that this is not an organ of thinking but an organ of survival bracket could deliver three-dimensional control like a claw and fang. It is made in such a way so of the teeth with horizontal, one directional as to make us accept as truth that which is only placement and simultaneous engagement of all advantage.” the teeth, he changed the bracket several times No matter how spectacularly orthodontic until he achieved it in 1928. It received early and therapy changes, it will benefit our patients enthusiastic endorsement from dental clinicians minimally if we do not have a concomitant throughout the United States and eventually improvement in our diagnostic and prognostic eclipsed other useful orthodontic appliances such knowledge. This remains the number one as the McCoy open tube appliance, the Atkinson imperative for those who practice orthodontics. universal appliance and the Johnson twin wire Orthodontists should view any new therapy attachment. unaccompanied by equally sophisticated The universal application and durability of diagnostic knowledge suspiciously. Patients have the edgewise bracket confirmed Angle’s immodest already received far too much orthodontic claim that it offered the “latest and best in treatment but diagnosis. orthodontic mechanisms”. Innovators have added minor but practical trimmings such as rotating Instrumentation wings, twin brackets, different dimensions, The first attempts to correct malocclusions used preadjusted appliances, lingual applications, etc., simple large arch wires ligated to the malposed but the essence has remained edgewise. For any teeth. Pierre Fauchard of France developed the instrument, particularly in the health sciences, to precursor of the modern appliance — expansion remain virtually unchanged (and almost as useful arch. for close to a century) approaches unbelievability. This arrangement gave only tipping control, In the automobile industry, this would be equivalent in one dimension, and soon proved inadequate to the Model T Ford remaining as the epitome of for controlling rotations. In 1887 Edward H Angle motoring sophistication. 170 History of Orthodontics

Other than adding wings and doubling the Self-ligating brackets that essentially form a bracket to make the popular twin edgewise bracket, tube, developed several decades ago with the Angle’s invention has remained basically Ormco Edgelok 26 being the first, closely followed unchanged. Holdaway suggested angulations for by the speed bracket. Both of these early self- brackets to help set anchorage, parallel roots and ligating systems suffered from the fact that the artistically position teeth, while Lee had built some straight-wire appliance phenomenon debuted at anterior brackets with the ability to torque incisors. approximately at the same time, plus a lack of But it was Andrews who was to develop an appreciation for what the newer titanium wires appliance that would apply first, second and third could achieve. order movements to the teeth without making Damon has persisted since 1995 with his changes in the wire—hence the Straight Wire version of a self-ligating bracket and has Appliance. Preadjusted orthodontic appliances fundamentally changed the types of arch wires have dominated the profession for the past 30 years, and the sequence in which clinicians use them. and the belief in them shows little sign of abating, His experience has shown that with many even though many have questioned the one-size- patients he can often eliminate distalization of fits-all idea. molars, extractions (excluding those needed to reduce bimaxillary protrusions) and rapid palatal And back again... expansion. He offers compelling clinical evidence The publication of Frankel’s work with functional of doing this with consistency. appliances illustrated significant enlargement of The Damon bracket is essentially a tube dental arches and reawakened an interest in non- designed with the right dimensions to foster extraction therapy. Nevertheless, Frankel sliding mechanics where needed and enough mechanics required the use of removable play in the system for torque and rotational appliances, and that did not resonate well with control using the larger cross section wires. many orthodontists or their patients. After a brief Damon starts cases with a large lumen arch wire flurry of interest in the United States, few clinicians slot and 0.014 or smaller diameter hi-technology continued to use the Frankel appliance on a arch wires. Starting cases with a large dimension regular basis. passive arch wire slot and small diameter wires Nevertheless, the successful use of orthopedic diminishes the divergence of the angles of the appliances alerted orthodontists to the possibility slots. This lowers the applied force and binding of increasing arch widths and arch perimeters friction. with minimum forces. Although mandibular The most logical questions readers could canines offer significant resistance to expansion, propose would be why has Damon shown mandibular premolars and first molars often successful expansion whereas Angle did not? demonstrate substantial and stable expansion. The quantity of expansion probably differs little, Brader hinted at this with his work on the tri- but the quality of expansion offers a quantum focal ellipse arch form, but he did not follow change. Mollenhauer has suggested as much through about how this might give wider and with his appeal for light forces. Even though more accommodating arch forms. Angle used a ribbon arch, (which suggests a thin, Low-force titanium coil expanders have delicate wire) the actual size of the wire had the shown their ability to develop arches laterally, dimension of 0.036 × 0.022 inches. Ligating to this and recently Damon has suggested that low arch wire would overwhelm the periodontium and wire forces, coupled with a passive tube and a prevent the development of a supporting small wire-to-lumen ratio, enable teeth and their dentoalveolus. Rather than forming new bone, the accompanying dentoalveoli to expand in all supporting dentoalveolus would simply bend and planes of space. Damon feels that using small, upon completion of treatment quickly return. low-force wires such as those of Copper Ni-Ti™ Astute clinicians often see this with molar (Ormco Corporation, Orange, CA) achieves the distalization from headgear use and over treat ideal biological forces proposed long ago by such movement in order to compensate for this several investigators. regressive bone bending. History of Fixed Orthodontic Appliances 171

Schwartz stated that it takes 20 to 26 g/cm² of force to collapse the capillaries in the Periodontal ligament. With RPEs and headgears, this force sometimes exceeds 10 pounds! Proffit states that optimal force levels for orthodontic tooth movement should be just high enough to stimulate cellular activity without completely occluding blood vessels in the periodontal ligament. True biomechanics is staying in the optimal force zone, i.e. keeping forces below capillary blood pressure. Conventional ties (o-rings and stainless steel ligatures and spring clips) make staying in the optimal force zone nearly impossible due to the increased binding and friction. The most important caveat Damon offers clinicians is not to use their ordinary mechanics with his system, and I could not agree more. When I first began to use the Damon system, I continued to use the regular sequence of arch wires and saw little advantage to these new, more expensive brackets. Nevertheless, as I began to use the brackets according to Dr Damon’s advice, I started seeing phenomenonal changes. The following patient illustrates typical responses to the biomechanics offered by the Damon system.

E-ARCH APPLIANCE E-arch appliance was developed by Angle in early 1900. It is also referred to as Edward Angle‘s E- arch. It was the first Angle’s orthodontic appliance developed to treat malocclusions. E-arch appliance consists of bands which are placed on molar teeth on either side of the arch of a heavy labial arch wire extended around the arch. The ends of labial extended arch wire threaded to the buccal aspect of the molar bands allowed the arch wire to be advanced so that the arch perimeter increased. Individual teeth were ligated with the heavy labial extended arch wire with ligature wire of 0.010" (Fig. 18.3).

PIN AND TUBE APPLIANCE Pin and tube appliance was also developed by Edward H Angle. In this pin and tube appliance, all teeth are banded. Vertical tubes were welded to the bands on the labial surface in the center of the crown for all teeth in the arch. Arch wires were secured with soldered pins that inserted into the vertical tubes (Fig. 18.4). Tooth movement was Fig. 18.3: E-arch appliances 172 History of Orthodontics

Fig. 18.4: Pin and tube appliance achieved by altering the placement of these pins. Pin and tube appliance is also used for treating malocclusions RIBBON ARCH APPLIANCE Ribbon arch appliance was also developed by Edward H Angle and it is the modification of pin and tube appliance. This appliance was introduced in 1910. Ribbon arch was the first appliance to use a true bracket. The bracket has a vertical slot facing occlusally. The brackets were attached to the bands at the center of labial surface Fig. 18.5: Ribbon arch appliance of teeth (Fig. 18.5). EDGEWISE APPLIANCE surface of arch wire with the bracket slot and thus In order to overcome the deficiencies encountered give accurate control over tooth movement (Fig. with his previous techniques, Angle desired a 18.6). The term Edgewise refers to the method by metal bracket that could give a better control over which rectangular arch wire is inserted into the individual tooth movement. The edgewise bracket horizontal slotted bracket. The edgewise appliance has a rectangular slot facing labially, rather than was developed and introduced to orthodontics by occlusally or gingivally, which receives a Edward H Angle in the year 1925. rectangular arch wire. This unique feature of Every generation of men admires his own rectangular arch wire in a rectangular slot enabled wisdom, skill, science, art and progress. In light control of tooth movement in all three planes of of today’s progress, it is interesting to know that space. Furthermore, the bracket has four wings, two today orthodontists believe he is doing something occlusal and two gingival, which increase the heretofore never practiced. Although the practical History of Fixed Orthodontic Appliances 173

suitably placed. The flat strip of metal was made in the form of an arch of various crooked teeth were secured to it by threads passing around them and through the holes. The threads were tied for force application. Thus the first Expansion arch was introduced. ii. Dwinelle’s jackscrew (1849): In 1849, Dwinelle invented the regulating Jackscrew. It delivered a pushing force on the teeth. Angle improved the jackscrew by making it more delicate and by increasing the force. He developed later a regulating retracting screw which delivered pulling force on the teeth soldering was introduced at this time to provide for the attachment of the Jackscrew and the retracting screw to bands. iii. Kingsley’s headgear: In 1861, Kingsley introduced the headgear to apply extra-oral force and provide acceptable anchorage. Angle respected Kingsley so much that he incorporated this headgear into his system. iv. Magill’s band: The practice of orthodontics has changed forever in 1870 with an invention that most orthodontist have not seriously associated with treatment. It was the invention of dental cements by Magill which later lead to the development of band which could be attached to tooth. v. Coffin flexible piano wire: In 1861, Coffin introduced flexible piano wire and after 26 Fig. 18.6: Edgewise appliance years, Angle (1887) developed the prototype of the first bracket attachment a delicate metal growth of orthodontist has occurred during the tube soldered to the band. These two last hundred years, hardly we find any material inventions which took 26 year apart enabled progress in this science until within the last half the orthodontist to apply the rotation force on century. Out of the great achievement by mankind teeth. in orthodontics the edgewise mechanics was one vi. Bakers (case) rubber elastic: In an article “the of the last and greatest contribution of Edward H use of Indian Rubber in Regulating teeth” Angle after a lifetime devoted to the development (1896) according to him, very light forces of the orthodontic appliance. The edgewise generated by the Indian rubber is sufficient for appliance reflexes the philosophy of Edward H regulating the tooth movement . Angle. This was designed to allow orthodontists He used it to provide intermaxillary force of to place the teeth into Angle concept of “Lines of anchorage. Occlusion”. EVOLUTION AND DEVELOPMENT OF THE WHAT WAS ORTHODONTICS BEFORE EDGEWISE APPLIANCE ANGLE SYSTEM? To start with, simple basic E-arch which is the i. Funchard’s bow (1728): The first scientist first appliance described by Angle in early 1900, attempt at tooth movement occurred in 1728 is capable of tipping tooth crowns into proper by a French Physician, Pierre Fauchard, made alignment. This is the first appliance to employ use of a flat strip of metal, pierced with holes stationary anchorage or bodily control of the 174 History of Orthodontics anchor molar teeth. But Dr Angle realized the short orthodontists who have conscientiously studied comings in this approach and thereafter developed the possibilities and potentials of this appliance. the pin and tube appliance in 1910, by which the It is interesting to note, that in 1943 Dr Robert tooth roots could be brought into proper axial Strang made the statement that he was certain relationships. But the difficulties encountered that undiscovered possibilities are still to be with this mechanism involved the high degree of brought forth, from this device to aid the specialist skill necessary to obtain proper parallelism in difficult corrective procedures. However, it is between the tubes and the arch wire and also the necessary to constantly bearing mind the basic necessity to unsolder the pins every time. It was philosophy and concepts of the edgewise designed to move teeth in different locations on appliance as originally presented by Dr Angle. the arch wire and also correction of rotations. The basic concepts are still the key success with The next step in the evolutionary process was its use. the development of the ribbon arch appliance in 1915. The ribbon arch bracket was actually the EVOLUTION OF BRACKET first bracket as such, to be used in an appliance. It The evolution of edgewise bracket is the study is obvious, therefore this was a great step forward that has to be heard and read and never to be in the development of orthodontic appliances. The forgotten. This story started in 1916 in the form of chief advantage of the ribbon arch appliance was ribbon-arch bracket as devised by Dr E H Angle. the fact that rotations were easily accomplished. Although it became very popular at that time the It is also offered buccolingual and incisogingival bracket could not mask its deficiencies. Some of movements. Gingivo-incisal and gingivo by the highlighting faults of these brackets were: occlusal movements are also possible. a. It could not control tooth movement in all three The main disadvantage was that mesiodistal planes. axial movement was difficult to obtain, second b. Root control was not upto expectations. disadvantage is the difficulty in obtaining distal Hence, Angle decided to modify this bracket tipping movements of the buccal segments, third and the year 1925 the “edgewise bracket” was born the size of ribbon arch itself did not offer the to overcome the deficiencies of the ribbon arch. stability thought necessary for stabilization or Angle reoriented the soft from vertical to horizontal anchorage of the posterior teeth. and inserted to rectangular wire rotated 90 degrees Dr Angle’s final achievement was presented to the orientation. It had with the ribbon arch, thus shortly before his death. The edgewise appliance the name “edgewise”. The bracket was referred to was introduced to the dental profession in 1925. initially as “open face” or “tie bracket”. The edgewise arch mechanism was designed to The edgewise bracket by Angle was made allow the orthodontist to place the teeth into with soft gold with a 0.022 × 0.028" slot that was Angle’s concept of “Line of occlusion”. The readily deformed by the forces of occlusion and original bracket was designed with slot 0.022 by by tying ligature wires to the bracket. The original 0.028 inch. Over the years, many changes and edgewise bracket was redesigned into the cross modifications have been made in the basic section that is used today. The original design appliance itself. has been modified to provide a slightly larger Gold alloy arch wires were used exclusively bracket and one with greatly increased tying area in the formative years of the appliance. Although under the wings; this increased area makes the Dr Angle intended the edgewise appliance to be placement and tying of ligature wires much easy. used only for treatment without the removal of The brackets are modified in so many ways. teeth, to fit into is concept of the line of occlusion, For examples, single width bracket, twin bracket, the mechanical principles of this original thinking curved base twin bracket, twin bracket tooth were so sound that the basic philosophy is still in rotation, etc. use today. It will probably have considerable value EVOLUTION OF EDGEWISE BUCCAL TUBES in orthodontics for many years to come. Over the years, new principles of force The last tooth in the arch that is banded, which is application and control have been evolved by usually a molar, has been commonly referred to History of Fixed Orthodontic Appliances 175 as the anchor tooth. A section of tubing instead of The architect must determine geometrically, the some type of edgewise bracket is placed on the curvature of the arch and the weight is to be buccal surface of the anchor molar and as is called maintained, because each unit of an arch is an the buccal tube. In edgewise appliance, the active, working component tending to maintain original buccal tube was a piece of 0.22 × 0.028" its own position and to give support to its gold or nickel silver tubing soldered to the molar adjacent component. There is a central distribution band. The buccal tube is for insertion and of force between the various blocks that maintain stabilization of the arch wire, which is inserted this structure in equilibrium. into the tube horizontally and is therefore The same principle applies in a dental arch; completely encased in the sheath like structure. consider each of the teeth as supporting structures, each maintaining itself against the THE CONCEPT OF THE IDEAL ARCH pressures transmitted from the adjacent teeth. The line of force resistances which maintains the teeth At an early stage in his development, man are properly positioned anatomically or recognized in the arch, a strong, stable frame work mechanically to produce a balanced arrangement. upon which to build structures. The igloos of the Therefore, it is imperative that each unit in a dental Arctic and the mud huts of the plains are examples arch be in a precise anatomical relationship to its of structures employing the keystone and neighbors and that each contact relationship be balancing effect of arches and domes. such that forces are distributed through the center An excellent comparison of the orthodontic of mass of the crown in the horizontal plane. arch with other natural arch formations was made some time ago by Dr Mathew Lasher. He noted There is arch integrity along a smooth curve, that the shell of an egg has extreme strength in through the center of mass in the mesiodistal plane spot of its delicate structure and that the curved in the anterior teeth. These may be termed the walls and ceilings of caves maintain their integrity “haunches” of the arch. The basis of this smooth for millions of years. Dr Lasher went to compare curve is the cuspids, which may be called the the architectural arch with the dental arch, a “Springers”. The bicuspids and molars are comparison, with slight modification, that is supports and may be termed the “pillars”. This worth reviewing. structure is buttressed or reinforced laterally by the cheek on the outside and the tongue on the Comparison of Architectural inside. Theoretically the dental arch will maintain and Dental Arches itself if the bicuspids and molars are not disturbed by lateral force. If such forces are present, then the To appreciate the concept of the ideal dental arch, entire arch may lose its continuity and its integrity it is necessary to describe the basic principles will be destroyed. which lead stability to the architectural formation known as the voussoir arch. A series of wedge— Cause for Collapse of Arches shaped units usually made from blocks of stone Four basic reasons for failure of arches: are arranged to form a structure with a curved 1. Slipping of the voussoirs: The curvature of outer surface and a curved inner surface. This arch the arch is either too flat or too pointed and will be self supporting even without and joining the haunches or side blocks are more in or material and it is possible to determine the out because they cannot take the strain, e.g. distribution of forces which tend to maintain and Irregular arrangement of teeth. support it. 2. Rotation of voussoirs: The line of action or The top block [A] is known as the keystone. Block resistance passes to the outer or inner third B, resting on the ground itself or the structure upon of the blocks, rather than through the middle, which the arch rests is called the abutment. Blocks C creating a tendency in part of the blocks to known as haunches. The curved inner surface is rotate in the arch and to cause failure. called the intrados and the curved outer surface is 3. Crushing: The weight imposed on the arch is called the extrados. The height of the arch is called greater than the strength of the material to the rise, and the width is called the span. resist. 176 History of Orthodontics

4. Failure of the buttresses: If lateral stresses the curvature of the lingual surfaces of the exceed the limits of the additional support, maxillary anterior teeth should conform to a the buttress will fail, and the entire structure continuous smooth arch. This being the case, the will collapse. labial outline of the maxillary anterior teeth at the The similarity of problems of the anatomical brackets will vary according to the differences in arrangement of teeth to those of the architectural thickness of the teeth themselves. The general arch has been noted for many years. In dental position of all the maxillary anterior teeth must arches, only slipping and rotations will cause the relate to the labial contour of the mandibular collapse of arches. Slipping is mainly because anterior arch. which irregular arrangement of the teeth and In the mandibular arch, arch wire rotations of the teeth occurs when the line of force configuration again is governed by tooth shape does not pass through the center of mass of the and size. The variation of the labial outline will tooth. Crushing of the voussoir arch, does not be governed by the dimensions of the individual occur in the dental arch. teeth at bracket level. Consequently, there is a difference between the labial outlines of the Failure of buttresses: The buttressing effect of the maxillary incisal teeth and of the mandibular cheeks and tongue against bicuspids and molars incisal teeth which relate to the labial contour of is demonstrated clearly by the integrity and the mandibular incisal teeth. In the mandibular stability of this area when arch widths are not arch, the labiolingual dimensions of the four changed during treatment. anterior teeth are the same, so that a continous arc is contoured. The smaller labiolingual dimensions Ideal Arch Form of the mandibular canine reduce the effect in this A consideration of the causes of failure of the area. dental arch automatically gives an insight into In its normal position, the mesiobuccal cusp the primary objectives of orthodontic treatment in the maxillary and mandibular molar is much for maximum stability, it is essential that arch more prominent than rest of the tooth. Therefore, integrity be established of ideal arrangement of an offset, or a step out, as it is sometimes called is the teeth. The teeth should be positioned as necessary to make the wire conform to the buccal indicated by Edward H Angle to conform to the surface of maxillary and mandibular molars. “line of occlusion”. The general form assumed by the arch wire in Accepting this it is also necessary to accept each arch, therefore, must be a curve in the anterior the concept of the ideal arch as essential to a well section and a general tapering distally, balanced tooth arrangement, that is progressively increasing in arch width. fundamentally stable and will more likely THE IDEAL ARCH WIRE maintain its integrity, with this objective all arch wires made, and towards it all planned tooth The purpose of an ideal arch wire is: to transmit movements are predicted. to the brackets through the contour of the wire, The variation in dimension and shape of the the ideal arch form of the teeth, for particular different teeth in each arch makes their patient. relationship which each of them unique and Forming the arch wire: There are different precise, if arranged in an ideal arch form. Since methods of forming an arch wire as well as there is a variation in anatomical dimension in a different techniques for different wires, i. e. gold labiolingual direction of various teeth at the alloys and stainless steel. Arches are made in one bracket level, it is necessary to consider several of the three ways. anatomical demands that determine the 1. By indirect measurement arrangement of teeth in an ideal arch form, the a. The Angle methods—using graph maxillary arch, the central incisor is a thicker b. The Bonwill-Hawley method tooth than the lateral incisor, and so as the cuspid. 2. By direct measurement—patient mouth (Chair Since the maxillary anterior teeth contact the side) mandibular anterior teeth, it is safe to assume that 3. By adaptation: on a plaster, model History of Fixed Orthodontic Appliances 177

The ideal arch wire can be made by any one of 2. Secondary or second order bends : Are also those three methods, depending upon the known as tip back bends are bends placed in understanding and skill of the operator. The the arch wire in the vertical plane. They are “Angle” and “Bonwill-Hawley” methods provide utilized to tip the teeth in the buccal segments a means of obtaining perfect arch symmetry by of both dental arches either mesially or distally. intermittent checking during the formation of the In edgewise appliance, three types of second arch wire. order bends are there; Characteristics of the Ideal Arch Wire i. Tip back bends ii. V bends An ideal arch wire has certain identifying iii. Artistic positioning bends characteristics. It is flat and without bends in its i. Tip back bends: Tip back bends for vertical plane other than the curve of speed. It is preparing anchorage in edgewise bilaterally symmetrical and has the following appliance. It is an upward and downward bends in the horizontal plane. bend. These bends are placed between II The anterior bend: This is the arch that extends bicuspid, first molar, and in between I around the labial of the teeth from cuspid to cuspid. molar and II molar. The degree of tip back The lateral set-back bends: Because of the in the terminal molar is such that, when labiolingual thickness of central and cuspids as the arch wire is placed in the buccal tubes, compared to the lateral incisors known as the it will cross the cuspid teeth at the dento- lateral set-back bends. enamel junction. The mesial cuspid bends: The demarcation The arch wire when raised and ligated to between the cuspid eminence bends and the lateral the two brackets on the first molars are set-backs is made at the mesial of the cuspid and depressed. At this point, the arch wire will is known as the mesial cuspid bend. lie gingival to the brackets of the second premolar teeth. The buccal sweep: The part of the arch wire that ii. V bend: These V bends are placed between extends distally from the cuspid eminence is not the lateral and cuspid teeth. The apex of a straight line, but instead it has a slight or gentle the V is pointed gingival. curve running from the cuspid to the end of the Significance: It separates anterior segment arch wire. This gentle curve forms an arch that is and posterior segment. It differentiates at least equal to the thickness of the archwire. torque in anterior and posterior segment. The molar bayonet bends: The first and second iii. Artistic positioning bends: Are important molars usually extend buccally out from the line for the finishing phase of treatment. These of the cuspid and bicuspid surfaces due to the bends are necessary because the long axis buccolingual thickness of those teeth. To of each tooth is inclined relative to the plane compensate, the arch wire is bent abruptly of a continuous arch wire. Without outward by a double bend called the bayonet bend. adequate artistic positioning bends, the incisor teeth are positioned straight up and Arch Wire Bends down with the roots too close together producing an effect sometimes All bends placed in arch wires during treatment disparagingly called “orthodontic look”. of the various types of malocclusions with the 3. Tertiary or third order bends: Better known Edgewise arch mechanism may by classified into as torque are placed in the arch wire to effect three general types. buccolingual or labiolingual root and crown 1. Primary or first order bends: Are those bends movements in single teeth or groups of teeth. placed in the arch wire that do not alter the Torque is a twist in the wire in the horizontal horizontal plane of the wire. plane. In upper anterior teeth the torque value Examples: The various bends used to form the in positive means palatal root torque or labial ideal arch wire when properly placed, permit crown torque and in upper/lower in posterior the arch wire to lie tangent to a glass slab in its teeth torque given in negative is buccal root entirety. torque. 178 History of Orthodontics

ADVANTAGES AND DISADVANTAGES OF 5. Tipping of tooth crown is impossible with EDGEWISE APPLIANCE rectangular wires. It is most important in certain stage of the treatment of almost every The edgewise appliance was invented by Angle patient, to produce no tooth movement other and introduced to the dental profession in 1925. than tipping of tooth crowns. For example, It was then far the advance of any other appliance in the control that it give the orthodontist over bidentoalveolar potrusion. the movement of the teeth, and it has never lost 6. Patient cooperation: Heavy forces cause pain, that position. as well as for anchorage using headgears. From mechanical viewpoint, the best appliance 7. Anterior movement of dental arches: It has would be one that offers the most complete control been found that, soon after edgewise arch of the teeth in all three planes of space with the wires are fully engaged in tie brackets on all or least amount of material. Edgewise is an exacting most of the teeth their is in most patients, some appliance, requiring thorough understanding anterior movements of the dental arches as a and skill in its manipulation. It is a labial arch whole. The explanation for this anterior technique offering excellent control in the movement is that the sum of the forces exerted labiolingual, mesiodistal and vertical directions. by the arch wires and transmitted through the It is possible with one rectangular arch wore to tie brackets to the roots of teeth is to produce move teeth in three planes of space. Other an anterior thrust on the dental arches. It is appliances may be able to achieve a comparable because tie brackets have a significant degree of control, but not without auxillary mesiodistal dimension arch wires exert force attachments to the main arch wire. mesially or distally on tooth roots when 1. The ability to obtain tooth movements in all engaged in the brackets. three planes of space with a single arch wire. BUILDING TREATMENT INTO THE EDGEWISE This is true for all the teeth in both arches. APPLIANCE 2. The philosophy of treating to an ideal arch or the Angle’s concept of the line of occlusion. There are several basic principles of appliance 3. The use of rectangular or square edgewise construction that have been referred to as arches which, if properly used; control arch building treatment into the appliance in this widths, arch form, buccolingual crown instances is defined as the basic components that inclinations, axial root inclinations and incisor are cemented to the teeth—the bends with their crown and torque. respective attachments. The shape and manipulation of arch wire and auxiliaries are Disadvantages directly related to the basic appliance that is fixed 1. Operator skill is required. Bends incorporated upon the teeth. Many of the adjustments and in the arch wire should be accurate to get tooth movements that require highly proper finishing of the case. complicated arch wire bends can be produced 2. Heavy forces generated: Causes pain without these time consuming adjustments, if discomfort to the patients, damage to tooth some of the treatment is built into the appliance, roots. by placing the brackets and tubes in such a 3. Anchorage control or extraoral anchorage: position that they become unnecessary. The Edgewise mechanism was designed to achieve following principles will result in more consistent universal tooth movements. But the forces results with far less effort. The time spent in delivered by it are much too high. These incorporation of these details into the basic excessive forces limit its tooth moving appliance construction will pay large dividends. efficiency because, high forces prevent tooth Bracket angulations: Angle described how movements from being kept under control. edgewise brackets were soldered to band stripes, When force is applied with the edgewise with the bracket slot parallel to the band strip, at mechanism, there is movement of the anchor the same time, he suggested angulated posterior teeth as well as of the teeth which are to be brackets to produce desired tooth movements. The moved. general rule in the earlier days of the edgewise 4. More chair side time. appliance was to place the band strip on the teeth History of Fixed Orthodontic Appliances 179 with the brackets parallel to the long axis of the think of solution and he came up with the light teeth. In 1941, Tweed pointed out the short wire differential force technique, now popular by comings of this approach. He advocated arch wire the name Begg technique. He modified the ribbon bends to obtain correct axial inclinations and arch bracket with a vertical slot facing gingivally. called them “artistic positioning” bends. Although biocompatible, the gold arch wire In 1952, a classic article by Holdaway was expensive and forces were insufficient. In described three uses for bracket angulation. search of an alternative, Begg approached his 1. As an aid in paralleling roots adjacent to friend AJ Willcock, who was a metallurgist. extraction spaces. Willcock developed Australian austenitic arch 2. As a method of sitting up posterior anchorage wires, which were biocompatible, flexible, units into tipped back or anchorage prepared positions. formeable, malleable, resilient and also 3. As a means of obtaining correct axial inexpensive. Begg technique advocates the use of inclinations or artistic positioning. differential force and tipping of teeth crowns rather than bodily movement. Roots are torqued at the Torqued Bracket Slot end of the treatment. In the original and basic edgewise bracket, the Although a number of other advanced fixed slot is cut at a right angle to the base. The techniques have been developed lately, Begg rectangular arch wire must be twisted or torqued technique is still used in many parts of the world. to obtain correct crown root inclinations. Begg appliance/technique uses stainless steel At the suggestion of “Ivan Lee”, manufacturers began to offer brackets with torqued slots. These brackets introduced in the later 1950s or early 1960s, were designed to eliminate the need for adding torque to the anterior portion of the upper archwire. Jarabak described the use of torque brackets in 1960s that had a raised base of approximately 0.016". This projected the bottom of his bracket slot further from the labial surface and eliminated the need for lateral offset bends. Angulated buccal tubes and brackets in the 1960 have to build the correct rotation into the appliance. In addition, during this period at least one of the Fig. 18.7: Begg appliance manufacturers introduced a biangulated tube that incorporated 10 degree of torque as well as rotational control for the upper molars.

BEGG APPLIANCE The Begg appliance (Fig. 18.7) was introduced by Dr PR Begg (Fig. 18.8) in the year 1930.Begg studied in Angle‘s school of orthodontics and later began practicing in Australia. After a couple of years of practice neither his patients nor himself were satisfied with the treatment using appliances available then, namely ribbon arch and pin and tube appliance. The treatment period was too long, oral hygiene was a prime issue and soft tissue irritation and oral ulcers due to extensive metallic design were common. These problems led him to Fig. 18.8: Dr.P R Beg 180 History of Orthodontics arch wires along with a number of auxiliaries and The Straight Wire Appliance springs to achieve the desired tooth movement. Origins: Since its introduction in 1971, the straight wire appliance has become widely appreciated STRAIGHT WIRE APPLIANCE by orthodontists. It was designed by “Lawrence Straight wire appliance/technique (Fig. 18.9) is a Andrews”, an orthodontist practicing in San modification of edgewise appliance and it was Diego, California. To assist in establishing a developed by Lawrence F Andrew in the year definition of ideal occlusion, a study of excellent 1970, based on his six keys to normal occlusion. untreated occlusions was undertaken and a Brackets used in this technique are having pre- remarkable collection of more than 120 sets of built tip, angulations and torque. study models amassed. From examination of the records of these “non-orthodontic normals” Introduction (Straight Wire Appliance) Andrews arrived at his six keys of normal occlusion and, with this clear goal in mind, set Prior to 1970, the Begg’s and Edgewise appliance about designing an appliance to facilitate were the most commonly used appliances in attainment of his treatment objectives. orthodontics. These appliances served the profession well for many years and quality ANDREWS SIX KEYS TO OPTIMAL results were achieved by those, who devoted the OCCLUSION time and effort to learn, their proper use. In the The following terms are necessary for discussing 1950s, both Begg’s and edgewise practitioners, the six keys. began to seriously consider ways to achieve, the 1. Andrews plane: The surface or plane on same or even higher quality results with less wire which the mid-transverse plane of every bending time and more simplified mechanics. crown in an arch will fall when the teeth are The results of this effort was the development of optimally positioned. the concept of ideal gnathologic or pre-angulated 2. Clinical crown: Normally, the amount of orthodontic appliance. Such an appliance was crown that can be seen intraoral, Orban has envisioned as follows. If an ideal gnathologic set defined the clinical crown as the anatomical up was completed on study models of a given crown height minus 1.8 mm. patient, the pre-adjusted appliance would; 3. Facial axis of the clinical crown (FACC): For 1. Have bracket bases that accurately fit each all teeth except molars, the most prominent tooth at a predetermined point portion of the central lobe on each crown’s 2. Have bracket slots that are passively a facial surfaces. For molars, the buccal groove “straight wire” coordinated to the patient’s that separates the two large facial cusps. arch form. 4. Facial axis point (FA point): The point on the facial axis that separates the gingival half of the clinical crown from the occlusal half. Tooth type: A subordinate category within a class of teeth. I molar, II molar. 5. Crown angulations: The angle formed by the facial axis of the clinical crown {FACC} and a line perpendicular to the occlusal plane. Crown angulation is considered positive when the occlusal portion of the crown, tangent line, or FACC is facial to its gingival portion, negative when distal. 6. Crown inclination: The angle between a line perpendicular to the occlusal plane and a line that is parallel and tangential to the FACC at its midpoint (the FA point). Crown inclination is determined from the mesial or distal perspective. Crown inclination is considered Fig. 18.9: Straight wire appliance positive if the occlusal portion of the crown, History of Fixed Orthodontic Appliances 181

tangent line, or FACC is facial to its gingival Key VIII: Anterior guidance: In mandibular portion, negative to lingual. protrusion, opening should be guided by the incisors. There should be disocclusion of all other Key I : Interarch Relationships: Key I patients to teeth. the occlusion and the interarch relationships of the teeth. This key consists of seven parts: Key IX: Canine guidance: Lateral movements of The mesiobuccal cusp of the permanent the mandible should guided by the working side maxillary first molar occludes in the groove canines. There should be disocclusion of all other between the mesial and middle buccal cusps teeth on both working and non-working sides. of the permanent mandibular first molar. Key X: Cusp embrasure contact: The intercuspal The distal marginal ridge of the maxillary first position should be even throughout both buccal molar occludes with the mesial marginal ridge segments. of the mandibular second molar. The buccal cusps of the maxillary first molar Historical Background occlude in the central fossa of the mandibular Until the mid 1970s, most fixed appliance therapy second molar. was carried out using the standard edgewise The buccal cusps of the maxillary premolars bracket, either in single or twin form, having a 90o have a cusp embrasure relationship with the bracket base and bracket slot angulations. Arch mandibular premolars. wire bending by the orthodontist was required in The lingual cusps of the maxillary premolars order to achieve adequate results. have a cusp fossa relationship with the Two major disadvantages resulted from this mandibular premolars. treatment method: The maxillary canine has a cusp-embrasure Arch wire bends were time consuming and relationship with the mandibular canine and tedious. Even in the hands of experienced operator, first premolar. The tip of its cusp is slightly adjustments were imprecise and hard work mesial to the embrasure. requiring hours of additional chairside attention. The maxillary incisor overlaps the mandibular The short comings of the bracket system and incisors and the midlines of the arches match. the extreme skill required of the orthodontist, Key II: Crown angulations: Essentially all crowns resulted in many undertreated cases which led to in the sample have a positive angulation. the second disadvantage. Molars were not in a true class I relationship, lacked torque. In effect Key III: Crown inclination: the resulting occlusion, had the appearance of a Most maxillary incisors have a positive “nice orthodontic result” rather than a pleasing inclination, mandibular incisors have natural dentition. Equally important, the long-term negative inclination. stability of tooth alignment was compromised by Canines and premolars are negative failing to establish ideal tooth relationships. inclination. I and II molars have more negative inclination. The Straight Wire Appliance Key IV: Rotations: The fourth key to optimal Prior to the 1970s, there were minor appliance occlusion is an absence of tooth rotations. adjustments made in the direction of preadjusted Key V: Tight contacts: Contact points should appliances (i.e. tipping of the brackets to minimize about unless a discrepancy exits in mesiodistal the need for II order bends), but it was not until crown diameter. Lawerence F Andrews evaluation and measurement of the non-orthodontic normal study Key VI: Curve of spee: The depth of the curve of models, followed by his development of the spee ranges from a flat plane to a slightly concave Andrews’ straight wire appliance that the surface. preadjusted appliance became a sophisticated Additional Keys three-dimensional system commercially available to the orthodontist. Key VII: Intercuspal position: Intercuspal It was hailed by clinicians as a radical step position and retruded jaw relation should be forward offering the dual advantage of less wire coincident. bending, coupled with an improved quality of 182 History of Orthodontics finished cases. For the first time, a system second 7. Self limitations of movement. Hence, even if to offer an escape from the drudgery of wire the patient misses one or two appointments bending. If the finished stage of treatment was nothing untoward can happen. less taxing on the patient and orthodontist then 8. Finishing is excellent, not only is the esthetics perhaps, the quality of the completed case would enhanced but it is possible to produce be greatly enhanced. mutually protected occlusion. The stability of The old mechanics and heavy force levels were result is thereby guaranteed. developed for standard edgewise brackets. Simply did not transfer to the new sophisticated bracket LIMITATIONS OF STRAIGHT system. Operators found that many unwanted WIRE APPLIANCE (SWA) changes occurred early in treatment in response It is wrong to assume that no wire bending at all is to the heavy forces in particular. A “Roller necessary with Single wire appliance (SWA). coaster” effect was frequently observed, with While no bending is necessary in the initial stages rapid, undesirable deepening of the bite. of treatment, finishing required some wire bending Another frequent observation was in the area in almost every case. First, because the appliance of the premolars and canines which tended to tip prescriptions are based on averages, they cannot and rotate into the extraction sites. Such possibly account for all the variations of tooth size unwanted tooth movement retarded treatment to and shape. This means that detailing bends would such a great extent, that the theoretical advantage be needed in finishing wires of some patients. offered by the new system was dramatically Second, bracket placement is such an exacting compromised. requirement of preadjusted appliance that when brackets are not properly positioned, they must The Late 1970s be repositioned or compensatory bends must be There was two possible ways to proceed. The route made. Wire bending may be necessary for over taken by Andrews (and later by Roth) was to correction. maintain the same force levels and treatment Other criticism that have been leveled against mechanics, but introduce features into the the SWA include: bracket system to prevent undesirable changes. 1. The higher forces that may be needed Hence extra torque was introduced into incisor 2. Torque values brackets and anti-tip and anti-rotation features 3. Attempt to confirm each patient arch to the were added to canine, premolar and molar same basic arch form. brackets. There was the extraction of translation Not withstanding these limitations, the SWA series of brackets, some of which were alter is a significant step forward in rendering grouped together to produce the definitive Roth “Quality orthodontic treatment and has come to appliance. stay at the end of the treatment, a stage of Today the straight wire concept has been finishing and detailing is required. Rectangular modified by Roth, Ricketts and Alexander. The finishing arch wires must incorporate a complex advantages of straight wire appliance include: series of adjustments to compensate for labio- 1. Precise control of premolar and molar torque. lingual crown position (first order bends) 2. Bilateral symmetry of buccolingual mesiodistal root position or tip (second-order inclination. bends) and labiolingual root position or torque 3. Bilateral symmetry of arch form. (third order bends)”. 4. Use of straight arch wires with few or no Straight wire attachments incorporate bends. This reduces chairside time. In individual adjustments for each tooth, the addition, the results are not compromised due thickness of the base of each bracket and tube to clinicians wire bending limitations. varies so that ideal alignment can be obtained from 5. Precise control of finishing in both areas in all a simplified arch form, omitting the inset and offset three planes of space. bends required with traditional edgewise 6. Elastic use is very minimal and confined to appliance. The angle at which the arch wire last stage of treatment. intersects the long axis of the labial faces of the History of Fixed Orthodontic Appliances 183 teeth is also predetermined in such a way so as to associated with potential back pain and related build in the optimum tip for each tooth. Finally discomfort may have discouraged many the angle at which the slot is set into the operators— although these difficulties were attachment is adjusted to provide the ideal torque. overcome with practice and enhanced efficiency of clinical technique — resulting in the LINGUAL TECHNIQUE abandonment of many early lingual orthodontic Since the earliest fixed lingual orthodontic treatments, which were completed with labial appliances appeared in the mid to late 1970s, they appliances. An early generation of frustrated have been subject to significant vicissitudes. clinicians came to believe that accurate, efficient Beginning in 1979, an initial wave of popularity lingual orthodontic treatment was an inherent occurred when the first mass-manufactured paradox — much like earlier views that, achieving lingual brackets were released in the United States. manned flight was impossible. Many negative At that time, the media and public had been made perspectives continue to be propagated, aware, rather suddenly, of a new technique that particularly in North America. Thus, much of the would allow straightening of teeth, without the long-term development of lingual orthodontic requirement for traditional labial “outside therapy has occurred in other parts of the world, braces”. No matter how vigorously esthetic labial including Japan, Italy, France, Korea, Germany, brackets (e.g. plastic, polycarbonate, vinyl and Singapore and Australia, Turkey, Israel and South ceramic brackets) or other moderately effective Africa, although there are a few dedicated alternatives (e.g. Invisalign [Align Technology practitioners in the United States. Inc., Santa Clara Calif.]) have been promoted over The lingual technique (Fig. 18.10) was the years, many adults do not seek orthodontic introduced by Craven kurz in 1976. Dr Craven kurz, treatment because of the perceived embarrassment of wearing braces. The earliest consistently documented work on lingual appliances began around 1975, when 2 orthodontists working independently in Japan and the United States started developing their own systems to place braces on the inside surfaces of the teeth. The early prototypes were based on modified, traditional “outside” braces. Much credit has been given to late Dr Craven Kurz of California, who with co-workers developed the early Kurz/Ormco lingual bracket system. However, over the same period, significant development was made by Professor Kinya Fujita, of Kanagawa Dental University in Japan, who continues to make great advances in this clinical discipline.

Why Lingual Orthodontics Developed Slowly in North America Clinical protocols had not been fully elucidated in those early days, resulting in many clinicians feeling impelled to begin lingual orthodontic cases without being fully prepared. Orthodontists found that the new lingual technique required much more rigorous attention in detail, as well as a fundamentally different approach to treatment planning and biomechanics. Postural challenges Fig. 18.10: Lingual technique 184 History of Orthodontics an assistant professor at UCLA school of dentistry, aspects of life than unattractive people. realized that many of his patients were adults. Improvement in one’s physical appearance, as is This led to the development of the concept of common with orthodontic treatment, can the lingually bonded appliance, consisting of positively affect social and professional plastic Lee Fisher brackets bonded to the lingual interactions. The use of unattractive labial aspect of the anterior dentition and metal brackets orthodontic practice can negatively affect one’s bonded to the lingual aspect of the posterior self-esteem. Many patients, if given the choice, dentition. The plastic brackets were used for the would opt for an appliance that was not visible, inherent ease of recontouring and reshaping them provided the course and treatment and quality to avoid direct contact with the opposing teeth. of results were the same as with a conventional Dr Fujita of Japan published cases treated with treatment. Thus was born the methodology of his modification of the Begg light wire appliance. lingual orthodontics. He had bonded the Begg brackets lingually or Even before the development of true lingual palatally and used the same AJ Willcock appliance, the orthodontic company Ormco in Australian austenitic arch wires contoured to the conjunction with Dr Wildman, had attempted to lingual aspect of the teeth. He explained the arch develop a system to align the dentition using the form which resembled a mushroom (when viewed lingual approach. This system consisted of a occlusally) and advocated the same basic steps pedicle positioner, rather than a multibracketed as in the conventional Begg technique to be used system. Although innovative, the inherent with the Begg brackets with a modified base. limitations of this system prevented it from gaining The 1970s was an exciting decade for widespread popularity in orthodontic community. orthodontics. The straight wire appliance was It was only in early 1970s that Dr Craven Kurz, developed, treatment demands had increased, and an assistant professor at UCLA school of dentistry, adults were seeking treatment in greater numbers. realized that a major portion of his private This increasing demand for adult treatment orthodontic practice was dominated by adult brought unique concerns to the profession. patients. Dr Kurz developed the first true lingual Esthetics was then and continues to be a primary appliance, consisting of plastic Lee Fisher brackets concern of patients. Adult patients present with bonded to lingual aspect of the anterior dentition unique challenge, of wanting to look good even and metal brackets bonded to lingual aspect of during orthodontic treatment. They have posterior dentition. The plastic brackets were used demands of their work and broader social needs for the inherent case of recontouring and to consider. They think that braces are normally reshaping them to avoid direct contact with meant for kids. In an effort to provide solution to opposing teeth. Around the same time Dr K Fujita these esthetic problems, tooth colored brackets and of Japan published cases treated with his wires were also introduced. But these brackets modification of the Begg light wire appliance. He were invisible only from a distance and staining had bonded the Begg bracket lingually and used of the bracket and the tooth presented a significant the same Australian A J Wilcock wire contoured problem. The search for improved esthetic to lingual aspect of teeth. He explained the arch alternatives to metal or clear brackets continued. form which resembled a mushroom and advocated Some orthodontists thought of placing braces on the same basic steps as in conventional Begg the lingual side, leaving the labial surface technique to be used with Begg bracket with retouched. modified base. Further, research was carried out During the evolution of lingual appliance by individuals and group of individuals therapy, the technique has moved in and out of associated together, with financial finding from public and professional favor. Over the years, the orthodontic manufacturing companies. The appliances and techniques have improved lingual task force was setup by Ormco to develop dramatically and as a result, a reliable system has a commercially viable lingual appliance. emerged. The lingual task force pioneers Dr Kurz, Research has shown that physically attractive Gorman and Smith were the first to conduct people achieve higher levels of success in many courses on the edgewise lingual appliance, Dr History of Fixed Orthodontic Appliances 185

Vince Kelly of Oklahoma and Dr Steve Paige of increased width of PM bracket Florida were the first to start giving courses using allows better angulation and Begg appliance lingually. rotation control. Dr Dilier Fillon of France is the only 9. Ligation. orthodontist to have restricted his practice to 10. Attachment. lingual orthodontics exclusively. Modifications were done from time to time to correct these drawbacks : Some of the drawbacks encountered during the development of lingual orthodontics were : Drawbacks of Lingual 1. Tissue irritation and speech difficulty 2. Gingival improvement 1. Discomfort to the tongue. 3. Occlusal interference 2. Difficulty in speech, which usually improves 4. Appliance control after two to three weeks of appliance 5. Base pad adaptation placement. 6. Appliance placement and bonding 3. Extended chairside time needed for appliance 7. Appliance prescription placement and adjustments. 8. Wire placement. 4. Expensive. Generation 1 1976 Flat maxillary occlusal bite Advantages plane from C-C the lower incisor and PM bracket were The labial enamel surface of anterior teeth low profile and half round. plays an important esthetic role. No hooks. In labially placed brackets, the susceptibility Generation 2 1980 Hooks were added to canine of enamel surface to chemical results and brackets. plaque accumulation with poor oral hygiene Generation 3 1981 Hooks added to all anterior is increased. and PM brackets the first Permanent and unsightly decalcification molar had a bracket with marks can result in labial. internal hook. Easy access for routine oral hygiene Generation 4 1982–84 Addition of low profile procedures on the labial surfaces. anterior inclined plane, hooks Clinical judgment of treatment progress can optional. be enhanced. Generation 5 1985–86 Anterior inclined plane Evaluation of individual tooth position can be because pronounced, easily accomplished by having labial surface increase in labial torque in free of distracting metal or plastic brackets. maxillary anterior region TPA attachment. Soft tissue responses of the lips and cheeks to Generation 6 1987–90 Inclined plane because more treatment can be judged accurately because square in shape. Hooks on there is no distortion of shape or irritation anteriors and premolars caused by labial appliance. were elongated. Hooks on all Four distinct situations exist where lingual brackets. appliances may be more effective than labial Generation 7 1990– Maxillary anterior inclined appliances because of their unique mechanical Present plane is now heart-shaped with characteristics. short hooks. The lower ante- Intrusion of anterior teeth rior brackets have larger incli- Maxillary arch expansion ned plane with short hooks. Combining mandibular repositioning The premolars brackets were therapy with orthodontic movements widened mesiodistally and hooks were shortened, the Distalization of maxillary molars. HHiiissstttooorrryyy oofff MMyyyooofffuuunnnccctttiiiooonnnaaalll 19 OOrrrttthhhooodddooonnntttiiiccc AAppppppllliiiaaannnccceeesss

History of Activator History of Herbst Appliances History of Frankel Appliance History of Twin-Block Appliance History of Bionator History of Double Plate History of Oral Screen History of Tooth Positioner

The term “Functional appliance” means that to orthopedic devices. The animal studies of the when the appliance is fully seated in the mouth, 1960s and 1970s created enormous enthusiasm the mandible is forced into an eccentric/Non- in the professional community and played an ecentric relation position. Any such mandibular important role in the rapid acceptance and use of posture causes the musculature to try to move the functional appliances in the United States that mandible toward a centric position. This results has been largely ignored up till that time. in force systems being exerted whenever the There were two important considerations that appliance is mounted on the teeth or soft tissues were left unanswered. First, would the increase of the mouth. in overall mandibular length achieved with Although functional appliances have been used orthopedic devices placed in growing rats and throughout the century in Europe and in the last monkeys also occur in growing children? Second, 40 years in the United States, it was not until the was the quantitative increase in condylar growth late 1960s that scientific data were available to demonstrated at a cellular level enough of an evaluate the empiric rationalization for their clinical increase to make a relevant clinical difference in effectiveness. This early data consisted of animal humans? In response to these issues, various experiments demonstrating histologic and investigators in the 1970s and 1980s conducted radiographic evidence of increased growth of the retrospective clinical studies. This was occurring condylar cartilage when the mandible was held at the same time that many clinicians were in a forward position. Breitner’s early monkey embracing functional appliances as the answer studies and Alexander Petrovic and coworker’s of mandibular deficient patient. A number of these initial findings and usually rats as models were retrospective studies demonstrated some average complemented by later primates and rat studies modest increases in mandibular growth (2–4 mm conducted by number of independent investigators. per year) during treatment with functional Petrovic suggested that the unique characteristic appliances. Other investigators did not consider of the condylar cartilage, including cell division the effect of functional appliance on quantities of the prechondroblast (as opposed to the lengthening of the mandible to be clinically chondroblast in epiphyseal cartilage of his long significant. In addition, it became clear that there bones or cartilage in the synchondroses of the was much greater variability in the mandibular cranial base) make this cartilage more responsive growth response of humans to functional History of Myofunctional Orthodontic Appliances 187 appliance that in the animal models. Also the variability of growth potential in response to orthopedic treatment was much greater for the mandible than for the maxilla. The enthusiasm for functional appliance in the United States during the 1980s considerably moderated in the 1990s in the light of the less impressive results of the retrospective clinical studies complemented by clinical experiences. Although a modest mean increase in mandibular growth may occur for a group of patients being treated with functional appliances, the increase is not predictable because of the great variability in patient’s response. In addition, there still is uncertainty whether discernible mandibular growth acceleration is nearly temporal and does not result in an absolute final gain in mandibular length. In other words, it is possible that the ultimate length of the mandible may not be altered appreciably in spite of accelerated growth during treatment. There still has been no clear demonstration that the observed treatment effects represent true growth stimulation beyond the limit of human growth variation. In spite of the continued controversy around the reliability of gains in mandibular length from functional Fig. 19.1: Viggo Andersen appliance treatment, there are the effects that sagittal corrections that he could not produce with contribute to the correction of Class II conventional fixed appliances. The original malocclusion. Andresen activator was a tooth-borne, loosely ACTIVATOR fitting passive appliance consisting of a block of plastic covering the palate and the teeth of both Viggo Andresen(1870–1950) (Fig. 19.1) in 1908 arches, designed to advance the mandible several in Denmark designed a loose filling appliance millimeters for Class II correction and open the which he first used on his daughter. He made a bite 3 to 4 mm. The original design had facets modified Hawley type of retainer on the maxillary incorporated into the body of the appliance to arch to which he added a lower lingual horse- direct erupting posterior teeth mesially or distally, shoe shaped flange which helped in positioning so, despite the simple design, dental relationships the mandible forward. Viggo Andersen removed in all 3 planes of space could be changed. In his daughter’s fixed appliances before she left for designing an inert appliance that fitted loosely in her summer vacation, as was customary at the the mouth and, because of its mobility, transferred time, and placed a Hawley-type maxillary muscular stimuli to the teeth, jaws, and retainer. On the mandibular teeth, he placed a supporting structures, Andresen had taken a lingual horseshoe flange that guided the mandible decisive step in orthodontic treatment. Although forward about 3 to 4 mm in occlusion. Andresen, he had effectively redesigned Robin’s monobloc a Danish dentist, did not start specializing in to correct Class II Division 1 malocclusions, he orthodontics until 1919. On his daughter’s return, declared that he had no knowledge of Robin’s he was surprised to see that nighttime wearing of work at the time. Andresen’s novel device was the appliances had eliminated her Class II not initially well received. First, removable malocclusion, and it was stable. Applying this appliances were not much accepted at that time. technique to other patients resulted in significant Second, the profession was under the influence of 188 History of Orthodontics

Martin Schwarz, whose active plate was then a there was no mention of “growth stimulation”. common form of removable not functional Activator use became so widespread among appliance. Finally, Andresen advocated European practitioners that there was concern that extractions, although not necessarily in proper diagnosis was being neglected. connection with activator treatment. And, in Unfortunately, reminiscent of Angle’s following, contrast to Angle’s concept of ideal occlusion that “functional jaw orthopedics became a profession was then prevalent, Andresen advocated a more of faith, a religion, beside which no other opinion realistic “individual and functional gnathological was tolerated”. Furthermore, Reitan, in his 1952 optimum”. Thus he was subjected to the same type doctoral thesis, questioned Roux’s hypothesis of ridicule that Tweed endured years later. In 1925, and demonstrated that no special histologic Andresen, then director of the orthodontic picture emerged from the use of functional department at the University of Oslo, began appliances. His findings were supported by later developing for the government a simple method researchers. Andresen and Häupl later of treating Norwegian children. He modified his collaborated on a textbook (Funktions- retainer into an orthodontic appliance, using a kieferorthopädie) about their system in 1936. The wax bite to register the mandible in an advanced sixth edition included Leopold Petrik as coauthor. position. At the university, Karl Häupl (1893–1960) Although Häupl’s complete rejection of fixed (Fig. 19.2), an Austrian pathologist and appliances led the profession astray for a time, periodontist, saw the possibilities of the appliance had it not been for his promotional efforts, the and became an enthusiastic advocate of what he activator might have languished in obscurity. The and Andresen called the “Norwegian system”. advantages of the activator include: Häupl’s theories were inadvertently strengthened 1. Treatment in the deciduous and early or late by the findings of Oppenheim, who showed the mixed dentition is possible and successful, potential tissue damage caused by the heavy 2. Appointments can be spread out to 2 months orthodontic forces of fixed appliances. At that time, or more 3. Tissues are not easily injured 4. The appliance is worn at night only and is acceptable from an esthetic and hygienic standpoint 5. It helps eliminate pressure habits, mouth breathing, and tongue thrusting. Its disadvantages include: 1. Success depends on patient compliance 2. Activators are of little value in marked crowding, so that patients must be selected 3. The appliance does not obtain a good response in older patients 4. Forces on individual teeth cannot be controlled with the same degree of exactness as in fixed appliances. During the time of Viggo Andresen and Häupl the appliances were made of vulcanized rubber, but this gave way to acrylic in the 1950s. Over the year, various modifications have been made to the original design of Andresen’s appliance such as: 1. The bow activator of AM Schwartz 2. Wunderer’s modification 3. The propulsor Fig. 19.2: Karl Häupl 4. Cutout or palate free activator History of Myofunctional Orthodontic Appliances 189

5. The reduced activator or cybernator of Types of Frankel Appliance Schmuth There are five types of Frankel’s Appliances a are 6. Kawetzky modification as follows: 7. Herren’s modification of the activator. 1. FR-I is further divided into 3 types: Most of the modifications of Andresen FR-I a appliance were based on Andresen’s concepts. FR-I b There can be advantages to using a simple design FR-Ic in terms of patient cooperation, case of adjustment 2. FR-II and freedom from breakages. 3. FR-III 4. FR-IV Graber Observed That 5. FR-V “Numerous modifications have been made to the Andresen—Häupl monobloc and have been Indications of Various Types of Frankel described in texts and periodical contributions by Appliance Petrik, Eschler, Hoffer, Grossman and others. These FR-I a appliance of Frankel: Treating Angle’s are surprisingly effective at times but generally a class I malocclusion with deep bite. simpler design of appliance is performed.” FR-I b appliance of Frankel: Indicated for treating cases of Angle’s class II division 1 malocclusion FRANKEL APPLIANCE where the overjet does not exceed 5 mm. A more recent innovation in functional appliance FR-I c appliance of Frankel: Indicated for treating design, the functional corrector or functional cases of the Angle’s class II division I maloccl- regulator or Frankel Appliance was designed by usion where the overjet is more than 7 mm. Rolf Frankel (Fig. 19.3) in Germany and was FR-II appliance of Frankel: Indicated for treating introduced to orthodontics in 1966. This appliance cases of Angle’s class II division 1 malocclusion was unique in that, it was principally tissue-borne, and class II malocclusion. FR-III appliance of Frankel: Indicated for Angle’s mostly supported in the vestibule rather than class III malocclusion supported by teeth. There are five types of Frankel FR-IV appliance of Frankel: Indicated for treating appliances and are used for management of bimaxillary protrusion and open bite. Angle’s class I, Class II and class III malocclusions FR-V appliance of Frankel: It is used with head- and even it is used in bimaxillary protrusion gear. .Types and their indication in specific malocclusion is explained below. BIONATOR The Bionator was developed in Germany by Wilhelm Balter in the early 1950s to increase patient’s comfort and facilitate daytime wear to increase the functional use of the appliance. Balter accomplished this by drastically reducing acrylic bulk of the appliance. There are three types of Bionators , 1. Standard bionator 2. Class III or Reverse bionator and 3. Open bite bionator.

Standard Bionator Standard bionator is used for the treatment of class II division 1 malocclusion and Angle’s class I malo- Fig. 19.3: Rolf Frankel cclusion having constricted (narrow) dental arch. 190 History of Orthodontics

Class III or Reverse Bionator Class III bionator is also known as reverse bionator and is used for the treatment of Angle’s Class III malocclusion caused due to mandibular prognathism.

Open Bite Appliance This type of bionator is used in open bite cases.

Uses of Bionatar 1. Class II malocclusion. 2. Class III malocclusion. 3. Deep bite cases. Fig. 19.4: Pancherz 4. Open bite cases.

ORAL SCREEN (VESTIBULAR SCREEN) determining the amount of anterior mandibular development. The tube is attached to a maxillary Newell in 1912 introduced oral screen. It is posterior root, whereas the plunger is fixed composed of acrylic base material which fits in anteriorly to the mandibular dentition and slides the buccal/labial vestibule of the mouth. through the tube during opening and closing movements. Indications Indications for oral screen includes TWIN-BLOCK APPLIANCE 1. Oral habits such as Twin-block appliance is a functional jaw a. Thumb sucking or Mouth breathing orthopedic appliance developed by Scottish b. Tongue thrusting orthodontist William Clark in the year 1977. c. Lip biting. The Twin-block appliance is composed of 2. In cases of mild proclination of maxillary maxillary and mandibular retainers that fit tightly anterior teeth. against the teeth, alveolus, and adjacent supporting structures. Delta clasps are used HERBST APPLIANCE bilaterally to anchor the maxillary appliance to The Herbst bite jumping mechanism was the first permanent molars and 0.030 inch ball developed by Emil Herbst in the early 1900s.The clasps are placed in the interproximal areas original banded design of this appliance was anteriorly. The precise clasp configuration introduced at the International Dental Congress depends on the type of deciduous or permanent in Berlin (Germany) by Herbst in 1905.It was teeth and number of teeth present at the time of introduced by Pancherz. Pancherz (Fig. 19.4) used appliance construction. a banded Herbst design that involved the Various designs are available for the lower Placement of bands on molar part of the twin block appliance. The original and premolar design advocated by Clark and it consists of a Bands are connected by copper Maxilla horse shoe of acrylic that extends anteriorly from lingual wire the mesial of the first permanent molars. Bands on lower right first premolar The acrylic covers the lingual aspect of the and lower right first premolar premolar/deciduous molars and the canines and Bands are connected by a Mandible incisors. In this design, delta clasps are used to lower lingual arch wire anchor the appliance to the first premolar/first The Herbst appliance is a fixed functional deciduous molar and ball clasp are present between orthopedic appliance having passive tube and the canines and lateral incisors, additional ball plunger system with the exact length of the tube clasps can be placed between the incisors if History of Myofunctional Orthodontic Appliances 191 appliance retention is thought to be a problem. which the patient could insert the remainder of There should not be any acrylic material touching his mandible. In so doing, however, the pull of the lower molars, this allows the lower molar to scar tissue led to a slight widening of the maxillary erupt vertically if the acrylic on the maxillary block arch. Bimler reasoned that it might be possible to is trimmed to increase the vertical dimension. expand the arch by means of crosswise The Twin-block appliance has been shown to mandibular movements, and the Bimler appliance produce increase in mandibular length, incisor was born. Bimler also developed, about 1938, the proclination and variations in lower anterior “roentgenphotogramm,” by superimposing a facial height. photograph on a head plate, to show the The posterior bite blocks of the twin-block relationship between the skull, the teeth, and the appliance can be trimmed to facilitate the eruption soft tissues something done today by computer. of the lower posterior teeth in patient with a deep World War II brought European orthodontic bite and an accentuated curve of spee. The blocks progress almost to a standstill. Nevertheless, also can be left untouched to prevent the eruption functional appliances got a boost because precious of the posterior teeth in patients with a tendency metals were no longer available for fixed toward an anterior open bite. appliances. In Germany, dentists were ordered to specialize in functional jaw orthopedics. Still, the Indications war brought its own brand of progress. After several modifications, the Bimler appliance Twin-block appliance most commonly used in the achieved its final form in 1949. Compared with treatment of class II malocclusions. previous functional appliances, its reduced size made it possible to wear all day, its elasticity Duration of Treatment allowed muscular movements to translate more Full time wearing of twin block appliance effectively to the dentition, and, because the upper including during eating and the duration of and lower parts were connected by a wire, gradual treatment usually is about (9–12) months. forward positioning of the mandible became Just as Andresen’s discovery of the activator possible. Also like Andresen, Bimler was attacked was an accidental outgrowth of his retainer, so by the functional establishment, in particular was Hans Peter Bimler’s (1916–2003) (Fig. 19.5) Häupl, for his new ideas, but every functional Elastischer Gebissformer (elastic bite former) a appliance subsequently developed has fortuitous development. As a surgeon treating jaw incorporated at least one of his innovations. injuries during World War II, Bimler had devised a maxillary splint for a patient who had lost his THE DOUBLE PLATE left gonial angle. The splint provided a guide into A Martin Schwarz (1887–1963) (Fig. 19.6) began his career as an ear, nose, and throat physician but was diverted into dentistry by famed histologist Bernhard Gottlieb. He became director of Kieferorthopaedia, Vienna Polyclinic, and the jaw orthopedics division of the Viennese government in 1939, where he expanded orthodontic service from 100 to more than 3000 patients. In 1956, Schwarz attempted to combine the advantages of the activator and the active plate by constructing separate mandibular and maxillary acrylic.

THE TOOTH POSITIONER In 1944, Harold D Kesling (1901–79) (Fig. 19.7) developed the tooth positioner. The technique Fig. 19.5: Hans Peter Bimler involved taking impressions of a patient nearing 192 History of Orthodontics

Fig. 19.7: Harold D Kesling Fig. 19.6: A Martin Schwarz completion, denuding the plaster of appliances, be used as a retainer or a recovery appliance. Later and resetting the teeth into ideal positions (the versions were made of other materials, including “diagnostic setup”). From the new models, a clear plastic. Out of these innovations developed rubber positioner was made that, if worn enough T(ooth) P(ositioner) Orthodontics (LaPorte, Ind), hours, acted as a finishing appliance. It could also which now markets them as Pre-Finishers. HHiiissstttooorrryyy oofff SSSuuurrrgggiiicccaaalll OOrrrttthhhooodddooonnntttiiicccsss 20

Hullihen Eiselberg and Pehr Gadd Mowlem Appliance Blair Rosenthal Pionears Brown Kazanjian Mandibular Procedures Bruhn and Linderman

Oral and maxillofacial surgical procedures are Children with congenital malformations such sometimes necessary to optimize the results of as cleft lip and palate often require surgical orthodontic treatment. Surgical orthodontics procedures along with orthodontic treatment for encompasses all those surgical procedures that their rehabilitation. are carried out as an adjunct to, or in conjunction In recent times, new approaches have been with orthodontic treatment. These procedures adapted in orthodontic treatment such as may range from minor surgeries such as tooth implant placement to gain anchorage and extraction to major procedures such as distraction osteogenesis for advancement of orthognathic surgeries of maxilla and/or maxilla or mandible. mandible. Although orthodontic treatment provides a In cases of crowding due to arch length -tooth means of correcting maxilla-mandibular skeletal material discrepancy, it may be necessary to discrepancies, it is limited to actively growing extract some teeth to obtain proper alignment of children. In non-growing individuals, surgical teeth. Unerupted teeth may require surgical intervention has been implemented to exposure to facilitate bracket placement and their circumvent this limitation. subsequent alignment. The first surgical procedure for the correction Adult patients with narrow maxilla may need of a craniofacial deformity was reported in 1848, surgically assisted rapid maxilla expansion to at which time Hullihen successfully performed correct malocclusion in transverse plane. a partial osteoplastic resection of a prognathic Cases with significant skeletal discrepancies mandible. The subapical osteotomy of the and dentofacial deformities cannot be treated anterior mandible was followed by the removal satisfactorily by orthodontic management alone. of a wedge-shaped section of bone from each side In such cases, surgical correction by means of of the mandibular body. The anterior segment orthognathic surgeries of maxilla and mandible was then setback into the new position. may be indicated to obtain optimal occlusal and Surgical treatment of mandibular esthetics results. Adult patients with significant retrognathia, however, was not reported until the skeletal malocclusion may also benefit from 1st decade of the 20th century, when Blair orthognathic surgery in whom, growth demonstrated the use of a bilateral horizontal modification procedures cannot be carried out. ramus osteotomy to advance the mandible. 194 History of Orthodontics

Two years later, Babcock suggested a similar technique did not gain immediate acceptance. This osteotomy for mandibular prognathism . was primarily due to the lack of control over bone Osteotomy of the mandibular corpus has also segment manipulation, inadequacy of distraction been advocated for advancement of the appliances, and the instability of osseous fixation. retrognathic mandible. According to Limberg, Instead, corrective osteotomies remained a Brown in 1918 and Bruhn and Linderman in 1921 principal treatment modality for the management performed a vertical osteotomy of the mandibular of mandibular deformities, especially after the body followed by acute advancement of the introduction of the sagittal split osteotomy by anterior segment. The ensuing defect usually Trauner and Obwegeser. healed by new bone in growth. However, the Although acute bone segment movements amount of advancement with these osteotomies remained the treatment of choice, the adaptation was limited and often associated with instability of orthopedic external skeletal fixation to the of bone segment fixation. mandible rekindled interest in osteodistraction. In an attempt to increase the contact surface The application of external skeletal fixation for area between divided bone segments and craniofacial fractures was first reported by provide greater stability of bone fixation, Haynes, in 1939. Using a number of pins different modifications of mandibular connected to a rigid bar, he applied this technique osteotomies were developed. For example, in to a comminuted, compound fracture of the order to obtain broader contact surfaces, Cryer mandible. and Limberg performed C-shaped arcing and Based on external skeletal fixators for the L-shaped oblique osteotomies, respectively, lower extremities, two other external mandibular concentric with the desired movement of the fixation devices were developed in 1941. The mandible. Likewise, Eiselberg and Pehr Gadd Mowlem appliance and the Converse and developed step-like sliding osteotomies for Waknitz appliance were similarly designed and lengthening or widening the mandible. consisted of three main parts: two pairs of According to Wassmund, in 1927 Rosenthal fixation pins with locking plates located on either performed the first mandibular osteodistraction side of the fracture, and an intervening procedure by using an intraoral tooth-borne telescoping fixation bar. appliance that was gradually activated over a Stader, in 1942, further modified the period of one month. mandibular external fixator by adding double- In 1937, Kazanjian also performed plane-joint elements and a threaded rod to connect mandibular osteodistraction by using gradual both pin fixation clamps (Shaar and Kreuz, 1942). incremental traction instead of acute Stader’s fixation appliance was the first advancement. After performing modified mandibular device that allowed angular L-shaped osteotomies in the corpus, he attached adjustments in two planes as well as a wire hook to the symphysis, thereby providing anteroposterior incremental compression or direct skeletal fixation to the bone segment to be distraction. distracted. Three days postoperatively, an “over The early 1950s began a period of rapid the face” appliance was placed and activated development in orthognathic surgery. In 1954, with an elastic band, thereby exerting traction Caldwell and Letterman developed a vertical on the chin and gradually pulling the mandibular ramus osteotomy technique, which had the anterior segment forward. Seventeen days later, advantage of minimizing trauma to the inferior the elastic force was removed. Occlusal splints, alveolar neurovascular bundle. This method could connected by rigid bars, remained in place for be used instead of a body ostectomy to correct 11 weeks at which time complete consolidation mandibular excess. Europe then became the center of the jaw had taken place. of progress. Pupils of the Vienna School of Kazanjian’s “over the face” appliance for maxillofacial surgery, Richard Trauner and Hugo gradual advancement of the mandible. Even Obwegeser (1957), introduced the intraoral though the first distraction osteogenesis bilateral sagittal split ramus osteotomy, allowing procedures applied gradual traction to the bone corrections in all three planes of space without a segments and surrounding soft tissues, this need for bone grafting. Even so, it was not until History of Surgical Orthodontics 195 the early to middle 1960s that mandibular surgeries this possible, even after the introduction of bonding. became popular in the United States. Marsh At the same time, training of oral surgeons started Robinson and SM Moos developed a reliable to include orthognathic procedures. Until about extraoral procedure for prognathism: the vertical 1975, the prevailing concept of facial deformities subsigmoid or vertical ramus osetotomy with a was that they existed only the sagittal plane, but, bone cut posterior to the inferior dental nerve. as diagnosis became more thorough, surgeons Spectacular changes in the midface resulted from acquired a measure of control over the vertical the treatment of craniofacial deformities and the and transverse dimensions. Plating techniques orbital areas by Paul Tessier in France during the (1983) and screws for the fixation of jaw fragments 1960s and 1970s. Derek Henderson also developed reduced the risk of relapse and allowed appropriate planning techniques using a intermaxillary fixation to be dispensed within many combination of photocephalometry and accurate patients. By the 1990s, the use of rigid fixation model surgery. He emphasized anticipating soft- had become routine, increasing precision and tissue changes. Alveolar surgeries were the next patient comfort (eliminating 6 to 8 weeks of wired procedures to gain popularity in the United States jaws, liquid diets, inability to brush lingually, and after being pioneered in Europe. In 1959, Heinz “claustrophobia”). More recently, the use of Köle, a student of Obwegeser, introduced resorbable bone plates in Helsinki and Groningen subapical dentoalveolar osteotomies in the anterior reduced the risk of leaving plates permanently mandible. In 1960, Obwegeser began performing in situ or the necessity of a second operation. Other maxillary surgery and, by 1969, had described technological improvements have included freeze- many LeFort I osteotomies, marking the beginning dried bone, bovine bone, and autogenous bone; of a new era in the correction of dentofacial biodegradable osteosynthesis material; deformities: before the mid-1960s, maxillary hypotensive general anesthesia (to reduce blood deficiency was typically treated by mandibular loss); smaller instruments with better intraoral surgery. Obwegeser also performed the first total designs; computer-aided treatment planning; and 2-jaw surgery (1970), facilitating the correction computerized axial tomography scans of extensive aberrations in a single operation. (3-dimensional reconstruction). Advances in mandibular surgery included intraoral vertical oblique osteotomy (for PIONEERS advancement or setback), total mandibular subapical osteotomy, and refinement of lower Wescott first reported placing mechanical forces border osteotomy. Again, Europeans led the way. on the bones of the maxilla in 1859. He used 2 In 1972, Paul Tessier came to New York to double clasps separated by a telescopic bar to demonstrate the surgeries he had perfected in correct a crossbite in a 15-year-old girl. However, the 1960s, and it was not until then that American the entire expansion procedure was slow and surgeons, concerned as they were about blood tedious, lasting several months. A year later, supply and total or partial loss of the osteotomized Angell performed a similar procedure with a fragment, could be convinced of the possibilities differentially threaded jackscrew connected to of moving the midface skeleton. In 1974, the the premolars. Palatal expansion was achieved European literature featured 104 LeFort I rapidly in 2 weeks by the separation of the osteotomies that demonstrated remarkable maxillary bones at the midpalatal suture. stability and predictability. In the mid-1970s, Bell Goddard, in 1893, further standardized the and Epker started to popularize the procedure, palatal expansion protocol. He activated the now commonplace in the surgeon’s repertoire. device twice a day for 3 weeks followed by a About that time, orthodontists and oral surgeons stabilization period to allow the deposition of began to realize that, contrary to current practice, “osseous material” in the created gap. Codivilla, orthodontists, having aligned the separate arches, who lengthened a femur to correct limb length could better detail the occlusion if the appliances deficiencies, first reported bone lengthening by were left inplace during surgery. Improvements DO in 1905. Abbot then reported lengthening the in the stiffness of orthodontic wire helped make tibia and the fibula in 1927. These early efforts 196 History of Orthodontics were complicated by edema, skin necrosis, advancement with these osteotomies was limited infection, and delayed ossification of the and often associated with instability of bone expanded bone. segment fixation. In 1927, Rosenthal performed the first mandibular osteodistraction procedure MANDIBULAR PROCEDURES by using an intraoral tooth-borne appliance that Osteotomy of the mandibular corpus was also was gradually activated over a month. In 1937, advocated for advancement of the retrognathic Kazanjian also performed mandibular mandible. According to Limberg, Brown in 1918 osteodistraction using gradual incremental and Bruhn- Linderman in 1921, each performed traction instead of acute advancement. After a vertical osteotomy of the mandibular body performing modified L-shaped osteotomies in the followed by acute advancement of the anterior corpus, he attached a wire hook to the symphysis, segment. The ensuing defect usually healed by thereby providing direct skeletal fixation to the new bone ingrowth. However, the amount of bone segment to be distracted. HHiiissstttooorrryyy oofff CCllleeefffttt LLLiiippp aanannddd CCllleeefffttt PPaPaalllaaattteee 21

Demographic Data Etiology of Cleft Lip and Palate Lip and Palate Embryological Aspects Clinical Features of Cleft Lip and Associated Problems Classification of Cleft Lip and Palate Palate

The history of surgery of cleft lip and palates rabbit’s mouth. It was once believed that children reaches as far backwards as the pre-christian era with cleft lips were born to women who, when to 390 BC when for the first time a cleft lip was pregnant, were frightened by the devil, who had closed successfully in China. Although Egyptian assumed the shape of a hare. The incidence of and Greek medicines developed to a remarkable cleft lip and palate—the single most common degree, no descriptions of cleft operations have defect affecting orofacial structures is survived. In the middle ages operations on cleft approximately 1 in 1000 births; for cleft palate lip have been several times described. A successful only, 1 in 200; isolated cleft lips occur in 20% of operation on a cleft palate did however not occur all clefts. Cosmetic surgery began in the ancient until 1816. This can be explained by the fact that world. The Romans performed simple techniques cleft palates were thought to be secondary to such as repairing damaged ears. Physicians in syphilis, but also because without anesthetic this ancient India used skin grafts for reconstructive operation was extremely painful and difficult. work as early as 800 BC. However, the early history Graefe in 1816 and Roux in 1819 published the of cleft lip and palate surgery describes only first satisfactory results. After the introduction of unilateral procedures. chloroform cleft surgery made remarkable The first report of surgical cleft lip repair progress. The development of cleft surgery has appears in Chin Annals, involving repair of an been chronologically described and finally the apparently congenital cleft in 390 BC. The present state of affairs is discussed. treatment consisted of cutting and stitching the Long before dentists held the notion that they edges of the cleft together, followed by 100 days of could give patients pretty smiles, innovative complete bed rest, when the patient could eat only surgeons were coping with a challenge far more thin gruel and was not allowed to smile or talk. fundamental: how to give certain unfortunate Hippocrates (400 BC) and Galen (150 AD) infants new faces. Many children born with cleft mentioned cleft lips, but not cleft palates, in their palates, unable to nurse, failed to survive because writings. The first exact description in the western of malnutrition. Others were left to die either world of cleft lip surgery was given by Johan because of superstition or because the anomaly Yperman, who practiced in the 14th century. He was too hideous to contemplate. The term performed a 2-layer operation with waxed, “harelip”, now considered demeaning, is believed twisted thread. In 1552, Houlier proposed suturing to have come from the cleft lip’s resemblance to a palatal clefts; 12 years later, Ambroise Paré 198 History of Orthodontics illustrated obturators for palatal perforations. For operation in 1827 with instruments that he designed centuries, perforations of the palate were himself. In 1828, Johann F Dieffenbach enhanced considered to be secondary to syphilis, and cleft cleft palate surgery by elevating the hard palatal palate was not recognized as a congenital disorder mucosa to allow closure of the hard palate cleft. until 1556, when Pierre Franco, along with Paré, He also performed the first closure of both hard described in detail the principles and techniques and soft palates in 1834. The introduction of general of cleft palate surgery. anesthesia in the late 1840s led to great advances Franco has been called the “father of cleft palate in cleft palate surgery. In the 1840s, Simon P surgery”. Hendrik van Roonhuyze of the Hullihen (1810–1857) advocated surgical repair Netherlands (1625–1672) advised that a cleft lip in infancy before eruption of the dentition and should be repaired when the baby was between 3 used an adhesive strap from cheek to the other and 4 months of age, because if done earlier, the before surgery. In 1861, von Langenbeck was the results would be unfavorable. James Cook of first to use a mucoperiosteal flap, which was Warwick (1614–1688) was the first to warn against separated from the hard palate. This method is removal of the pre-maxilla because of the danger still used in many centers. Norman W Kingsley’s of interfering with subsequent growth. Pierre Treatise on Oral Deformities as a Branch of Mechanical Fauchard, in his book Le Chirurgien Dentiste, Surgery in 1880 was the first recognized work on described several different obturators to close the orthodontic and prosthetic treatment of cleft palates. cleft palate defect. The first successful closure of a In the field of cleft lip surgery, Hagedorn was a soft palate defect was reported in 1764 by Le leading pioneer (1884). He used a quadrangular Monnier, a French dentist, using sutures along flap to increase the thickness of the medial part of with cautery of the edges (the first palatorrhaphy). the lip. The first attempts at bone grafting in patients In the United States, Matthew Wilson, practicing with clefts were performed by von Eiselberg in in the 18th century, was the first to publish an 1901 and Lexer in 1908. Drachter in 1914 reported account of a cleft lip surgery. Because of the dangers closure of a cleft with tibial bone and periosteum. associated with surgery in any form, especially The 1930s were an important decade for that involving the head or face, it was not until developments in both cleft palate and cleft lip. the 19th and 20th centuries that such surgeries Blair and Brown (1930) attempted to correct the became commonplace. A successful operation on anterior nares by shifting the tissues toward the a cleft palate finally occurred in 1816 when C von midline. Also that year, V Veau, a leading figure Graefe published the first satisfactory results in cleft surgery, advised that bilateral cleft lips (Philbert J Roux, called by many the founder of could be closed in 2 to 3 stages, depending on the modern cleft lip and palate surgery, did so in 1819). width of the gap. His name was perpetuated when Von Graefe cauterized the margins before suturing he devised a 4-part classification of clefts. Later in them together. When the wound failed to heal, he the decade, Kilner and Wardill independently freshened the wound margins and fastened them developed the “pushback” procedure (in which to the cheeks, so that they could not rip out. Roux’s tissue from the palate is moved back to lengthen operation is well known because the first patient it). The first cleft palate clinic in the United States to undergo this procedure, medical student John was established in 1939 when Herbert Cooper Stephenson, wrote a thesis about it to complete opened the Lancaster (Pa) Cleft Palate Clinic. his degree in medicine. After the introduction of Cooper’s recognition of the need for chloroform, cleft surgery made remarkable multidisciplinary involvement resulted in the progress. In 1820, Jonathan C Warren was probably formation of a clinic that had all the necessary the first American surgeon to perform reconstructive dental and surgical specialists in one location. rhinoplasty and close a palate successfully. In 1828, He was also among the first to use cineradiography he performed a successful closure of a soft palate, to evaluate velopharyngeal function. In a patient noting that, after closure, the width of the hard with a bilateral cleft palate, the surgical closure of palate cleft also diminished. Thus, Warren became the lip is different from that of a unilateral condition an early pioneer in preoperative orthopedic because of the position of the pre-maxilla, the short repositioning of the pre-maxilla. The first plastic columella, and the absence of the muscles in the surgeon in the United States was John Peter prolabium. Surgeons who excised the pre-maxilla Mettauer. He performed the first cleft palate to suture the gap in the lip did not realize the History of Cleft Lip and Cleft Palate 199 damage being done to maxillary growth with this The term harelip often used to denote cleft lip operation. Elastic traction to reposition the pre- should be discouraged. Cleft lip and cleft palate maxilla in bilateral cleft lip and palate patients is exhibit wide range of presentation with varying still being practiced. In 1950, C Kerr McNeil, often degrees of severity; from a small notch in the lip called the founder of modern-day, pre-maxillary vermillion to a complete bilateral cleft of lip and orthopedic treatment, described the use of acrylic cleft palate. Cleft may occur in isolation or as part appliances to reposition bony cleft segments, in of a syndrome. addition to traction. Also in 1950, TM Graber, in Management of these patients is quite his PhD dissertation, was the first to document a challenging since clefts of lip and palate are usually disturbance in facial growth as a result of palatal associated with impaired facial appearance, surgery. His work led to the alteration and staging speech, hearing, mastication, deglutition, dental of surgical procedures. About that time, surgeons occlusion and treatment should address these in Europe were inserting bone grafts as a primary problems. Thus, management of cleft lip and palate procedure. In the 1960s, Sheldon W Rosenstein, requires a multidisciplinary approach with a long working with surgeons, introduced the technique term treatment plan and individualized of placing a plate in the maxilla of a newborn rehabilitation program designed to address the before surgical lip closure to guide the maxillary treatment needs have given patient. Malocclusion segments into proper alignment. After lip closure, is usually present and orthodontic therapy with the aligned segments helped guide the teeth into or without corrective jaw surgery is frequently better positions and reduced the incidence and indicated. severity of cross-bite and segment malalignment. The defects generally have profound The late 1960s and early 1970s was a period when psychosocial implications on the afflicted children primary bone grafting and maxillary orthopedics and their patents. It is reassuring that, with a team were in vogue, but by the 1970s many who had approach, the defects are fairly correctable and previously advocated the bone-graft procedure had need not adversely affect the child’s future. abandoned it because their results had negative effects on the growth of the maxilla and the DEMOGRAPHIC DATA midface. Others, including Hugo Obwegeser, Race recommended the LeFort I osteotomy with The reported incidence of clefts of the lip and secondary bone grafting after development of the palate varies from 1 in 500 to 1 in 2500 live births adult dentition, especially as an aid to orthodontic depending on geographic origin, racial and ethnic and prosthetic reconstruction. Additionally, much backgrounds. The incidence of cleft lip and palate discussion has occurred over the role and the timing is reported to be highest in Asians (Mongoloids - of pre-surgical appliances. Both the hard palate 1 in 500), intermediate in Caucasians and least in and the alveolus can be molded with passive molds Negroid populations (1 in 2000 to 2500). and active devices, with the shared ultimate goals Jones C (2000) estimated the occurrence of oral of facilitating surgical repair and providing an clefts in UK to be 1 in 700 births. improved long-term outcome in both facial form Fough-Anderson (1956) cited 1 in 665 as and palatal function. incidence of cleft lip and palate in Denmark. The word ‘cleft’ literally means a crack, split Overall incidence of cleft lip and palate in or a gap. Orofacial clefts are congenital deformities, human appears to be 1:700 live births. which manifest at birth. Cleft lip and cleft palate are the most common congenital malformations Sex of the head and neck region. The term cleft lip and cleft palate is commonly used to represent two Males are more commonly affected by orofacial types of malformation which are embryologically clefts, than females by a ratio of 3:2. distinct that, is, Cleft lip with or without cleft palate is more 1. Cleft lip with or without associated cleft palate common in males than in females (2:1),whereas (CL ± CP). isolated cleft palate is observed to be more common 2. Isolated cleft palate (CP). in female. 200 History of Orthodontics

Type and Side ♦ Two palatine shelves, which extend from left and right maxillary process towards Cleft lip with or without cleft palate is more the midline. common than isolated cleft palate. ♦ Nasal septum which grows downwards Unilateral clefts are more common as from the frontonasal process along the compared to that of bilateral clefts (pre- midline. alveolar clefts) . After the descent of the tongue, the elongated Unilateral clefts account for 75% of all cleft palatine shelves become horizontally oriented seen, while bilateral clefts account for the and are in close proximity to each other by 8th remaining 25%. week. They fuse with each other in the midline In cases of unilateral clefts, left side is more and is represented by the median palatine raphe. commonly affected than the right side. The The palatine shelves also fuse with primary palate reason why left side is more frequently and the nasal septum. involved is unknown. Incisive foramen is present at the junction of primary and secondary palates. Fusion between Syndromic and Nonsyndromic palatine shelves and nasal septum proceeds from As stated earlier orofacial clefts can occur alone incisive foramen in a posterior direction ending (nonsyndromic) or as part of syndrome with at uvula; whereas, fusion between the primary congenital deformities of other parts of the body palate and anterior borders of the palatine shelves (syndromic). Over 300 syndromes are known to progresses in an anterior direction towards the be associated with orofacial clefts. However, lip. clefting syndromes are rare and make up only 5 % of all clefts. Cleft Lip and Palate Formation Cleft lip and palate occur when mesenchymal EMBRYOLOGICAL ASPECTS connective tissues from various embryological An understanding of the embryological structures fail to merge with each other. development of these structures is essential so as Cleft lip— Arises from failure of fusion between to appreciate the etiology of these clefts. medial nasal processes and the maxillary The embryonic development of palate takes process. It can be unilateral or bilateral; and place between 6th and 9th weeks of intrauterine can be extended into the alveolar process life. The entire palate develops from two (CL + CP). structures: Cleft palate— Arises from failure of palatine Primary palate (premaxilla) and shelves to fuse with each other, or with the Secondary palate. nasal septum or with the primary palate.

Primary Palate CLASSIFICATION The primary palate is the triangular shaped There are many classifications of clefts. Few part of the palate anterior to the incisive commonly used ones are given below. foramen. It is developed from frontonasal process by fusion of two medial nasal I. Embryologic Classification processes; primary palate forms the premaxilla Patients with cleft lip and palate can be divided which carries the incisor teeth. into two groups which are embryologically distinct. 1. Cleft lip with or without cleft palate (CL ± CP) Secondary Palate Include: The secondary palate gives rise to the hard ♦ Patients with cleft lip and cleft palate (CL and soft palate posterior to the incisive + CP) foramen. It develops from the fusion of three ♦ Patients with cleft lip without cleft palate parts as follows: (CL) History of Cleft Lip and Cleft Palate 201

2. Isolated cleft palate (CP) include: Patient with IV. Kernahan’s Stripped ‘Y’ Classification cleft palate alone Kernahan proposed a symbolic classification of II. Classification by the International cleft lip and palate deformity using a stripped ‘Y’ Confederation for Plastic and having numbered blocks. The incisive foramen is Reconstructive Surgery (1968) represented symbolically by a small circle with the dividing pointing between the primary and This classification has three main groups. secondary palates. Group 1—Cleft of Anterior Primary Palate Each right and left limb is divided into three portions representing respectively the lip, alveolus a. Lip: and area between alveolus and incisive foramen. ♦ Right side The stem of the Y is similarly divided into three ♦ Left side portions representing hard palate and soft palate. ♦ Both Each block represents a specific area of the oral b. Alveolus: cavity: ♦ Right side Block 1 and 4 — lip ♦ Left side Block 2 and 5 — alveolus ♦ Both. Block 3 and 6 — hard palate anterior to the Group 2—Clefts of Anterior and Posterior Palate incisive foramen Block 7 and 8 — hard palate posterior to the a. Lip: incisive foramen ♦ Right side Block 9 — soft palate ♦ Left side Each individual can be diagrammatically ♦ Both represented by stippling appropriate areas of b. Alveolus: clefting. In submucous cleft of palate the ♦ Right side appropriate section is cross hatched. ♦ Left side ♦ Both ETIOLOGY OF CLEFT LIP AND PALATE c. Hard palate: ♦ Right side Despite numerous clinical and experimental ♦ Left side investigations, the etiology of cleft lip and palates ♦ Both. in humans is still largely unknown palate. In most cleft cases, no single factor can be identified as the Group 3—Clefts of Posterior Secondary Palate cause. Heredity with superimposed a. Hard palate: environmental factors is considered to be the most ♦ Right side probable cause of cleft formation. ♦ Left side It is important here to distinguish between two b. Soft palate : Median. forms of clefts; Non-syndromic clefts with no other related health problem and syndromic clefts III. Veau’s Classification associated with other birth disorders or syndromes. This classification is morphological and described as four types of clefts: Syndromic Cleft Cases Group I Clefts of the soft palate only. Group II Clefts of the hard and soft palate In syndromic cases, cleft occurs by monogenic extending up to the incisive foramen. mode of transmission, i.e. by a single mutant gene Group III Complete unilateral clefts involving producing a large effect. Over 300 syndromes have the soft palate, hard palate, alveolar been reported in the literatures which have ridge and the lip on one side. associated clefts along with other defects. Most of Group IV Complete bilateral clefts of the soft these syndromes are rare. Some of the relatively and hard palate, alveolar ridge and common syndromes associated with cleft lip and the lip. palate are listed in Box 21.1. 202 History of Orthodontics

Velocardiofaial syndrome (velum=palate, cardia palate is genetic in origin; less than 20% of isolated = heart, facies = face) is the most common cleft palates (CP) are genetically determined. syndrome to exhibit clefts. The features include the following— Environmental Factors Cleft palate Earlier, heredity was thought be single most Cardiac defects important causative factor. However, recent Characteristic facial appearance studies have shown that, environmental factors Learning problems and speech play a significant contributory role at the critical Feeding problems. time of embryogenic development when lip and palate shelves are fusing. Box 21.1: Common syndromes associated with cleft A number of environmental factors have been lip and palate suggested as causative factors including: Craniofacial Syndromes 1. A defective vascular supply to the area Velocardiofacial syndrome involved during critical time of embryonic Apert’s syndrome development. Crouzon’s syndrome 2. A mechanical disturbance in which, size of Carpenters syndrome the tongue may prevent union of parts. Down syndrome 3. Excessive concentration of circulating Encephalocele substances such as alcohol, certain drugs Goldenhar syndrome (antibiotics, steroids, insulin) and toxins. Hypertelorism Pfeiffer syndrome 4. Viral infections. Pierre robin syndrome 5. Exposure to radiation. Saethre-Chotzen syndrome 6. Hypoxia. Treacher Collins syndrome 7. Vitamin deficiencies and excesses. Van der Woude’s syndrome 8. Stress.

Nonsyndromic Clefts Risk of Producing a Child with Cleft Deformity Recent investigations show that both heredity and 1. Every parent has approximately a 1 in 700 risk environmental factors act together in causation of of having a child with a cleft. non-syndromic clefts. Such a mode of transmi- 2. Parents having a child with a cleft have ssion of a defect/trait caused by interaction of increased risk of having the 2nd child affected- multiple genes and multiple environmental 2% to 5%. factors is known as multifactorial inheritance. 3. If more than one person in immediate family has a cleft→ risk rises to 10% to 12%. Heredity (Genetic Predisposition) 4. A parent having a cleft→ has 2% to 5% chance of producing a child with a cleft. In contrast to syndromic clefts caused by single 5. If a syndrome is involved, the risk for mutant gene, clefts in non-syndromic patients are recurrence within a family can be as high as caused by multiple genes (polygenic), each 50% producing small effects which together create this 6. Maternal age→ increased risk of clefting is condition. observed when age of conceiving is late. Every individual carries some genetic liability for clefting, but there is no cleft formation until the CLINICAL FEATURES threshold level for expression is reached. When the total genetic liability of an individual reaches Oral clefts commonly affect the upper lip, alveolar a certain level, the threshold for expression is ridge and hard and soft palates. reached and cleft occurs. The clefting anterior to the incisive foramen is Genetic basis of cleft lip and palate is defined as the cleft of primary palate. significant but not predictable. Studies reveal that, The clefting posterior to the incisive foramen less than 40% of cleft lip with or without cleft is defined as a cleft of secondary palate. History of Cleft Lip and Cleft Palate 203

A patient may have clefting of primary palate, Periodontal complications secondary palate or both. Crowding may be seen The clefts can be complete, i.e. extending the Spacing may be present. entire distance from the lip to the soft palate or incomplete. Occlusal Problems CL ± CP can e unilateral or bilateral; isolated Clefts involving alveolus and palate cleft palate occurs in midline. invariably show malocclusion. Patients with Severity of CL ± CP may range from a small clefts especially of the palate, show notch on the edge of the vermilion border to a discrepancies in size, shape and position of wide cleft extending into the nasal cavity. their jaws. Isolated cleft palate may also present with Most patients exhibit class III malocclusion varying degrees of severity. Mildest form is the with hypoplastic maxilla and relative bifid uvula. A more severe form is a cleft of the prognathism of the mandible. soft palate. A complete cleft palate constitutes Along with missing teeth or supernumerary a cleft of the hard palate, soft palate and cleft teeth, retardation of maxillary growth uvula. significantly contributes to the development of malocclusion. Scar contracture following CLEFT LIP AND PALATE ASSOCIATED early closure of cleft palate significantly PROBLEMS retards the growth and development of maxilla Most patients with cleft lip with cleft palate (CL + in all three planes of space. Narrow high arch CP) and isolated cleft palate (CP) present with a palate with constricted and retruded maxilla myriad associated problems. is a common finding. 1. Dental problems 2. Occlusal problems (malocclusion and Feeding Problems impaired facial aesthetics) Structural defects of cleft lip and palate prevent 3. Feeding problems negative oral pressure required for effective 4. Nasal deformity sucking. Feeding is a major problem in these 5. Ear problems patients as food and liquids regurgitate through 6. Speech difficulties the nose. Thus, breast or bottle feeding by sucking 7. Psychological problems. is difficult. However, babies can swallow normally, if they are fed directly toward the hypo- Dental Problems pharynx. The problem can be overcome through Cleft involving alveolus often affects the the use of specially designed nipples that are development of primary and permanent teeth and elongated and have bigger opening which extend the jaw. The cleft usually extends between the directly into the hypopharynx. Child may swallow lateral incisor and canine area. Teeth may be lot of air during swallowing and need frequent congenitally absent in the area of cleft or even burping. supernumerary teeth may also be present. Teeth present near the region of cleft may be Nasal Deformity morphologically deformed or hypomineralized. Patients with cleft lips often exhibit deformities of Crowding or severe displacement of the teeth near nasal architecture, especially when the cleft the region is a common finding. The patient with extends into the floor of the nose. Plastic surgery cleft lip and palate shows the following features . of nose is usually done at later stage and treatment Lateral incisor on the cleft side may be absent. after correction of all clefts and associated Presence of supernumerary teeth problems. Fusion of teeth Enamel hypoplasia Ear Problems Multiple missing teeth Ectopically erupting teeth Clefts involving soft palate predispose to middle Anterior and/or posterior cross bite ear infections. This is because the levator and 204 History of Orthodontics tensor veli palatine, the muscles of soft palate are nasopharynx. This is called valopharyngeal left unattached in case of soft palate clefts. These mechanism. (Valo = softpalate). muscles have their origins near the auditory tube During speech and deglutition, soft palate is and under normal circumstances allow opening elevated towards the posterior pharyngeal wall of the auditory tube into the nasopharynx by contraction of its muscles. Valopharyngeal facilitating equilibrium and the pressure. mechanism cannot function when a soft palate is In palatine clefts this function is disrupted, involved by the cleft. The soft palate cannot elevate the middle ear becomes a closed space without a to make contact with the pharyngeal wall and drainage mechanism. When tube opening this result in escape of air into the nasal cavity mechanism is impaired, there is greater producing hyper nasal speech. susceptibility of middle ear infections. Hearing impairment may further aggravate the Accumulation of serious fluids and then bacteria speech problem. Retardation of consonant sounds can lead to serous otitis media. Chronic otitis (i.e. p, b, t, d, k, g) is the most common problem. media causes hearing impairment, that is common Speech problem should be addressed at the in patients with cleft palate. earliest, and several years of speech therapy may be needed to achieve intelligible speech. Speech Difficulties Psychosocial Problems During normal speech, the tongue, lips, lower jaw and soft palate work together in a highly Impaired facial aesthetics, hearing and speech coordinated fashion to produce the sounds. The problems often produce psychosocial problems soft palate is raised during the speech, preventing in these patients. Support of the family, air from escaping from the nose. The soft palate professional help and social worker are all functions as a valve to control the distribution of necessary to the normal well being of these escaping air between oropharynx and patients. HHiiissstttooorrryyy oofff MMaaallloooccccccllluuusssiiiooonnn IIInnndddiiiccceeesss 22

Index of Orthodontic Treatment Needs Index of Complexity, Outcome and Need Peer Assessment Rating Dental Aesthetic Index

Traditional orthodontic thinking has emphasized record treatment need in a sample of 256 patients the major benefits of orthodontic treatment on: in the Scottish Dental Service, most of the the ‘improvement of physical functions, the treatment being undertaken with removable prevention of tissue destruction and the appliances. Some reduction was seen in 88 per correction of aesthetic impairment’. (Standard cent of cases. However, 30 percent of cases were Dental Advisory Committee, 1973). In times of minimally improved or made worse, and in those limited resources, it is important that patients cases which started with a marked malocclusion who need treatment should be treated and that, only about one-third showed a sizeable when treatment is undertaken, the malocclusion improvement. Sixty-five percent of cases falling should be corrected to an appreciable extent. in the ‘No treatment need’ category at the start Many studies in the UK and Scandinavia have of treatment showed a sizeable improvement. assessed the success of treatment by recording Thirty-five percent of cases falling in the ‘no the various occlusal traits before treatment, and treatment need’ category at the start of treatment after treatment. showed no improvement and, in fact, 15 percent were made worse. British Studies In a further survey of 51 cases with a class II Over recent years, the standard of orthodontic division 1 malocclusion treated with removable treatment undertaken within the general dental appliances (Elderton and Clark 1984), 41 percent services has given cause for concern. Several of cases finished in the two best categories and reports have suggested that British orthodontic substantial improvement was found for one results are not as good as Northern European quarter of the whole sample. However, 20 percent countries (Cousins, 1973; Shaw, 1983; Haynes, of the cases showed no improvement at all. 1979; British Orthodontic Standards Working In a study undertaken by the Dental Party, 1986). Reference Service in 1984 (DHSS 1986), for 59 A report on child dental health in England percent of the estimate references (852), the and Wales (Todd and Dodd, 1985) found that 30 dental officer disaggreed substantially or percent of 15-year-olds who had previously fundamentally with the proposed treatment. In received orthodontic treatment were in need of 49 percent of the completed treatments, the further treatment. The occlusal index (Summers, dental officer considered the treatment unsatis- 1971) was used by Elderton and Clark, (1983) to factory to a major or fundamental extent. 206 History of Orthodontics

During the year 1986—87, 35,800 orthodontic treatment. Mohlin suggested that the need was cases treated within the General Dental services still high as much of the orthodontic treatment were reported as discontinued (14 percent of all was provided 20-30 years ago, probably as a non-prior approval cases and 26 percent of prior- compromise owing to limited orthodontic approval cases). resources, removable appliances having been used in two-thirds of the treatments. The Scandinavian Studies treatments had probably reduced the severity of malocclusions, but had not eliminated them. Myrberg and Thilander, (1973) assessed However, Myrberg and Thilander (1973), have treatment results in 1486 cases. In 60 percent, reported mild to severe relapse in 24 percent of removable appliances were used, whilst the orthodontically treated children, 1–5 years after remainders were treated with fixed appliances. treatment. In 54 percent of the cases the result was good The long-term stability of orthodontic and in 1 percent treatment had no effect. treatment has been reported for a group of 96 However, the criteria for assessing the success patients treated 12–35 years previously of treatment were not stated. (Sadowsky and Sakols, 1982), the majority of Berg, (1979) analyzed 246 consecutively cases having been treated with both upper and treated cases, the majority having undergone lower Edgewise appliances. The authors fixed appliance treatment. The author looked at revealed that 72 percent of cases still had both dental cast and radiographic records. He deviations outside the ‘ideal’ range. There was found that the objectives were only achieved in a tendency for overjet and overbite to increase, 43 percent of all cases. Root resorption was as well for the development of lower anterior present in 14 percent of all cases and overjet was crowding. not eliminated in 13 percent of Class II cases. the Other studies have shown that even when objectives were not achieved in a substantial optimal treatment results had been achieved, percentage of class I, class II, and class III imperfection in alignment and occlusion often malocclusions. Although all the objectives had developed in the long-term (Water, 1953; Simons not been attained, substantial improvement had and Joondeph, 1973; Little et al 1981, 1988; Udhe been achieved and the author coined the phrase et al 1983; Shields et al 1985). The constraints ‘partial success’. imposed by underlying skeletal discrepancies In a further study, Berg and Fredlund, (1981) which could not be changed by orthodontic used the Treatment Priority Index, TPI (Grainger, treatment alone were highlighted in a review of 1967) on 60 cases randomly selected from 329 50 consecutively treated patients with an original consecutively treated patients in two private overjet of 10–15 mm. As few as 6 percent practices. At the end of treatment, 36 cases (60 displayed an overjet within the normal range percent) achieved normal or near normal (less than 4 mm) on follow-up (Nashed and occlusion. They found the greater reduction in Reynolds, 1989). However, 60 percent of all the the TPI score resulted from an improvement in patients had their overjets reduced to less than 5 overjet. It was suggested that the degree of mm as a result of treatment. improvement was more important than the Some studies have attempted to determine ‘success’ of treatment. the effectiveness of the orthodontic treatment provision by the hospital orthodontic service, Post-retention Survey using recently developed occlusal indices as There have been several investigations involving measures of outcome and assessed the influence the prevalence of malocclusions over 20 years of of operator, treatment methods, and individual age (Ingervall et al 1978 ; Mohlin, 1982 ; Bernhold departments upon treatment outcome in terms and Lindquist, 1981). These studies indicate that of dento-occlusal change. Pickering and Vig, the prevalence of malocclusion in men and (1974) in the first application of an index to assess women is similar to that found in children, the effectiveness of orthodontic treatment used although 10 percent of men and 25 percent of Summer’s Occlusal Index (Summers, 1971) as an women had previously received orthodontic outcome measure to evaluate the effectiveness History of Malocclusion Indices 207 of treatment provided for 351 patients treated in Petterson and Andren (1978) found that the one London hospital. This study revealed that a majority of orthodontic patients were satisfied proportion of patients did not benefit from with their treatment results. Although most of treatment and that fixed appliances were the the patients had found treatment to be most effective treatment method. Berg, (1979) ‘troublesome’ 76 percent would have been willing used a criterion based approach to assess a to go through the same procedure again. About sample of consecutive cases treated in his 94 percent would have had their children treated practice. He found that optimal treatment results if they had developed a similar malocclusion. were achieved in only 43 percent of cases. In a Fredlund in 1977 (unpublished material) similar evaluation, Berg and Fredlund, (1981) examined the treatment results in all of the 209 concluded that 60 percent of a sample of cases cases he had started in 1973. Berg (1979) examined collected form two private practices had normal the treatment results in 264 consecutively treated occlusions following treatment. While both cases. Both Fredlund and Berg found the investigations produced favorable results, an reproducibility of criteria such as ‘good’, analysis of 256 completed cases at the Scottish ‘acceptable‘, etc. to be questionable and they Dental Estimates Board using Summer’s Occlusal therefore based their observations on whether or Index (Summers, 1971) revealed that treatment not so-called ‘text-book’ normal occlusion had change was inadequate and the standard of been achieved. The results of the two independent treatment required improvement (Elderton and Clark, 1984). More recently, Jones (1988), carried studies were similar : text-book normal occlusion out an extensive study using a three- dimensional was achieved in less than 50 percent of the cases. assessment of occlusal change of 109 patients. He While many practitioners are convinced that concluded that the overall success of treatment orthodontic treatment influences the soft tissue was high. This was influenced by the method of profile, controversy remains concerning the treatment; two arch fixed appliances being more precise soft tissue response to changes in tooth effective than removable appliances. position. A positive correlation between incisor The only large scale study has been carried out movement and soft tissue changes has been by Richmond (1991). He assessed 1210 patients’ reported (Roos, 1977). On the other hand, the records obtained from the Dental Practice Board studies of Angelle (1973) and Hershey (1972) of England and Wales for orthodontic treatment showed that changes in tooth position are not need and treatment standards with the Index of systematically followed by proportional soft Orthodontic Treatment Need (Brooke and Shaw, tissue profile changes. Variables such as lip 1989) and the Peer Assessment Rating (Richmond morphology, type of treatment (extraction versus et al 1992) respectively. He concluded that the non extraction therapy, choice of extraction), standard of treatment was poor and many patients patient gender, and age have been held did not receive an improvement in occlusion responsible for individual differences in soft following a course of orthodontic treatment. tissue response (Wisth, 1972, 1974). Again, two arch fixed appliance therapy was the Extraction decisions have to be made not only most effective treatment method. by considering the among of crowding but also There are very few recorded studies dealing the eventual influence of orthodontic tooth with the evaluation of treatment results in large displacement on the soft tissue surface of the face. samples or in randomly selected cases. In many No information concerning the correlation published studies, only successful cases are between the initial among of crowding and the analyzed and the frequency with which the changes in profile during orthodontic treatment demonstrated results could be achieved is often was found in the literature. In nonextraction not considered. However, Myrberg and therapy without extraoral traction, one can Thilander (1973) examined 1486 treated cases assume that tooth alignment protrudes the and graded the treatment results. In their clinical anterior teeth and the facial profile. In extraction judgment, good results were obtained in 54% of therapy, tooth alignment partly consumes the the cases. extraction spaces. Closing the remaining spaces 208 History of Orthodontics could retrocline the anterior teeth and retracts the indicated that a high self- esteem could be related facial profile. to orthodontic concern (Birkeland et al 1996). Williams and Hosila (1976) found that Whilst many indices exist to record orthodontic treatment with extraction of malocclusion, it is important to distinguish those premolars was accompanied by changes of the that classify malocclusions into types (Angle, soft tissue profile. In some cases these changes 1899) and those that record prevalence in improved the facial aesthetics; in others an epidemiological studies (Bjork et al 1964), from undesired profile outcome could be seen. For those indices that attempt to record treatment this reason, a carefully studied extraction policy, need for priority. Furthermore, indices used to accounting for all possible changes, would be record treatment success and treatment difficulty very valuable. The same study indicated that will have differing requirements. orthodontic treatment with extraction of four first Many indices have been developed with the molars results in less incisor retraction than cases intention of categorizing malocclusions into treated with extraction of four-first premolars various groups, according to the urgency and or maxillary first premolars and mandibular need for treatment (Summers, 1971; Salzmann, second premolars. Clinical observation points 1968; Linder-Aroson, 1974; Lundstrom, 1977; in the same direction: therapy with more Grainger, 1967; Draker, 1960). Individuals with posteriorly situated extraction seems to result in greatest treatment need can then be assigned less incisor retroclination. De Castro (1974) priority when orthodontic resources are limited recommended extraction of second premolars in and when the availability of treatment is cases where retraction of anterior teeth has to be unevenly spread. Similarly, individuals with avoided. By this choice, the closing of extraction little need for treatment can be safeguarded from spaces after alignment would be mainly realized the potential risks of treatment (Shaw, 1988). by mesial movement of posterior teeth instead The early efforts to design indexes were the of distal movement of anterior teeth. product of workers in the public health field, trying An important motivation factor for to establish data about pathologic or handicapping orthodontic treatment is improved dentofacial dental conditions. Thus, Klein et al developed appearance (Gosney, 1986 ; Birkeland et al 1999). the DMF (decayed, missing, filled) scale that was The relationship between physical appearance and is the ultimate in simplicity is measuring dental and perception of an aesthetic deviation, and the conditions for large numbers of people. Early impact of such a deviation on self-esteem and efforts to quantify the extent of malocclusion were body image are important issues in determining based on the assumptions about ideal occlusion the benefits from orthodontic treatment. previously outlined. As a result, researchers like Attention should be given to the specific occlusal Graineger produced data on that basis. From this and aesthetic deviations that cause concern to the data, he developed the Orthodontic Treatment patients, and assumptions based purely on the Priority Index. Salzmann published the general occlusal condition should be avoided Handicapping malocclusion Assessment (the (Gosney, 1986). A variety of social, cultural, and Salzmann index) that also measures variations psychological factors, and personal norms from this arbitrary standard. Others working on influence perception of physical attractiveness this vein of thought include Massler and Frankel, (Jenny, 1975; Baldwin, 1980). Studies in social VanKirk and Pennell, Bjork et al, Summers, Freer psychology indicate that physical attractiveness and Adkin, Ingervall and Ronnerman, and Helm. plays a major role in social interaction and Experience made it apparent to some influence the impression of an individual’s social observers that variation from a very narrow ideal skill (Baldwin, 1980; Shaw, 1981). often failed to equitably identify the truly As orthodontic treatment improves facial handicapping malocclusions. Because of the appearance, it is assumed to increase self-worth. CHAMPUS program, the Armed forces of the However, this hypothesis has been difficult to United States in 1976 contracted with the verify. One study on self-concept changes during National Research Council to organize a work orthodontic treatment showed no long-lasting force to define “Seriously handicapping effect on self-esteem (Korabit, 1994). Another orthodontic conditions”. An excellent committee History of Malocclusion Indices 209 of highly qualified workers in the field labored for epidemiological importance in establishing some time but was unable to produce such a prevalence rates for physically handicapping definition. orthodontic defects, and degree of the physical HL Draker Suggested a different approach handicap. These deviations are measurable in in which selected deviations from ideal were definite units. scored and weighted. He called it the Fastlicht J in 1970 did a study to compare the Handicapping Labiolingual Deviation index or degree of crowding of the anterior teeth in cases HLD Index. Careful reading of the original article which were treated orthodontically years before makes it clear that he made some of them with those which were not treated, in order to wanting. Then he suggested some changes but determine whether treatment had an influence never reported any more test results in his article. through time on the crowding of the incisors. He A number of indices have been introduced, concluded that the crowding of the incisors was however, based on his suggestions and have been an anatomic-physiologic phenomenon of called an HLD Index. adaptation observed in orthodontically treated Cons et al approached the index problem cases, as well as in untreated cases, which from purely the appearance standpoint and resulted from the combination of several factors, developed the Dental Aesthetic Index. They such as sex, anatomic predisposition of generally used the opinions of the lay public as dolichocephalic or long-faced persons, tooth-size to what constituted unacceptable dental discrepancies, exaggerated overbite, extrusion of arrangements from the aesthetic standpoint. The the canines, reduction of the intercanine width, Dental Index has been accepted by the World age, muscle function, and, in some cases, Health Organization as a screening tool. imperfect mechanotherapy. There was less Meanwhile in Europe, probably because of crowding of the incisors in the treated group. government pressure, much effort was spent on Thus, it was assumed that treatment had a defining which patients qualified as needing favorable influence over the stability of the dental orthodontic treatment to be paid for by the arches. government. It would be helpful to remember Summers CJ in 1971 developed the Occlusal the extent to which dentistry is socialized in Index (OI) Nine characteristics were scored in many of those countries. Brook and Shaw in 1989 the occlusal index: dental age, molar relation, developed the Index of Treatment Need used in overbite, overjet, posterior cross-bite, posterior the United Kingdom. Richmond et al also open-bite, tooth displacement (actual and developed the PAR (Peer Assessment Rating) potential), midline relations and missing Index (1990, 1992) as a tool to measure the results permanent teeth. The purpose of describing these of orthodontic treatment and not the need. scoring procedures in detail are as follows : to Espeland et al produced a new approach in standardize scoring procedures, to indicate how Norway for their mixture of public and private each scoring procedure is mutually exclusive and funding of treatment. enable investigators to apply subjective Draker HL, Albany NY in 1960 proposed the classification to the objective measurements. The Handicapping Labiolingual Deviation (HLD) OI was tested for validity, validity during time, index which was an attempt to obtain a method and intraexaminer reliability. The OI appears to which would complement and perhaps substitute correlate highly (rs = 0.920) with the clinical for clinical judgment which, although useful to a standard indicating high validity; the OI also degree, is vulnerable because it is entirely appears to be valid during time, since the average subjective. The three planes commonly used for group scores did not decrease during time. Intra- orthodontic orientation, i.e. the sagittal plane; examiner reliability was very high (rs = 0.963). frankfurt plane and orbital plane are the basis Little RM in 1975 proposed the Irregularity for HLD measurements. The intention was to index, a scoring method which involved measure the presence or absence, and the degree, measuring the linear displacement of the of the handicap caused by the components of the anatomic contact points (as distinguished from index, and not to diagnose “malocclusion”. He the clinical contact points) of each mandibular found that labiolingual deviations from a fictitious incisor from the adjacent tooth anatomic point, norm rather than the state of occlusion are of the sum of these five displacements representing 210 History of Orthodontics the relative degree of anterior irregularity. Perfect treatment be undertaken or at least supervised by alignment from the mesial aspect of the left canine specialists, (b) improvement in the ratio of to the mesial aspect of the right canine would specialists to susceptible age groups by theoretically have a score of 0, with increased maximizing training capacity, (c) extension of the crowding represented by greater displacement role of dental surgery assistants, (d) guidelines and, therefore, a higher index score. Rather than to eliminate unnecessary treatment of acceptable measuring from contact point to ideal arch form malocclusions. or to another subjective point, the actual linear Brook PH, Shaw WC in 1989 conducted a distance between adjacent contact points is study to formulate a valid and reproducible determined. Such a measure represents the index of orthodontic treatment priority using 222 distance that anatomic contact points must be patients referred to a regional orthodontic center moved to gain anterior alignment. for advice or treatment. To simulate the use of Eismann in 1980 carried out an investigation the indices in a screening program, 333, 11–12 on pre-treatment, post-retention and follow-up year old school children were also examined. The casts of 200 patients treated with removable functional and dental health component of the orthodontic appliances to assess changes index was based on the index of treatment resulting from orthodontic treatment. He found priority used by Swedish Dental Board with five that the extent of abnormal criteria between the grading, grade 1 representing little or no need initial casts and the post-treatment casts was for treatment and grade 5 representing great reduced on average to about one-fifth and this need of treatment. The second part of the overall improvement generally remained constant over assessment of treatment priority, the aesthetic the follow-up period, apart from slight further component was based on the SCAN index improvements resulting from reduction of (Standardized Continuum of Aesthetic Need). extraction spaces. The dental photographs of the patients were Berg R, Fredlund A in 1981 tried to evaluate evaluated on a 10-point scale in the aesthetic the degree of morphological improvement component. Satisfactory levels of intra- and inter- achieved during treatment. 30 cases were examiner agreement was obtained and it was selected; the recordings were made on pre- and proposed that the main benefit by use of this post-treatment plaster models. The degree of index to the patient of orthodontic treatment improvement, or change during treatment, was would be in improved aesthetics and social- assessed by means of a treatment priority index psychological well-being and additionally the worked out by a study-group of Norwegian effect this may have on attitudes to dental health. orthodontists. The findings indicated that Richmond S, Shaw WC, O’Brien KD, evaluation of treatment results by an index score Buchanan IB, Jones R, Stephens CD, et al in system may be a contribution to the quantification 1992 developed the PAR (Peer Assessment of the changes achieved; may relate the degree Rating) index to assign a score to various occlusal of change to the condition before treatment and traits which make up a malocclusion. The perhaps to the need for treatment; and may also individual scores were summed to obtain an permit comparison of the effects of different overall total, representing the degree a case treatment methods. deviates from normal alignment and occlusion. Shaw WC in 1983 compared the orthodontic The score of zero indicated good alignment and manpower, finance and training in England and higher scores (rarely beyond 50) indicated Wales, the Netherlands, Norway, Sweden and increased levels of irregularity. The overall score Denmark to find out the criteria for general was recorded on the pre- and post-treatment acceptance of an adequate orthodontic service. dental casts. The difference between these scores The following criteria were concluded: (a) represented the degree of improvement as a treatment should be available to all those in need, result of orthodontic intervention and active (b) the cost should be reasonable, (c) treatment treatment. After all 272 cases were evaluated by should be of a satisfactory standard. The 74 examiners and they concluded that the PAR principles emerging from the comparison that index provided a single summary score for all seemed to be relevant to these criteria were—(a) the occlusal anomalies and may be used for all acceptance of the principle that the majority of types of malocclusions, treatment modalities and History of Malocclusion Indices 211 extraction/non-extraction cases. The score models. They found that the occlusal index was provided an estimate of how far a case deviates fairly complicated in use and incorporated from normal and the difference in scores for pre- several weighting mechanisms appropriate to and post-treated cases reflected the perceived each developmental stage. The PAR index was degree of improvement and therefore the success a simple, easy to grasp method of assessing of treatment. treatment standards as opposed to the more Richmond S, Shaw WC, Roberts CT, complicated approach of Summer. On the basis Andrews M in 1992 developed a method for of this study it was found that the PAR index is relating numerical change in the weighted PAR as reliable and as valid a method of assessing scores to consensus professional judgments in orthodontic treatment outcome as is the occlusal order to express the degree of improvement index. resulting from treatment. A panel of 74 O’Brien KD, Shaw WC, Roberts CT in 1993 examiners was asked to examine 128 pairs of studied the effectiveness of orthodontic dental casts. Using this index, it was revealed that treatment provided by a sample of 17 hospital at least 30 percent reduction was needed for a based orthodontic departments. They used index case to be judged ‘improved’ and a change in of orthodontic treatment need and the PAR index score usually of 22 to bring about a change judged as a measure of orthodontic treatment need and to be ‘greatly improved’. It was concluded that standard of treatment respectively, in 120 for a practitioner to demonstrate high standards, consecutively started patients from each the proportion of an individual’s case load lying department. The influence of operator, treatment in the ‘worse or no different’ category should be methods and individual departments upon negligible and the mean percentage reduction treatment outcome in terms of dento-occlusal should be as high as possible (greater than 70 change was also assessed. They found that the percent). The greater the mean percentage hospital orthodontic service provided treatment reduction in weighted PAR scores the higher the of a high standard. It was also seen that the standard of orthodontics achieved. If the mean greatest influence upon the standard of treatment percentage reduction is high and the proportion was the choice of treatment methods and of cases that have been ‘greatly improved’ is also operator experience. Two arch fixed appliances high, this indicates that the practitioner is treating were found to be more effective than single a great proportion of cases with a clear need for arched fixed appliances and removable treatment, to a high standard. appliances. Single arch fixed appliances were Richmond S, Andrews M in 1993 assessed more effective than removable appliances. There the outcome of treatment provided by a sample was also an additional effect arising from the of Norwegian orthodontists using objective aspirations of the consultant and supporting measures of assessment. A sample of 220 cases staff. was collected from Norwegian specialist Kerr WJS, Buchanan IB in 1993 used Peer orthodontists who had agreed to participate in Assessment Rating Index to assess the this study. The index of orthodontic treatment improvement produced is a series of 150 cases need and the PAR index were applied to the pre- treated with removable appliances and to and post-treatment cases. They concluded that ascertain in which circumstances they performed the indices could be used to identify differences most successfully. The pre- and post-treatment not only between individual practitioners, but study models were used to assess the also health care systems in different countries. It effectiveness of the appliance. As measured by was confirmed that the Norwegian orthodontists the PAR index 89.3 percent of a group of patients were producing a high standard of orthodontic selected as suitable for treatment with removable treatment. appliances were either ‘improved’ or ‘greatly Buchanan IB, Shaw WC, Richmond S, improved’. Of 10.7 percent cases which were O’Brien KD, Andrews M in 1993 compared the classified as being ‘worse, no different’, six were relative merits of the PAR index and Summer’s mixed dentition cases where the treatment Occlusal Index in terms of validity and reliability. objectives were limited to the alignment of one A panel of 74 examiners rated 256 sets of study incisor tooth and only seven were judged as 212 History of Orthodontics being unsuitable for removable appliances on the difficulty, according to the perceptions of a panel ground of their malocclusion. of orthodontists. As a result, the PAR index may Richmond S, Roberts CT, Andrews M in be considered to represent a good approximation 1994 assessed the need for orthodontic treatment of malocclusion severity and treatment difficulty, before and after treatment, on a systematic and may be used as an outcome measure for the sample of 1225 cases, using the Index of assessment of dento-occlusal change. Orthodontic Treatment Need (IOTN). The Jenny J, Cons NC in 1996 modified the Dental results showed that the number of patients Aesthetic Index (DAI), an orthodontic index that needing orthodontic treatment on aesthetic provides a single score linking the public’s grounds after appliance treatment fell by 27 perceptions for dental aesthetics with objective percent for non-prior approval cases and 45 measurements associated with malocclusion. It percent for prior approval cases. The number of now had decision-points along the DAI scale patients needing orthodontic treatment on dental defining specified case severity levels. DAI scores health grounds fell by 36 percent for non-prior of 25 and below represent normal or minor approval cases and 45 percent for prior approval malocclusion with no treatment needed or slight cases. They also found that upper and lower fixed treatment need. DAI scores of 26 to 30 represent appliances had the greatest influence or outcome definite malocclusion with treatment elective. of treatment in terms of aesthetics and dental DAI scores of 31 to 35 represent severe health. malocclusion with treatment highly desirable. Shaw WC, Richmond S, O’Brien KD in 1995 DAI scores of 36 and higher represent very severe published an article describing the development or handicapping malocclusion with treatment and validation of two indices, IOTN (an index considered mandatory. of treatment need) and PAR (an index of Turbill EA, Richmond S, Wright JL in 1996 treatment outcome). To assess the extent to conducted a study in which subjective grading which the indices reflect current orthodontic of cases at the Dental Practice Board of England opinion, a validation exercise was carried out. and Wales was compared to the Peer Assessment A panel of 74 dentists was enlisted. Each member Rating Index (PAR) and Index of Orthodontic of the panel recorded a personal opinion on the Treatment Need (IOTN) in assessing 1505 cases need for orthodontic treatment and the change sampled at the Board between late 1990 and mid- due to treatment of 234 starts and finish study 1991. They concluded that some cases rated as casts, with standardized rating scales. The ‘greatly improved’ or ‘improved’ by PAR still models were independently scored with the had substantial residual malocclusion (weighted IOTN and the Index of Treatment Outcome (PAR PAR at finish) and/or residual need for treatment index) by the investigating team. Experience and that the dental advisers disliked PAR’s low with their use in Europe suggested they have a weighting of buccal occlusion and residual buccal useful role in resource allocation and planning, spaces. monitoring and promoting standards, better Turbill EA, Richmond S, Wright JL in 1996 uniformity in patient identification and referral, used the Index of Treatment Need and Peer and informed consent. Assessment Rating index to assess targeting, use DeGuzman L, Vig PS, O’Brien K in 1995 of appliances, and standards of outcome for conducted a study to evaluate the relationship General Dental Service orthodontic cases collected between the subjective estimates of severity of between 1990 and 1991 and compared them with malocclusion and treatment difficulty by using a sample of cases from an earlier study, collected a panel of American Orthodontists and to between 1987 and 1988. The samples of cases evaluate the relationship between severity and used in this study were sub-samples from two difficulty, and the PAR index. A group of 11 parent samples, each of around 1500 cases. They orthodontists examined the 200 study casts. The concluded that since the 1988 study, there had results of this study made it possible to derive a been a trend to acceptance of more cases with set of weightings for the PAR index and to lower need for treatment, but no increase in calculate scores that would represent groupings treatments previously defined as ‘unnecessary’. of malocclusion’s severity and treatment The standard of completed cases had improved History of Malocclusion Indices 213 slightly in terms of both residual need for treatment extraction groups but then proclined in the non- and residual malocclusion (IOTN and weighted extraction group. The upper incisors were PAR scores at finish). These limited improvements retroclined approximately 2 mm in the extraction were apparently associated with increased use groups. A change in lip protrusion was found in of fixed appliances. the non-extraction group, where tooth alignment Buchanan IB, Russell JI, Clark JD in 1996 was accompanied by proclination. It was concluded did a study to investigate the usefulness of the that within the appropriate indications, extraction PAR index as a means of differentiating between of first or second premolars, or non-extraction results achieved by two different fixed appliance therapy with light-wire appliances and no extra- techniques: the preadjusted Edgewise and the oral anchorage, leads to good occlusal results Begg appliance. A group of 41 cases treated using without unfavorable changes in the facial profile. the Begg appliance and 41 cases treated using Parker WS in 1998 discussed the the preadjusted Edgewise appliance were Handicapping Labiolingual Deviation Index gathered. Comparison of results using the (CalMod), a lawsuit-driven modification of some monogram and percentage reduction on the two 1960 suggestions by Dr Harry L Draker, which appliance system groups indicated that the cases proposed to identify the worst looking treated by the preadjusted Edgewise appliance malocclusions as handicapping and offered a cut- had a better outcome. This comparison showed off point to identify them. The HLD (CalMod) that there was a significant difference between index went into official use late in 1991, and as the two appliance types in terms of treatment of January 1 1998, 135,655 patients had been success when the monogram, percentage examined orally by qualified orthodontists and reduction and comparison of the actual PAR screened using this index. Of this number, 49,537 scores were considered. Preadjusted Edgewise were found to have a score of 26 or greater, and cases being more successful than the Begg. This study models of these patients were produced difference was much more marked in the cases and screened by board-qualified orthodontists with low start PAR score than it was in the high for the fiscal intermediary. The HLD (CalMod) start group, where the appliance type seemed to index proved to be a successful tool to identify a be of less relevance. large number of very disfiguring malocclusions Birkeland K, Furevik J, Boe OE and Wisth and two known destructive forms of mal- PJ in 1997 used the Peer Assessment Rating index occlusion (deep destructive impinging bites and to assess the treatment results in a postgraduate destructive individual anterior cross bites). These clinic and to assess the occlusion at a 5 year were all then certified as medically necessary follow-up control, in relation to the original handicapping malocclusions. malocclusions, and the changes occurring in the Firestone AR, Hasler RU, Ingervall B in 1999 follow-up period. 224 cases were selected and did a study to investigate the objective need for the treatment result was a 76.9 percent PAR score treatment and the treatment results for two reduction. The treatment success was greatest for groups of patients who were treated in a dental Angle Class II division 2 with 80.8 percent PAR school orthodontic clinic approximately 10 years score reduction, closely followed by Angle Class apart and to investigate factors predictive of II division 1 (78.4 percent). Extractions did not change in PAR score and the length of treatment. significantly influence treatment success and They concluded that changes in treatment neither did the sex difference. techniques and the introduction of new materials Saelens NA, deSmit AA in 1998 did a study to have had a significant positive effect on investigate (in extraction and non-extraction treatment outcome in a postgraduate dental therapy), the initial amount of crowding, the school orthodontic clinic and improvement in changes in the position of the incisors and molars, occlusion and alignment was primarily the result the changes in the soft tissue profile, and the clinical of a reduction in overjet, an increase in the outcome. Three groups of 30 patients were alignment of the maxillary anterior teeth, and a investigated. In all cases, the orthodontic treatment reduction in overbite. moved the molars mesially. The lower incisors Hamdan AM, Rock WP in 1999 did a study remained in about the same position in the to re-test the validity of the PAR index against 214 History of Orthodontics assessments by West Midland Consultant post-treatment mean PAR scores of 5.8 in this Orthodontists, to compare the validity of three study with 6.0 in the former showed a high new weighting systems and to apply the best new standard of treatment results. weighting system to unweighted PAR scores and Cooper S, Mandall NA, Dibiase D, Shaw examine the effect for each malocclusion class. WC in 2000 did a study to establish whether Eighty sets of pre- and post-treatment dental IOTN was reliable over time, between the age of casts, representing equal numbers of Class I, 11 and 19 years old, for subjects who had not Class II division 1, Class II division 2, and Class received orthodontic treatment and to investigate III cases were randomly selected. The results the changes over time in the occlusal traits that supported the hypothesis that it is inappropriate comprise the dental health component of IOTN. to group all orthodontic cases together to derive Study casts of a longitudinal sample of 11 year a generic weighting formula and that weightings old (n = 314), 15 year old (n = 314) and 19 year should be derived separately for each old (n = 142) subjects were examined. They found malocclusion class. The most valid PAR index that the dental health component of IOTN is weightings were derived by multiple regressions, reliable between 11 and 19 years despite modified by the addition to base weights for temporal changes in the separate occlusal traits buccal occlusion and lower anterior displa- that comprise the index and IOTN DHC grading cements. Assessments of treatment outcome at the age of 11 years is likely to be similar when using point and percentage reductions were the patient reaches 19 years. They also found that more valid than using the original PAR most of the occlusal traits contributing to IOTN monogram. DHC improved over time except posterior cross Arnett GW, Jelic JS, Kim J, Cummings DR, bite and displacement of contact points that Beress A, Worley M et al in 1999 presented a worsened between 11 and 19 years. technique for soft tissue cephalometric analysis. Fastlicht J in 2000 developed a visual Forty-six adult white models comprised the cephalometric analysis based on two geometric cephalometric database for this analysis. They constructs the “Tetragon”, a polygon that concluded that, (a) natural head position must represents the maxillo-dento-mandibular be adjusted for some patients using clinical complex, made up of reliable and familiar judgment,(b) the Soft Tissue Cephalometric cephalometric landmarks—the palatal plane, the Analysis (STCA) is a facial diagnostic tool, (c) mandibular plane, and the axes of the maxillary STCA diagnosis is used for cephalometric and mandibular central incisors, the “Trigon”, a treatment planning(CTP), (d) clinical facial complementary triangle situated above the analysis is used to augment cephalometric Tetragon and formed by one plane that is information, (e) absolute projection values for intrinsic to the Tetragon—the palatal plane important soft tissue structures are measured to (PNS-ANS)—and two that are extrinsic – the the true vertical reference line, (f) the true vertical pterygo-palatal plane (Pt-PNS). He concluded reference line is placed through subnasal and (g) that the Tetragon and the Trigon provide a clear the true vertical reference line is moved forward picture of the position of the maxillo-dento- from subnasale when maxillary retrusion is mandibular structures within the craniofacial indicated by clinical and cephalometric findings. complexes and that this visual cephalometric Birkeland K, Boe OE, Wisth PJ in 2000 did a analysis could be a useful diagnostic tool for study to measure aesthetic and occlusal changes treatment planning, surgical preparation, and from 11 to 15 years of age using the Index of evaluation of growth, treatment progress, and Orthodontic Treatment Need (IOTN) and Peer post-treatment results. Assessment Rating (PAR) Index, to compare Pinto N, Woods M, Crawford E in 2000 treated and untreated groups using the same conducted a study, designed to determine the indices. Out of a sample of 359 children simple influence of the pretreatment vertical facial treatment with removable appliances was used pattern on post-treatment occlusal change (as in 23.8 percent. They found that children were assessed with the PAR index) occuring after less critical in their aesthetic evaluation fixed-appliance orthodontic treatment of patients compared with that noted by the examiners. The managed by one orthodontist with consistent History of Malocclusion Indices 215 aims and methods. Pretreatment, post-treatment proportion of cases the overjet reduction was and follow-up casts of 60 patients were assessed achieved by lower incisor proclination, which is by the PAR index. The pretreatment vertical considered by some authorities to be unstable. facial pattern for each subject was established Daniels C, Richmond S in 2000 formulated using the Jarabak Facial Height Quotient. The a study to propose orthodontic indices to assess results of this study suggested that the treatment need, complexity, treatment pretreatment vertical facial pattern, at least on improvement, and outcome based on its own, is not likely to be predictive of the international professional opinion, intended for amount of post-treatment occlusal change. use in the context of specialist practice, and to Beatrice M, Woods M in 2000 conducted a compare treatment thresholds in different study designed to assess whether or not countries and serve as a basis for quality rotational changes occurring during or after assurance standards in orthodontics. An treatment, in one accepted indicator of vertical international panel of 97 orthodontists from nine facial dimension, the Facial Axis, are in any way countries was asked to judge 240 dental casts for related to post-treatment occlusal changes. The assessment of treatment need and 98 paired pretreatment, post-treatment and follow-up pretreatment and post-treatment cases for cephalograms of 55 cases were assigned numbers assessment of treatment outcome. The outcome and arranged in random order by an was a new index, Index of Complexity, Outcome independent observer before being traced and and Need (ICON) which was based on the digitized by one examiner. The pretreatment average opinion of a large panel of international vertical facial pattern for each subject was orthodontic opinions. For the first time the established using the Jaraback Facial Height design of the index had been specifically Quotient. Occlusal assessment using the developed to enable assessments of treatment pretreatment (T1) post-treatment (T2) and need and outcome using one set of occlusal traits. follow-up (T3) models was undertaken using the The accuracy of the index to reflect professional opinion for a diverse sample of cases was PAR index. They concluded that the facial axis estimated at 84 percent for decisions of treatment tends to change in the long-term following need and 68 percent for treatment outcomes. The routine, comprehensive orthodontic treatment. method was heavily weighted by aesthetics. A change in the Facial Axis does not seem to be Kim JC, Mascarenhas AK, Joo BH, Vig KWL, directly related to the underlying vertical facial Beck FM, Vig PS in 2000 conducted a study to type. Long-term post-treatment Facial Axis assess the value of cephalometric variables in changes and long-term changes occurring in the predicting orthodontic outcomes for patients with occlusion are not directly related. Class II malocculusions and variables that are most Wijayaratne D, Harkness M, Herbison P in useful as predictors of pre-PAR, post-PAR, percent 2000 conducted study to determine in children PAR reduction, and treatment duration. This study with Class II, division 1 malocclusions treated evaluated selected cephalometric variables with with functional appliances, first, if lower incisor the intention of identifying predictors of the proclination affects the assessment of treatment occlusal outcome of orthodontic treatment in 223 outcome using the PAR index and, second to patients with Class II malocclusions. The results evaluate the effectiveness of functional showed that Cephalometric variables explained appliances after adjusting the PAR score for any 39.2 percent of the variation in the pre-PAR scores; lower incisor proclination. The subjects in this they suggested that cephalometrics may be more study were 43 consecutively treated children valuable as a diagnostic tool than a prognostic who were assigned to either an untreated group, tool. The selected cephalometric variables a group treated with Frankel function regulators, explained only 18 percent of the variance of the or a group treated with Harvold activators. The post-treatment occlusal result (post-PAR). Sixteen PAR index showed that improvements were percent of the variance in improvement of the made during treatment with functional malocclusion (percent PAR reduction) could be appliances in 50 percent of the cases in this study; explained by cephalometric variables. however, cephalometric analysis, which is not Mascarenhas AK, Vig K in 2002 did a study part of the PAR assessment, showed that in a to compare the quality of orthodontic treatment 216 History of Orthodontics provided by orthodontists in private practice severity (e.g. the PAR index) or an index of (experts) with that of graduate orthodontic orthodontic treatment need (e.g., the IOTN) residents (novice). The sample consisted of 143 could be used to differentiate between easy and cases treated by private practice orthodontists difficult cases. A further aim was to investigate and 165 cases treated at the graduate orthodontic whether factors related to the treatment or the clinic. The results of study showed that although patients were associated with orthodontists’ there was no difference in the final occlusal evaluations of cases as easy or difficult after outcome there was a difference in the treatment treating the patients. Ten orthodontists practicing duration between the graduate educational in Ohio were selected by telephone solicitation, setting and private practice, favoring the GOC. and each orthodontist was asked to identify the These results indicated that the clinical complete records of 10 treated cases he or she proficiency of graduate orthodontic program was judged as having been easy to treat and 10 cases comparable to that of highly experienced private as having been difficult to treat. The cases practice orthodontists. selected were to be chosen from the last 100 Yang-Powers LC, Sadowsky C, Rosenstein patients the orthodontist had treated. This study S, BeGole EA in 2002 conducted a study to showed that complexity, or difficulty in determine whether dental relationships at the achieving an ideal occlusion, increases as the end of orthodontic treatment in a university severity of the initial malocclusion increases. postgraduate clinic are within the ABO’s limit Complex cases are associated with patients who for passing the phase III examination, to assess are seen more often and receive repeated the contribution of each of the 8 components of warnings about compliance problems. Easy the OGS to the total OGS score, to determine cases have less severe malocclusions initially, are whether treatment outcome is different for the associated with compliant patients, and are more various malocclusion categories, and to likely to have 2-phase treatment. investigate treatment outcome in a sample of Weerakone S, Dhopatkar A in 2003 cases that passed ABO certification compared conducted a study to demonstrate the potential with cases treated in a university clinic. The of a new software package, clinical outcomes sample used in this retrospective study consisted monitoring program (COMP), for use in clinical of records of 96 patients treated in the graduate research by carrying out a limited audit for orthodontic clinic at the University of Illinois at illustration. The program can collect data from Chicago. They concluded that there was a PAR, IOTN, and ICON indexes with built-in statistically significant difference (P < 0.05) in “Wizards” capable of calculating all 3 scores overall treatment outcome (OGS score) between automatically. The COMP database contained the university group (average total score 45.54) information on 205 consecutively finished cases and the ABO group (total score 33.88). Significant over a period of approximately 1 year after the differences in treatment outcome (using OGS introduction of the COMP. This study scores) were found between the university and demonstrated that this approach is useful in the ABO groups for the components of root comparing outcomes from various providers and paralleling (panorex), occlusal contact, and monitoring the general quality of treatment in a overjet. Occlusal contact and overjet were practice with many orthodontists. significantly higher (worse) in the university Lieber WS, Carlson SK, Baumrind S, sample. Panorex was significantly higher Poulton DR in 2003 tested the reliability and (worse) for the ABO group. The ABO group subtraction frequency of the study model— exhibited better finishing details in the anterior scoring system of the American Board of segment and in the second molar region than did Orthodontists (ABO). Thirty-six post-treatment the university group. study models were selected from six different Cassinelli AG, Firestone AR, Beck MF, Vig orthodontic offices. They found that the greatest KWL in 2003 did a study to test whether objective limitation of the ABO index, its dependence on criteria can be used to identify difficult and landmark identification. Most of the scoring complex cases before treatment, and to determine involved measuring “landmark-to-landmark” whether objective measures of malocclusion linear distances using the ABO scoring tool. History of Malocclusion Indices 217

Reliability was lower than expected, suggesting to examine the outcomes for growing patients with that the ABO index may still be overly subjective. a range of skeletal anteroposterior and vertical Subtraction frequency revealed a significant dysplasias, who were treated with orthodontics emphasis on second molars. and growth modification techniques. Cangialosi TJ, Riolo ML, EdOwens S, Pretreatment and post-treatment cephalograms of Dykhouse VJ, Moffitt AH, Grubb JE et al in 100 growing Class II division 1 patients with 2004 have discussed criteria for determining the mandibular skeletal retrusion were divided into acceptability of a case presented for the American 5 groups depending on initial vertical and Board of Orthodontics (ABO) Phase III clinical anteroposterior measurements. Post-treatment examination which is case difficulty. Case soft and hard tissue measurements were assessed difficulty can often be subjective; however, it is and compared between the groups. They related to case complexity, which can be concluded that conventional orthodontic therapy quantifiable. Over the past 5 years, the ABO has successfully correct and Class II division 1 developed and field-tested a discrepancy index, malocculusions in growing patients through a made up of various clinical entities that are combination of skeletal and dentoalveolar measurable and have generally accepted norms. changes, with the greatest changes occurring in These entities summarize the clinical features of patients who initially had the most severe skeletal a patient’s condition with a quantifiable, dysplasias. objective list of target disorders that represent Janson G, de Souza JEP, Henriques JFC, the common elements of an orthodontic Cavalcani CT in 2004 did a study to compare diagnosis: overjet, overbite, anterior open bite, the occlusal changes of the FRI and the eruption lateral open bite, crowding, occlusion, lingual guidance appliance, using the Peer Assessment posterior crossbite, buccal posterior crossbite, Rating (PAR) index. From the treated-patients ANB angle, IMPA, and SN-Go-Gn angle. The records of the Orthodontic Department, Bauru greater the number of these conditions in a Dental School, and two samples of Class II patient, the greater the complexity and the patients were retrospectively drawn. Group 1 greater the challenge to the orthodontist. consisted of 25 patients treated with the FRI. Read MJF, Deacon S, O’Brien K in 2004 Group 2 included 30 patients treated with the G conducted a prospective cohort study. Thirty-two series of the eruption guidance appliance known children were included in the study over a 2-year as Occlus-o-Guide. The results of this research period. Study casts were analyzed with the Peer showed that there was a similar effectiveness in Assessment Rating (PAR index), weighted with producing occlusal changes in the two the UK weights. Cephalometric radiographs investigated appliances, regardless of treatment were analyzed with the Pancherz analysis. This time. The main shortcoming of the Frankel prospective cohort study showed that the appliance was its large size and the initial modification of the Twin-block appliance was an discomfort and the eruption guidance appliance effective method of treating Class II malocclusion presented advantages because it was smaller but in terms of the morphological effects on the presented a slightly greater mean treatment time. dental and skeletal tissues; and the main Abei Y, Nelson S, Amberman BD, Hans MG theoretical advantages of this appliances over the in 2004 conducted a study to compare removable twin-block were that patient orthodontic treatment outcome in a sample of cooperation is enhanced and the appliance is patients divided on the basis of orthodontic active for 24 hours a day, there is no transition provider education by using 2 outcome phase between the functional and fixed measures. The first measure was the patient’s appliances phases, and it is less bulky. perception of the improvement in his or her Fogle LL, Southard KA, Southard TE, Casko smile. A visual analog scale (VAS) was used to JS in 2004 conducted a retrospective study to estimate this variable. Second, we used the ABOI provide soft and hard tissue cephalometric to compare the alignment of the teeth. The goal analysis of treatment effects after correcting Class was to obtain evidence to support the commonly II malocclusions in growing patients with held belief that orthodontic specialists provide moderate to severe mandibular retrognathia and better orthodontic care than do general dentists. 218 History of Orthodontics

Survey data were obtained from 280 students. In health and perceived aesthetic impairment. It intends this sample, significantly lower ABOI scores were to identify those individuals who would most likely found per patients treated by orthodontic benefit from orthodontic treatment. The index has specialists compared with patients treated by two components, the aesthetic and dental health general dentists. components, which rank malocclusion in increasing Malocclusion is a common oral disorder priority according to aesthetic considerations and which manifests itself during childhood and the dental health implication. correction of malocclusion (orthodontic treatment) is frequently carried out during Aesthetic Component childhood. With the growing demand for Aesthetic component (AC) consists of a scale of orthodontic treatment a variety of clinician-based ten color photographs showing different levels indices have been developed to classify various of dental attractiveness. The dental attractiveness types of malocclusion and determine their of prospective patients can be rated with orthodontic treatment need. These indices can reference to this scale. Grade 1 represents the be used in estimating orthodontic treatment most and grade 10 the least attractive need, prioritizing of treatment need in patients arrangement of teeth. The score reflects the referred for orthodontics particularly where aesthetic impairment. Aesthetic Component there are limited resources for orthodontics value indicates patient’s esthetic concern and among public health care services, and reflects sociopsychological needs. safeguarding for the patients. The most commonly employed malocclusion Grade 1, 2, 3 and 4 — no or slight need for indices are the Dental Aesthetic Index (DAI), treatment, Index of Orthodontic Treatment Need (IOTN), Grade 5, 6 and 7 — moderate or borderline Peer Assessment Rating and Index of need for treatment, Grade 8, 9 and 10 — need for orthodontic Complexity, Outcome and Need (ICON). treatment. Generally, among the commonly used indices, IOTN (AC, DHC), DAI and ICON are used to Dental Health Component assess the orthodontic treatment needs while ICON and PAR are used to assess the treatment Dental health component (DHC) involves features outcome. In some ways, the indices of IOTN, DAI that might impair the health and function of the and ICON are similar. All include two dentition. DHC records the various occlusal traits components-morphological and esthetic. The of a malocclusion that would increase the difference is that for the IOTN, the esthetic morbidity of the dentition and surrounding component is separated from the dental health structures. The traits of malocclusion are: overjet, component. All the three indices measure similar reverse overjet, overbite, open bite, crossbite, traits such as overjet, reverse overjet, open bite, displacement of teeth, impeded eruption of teeth, overbite, anteroposterior molar relationship, and buccal occlusion, hypodontia and defects of cleft displacement. However, the weights of these lip and palate. Functional disturbances are also traits are rated differently by each index. The four recorded which included lip competency, indices are described below. mandibular displacement, traumatic occlusion and masticatory or speech difficulties. Only the worst INDEX OF ORTHODONTIC TREATMENT occlusal feature is recorded. The components of NEEDS (IOTN) DHC are shown in Table22.1. There are five grades. Brook and Shaw in 1989, developed a valid and Grade 1 and 2 – no need or slight need for reproducible index (Index of orthodontic treatment, treatment need—IOTN) to determine orthodontic Grade 3 – moderate or borderline treatment need. This index attempts to rank need for treatment, malocclusion in terms of the significance of Grade 4 and 5 – need for orthodontic various occlusal traits for an individual’s dental treatment. History of Malocclusion Indices 219

Table 22.1: The dental health component is usually 3.e Lateral or anterior open bite greater than 2 recorded at the chair side by direct examination of mm but less than or equal to 4 mm. the subject but can also be recorded from dental 3.f Deep overbite complete on gingival or palatal casts need (IOTN) (Shaw et al, 1989) tissues but no trauma. Grade 2 (Little need) Grade 5 (Need treatment) 2.a Increased overjet greater than 3.5 mm but less 5.a Impeded eruption of teeth (except for third than or equal to 6 mm with incompetent lips molars) due to crowding, displacement, 2.b Reverse overjet greater than 0 mm but less than presence of supernumerary teeth, retained or equal to 1 mm deciduous teeth and any pathological cause 2.c Anterior or posterior crossbites with less than 5.b Extensive hypodontia with restorative or equal to 1 mm discrepancy between implications (more than 1 tooth missing in any quadrant) requiring pre-restorative orthodo- retruded contact position and intercuspal ntics position 5.c Increased overjet greater than 9 mm 2.d Contact point displacements greater than 1 5.d Reverse overjet greater than 3.5 mm with mm but less than or equal to 2 mm reported masticatory or speech difficulties 2.e Anterior or posterior open bite greater than 1 5.e Defects of cleft lip and palate and other mm but less than or equal to 2 mm craniofacial anomalies 2.f Increased overbite greater than or equal to 3.5 5.f submerged deciduous teeth mm without gingival contact Grade 4 (Need treatment) 2.g Pre-normal or post-normal occlusions with no 4.a Less extensive hypodontia requiring pre- other anomalies (includes up to half a unit restorative orthodontic or orthodontic space discrepancy) closure to obviate the need for prosthesis Grade 1 (None) 4.b Increased overjet greater than 6 mm but less 1. Extremely minor malocclusions including contact than or equal to 9 mm points displacements less than 1 mm 4.c Reverse overjet greater than 3.5 mm with no mastieatory or speech difficulties Limitations 4.d Reverse overjet greater than 1mm but less than 3.5 mm with reported masticatory or speech Aesthetic component cannot be used accurately difficulties in mixed dentition. There is a shortage of 4.e Anterior or posterior crossbites with greater scientific information regarding the long-term than 2 mm discrepancy between retruded contact position and intercuspal position effects of malocclusion. Nonetheless the DHC of 4.f Posterior lingual crossbite with no functional IOTN provides a structured method for occlusal contact in one or both buccal segments assessment of malocclusion. 4.g Severe contact point displacements greater than 4 mm PEER ASSESSMENT RATING 4.h Extreme lateral or anterior open bite greater than 4 mm. The Peer assessment rating (PAR) index, 4.i Increased and completed overbite with previously refered to as the index of treatment gingival or palatal trauma standards, was described by S Richmond, W C 4.j Partially erupted teeth, tipped and impacted Shaw, K D O’Briene, I B Buchaman, R Joes, C D against adjacent teeth Stephens and M Andrew in 1992.The PAR index 4.k Presence of supernumerary teeth. is a quantitative occlusal index measuring how Grade 3 (Borderline need) much a patient deviates from normal alignment 3.a Increased overjet greater than 3.5 mm but less and occlusion. This index is designed to measure than or equal to 6 mm with incompetent lips 3.b Reverse overjet greater than 1mm but less than the efficacy or the outcome of orthodontic or equal to 3.5 mm. treatment by comparing the severity of occlusion 3.c Anterior or posterior crossbites with greater on pretreatment and post-treatment casts. The than 1 mm but less than or equal to 2mm PAR index has five components. discrepancy between retruded contact position 1. Upper and lower anterior segments: Scores are and intercuspal position recorded for both upper and lower anterior 3.d Contact points displacements greater than 2 segment alignment. The features recorded are mm but less than or equal to 4 mm crowding, spacing and impacted teeth. 220 History of Orthodontics

2. Buccal occlusion: The buccal occlusion is INDEX OF COMPLEXITY, OUTCOME AND recorded for both left and right sides. The NEED recording zone is from the canine to the last The Index of Complexity, Outcome and Need molar. All discrepancies are recorded when (ICON) has been developed recently and claims teeth are in occlusion. among other things, to evaluate orthodontic 3. Overjet: Positive overjet as well as teeth in treatment complexity. ICON is based on the crossbite is recorded. The most prominent subjective judgments of 97 orthodontists from aspect of any one incisor is recorded. If the nine countries. It is a single assessment method two lateral incisors are in crossbite while the to quantify orthodontic treatment complexity, centred incisors are with increased overjet of outcome and need. The ICON consists of 4 mm, the score will be 3 for crossbite and 1 following five weighted components, Table 22.2: for the positive overjet, 4 in total. 1. The Aesthetic Component (AC): The dental 4. Overbite: The vertical overlap or open bite of aesthetic component of the IOTN is used. the anterior teeth is recorded. Once this score is obtained it is multiplied by 5. Centerline assessment: The centerline the weighting of 7. discrepancy between the upper and lower 2. Crossbite: Crossbite is deemed to be present if dental midline is recorded in relation to lower a transverse reaction of cusp to cusp or worse central incisors. exists in the buccal segment. This includes The PAR index is applied to an individual’s pre- buccal and lingual crossbites consisting of one and post-treatment study casts. Scores are or more teeth with or without mandibular assigned to each component. The individual displacement. scores are calculated in each component and 3. Anterior vertical relationship: This trait includes multiplied by a weight of each component. Scores both open bite (excluding development are summed to obtain a total score that represents conditions) and deep bite. If both traits are the degree a case deviates from normal alignment present only the highest scoring raw score is and occlusion. The degree of improvement as a counted. Scoring protocol is given in Table result of orthodontic intervention is obtained by 22.2. calculating the difference between the pre- and 4. Upper arch crowding/spacing: The sum of the post-treatment PAR scores. The degree of mesiodistal crown diameters is compared to improvement can be assessed using two different the available arch circumference, mesial to the methods: last standing tooth on either side. 1. Nomogram: The degree of change is Buccal segment anteroposterior relationship: The separated into 3 sections: anteroposterior cuspal relationship is scored a. Worse or no difference, according to the protocol given in Table 22.2 for b. Improved and each side in turn. The raw scores for both sides c. Greatly improved are added together. 2. Percentage improvement: This method gives a more sensitive assessment than the Calculation of the Final Scores nomogram which only provides three broad bands of treatment change. A change of score Once all of the raw scores have been obtained from 40 to 10 would represent an 80% and multiplied by their respective weights, they improvement as would a change from 15 to are added together to yield a weighted summary 3. However, the actual reduction in PAR score for a particular cast. The summed score is scores is also relevant as in the first case where interpreted as following: pre-treatment scores there has been a much greater change with a give the treatment needs and complexity grades; 30 point reduction as opposed to the second end of treatment scores gives the acceptability; case in which the degree of change is less with while (pre-treatment scores)—(4 × post-treatment only a 12 point reduction. scores) gives the degree of improvement. History of Malocclusion Indices 221

Table: 22.2: Protocol for occlusal trait scoring (Daniel and Richmond, 2000) Score 0 1 2 3 4 5

Aesthetic 1–10 as judged using IOTN AC Upper arch Score only the Less than 2.1–5.0 mm 5.1–9.0 mm 9.1–13.0 mm 13.1–17.0 mm >17.0 mm crowding highest trait 2.0 mm or either spacing impacted or crowding teeth Upper Transverse Up to 2.0 mm 2.1–5.0 mm 5.1–9.0 mm >9.0 mm spacing Cross bite Relationship No cross bite Cross bite of cusp to present cusp or worse Incisor Score only the Complete bite Less than 1.1–2.0 mm 2.1–4.0 mm >4 mm open bite highest trait 1 mm either open bite or over bite Incisor Lower incisor Up to 1/3 1/3–2/3 1/3 upto Fully covered over bite coverage tooth coverage full covered Buccal Left and right Cusp to Any cusp Cusp to segment added together embrasure relation up cusp anteropo- relationship to but not relationship sterior only, class I, including II or III cusp to cusp

Limitations weighted on the basis of their relative importance according to a panel of lay judges. The codes and The PAR is based solely on study models and does not account for changes in facial profile, criteria are as follows: iatrogenic damage, tooth inclination, arch width 1. Missing incisor, canine and premolar teeth: The or posterior spacing, and is not appropriate for number of missing permanent incisor, canine assessment of mixed dentition treatment. and premolar teeth in the upper and lower arches should be counted and recorded. DENTAL AESTHETIC INDEX 2. Crowding in the incisal segments: Both the upper and lower incisal segments should be The Dental Aesthetic Index (DAI) was examined for crowding. Crowding in the developed by NC Cons, J Jenny, F J Kohaut in incisal segments is recorded as following: 0— 1986 to assess orthodontic treatment need. It is no crowding; 1—one segment crowded; 2— an orthodontic index based on socially defined two segments crowded. esthetic norms. 3. Spacing in the incisal segments: Both the upper The Dental Aesthetic Index (DAI) has been adopted by the World Health Organization as a and lower incisal segments should be cross-cultural index. It identifies deviant occlusal examined for spacing. Spacing in the incisal traits and mathematically derives a single score. segments is recorded as following: 0—no Its structure consists of 10 occlusal features of spacing, 1—one segment spaced, 2—two malocclusion; overjet, underjet, missing teeth, segments spaced. diastema, anterior openbite, anterior crowding, 4. Diastema: A midline diastema is defined as anterior spacing, largest anterior irregularity the space, in millimetres between the two (mandible and maxilla), and anteroposterior permanent maxillary incisors at the normal molar relationship. The ten occlusal features are position of the contact points. 222 History of Orthodontics

5. Largest anterior maxillary irregularity: and only the largest deviation from the normal Irregularities may be either rotation out of, molar relation is recorded. or displacements from, normal alignment. The following codes are used: 0—normal, 1—half The four incisors in the maxillary arch should cusp, 2—full cusp. be examined to locate the greatest irregularity. Calculation of DAI Scores 6. Largest anterior mandibular irregularity: The measurement is the same as on the upper arch The regression equation used for calculating except that it is made on the mandibular arch. standard DAI scores is as follows: (missing 7. Anterior maxillary overjet: The largest visible teeth × 6) + (crowding) + (spacing) + maxillary overjet is recorded to the nearest (diastema × 3) + (largest anterior maxillary whole millimeter. irregularity) + (largest anterior mandibular 8. Anterior mandibular overjet: Mandibular irregularity) + (anteriormaxillary overjet × 2) + overjet is recorded when any lower incisor is (anterior mandibular overjet x 4) + (vertical in crossbite. anterior openbite × 4) + (antero-posterior molar 9. Vertical anterior openbite. relation × 3) + 13. The severity of malocclusion 10. Anteroposterior molar relation: The right and left is classified on the basis of the DAI scores as sides are assessed with the teeth in occlusion shown in the Table 22.3.

Table: 22.3: Severity of malocclusion and decision of treatment need Severity of malocclusion Treatment indication DAI Scores

No abnormality or minor malocclusion No or slight need < 25 Definite malocclusion Elective 26–30 Severe malocclusion Highly desirable 31–35 Very severe or handicapping malocclusion Mandatory > 36 HHiiissstttooorrryyy oofff IIInnnttteeerrrppprrroooxxxiiimmmaaalll EEEnnnaaammmeeelll RReeeddduuuccctttiiiooonnn iiinnn 23 OOrrrttthhhooodddooonnntttiiicccsss

History of Interproximal – Paskow Indications of Interproximal Enamel Reduction – Shillingbourg and Grace Enamel Reduction – Ballard – Tuverson Contraindications of – Hudson – Doris, Bernard and Kuftinec Interproximal Enamel – Bolton – Sheridan Reduction – Kelsten – Zachrisson

Interproximal enamel reduction (IER) is Stone age man’s dentition, where he referred to understood to be the clinical act of removing part the shortening of the dental arch over time, which of the dental enamel from the interproximal occurred through abrasion. Although the degree contact area. The aim of this reduction is to create of shortening of the dental arch found by Begg space for orthodontic treatment and to give teeth was contested, the existence of this natural a suitable shape whenever problems of shape or reduction led to the publication and size requires attention. In the literature, this clinical development of the technique for interproximal act is normally referred to as “stripping”, although enamel reduction. other names can be found, such as “slendering”, In 1956, Hudson stated that mesiodistal “slicing”, “Hollywood trim”, “selective grinding”, reduction of the mandibular incisors is only “mesiodistal reduction”, “reapproximation”, occasionally referred to in the literature, and “interproximal wear”, and “coronoplastia”. IER listed just three previous articles with direct is a critical procedure. Therefore, planning and reference to the mesiodistal reduction of execution need to be carefully assessed. This mandibular incisors. In his study, Hudson stated treatment should be considered as an exact that stripping should be carried out with medium reduction of interproximal enamel and not just as and fine metallic strips, followed by final a simple method to solve problems. polishing and topical application of fluoride. He stated that it was possible to gain 3 mm of space HISTORY OF INTERPROXIMAL between mandibular canines, and presented an ENAMEL REDUCTION enamel thickness table for incisor and Interproximal dental stripping has been used by mandibular canine contact points. orthodontists for many years. It was initially used In 1958, Bolton published his seminal study to gain space when correcting mandibular incisor titled “Disharmony in tooth size and its relation crowding or to prevent such crowding. to the analysis and treatment of malocclusion”. In 1944, Ballard recommended a careful This study, together with Ballard’s study, stripping of the interproximal surfaces, mainly supported the need in dental dimension from the anterior segment, when a lack of balance discrepancy problems, to use interproximal is present. In 1954, Begg published his study of stripping to correct problems of dental balance. 224 History of Orthodontics

In 1969, Kelsten recommended the use of update”. These articles totally revolutionized the mechanical means to carry out stripping and technique and aims of interproximal enamel recommended prior alignment of teeth. He reduction. He recommended: posited that, only after alignment stripping could 1. Use of a turbine with carbide drill, instead of be simply and accurately achieved. That same diamond disks and strips. year, Rogers and Wagner described an in vitro 2. Stripping on buccal sectors; in other words, study that used teeth extracted for orthodontic distally on canines or mesially on the second reasons. These extracted teeth were subjected to molars on both arches. This achieves greater stripping and polishing. It was found that if the space and allows the preservation of incisors. extracted teeth were treated with fluoride after 3. Use of stripping procedures to achieve space stripping, they offered greater resistance to acid (up to 8 mm per arch) for the correction of attacks, mainly in the 48 to 96 hours after the moderate dentomaxillary disharmony, procedure. This scientifically justified the without recourse to extraction or excessive importance, already highlighted by Hudson, of expansion. topical fluoride application after stripping and In 1986, Zachrisson proposed a new direction polishing. for stripping: improvement of the shape of the In 1971, Paskow published an article that teeth, mainly for incisors and reduction of the recommended the use of mechanical methods of black triangular space above the papilla. IER (interproximal enamel reduction). In 1973, Shillingbourg and Grace wrote an INDICATIONS article entitled “Thickness of enamel and dentin”, which was an important study on enamel and The IER (Interproximal enamel reduction) dentin thickness. The results of this study later technique has evolved over the years; it was first served as the scientific basis for work on stripping used only for stripping mandibular incisors, with and allowed the amount of enamel that could be the aim of preventing and correcting crowding. safely removed from each dental face to be Areas of application have continued to grow: accurately determined. Also in the 70s, Peck and 1. Tooth size discrepancy: In 1944, Ballard Peck published articles, on crowding of the recommended careful stripping of the mandibular incisors and presented the Peck proximal surfaces of the anterior teeth when index. They advised stripping whenever the there was imbalance. mesiodistal dimension of the mandibular incisors 2. Crowding of mandibular incisors: Stripping was did not fall within acceptable figures calculable first used to obtain space for the correction from their index. They claimed that anything in and prevention of crowding. excess would constitute predisposition toward 3. Tooth shape and dental esthetics: Stripping can crowding. and should be used for the reshaping of In 1980, Tuverson published “Anterior enamel on some teeth, thus contributing to interocclusal relations: Part 1”, which presented an improved finishing of orthodontic a highly, detailed description of the stripping treatment and dental esthetics. technique using a back angle and abrasive disks. 4. Normalization of gingival contour and In 1981, Doris, Bernard, and Kuftinec concluded that one of the strongest determining elimination of triangular spaces above the factors for dental crowding is the dimension of papilla, thus greatly improving esthetics and teeth in the arch. In 1981, Betteridge presented smile. the results of stripping on the anterior and 5. Moderate dentomaxillary disharmony: This is a inferior segment after 1 year without retention. primary area of application for interproximal She observed some relapse, but concluded that enamel reduction in the technique developed esthetics were clearly acceptable after by Sheridan in 1985 and 1987, which allowed observation by a panel of three dentists, three space to be obtained for the correction of orthodontists, and three non-dentists. moderate dental crowding; up to 8 mm per In 1985, Sheridan published his article “Air- arch could be achieved without the need for rotor stripping” and, in 1987, “Air-rotor stripping extraction or excessive expansion. History of Interproximal Enamel Reduction in Orthodontics 225

6. Reduced expansion and premolar extraction. there is active periodontal disease or lack of 7. Camouflage of class II and III malocclusions: The dental stability. Although little scientific use of mandibular stripping can be beneficial evidence exists linking IER and increased in camouflaging slight to moderate class III dental mobility, it is prudent to avoid this conditions and overjet. In orthodontic treatment technique in these situations. In addition, IER to camouflage class II with the extraction of should not be used when there is poor oral two maxillary premolars, correcting the hygiene, the orthodontist could be held crowding and inclination of the mandibular responsible for all subsequent iatrogenic incisors with stripping is an ideal solution. activity. Vanarsdall has called attention to the 8. Correction of the curve of spee: For the correction potential deleterious consequences. of an exaggerated curve of spee, it is necessary 3. Small teeth and hypersensitivity to cold: to create a few millimeters of space in the Stripping should not be used in these arch. This can be achieved through moderate situations, as the risk of the appearance of or stripping. an increase in dental sensitivity is great. 4. Susceptibility to decay or multiple restorations: CONTRAINDICATIONS There is a risk of causing imbalance in There are several contraindications for the unstable oral situations, although the approximation technique: stripping of restorations, instead of enamel 1. Severe crowding (more than 8 mm per arch): With surfaces, is an option to consider. application of IER, it would be hazardous to 5. Shape of teeth: Stripping should not be carried carry out orthodontic correction. There would out on “square” teeth—teeth with straight be risk of excessive loss of enamel and all of proximal surfaces and wide bases—as these the ensuing consequences. shapes produce broad contact surfaces, and 2. Poor oral hygiene and/or poor periodontal could potentially cause food impaction and environment: IER should not be used when reduce interseptal bone. HHiiissstttooorrryyy oofff IIInnnvvviiisssaaallliiigggnnn 24

Historical Perspective of Summary of the Invisalign Care of Teeth with Invisalign Invisalign Technique Study 1 What Exactly the Invisalign Indications of Invisalign Study 2 Means? Advantages of Invisalign Study 3 Developing the Invisalign Brand Disadvantages of Invisalign Study 4 Philosophy of Invisalign Limitations of Invisalign Study 5 Fabrication of Invisalign Procedure of Treatment with Study 6 Principle of the Invisalign Study 7 Stereophotolithography Benefits of Invisalign Other Studies

As far back as 1945, orthodontists realized that a Chishti nor Wirth had any professional dental sequence of removable plastic appliances could training. Invisalign braces were first made move teeth toward a predetermined result. Some available to the public in May, 2000 and proved orthodontists even made simple plastic “aligner extremely popular with patients. Soon similar trays” in their offices for minor adjustments. But products began appearing on the market, made it took an adult who’d just had braces to take the by GAC, 3-M Unitek, Ormco, OrthoClear, and concept a step further. others. Invisalign was the brainchild of Zia Chishti Manufactured by American dental product and Kelsey Wirth, graduate students in Stanford manufacturer Align Technology, Inc., these University’s MBA program. Wirth had aligners are based on the suggestions of dentist traditional braces in high school (she reportedly Dr H.D. Kessling, who first proposed the removable hated them). Chishti had finished adult treatment tray alternative to braces in 1945. Of great with traditional braces and now wore a clear importance was Dr Kessling’s idea that the plastic retainer. He noticed that if he didn’t wear removable tray be part of a series of trays, with his retainer for a few days, his teeth shifted each tray forcing teeth to maneuver one step further slightly — but the plastic retainer soon moved into line. In 1998, Align Technology received full his teeth back the desired position. In 1997, he FDA approval for Invisalign as a Class II medical and Wirth applied 3D computer imaging device. Align Technology continues to get FDA graphics to the field of orthodontics and created testing and approval for modifications made in Align Technologies and the Invisalign method. the years since. Nearly one million patients have With a boost from ample Silicon Valley venture used Invisalign under the guidance of their funding, Align soon took the orthodontic dentists, orthodontists and cosmetic surgeons. industry by storm. Dentists and other dental When used properly, these aligners get the same companies were skeptical at first, because neither or similar results as traditional braces. History of Invisalign 227

HISTORICAL PERSPECTIVE OF INVISALIGN Boyd and Vlaskalic(2001), Womack (2002), Norris(2002), Miller(2002), Christianson (2002), The movement of teeth through sequential stages, Joffe (2003), Faltin (2003) have documented individually planned by a set up in casts, and the successful treatment outcomes and deliberated on use of elastomeric appliances was initially the finer nuances of Invisalign therapy. suggested by: Lagravere (2005) conducted a systematic Remensyner (1926) when he introduced the review on the system. The authors could make no FLEX-O-LITE gum massaging appliance, through conclusion from the same about the indications which reported minor tooth movements and for, limitations of and outcomes of use of the Kesling (1945) by introducing a vulcanite Invisalign system because the author found no appliance called the Tooth Positioner. study that quantified treatment effects or Though thermoplastic sheets were accomplishment of treatment goals using it. manufactured as far back as 1896, thermoforming Djeu et al (2005) assessed the treatment as a process was not known until a little before outcome of Invisalign and traditional orthodontic 1950. treatment compared with the American Board of The Dental Contour Appliance was Orthodontics objective grading system and found manufactured using an industrial grade vacuum treatment effects with Invisalign deficient in former and reported by Nahoum (1964). certain respects. Tuncay (2006) edited a Modlin (1974) reported realignment of teeth publication on the Invisalign concept and its using vacuum formed appliances. clinical management. Ponitz (1971), McNamara et al (1985) BOYD (2006, 2008) demonstrated use of described the use and efficacy of invisible Invisalign in a surgical case, and reviewed retainers. previous Invisalign studies showing significant The Essix System was described by limitations for complex tooth movement with SHERIDAN et al. for fabricating retainers in 1993. current case reports showing successful treatment Rinchuse and Rinchuse described active of moderate to severe malocclusions, attributing tooth movement with the same in 1997. it to technological advancements in the system Lindor and Schoff (1998), Hilliard (2000), during a decade of its existence. Armbruster (2003), Giancotti (2004) and others The Clear Aligner concept and branding of have contributed to the treatment possibilities an alternative low-cost orthodontic appliance with the Essix System. The limitations of all Essix system to both orthodontists and general dentists appliances were the small magnitude of changes was introduced by TAE WEON KIM (2004).The achieved, associated with the technical system uses digital aid combined with manual difficulties, to manually subdivide, in stages, a manipulation to fabricate aligners. movement, desired in several small progressive Kim (2007) authored the Clear Aligner movements. Manual. The Invisalign System was developed in 1998 The Orthoclear system introduced itself as an by Align Technology. This was the first technique alternative to Invisalign.CHISTI, WEN & to be based on 3D Digital Technology. A series of Riepenhausen (2005) were the founders of the algorithm stages were produced to move teeth into same. 0.015–0.025 mm, successive precise movements Miller, Crawford and Nanda (2006) described using computer programmes that manipulate the case reports with the Orthoclear system. virtual images of the individual malocclusion. Orthoclear was involved in a legal battle over Chisti and Wirth, 2 MBA Students from patents with Invisalign and a settlement was Stanford University were credited with the reached in 2006 wherein Orthoclear decided to formation of Align Technology. stop operations in the US. Boyd et al (2000) published the first clinical 3D Ortholine was established as a system study carried out in the Pacific university, offering aligner therapy by Abouhassan (2006) California reporting successful treatment and inculcated an advanced system of virtual set outcomes in cases with mild crowding and ups and appliance design where special emphasis spacing between 3–6 mm. was placed on the sequential division of tooth 228 History of Orthodontics movement to enhance patient comfort and towards their optimum positions. But whereas increase the scope of tooth movements with aligner conventional braces are built from stainless steel therapy. and metal wire, Invisalign products are clear Vaid and Abouhassan (2008) reported clinical plastic aligners that are less than one millimeter reports and technological parameters of the thick. They are also removable, which makes system, designed to provide efficacy. Long-term everyday tasks such as eating much easier—as results were still awaited. you can probably imagine. Profit (2007) described a role for Aligner One of the reasons why Invisalign has grown Therapy in treating complex malocclusions with in recent years is because orthodontic work for limitations in specific scenarios and predicted a adults is becoming much more popular. In the future for this method of treatment. past, most people believed that braces could only Namiranian (2008) studied the effect of aligner really make a difference to your teeth as a teenager, thickness on stress production and concluded that when your teeth were still growing. But that is a thick and medium aligners were more likely to myth. Braces can still move your teeth as an adult produce effective tooth movement compared to and you can still achieve the smile you want later medium aligners.Different Systems of Plastic in life. As more adult orthodontic treatments are aligners differ in the clinical and laboratory steps becoming available, more people are keen to learn and the modifications possible, that they offer the about the options available to them. operator. A lot of the published data is “system The growth in adult orthodontic treatment has based “rather than “therapy based” and has led to greater consumer demand for more flexible commercial or system specific allegiance to it. The products that can be adapted to suit a customer’s literature on the therapy is definitely encouraging, lifestyle. For example, conventional braces may but is mostly anecdotal including case reports or get just the same results as Invisalign aligners. clinician’s innovations. But if you’ve got a big presentation with your boss Randomized clinical trials that follow the next week, what would you rather be wearing: an CONSORT statement are needed to evaluate the old-fashioned metal and wire bracket or a treatment effects of Aligners. Technological virtually invisible aligner that you can even analysis of the biomechanical properties of the remove if you need to? In a nutshell, that’s why materials used and the permutation of tooth most adults choose Invisalign. movements effectively possible, with an Over the years, Invisalign has developed into organized classification of stages involved will a successful brand with a number of products in and should be the trend of future research. its portfolio. There is the original, definitive Invisalign program, which this site covers in detail WHAT EXACTLY THE INVISALIGN MEANS? from treatment through to costs. Recently, however, Invisalign has also released modified Invisalign refers to a series of clear, removable versions of the original system to exploit new heavy-duty plastic aligners that gradually correct opportunities within the dental market. minor crookedness and gaps, overcrowded teeth, Invisalign Express is a new version of the overbites and/or minor underbites. When Invisalign system which is designed to correct considering your options, there are a number of minor orthodontic issues in short timescales. reasons to select this procedure over other choices Invisalign Teen is the program that Invisalign such as metal braces, crowns, veneers and has designed specifically for teenagers. It includes implants. a number of modifications that make it easier for teenagers and parents to manage the treatment DEVELOPING THE INVISALIGN BRAND and therefore achieve the desired results. So where does Invisalign fit into this picture? The For a long time now Orthodontists and patients Invisalign brand was first launched in America have wanted to correct teeth inconspicuously and in 1999. Invisalign products work in much the without the use of fixed dental brackets. New same way as conventional brackets in that technology has turned this dream into reality; the appliances are fitted to your teeth, and those new type of treatment is called Invisalign (Fig. appliances then move the teeth slowly and gently 24.1) (Invisible/Align) Technique. History of Invisalign 229

the PVS impressions and to record treatment changesor modifications immediately in a digital format. Adding the other 3D compartments (skeletal, facial, jaw movements and animation to the current surface map of the teeth) will greatly enhance the diagnostic and treatment capabilities of this appliance. Thus the clinician must have indepth understanding of the biomechanics, biology, periodontal concerns and optimal therapeutic occlusion achieved during orthodontic treatment to successfully plan and use this appliance.

FABRICATION OF INVISALIGN The orthodontist submits the following to align technology: Fig. 24.1: Invisalign appliance A set of a polyvinyl siloxane impressions A centric occlusion bite registration Align Technologies introduced Invisalign A panaromic radiograph (invisible/align) in 1999. Invisalign incorporates A lateral cephalometric radiograph a series of invisible (clear) plastic aligners that fit Photographs. comfortably over teeth and are designed to move The impressions are poured up in dental teeth gradually into the desired position. plaster and then placed in a tray and encased with Invisalign aligners are manufactured at the align epoxy and urethane. The impressions are technologies dental laboratory using computer- inspected by the laboratory to ensure that the aided design/computer-aided manufacturing patients dentition has been fully captured. The tray (CAD/CAM) processes. is placed into a destructive scanner (Figs 24.2A and B) using computed tomography. The scanners PHILOSOPHY OF INVISALIGN rotating blades makes numerous passes over the Invisalign takes the principles of Kesling, epoxy encased models removing a thin layer with Nahoum, and Raintree Essix even further, each pass. A computer linked with a scanner then using cter-aided-design-computer-aided- assembles the scanned information to create a manufacture (CAD-CAM) technology combined three-dimensional rendering of the models. with laboratory techniques to fabricate a series of After the bite has been established, based on custom appliances that are esthetic and the clinician’s treatment plan technicians generate removeable, and that can move teeth from a virtual correction of malocclusion that is then beginning to end. reviewed by the clinician this process is called The Invisalign system has been tested in the Clin-Check. The software cuts the virtual university clinical trials and is available to public. models and separates the teeth allowing them to There are currently certain limitations to this be move individually (Fig. 24.3). A virtual gingival appliance in terms of cost, case selection, is placed along the gingival line of the clinical experienced required for computer treatment crown to serve as the margin for the manufacturing planning, difficulty obtaining certain tooth of the aligners (Fig. 24.4). movements and lack of potential in cases involving After final approval the treatment sequence is mixed dentition or impacted teeth. However as the divided into a series of algorithmic stages. Each number of clinicians using this appliance increases stage has maximum tooth movement potential of more information will be available to evaluate the 0.25 mm/appliance. Models of each stage of risks and benefits of this system. treatment are made by having the computer direct A great help in the future will be to use one of their fabrication in a process called the emerging intraoral scanning devices to replace Stereolithography (Figs 24.5A to C). 230 History of Orthodontics

These models are then used to fabricate the reason the aligners appear not to be achieving the aligners on a Biostar pressure molding machine treatment goals (compliance, difficult movements (Fig. 24.6). The aligners are trimmed and laser etc) a midcourse correction protocol can be etched with the patients (Fig. 24.7). initiated. Mid course correction involves new Patients initial impressions and a new clean check which is send Case number to the clinician within 2 weeks. A new series of Aligner number aligners are constructed and send to the clinician. And arch upper/lower. At the end of the treatment, the clinician may also They are then disinfected, packaged, and be able to initiate a case refinement for detailing shipped to the doctor’s office. If for whatever and final corrections if needed.

A Fig. 24.3: Cutters separate teeth

B Figs 24.2A and B: (A) Destructive scanner; (B) 3D Generated computer model Fig. 24.4: Placement of virtual gingiva

A B C

Figs 24.5A to C: (A) Stereolithography machines; (B) Stereolithography models; (C) Aligners History of Invisalign 231

Fig. 24.6: Biostar machine Fig. 24.8: The principle of stereophotolithography applied to the rapid prototyping of 3D objects

Fig. 24.7: Stereolithographic models

PRINCIPLE OF STEREOPHOTOLITHOGRAPHY Principle A system able to create 3D objects of any complexity by successive layers (slices). Each slice Fig. 24.9: Diagram of a typical stereophotolithograhy system, according to Kristi S Anseth, Dept Chem. Eng. Univ. of is produced by action of a laser light on a liquid Colorado at Boulder material. This 2D shape of the solid slice is obtained by the movements of the laser, The impression is inspected by the laboratory commanded by a computer. The precision is to ensure that patient’s dentition has been fully defined by the thickness of each slice (Fig. 24.8). captured. Then the impression is scanned The process called stereophotolithography (SPL) using computer tomography to create a highly has been developed in the 90’s by Laser 3D accurate and detailed three-dimensional study (Nancy, France), based on the French Patent No. 84 model. 11 241 (CNRS- July 84 (Fig. 24.9)). Based on the clinician’s treatment plan technicians generate a virtual correction of the SUMMARY OF THE INVISALIGN TECHNIQUE malocclusion that is than reviewed by the The technique for using the invisalign system is clinicians. This process is called clin-check. as follows: The clinician reviews the planned corrections The clinician sends a rubber base impression and if necessary, sends any revisions to align of maxillary and mandibular arches to align technology. The final step of clin-check must technologies laboratories along with patient be approved by the treating clinician. facial photograph, radiographs and a detailed After final approval, the treatment sequence is treatment plan. divided into a series of algorithmic stages. Each 232 History of Orthodontics

stage has a maximum tooth movement 2. The treatment procedures do not allow for potential of 0.25 mm per appliances. continued eruption of teeth, or significant Models of each stage of treatment are made by dental arch changes during growth that may process called stereolithography Individual occur during the mixed dentition phase. appliances (aligners) are made from the 3. There is currently no capability to incorporate computer-generated models of each stage. basal orthopedic change with this appliance A typical invisalign treatment requires 20 to system, thus restricting it to malocclusions 30 aligners for the maxillary and mandibular requiring pure dental movements. arches. 4. Unlike fixed or removable appliances, the In most of the cases, treatment with invisalign treatment plan cannot be changed once the is done in less than a year; however, treatment appliance series has begun. If change in time depends on the specific alignment treatment is desired the current series may be problem. completed and a new plan and appliances are made or the current series may be stopped. INDICATIONS OF INVISALIGN 5. The inability to integrate hard and soft tissues of the head into the computer treatment thus According to researchers and align technologies, there is no direct indication of where teeth are invisalign can be used to correct the following in relation to basal bone or in relation to the types of mild malocclusions: lips or other soft tissues of head. 1. Malocclusion with mild crowding cases. 6. Invisalign is generally not recommended in 2. Malocclusion with mild spacing case. treating more complicated malocclusions such 3. In cases mild relapse – after traditional braces as severe deep bite, anterior-posterior have been removed, when some relapsing corrections greater than 2mm, uprighting tooth movement has occurred. severely tipped teeth and closure of premolar extraction spaces. ADVANTAGES OF INVISALIGN 1. Improved esthetics compared to fixed PROCEDURE OF TREATMENT WITH THE orthodontic appliance and ability to remove INVISALIGN the appliance. First Evaluation 2. Invisalign patients showed no measurable root resorption. Orthodontist evaluates and creates a program 3. It gives the patient an esthetic choice in their of treatment. orthodontic treatment. Records and impressions of arches are taken. Invisalign Aligners Made and Delivered DISADVANTAGES OF INVISALIGN A CT-scan (Computed Tomography or CAT- 1. Fabrication of the aligners is a very time scan), is made from your dental impressions consuming and tedious process that probably that produces an extremely accurate, 3D would not be practical day to day orthodontic digital model of your teeth. practice. CAD (Computer-aided design) software is 2. Severe derotations, complex extrusions and then used to simulate the movement of your large translations are less predictable with teeth during treatment. invisalign and may require auxiliary The treatment plan are reviewed, modified, treatment. and approved before the aligners are created. LIMITATIONS OF INVISALIGN Invisalign then uses advanced stereolithography (SLA) technology to build precise 1. All permanent teeth should be fully erupted moulds of teeth at each stage of treatment. for treatment using invisalign as it is difficult Individualized, custom-created clear aligners to achieve retention of the appliance on short are made from these models and sent to clinical crowns. orthodontist. History of Invisalign 233

Wearing of Invisalign (Fig. 24.10) the teeth. The principal difference is that Invisalign not only controls forces, but also Visits are made to orthodontist for adjustments controls the timing of the force application. At and to check progress on a monthly basis. each stage, only certain teeth are allowed to At regular intervals, a new set of custom- move, and these movements are determined by molded clear aligners are received to continue the orthodontic treatment plan for that the straightening process. particular stage. This results in an efficient The total number of clear aligners is specific to force delivery system. you, determined by orthodontist for the course of treatment. STUDY 1 BENEFITS OF INVISALIGN OUTCOME ASSESSMENT OF INVISALIGN AND 1. Invisible thus no unwarranted attention to TRADITIONAL ORTHODONTIC TREATMENT your mouth. COMPARED WITH THE AMERICAN BOARD OF 2. Removable thus easy to eat, brush and floss. ORTHODONTICS OBJECTIVE GRADING 3. No brackets to catch food or plaque. SYSTEM 4. Healthier gums from properly aligned teeth that help gums to “fit” tighter around each Garret Djeu,a Clarence Shelton,b and Anthony tooth. Maganzinic 5. Easier cleanings in maintaining a good oral New York, NY hygiene program that reduce chances of Introduction plaque build-up, tooth decay and periodontal disease. This treatment-outcome assessment objectively compares Invisalign (Align Technology, Santa CARE OF TEETH WITH INVISALIGN Clara, Calif) treatment with braces. 1. Teeth and the aligners would need to be kept Methods cleaned every day if the teeth and gums are to be healthy during and after orthodontic This study, a retrospective cohort analysis, was treatment. conducted in New York, NY, in 2004. Records from 2. Follow orthodontist directions on how often 2 groups of 48 patients (Invisalign and braces to brush, how often to floss and use of other groups) were evaluated by using methods from the cleaning aids to help maintain good dental American Board of Orthodontics Phase III health. examination. The discrepancy index was used to Like brackets and arch wires are to braces, analyze pretreatment records to control for initial Invisalign aligners move teeth through the severity of malocclusion. The objective grading appropriate placement of controlled force on system (OGS) was used to systematically grade posttreatment records. Statistical analyses evaluated treatment outcome, duration, and strengths and weaknesses of Invisalign compared with braces.

Results The Invisalign group lost 13 OGS points more than the braces group on average, and the OGS passing rate for Invisalign was 27% lower than that for braces. Invisalign scores were consistently lower than braces scores for buccolingual inclination, occlusal contacts, occlusal relationships, and overjet. Invisalign’s OGS scores were negatively correlated to initial overjet, occlusion, and buccal Fig. 24.10: Wearing invisalign appliance posterior crossibite. Invisalign patients finished 234 History of Orthodontics

4 months sooner than those with fixed appliances Results on average. P _ .05 was used to determine The mean accuracy of tooth movement with statistically significant differences. Invisalign was 41%. The most accurate movement Conclusion was lingual constriction (47.1%), and the least accurate movement was extrusion (29.6%)— According to the OGS, Invisalign did not treat specifically, extrusion of the maxillary (18.3%) and malocclusions as well as braces in this sample. mandibular (24.5%) central incisors, followed by Invisalign was especially deficient in its ability to mesiodistal tipping of the mandibular canines correct large anteroposterior discrepancies and (26.9%). The accuracy of canine rotation was occlusal contacts. The strengths of Invisalign were significantly lower than that of all other teeth, with its ability to close spaces and correct anterior the exception of the maxillary lateral incisors. At rotations and marginal ridge heights. This study rotational movements greater than 15°, the might help clinicians to determine which patients accuracy of rotation for the maxillary canines fell are best suited for Invisalign treatment (Am J significantly. Lingual crown tip was significantly Orthod Dentofacial Orthop 2005;128. more accurate than labial crown tip, particularly for the maxillary incisors. There was no statistical STUDY 2 difference in accuracy between maxillary and mandibular teeth of the same tooth type for any HOW WELL DOES INVISALIGN WORK? A movements studied. PROSPECTIVE CLINICAL STUDY EVALUATING THE EFFICACY OF TOOTH MOVEMENT WITH Conclusion INVISALIGN In this prospective clinical study evaluating the Neal D. Kravitz,a Budi Kusnoto,b Ellen BeGole,c efficacy of tooth movement with Invisalign, the Ales Obrez,d and Brent Agrane following conclusions were made: South Riding, Va, White Plains, Md, and 1. The mean accuracy of tooth movement with Chicago, Ill Invisalign was 41%. The most accurate tooth movement was lingual constriction (47.1%). Introduction The least accurate tooth movement was The purpose of this prospective clinical study was extrusion (29.6%). The mandibular canine was to evaluate the efficacy of tooth movement with the most difficult tooth to control. removable polyurethane aligners (Invisalign, 2. Maxillary and mandibular canines achieved Align Technology, Santa Clara, Calif). approximately one-third of the predicted rotation. The accuracy of canine rotation was Methods significantly lower than the rotation of all other teeth, with the exception of the maxillary lateral The study sample included 37 patients treated incisors. At rotational movements greater than with Anterior Invisalign. Four hundred one 15°, the accuracy for the maxillary canines was anterior teeth (198 maxillary and 203 mandibular) significantly reduced. were measured on the virtual treat models. The 3. With the exception of canine rotation, no tooth virtual model of the predicted tooth position was was significantly less accurate in movement. superimposed over the virtual model of the 4. Lingual crown tip was significantly more achieved tooth position, created from the accurate than labial crown tip, particularly for posttreatment impression, and the 2 models were the maxillary incisors. superimposed over their stationary posterior teeth 5. The severity of pretreatment overjet might by using Tooth Measure, Invisalign’s proprietary influence the accuracy of anterior tooth superimposition software. The amount of tooth movement with Invisalign. movement predicted was compared with the 6. There was no statistical difference in accuracy amount achieved after treatment. The types of between maxillary and mandibular teeth of movements studied were expansion, constriction, the same type for any tooth movement studied. intrusion, extrusion, mesiodistal tip, labiolingual These results indicate that we still have much tip, and rotation. to learn regarding the biomechanics and History of Invisalign 235

efficacy of the Invisalign system. Clinicians microscopy and energy dispersive X-ray who prescribe Invisalign treatment should microanalysis to identify the elemental composition fully recognize its limitations and commit of integuments formed on the surface, and (4) Vickers themselves to providing the gold standard of hardness (HV200) testing. Another set of reference care for their patients. Providing quality care, and retrieved appliances was subjected to artificial regardless of the treatment modality, is only aging for 2 weeks, and the extracts were subjected to way to truly be a premiere provider. gas chromatography-mass spectroscopy. The retrieved appliances demonstrated substantial STUDY 3 morphological variation relative to the as-received specimens involving abrasion at the cusp tips, RETAINING ALIGNMENT CHANGES WITH adsorption of integuments, and localized INVISALIGN calcification of the precipitated biofilm at stagnation sites. Buccal segments of retrieved appliances Kuncio D, Maganzini A, Shelton C, et al: Invisalign showed an increase in hardness, which might be and traditional orthodontic treatment attributed to mastication-induced cold work; postretention outcomes compared using the however, the clinical implication of this effect on American Board of Orthodontics objective grading mechanotherapy is unknown. In vitro aged and system. Angle Orthod 77:864-869, 2007. retrieved appliances were found to leach no Relapse of orthodontic cases, while extensively traceable amount of substances in an ethanol aging studied, remains poorly understood. In this study, solution. (Am J Orthod Dentofacial Orthop while both techniques produced acceptable initial 2004;126:725-8). results, cases treated with conventional braces were more stable over time. Retention times were Conclusion comparable but changes in resultant treatment forces were more frequent with Invisalign than Retrieved Invisalign appliances demonstrate with fixed appliances. substantial morphological variation in relation to new specimens, involving abrasion at the cusp STUDY 4 tips, adsorption of integuments at stagnation sites, and localized calcification of the biofilm STRUCTURAL CONFORMATION AND developed during intraoral service. An increase LEACHING FROM IN VITRO AGED AND in hardness of the buccal segments of the retrieved RETRIEVED INVISALIGN APPLIANCES appliances was found; this could mainly be attributed to cold work during mastication. The Susan Schuster, DDS,a George Eliades, DDS, clinical implication of this effect in the force DrDent,b Spiros Zinelis, PhD,c Theodore Eliades, delivery of the appliance requires further study. DDS, MS, DrMed, PhD,d and T. Gerard Bradley, In vitro aged appliances were found not to release BDS, MSe traceable monomers or byproducts after Milwaukee, Wis, and Athens, Greece immersion in an ethanol-water solvent. The aging The objectives of this study were to investigate the pattern of these appliances intraorally involves structure of Invisalign appliances (Align abrasive wear arising from mastication, and, thus, Technology, Santa Clara, Calif) after intraoral no definitive consensus on their reactivity and exposure, and to qualitatively and quantitatively biological properties can yet be established. characterize the substances leached from the aligners after accelerated in vitro aging. Samples of Invisalign STUDY 5 appliances were randomly selected from 10 patients before intraoral placement and after retrieval, and CYTOTOXICITY AND ESTROGENICITY OF the prepared specimens were subjected to (1) bright- INVISALIGN APPLIANCES field optical reflection microscopy to study the surface morphology; (2) Fourier transform infrared Theodore Eliades,a Harris Pratsinis,b Athanasios microspectroscopy to characterize the in vivo E. Athanasiou,c George Eliades,d and Dimitris changes in molecular composition induced on Kletsase appliance surfaces, (3) scanning electron Thessaloniki and Athens, Greece 236 History of Orthodontics

Introduction Materials and Methods Our purpose was to study the in-vitro cytotoxic The compliance indicators in the Invisalign Teen and estrogenic properties of Invisalign appliances aligners were tested for color resistance in various (Align Technology, Santa Clara, Calif). Methods: aqueous models with no saliva involved. Three sets, each consisting of a maxillary and a mandibular appliance, of as-received aligners Results were immersed in normal saline solution for 2 Color fading was observed as a function of time, months. Samples of eluents were diluted to 3 pH, and temperature while compliance concentrations (5%, 10%, and 20% vol/vol) and indicators were stored in drinking water or sour tested for cytotoxicity on human gingival soft drinks and in conjunction with the use of fibroblasts and estrogenicity by measuring their cleaning tablets and a dishwasher. The findings effect on the proliferation of the estrogen- of color fading were consistent with the color responsive MCF-7 breast cancer cells. All assays changes observed when the aligners were being were repeated 4 times for each maxillary and worn by patients. Color fading, notably as mandibular set, and the results were analyzed observed in connection with acidic soft drinks with 2-way analysis of variance (ANOVA) with and cleaning techniques, introduces uncertainty appliance and concentration serving as predictors into the assessment of actual patient compliance, at the .05 level of significance; differences among as reflected by the fading colors of compliance groups were investigated with the Tukey test. indicators. Results Conclusion There was no evidence of cytotoxicity on human Compliance indicators are not immune to simple gingival fibroblasts and no stimulation of intentional or unintentional manipulations. proliferation of the MCF-7 cell line at any Therefore, they can best show an estimate of wear concentration, indicating no estrogenicity of aligner time but cannot be recommended as objective eluents. Conclusions: The use of Invisalign wear-time indicators. (Angle Orthod. appliances did not seem to induce estrogenic effects 2011;81:185–191). under the conditions of this experiment. (Am J Orthod Dentofacial Orthop 2009;136:100-3). STUDY 7 Conclusion A COMPARISON OF TREATMENT IMPACTS No cytotoxic or estrogenic activity of Invisalign BETWEEN INVISALIGN ALIGNER AND FIXED appliances was documented in this in-vitro assay, APPLIANCE THERAPY DURING THE FIRST which used a standard model for the assessment WEEK OF TREATMENT of estrogenicity of materials. Kevin B. Miller,a Susan P. McGorray,b Randy STUDY 6 Womack,c Juan Carlos Quintero,d Mark Perelmuter,e Jerome Gibson,f Teresa A. Dolan,g and Timothy T. Wheelerh COLOR FADING OF THE BLUE COMPLIANCE Rock Hill, SC, Gainesville and Miami, Fla, INDICATOR ENCAPSULATED IN REMOVABLE Glendale, Ariz, Louisville, Ky, and CLEAR INVISALIGN TEEN ALIGNERS San Antonio, Tex Timm Cornelius Schotta; Gernot Go¨ zb Introduction Objective The aim of this study was to evaluate the To evaluate the color fading in aqueous solutions differences in quality of life impacts between of the blue dot wear-compliance indicators of the subjects treated with Invisalign aligners (Align Invisalign TeenH System outside the oral cavity. Technology, Santa Clara, Calif) and those with History of Invisalign 237 fixed appliances during the first week of the effectiveness of the Invisalign system. They orthodontic treatment. Methods: A prospective, pointed to the need for randomized clinical trials. longitudinal cohort study involving 60 adult Since this paper, more studies about the clinical orthodontic patients (33 with Invisalign aligners, effectiveness have been published; for example in 27 with fixed appliances) was completed by using the UK, Dr Paul Humber has analyzed 100 back- a daily diary to measure treatment impacts to-back Invisalign cases. Assessing the patients including functional, psychosocial, and pain- after two sets of aligners, he found that 94% of the related outcomes. A baseline survey was dentitions had achieved the objectives set. In the completed before the start of treatment; diary USA, Akhlaghi and colleagues compared entries were made for 7 consecutive days to treatment with the invisalign system with measure various impacts of the subjects’ treatment with conventional braces and orthodontic treatment over time. The data were concluded that “conventional fixed appliances then analyzed for differences between treatment achieved better results in the treatment of Class I modalities in terms of the subjects’ reported mild crowding malocclusions” In a comparison impacts from their orthodontic treatment. of outcomes between the two approaches, Kuncio et al reported that the Invisalign group displayed Results greater relapse saying “the mean alignment of the The baseline mean values did not differ between Invisalign group was superior to the Braces group groups for pain reports (P _ .22) or overall quality before and after the retention phase, but these of life impact (P _ .51). During the first week of differences were not statistically significant. treatment, the subjects in the Invisalign group Therefore, even though the Invisalign cases reported fewer negative impacts on overall quality relapsed more, they appear to have the same, if of life (P _.0001). The Invisalign group also not better, overall alignment scores.” In a larger recorded less impact in each quality of life study Djeu and colleagues had similar findings subscale evaluated (functional, psychosocial, and to Akhlaghi above and concluded that “Invisalign pain-related, all P _.003). The visual analog scale was especially deficient in its ability to correct pain reports showed that subjects in the Invisalign large anteroposterior discrepancies and occlusal group experienced less pain during the first week contacts”. They felt that “The strengths of of treatment (P _.0001). The subjects in the fixed Invisalign were its ability to close spaces and appliance group took more pain medications than correct anterior rotations and marginal ridge those in the Invisalign group at days 2 and 3 (both heights.” They added “Invisalign patients P _.007). finished 4 months sooner than those with fixed appliances on average.” Furthermore, work at Conclusion NYU/Buffalo University by Dr Omar Fetouh was published in 2009 where 67 patients were studied, Adults treated with Invisalign aligners half of whom were treated with Invisalign and experienced less pain and fewer negative impacts half with fixed appliances. He concluded that on their lives during the first week of orthodontic ‘There was no statistical significant difference treatment. between the scores of the Invisalign group and Braces group for Alignment, Occlusal OTHER STUDIES Relationship and Interproximal Contacts. The Invisalign group had higher scores in Marginal SCIENTIFIC STUDIES ridges, Bucco-lingual inclination, Occlusal In a systematic review of the literature, published Contacts, and Overjet than the Braces group.’ His in the Journal of the American Dental Association in conclusion was that Invisalign can treat mild 2005.Drs. Manual Lagravere and Carlos Flores- malocclusions ‘as efficiently, if not better, as Mir were unable to draw strong conclusions about braces.’ HHiiissstttooorrryyy oofff MMooolllaaarrr DDiiissstttaaallliiizzzaaatttiiiooonnn iiinnn 25 OOrrrttthhhooodddooonnntttiiicccsss

History of Molar Distalization Intermaxillary Class II K-loop Molar Distalizer Indications for Molar Malocclusion Correction The Distal Jet Appliance Distalization Appliances The Crozat Appliance Contraindications of Molar Vertical Holding Appliance Molar Distalization by Magnets Distalization Removable Molar Distalization The Magnets An Ideal Intraoral Molar Splint The Klapper Superspring Distalization Appliance should Symmetric Distalization with a Herbst Appliance meet the following Criteria TMA Transpalatal Arch The Mandibular Anterior Mechanism of Action of Tube Plates for Distalization of Repositioning Appliance Distalizing Appliances Molars (MARA) Pendulum Appliance Cetlin Appliance Saif Springs Pend-X Appliance Anchorage Need The ‘Fastback’ Appliance for M-pendulum Appliance Extraoral Force Molar Distalization Pendulum F Appliance The Force Applied Features of Fast Back Appliance Jones Jig The Lokar Appliance

Whenever there is space deficiency, the methods HISTORY OF MOLAR DISTALIZATION of gaining space that strikes to our mind first are, extraction, expansion and stripping. Angle, The concept of ‘distal driving’ of the maxillary proposed expansion of dental arches for nearly posterior teeth has a long orthodontic history in every patient and extraction for orthodontic 1920s. Class II elastic treatment was thought to be purpose was not necessary for stability of results an easy and effective tool but early cephalometric or for aesthetics. He believed that when teeth could studies in 1940s showed little or no distal be saved by dental treatment, extraction of teeth movement of upper molars. Thus headgears were for orthodontic purpose seemed particularly reintroduced as means of moving upper molars inappropriate unacceptable. back. These extra oral appliances were heavily In 1930’s, Charles Tweed observed relapse after dependent on patient cooperation, forces non-extraction expansion treatment and decided generated were high and intermittent causing to retreat with extraction. In recent years, the severe patient discomfort and prolonged percentage of patients having extraction as a part treatment time. of orthodontic treatment has decreased To overcome these difficulties, more recently considerably as experiments has shown that several intra oral appliances employing palatal premolar extraction does not necessarily anchorage have been used to produce distal guarantee stability of teeth alignment. Proximal movement of upper molars. Distalization stripping also has its own limitation. mechanics has found many supporters in its History of Molar Distalization in Orthodontics 239 quarters since it provides the arch with increase control of the clinician. Relying on the patient’s length which may correct arch relationship as well willingness to wear an appliance consistently as do away with extraction and loss of tooth. In may result in increased treatment time, a change some cases the operator gets bonus of achieving of treatment plan or both. expansion or molar derotation also. In recent years, appliances largely Molar distalization, in recent years is evolved independent of patient compliance increasingly as an alternative method of gaining space to have been used for maxillary molar distalization. conventional methods where ever is indicated. Kingsley was the first person to try to move the INDICATIONS FOR MOLAR DISTALIZATION maxillary teeth backwards in 1892 by means In a Growing Child of headgear. Oppenheim advocated that position of To relieve mild crowding mandibular teeth as being the most correct for Causes permanent increase in arch-length of individual and use of occipital anchorage for about 2 mm on each side. moving maxillary teeth distally into correct relationship without disturbing mandibular Late Mixed Dentition teeth. In 1944, he treated a case with extra-oral When lower E space – utilized for relief of anchorage for distalizing maxillary molar. anterior crowding Renfroe (1956) reported that lip bumper Upper molars distalized to get a class I relation primarily devised to hold hypertonic lower lip Class I malocclusion—with highly/labially caused a distal movement of lower molars placed canine/impacted canine sufficient to change class I to Class II. Lack of space for eruption of premolars due to Gould (1957) was first person to discuss about mesial migration of permanent first molars unilateral distalization of molars with extra- Good soft tissue profile oral force. Borderline cases Kloehn (1951) described the effects of cervical Mild-to-moderate space discrepancy with pull headgear. missing 3rd molars/2nd molars not yet erupted Graber T-M. (1969) extracted the maxillary II Axial inclination : Mesially angulated upper molar and distalized the first molar to correct molars class II div.1. Normal or hypodivergant growth pattern Non-extraction treatment plans for angle class Late mixed dentition with mild crowding of II malocclusions often require the distal movement anteriors. of maxillary molars in the initial stage of treatment to convert the class II molar relationship to a class CONTRAINDICATIONS OF MOLAR I molar relationship. DISTALIZATION Most traditional approaches to molar distalization including extra-oral traction Profile: through use of a headgear, Wilson distalizing – Retrognathic profile. arches, spring appliances and inter-maxilalry Functional: elastics with sliding jigs, require considerable – Numerous signs and symptoms of patient compliance to be successful. temperomandibular joint With heightened awareness of balance and – Posteriorly and superiorly displaced harmony of the facial profile combined with a need condyles. to treat patients with marginal space Skeletal: discrepancies, a variety of methods have been – Class II skeletal proposed to move molars distally with reduced – Skeletal open dependence on patient co-operation. More – Excess lower face height recently, the subjectivity and problems of – Constricted maxillary arch predicting patient behavior have led many – Dolicocephalic growth pattern. clinicians to devise appliances that minimized Dental: reliance on the patient and that are under the Class I or III molar relation. 240 History of Orthodontics

Dental open bite Crozat appliance Maxillary first molar distally inclined. Crickett appliance CETLIN appliance AN IDEAL INTRAORAL MOLAR Removable molar distalization splint DISTALIZATION APPLIANCE SHOULD Modified Nance Lingual appliance MEET THE FOLLOWING CRITERIA Non-extraction treatment (lip bumper) Molar distalization with magnets 1. Minimal need for patient compliance. Transpalatal arch 2. Acceptable esthetics and comfort. Use of Super elastic NiTi 3. Minimal loss of anterior anchorage (as Double loop niti evidenced by axial proclination of the incisors. The Pendulum appliance 4. Bodily movement of molars to avoid Jones Jig undesirable side-effects, lengthening of C-space regainer treatment and unstable results. Lokar appliance 5. Minimal chair time for placement and Intra oral bodily molar distalizer (IBMD) reactivations. Maillary distalizing system (MDS) Fixed piston appliance Advantage The K-loop appliance No patient cooperation was necessary to obtain The distal jet molar movement. Using Implants Fixed functional appliances. MECHANISM OF ACTION OF DISTALIZING APPLIANCES PENDULUM APPLIANCE Passive 0.016 × 0.22 inch wire with stops that This appliance first described by Hilgers in 1992 abut the distal wings of premolar brackets is uses a large Nance button in the palate for inserted, and the coils are placed on the wire anchorage and 0.032-inch TMA springs (Ormco between first premolars and molars. The coils Corporation) that delivers a distalizing force to are activated 8 to 10 mm by compressing and the upper molars. The springs insert into lingual maintaining them against the molars by sheaths on the palatal surface of the band. The crimpable hooks. anterior portion of the appliance is retained with Since the reaction force of the coil moves the premolar bands, which are joined to the appliance wire anterior, the function of the stop against using a retaining wire. Occlusally-bonded rests premolar bracket is to ensure that the wire on the primary molars or second premolars add cannot move past first premolars, thus placing to the retention. If expansion of the upper arch is reaction force on Nance appliance. To enhance indicated, then a midline screw can be added to anchorage, 0.018 inch uprighting spring is the appliance. This version of the appliance is placed in the vertical slot of the premolar known as the Pend-X appliance. brackets directing the crowns distally. Byloff and Darendeliler (1997) showed that When class II elastics are attached, rectangular the appliance moved molars distally without wire with 10 degree of incisor lingual root torque creating bite opening, but the molars did tend to is inserted in the mandibular arch to maintain tip. At the incisal edge was the anchorage loss lower incisor position. Molar position is was measured at 0.92 mm (SD ±0.67). Second maintained by inserted of 0.016 x 0.022 inch premolar anchorage loss was measured at a wire with stops that about the molar tubes. mean of 1.63 mm (SD ±1.23), but distal movement Various types of molar distalization of the molar represented 71 per cent of the space appliances in orthodontics are listed below and opened. If molar uprighting bends were few of them are described in this chapter: incorporated into the appliance it reduced the Headgears tipping, but increased the anchorage loss at the Wilson Bimetric arch design premolars by 0.61 mm and the incisal edge by ACCO 0.62 mm (Byloff et al., 1997). History of Molar Distalization in Orthodontics 241

Ghosh and Nanda (1996) also found that the anchorage along with 0.032" TMA springs that pendulum appliance is a reliable method for deliver light, continuous force to the upper first distalizing maxillary molars at the expense of molars without affecting the palatal button. Thus, moderate anchorage loss. The advantages of the the appliance produces a broad swinging or appliance lies in its minimal dependence on pendulum of force from the midline of the palate patient’s compliance, ease of fabrication, one to the upper molars. time activation, adjustment of the springs, if necessary to correct minor transverse and vertical PEND-X APPLIANCE molar positions, and patient’s acceptance. The In cases with severe narrowing of maxillary mean maxillary molar movement was 3.4 mm posterior segments, if expansion of upper arch with a distal tipping of 8.4 degrees. There was, is needed, a mid palatal jack screw can be however, 2.5 mm mesial movement of the first incorporated into the center of the Nance premolar, which represents some anchorage loss. button. Thus, for every millimeter of distal molar The screw is activated one-quarter turn every movement, the premolar moved mesially three days, after a week or so for patient 0.75 mm. adjustment, to produce a slow, stable Hilgers (1992) reports that when the expansion. appliance is placed before the eruption of the The resulting activation is usually sufficient second molars, two-thirds of the tooth movement not only to correct any transverse is molar distalization, one-third is experienced discrepancies, but also to control molar as forward shift of the anchor bicuspids. If placed rotation during distalization. after eruption of the second molars, the experience tends to be reversed, one-thirddistal M-PENDULUM APPLIANCE movement of the first molar, and two-thirds anchorage slip. Giuseppe Scuzzo in 1999 introduced M- pendulum: Advantages In this horizontal pendulum loops are inverted, it will allow bodily movement of Minimal dependence on patient compliance both the roots and crowns of the maxillary Ease of fabrication molars. Once the distal molar movement has One time activation occurred, the loop can be activated simply by Adjustment of the springs if necessary to opening it. correct minor transverse and vertical molar The activation produces buccal/distal up positions. righting of the molar roots and thus a true Patient’s acceptance. bodily movement rather than a simple tipping Unilateral class II corrections. or rotation. Used to regain space lost through mesial Pendulum springs are activated to 40–45o, drifting of the upper first molars because of resulting in about 125 g of force on each side. either early loss of second deciduous molars This activation is repeated until the desired or impaction of first molars under distal crown distalization of the molars is obtained. contour of the deciduous molars. Rapid distalization of upper first molars and Advantages stabilization with an insta Nance provide True bodily molar movement space for the erupting second bicuspids. Minimal dependence on patient compliance Disadvantages Ease of fabrication Little need for reactivation James J Hilgers in 1992 introduced an appliance Patient’s acceptance. for class II correction in non-compliant patients. An intra-maxillary anchorage unit is needed The “pendulum appliance” is a hybrid that uses to counteract the reactive forces and moments in large Nance acrylic button in the palate for molar distalization. 242 History of Orthodontics

Anchorage Design of the M-pendulum Nance button and permit uniform periodontal Appliance pressure distribution.

The anchorage block consists of a Nance Anchorage Quality of Deciduous Molars and palatal button and anchoring teeth in the same Premolar Root Topography dental arch. The acrylic button fits tightly against the palatal mucosa in the region of the The desmodontal anchorage quality of the palatal rugae and is linked to the teeth with anchoring teeth depends largely on their root occlusally bonded onlays. After placement of surfaces and root topography. the pre-activated pendulum springs, the Even if root surface of deciduous molars and anchorage unit is designed to counteract the premolars are identical, anchorage quality of reactive forces and moments. deciduous molars undergoes a constant The anchorage effect of the anterior palatal decrease during physiologic resorption plate to the resilient palatal mucosa might be resulting in imbalance in the favor of the due to hydrodynamic interactions. Additional premolars. vertical stabilization might result from tongue The results of this study show that extent and pressure while swallowing. Anchorage value quality of molar distalization are better and of the soft tissue supported Nance holding side-effects are less pronounced in the arch should not be overestimated. anchorage and the incisor region if premolars The anchorage mainly depends on the dental alone are used for anchorage. anchorage quality of the teeth. The resistance It is advisable to perform an initial test for potential of these anchorage teeth is increased tooth mobility when using dec. determined by the size of the anchorage molars for anchorage, to avoid having to relevant surfaces and thus by the number of remove the appliance prematurely when the teeth involved, by root topography and the anchorage quality is overestimated. attachment level and by the bone structure and A panoramic radiograph provides the desmodontal reactive state. information on the extent of root resorption of The bone structure and attachment level is dec. molars and indirectly quality of such teeth constant among children and adolescents for anchorage purposes during pendulum treated with pendulum appliance but appliance therapy. differences might occur with respect to the Desmodontal Reactive State, Potential number of teeth, root topography and Causes of Reduced Anchorage desmodontal reactive state. The primarily unmoved tooth in a desmodontal Number of Anchorage Teeth resting state offers the best tissue resistance. Initial leveling increases the proliferation rate Hilgers used only anterior part of the of cells relevant to the remodeling process in appliance, using bands on maxillary first the anchorage unit and increases readiness premolars or deciduous molars and a holding for reactive movement. Therefore initial arch to the Nance button. He observed that leveling should not be performed in the region after placing the springs, Nance buttons of the anchorage unit when placing pendulum tended to lift. So the recommended that appliance. supporting elements should be bonded Omission of Nance anterior palatal plate also occlusally to the maxillary second premolars leads to increased loss of anchorage. or second deciduous molars for additional stability. Additional bonding of occlusal on Potential Measures for Increased lays to the canines to obtain additional Anchorage anchorage support is also recommended. The reactive segment should consist of as When an end osseous implant is used in the region many anchorage teeth as possible, which are of the hard palate or miniscrews, stationary intra- combined to form a multi-rooted anterior oral anchorage can be achieved without teeth being anchorage unit with occlusal onlays and the incorporated. The fixing of pendulum appliance History of Molar Distalization in Orthodontics 243 to an Osseo integrated palatal implant of the ortho INTERMAXILLARY CLASS II MALOCCLUSION system not only represents a significant CORRECTION APPLIANCES improvement in anchorage quality during molar Several intermaxillary fixed non-complaint distalization but also permits stationary anchorage appliances have been proposed and used over with a transpalatal arch during the subsequent the past two decades. distal guidance of premolars and canines. They are used in exceptional cases such as adults with Advantages problematic periodontal anchorage or in mixed dentitions with early loss of the decidduous molars. Forward displacement of the mandible. Backward displacement of the maxilla PENDULUM F APPLIANCE Anterior force on the mandibular dentition. All above three actions and movements will Favero modified pendulum appliance for lingual bring about the correction of class II technique. Acrylic portion of the Nance button malocclusion. has a larger dimension than in other pendulum appliances and can accommodate in the anterior Disadvantages region a segmented wire, which is inserted in the lingual brackets of the incisors. The common disadvantage of intermaxillary An increase in biological anchorage quality is appliances is undesirable steepening of the possible. Occlusal forces can be used occlusal plane with concomitant flaring of the therapeutically for increased anchorage if the lower incisors and distal tipping along with composite on lays to which the wires are attached extrusion of the maxillary incisors. were formed with an occlusal relief. This method can be applied only if VERTICAL HOLDING APPLIANCE mandibular arch has sufficient teeth which are Vertical Holding Appliance is a fixed functional in stable position (i.e. no orthodontic treatment intra-oral distalizing appliance, as it is activated is performed simultaneously in the mandible). from the functional activity of the tongue. Drawbacks Wire used for the fabrication of this appliance: 0.040 inch wire is used for the 1. Lingual tipping of molars. fabrication of this appliance. 2. Difficult to fabricate. Helices of Vertical Holding Appliance JONES JIG Vertical holding appliance consist of four The Jones Jig was first introduced by Richard D. helices in its design Jones and J. Michael White. Jones Jig is one of the The two helices are placed just distal to each appliances which accomplish tooth movement maxillary first molar without the need for patient compliance. The Other two helices are placed at the center of appliance uses an open coil Nickel titanium the appliance. spring to deliver 70–75 g. Over a compressive range 1–5 mm to the molars. V-Bend Advantages V-bend is fabricated using 0.040 inch wire V-bend separates the helices of VHA which The advantages of the Jones Jig appliance are that, are placed at the center of the appliance it can achieve class I relationship even when: V-bend portion of the wire is embedded in the 2nd motors erupted or unerupted acrylic button. In mixed and permanent dentition Unilateral as well as bilateral distalization Acrylic Button Growing and non-growing patients. The appliance is also said to be a predictable, Acrylic button is composed of self –cure acrylic painless sand rapid method of correcting class II material relationship with minimum patient co-operation. Size of the acrylic button—size of a dime 244 History of Orthodontics

Thickness of the button—the acrylic button Advantages should be 2–5 mm away from the palate This method has several advantages: Acrylic button contributes greater proportion 1. ‘TMA’ has better shape memory and resilience as compared to the any other portion of the than stainless steel. appliance. 2. The arch is simple to construct. Action 3. The system is hygienic and economic. 4. This is no anterior anchorage loss; the Vertical holding appliance results in intrusion premolars and canines spontaneously follow and distally directed force. the molar distally.

REMOVABLE MOLAR DISTALIZATION SPLINT Drawbacks The removable molar distalization appliance was 1. Because the ‘TMA’ is more fragile than put forward by Dr A. Korrodi Ritto, to overcome stainless steel, the arch must be bent carefully, the drawbacks of patient co-operation, needed and fractures in the mouth are more common. with other removable appliances like the 2. Since the ‘TMA’ arch rotates the anchor molar removable plates and headgears. more mesiobuccally than a conventional arch does. It should be combined with a fixed Advantages orthodontic appliance using a rectangular 1. It is smaller than conventional removable plates. arch-wire or a passive stainless steel wire 2. It is comfortable. segment between the second molar and canine 3. Esthetics. on the anchor side. 4. Better patient co-operation. 3. The system can only distalize one molar at a time, and therefore is recommended for use Disadvantage with unilateral or slight bilateral class II molar relationships. There is more amount of molar tipping seen rather 4. An extra-oral appliance should be worn at than bodily, molar distalization. Therefore the best night to reinforce anchorage. cases for treatment with this appliance are those where the molars are already messily tipped. TUBE PLATES FOR DISTALIZATION OF MOLARS SYMMETRIC DISTALIZATION WITH A TMA TRANSPALATAL ARCH Lain Benauwt explained the use of a removable appliance for distalizing the molars. These The intra-oral distalization methods can all appliances were introduced as the appliances produce bodily distal movement of the maxillary with wires sliding in tubes. molars, but can also cause a mesial movement of the maxillary premolars and canines, or a Advantages proclination of the mandibular incisors when class II elastics are used. In addition, the loss of anterior 1. Retention of the appliance is very good, as the anchorage often leads to relapse of the maxillary movable parts contribute to the retention (due molars during the correction of canine to incorporation of Adam’s clasp). relationship, overbite and over jet. 2. It is very helpful in mixed dentition, when According to Cetlin’s method, maxillary deciduous molars are not too retentive or are molars can be distalized unilaterally by using a broken down or missing. Goshgarian transpalatal arch in conjunction with 3. Unwanted displacement of teeth is minimized extra-oral traction. A toe-in-bend in the due to the Adam’s Clasp who holds the molar transpalatal arch applies a mesiobuccal rotation and avoids rotation. to the molar on the side of the bend and a distally 4. An extra-oral appliance can be used along directed force against the molar on the opposite with this appliance to support and reinforce side. This procedure does not cause a loss of the stationary part or indirectly the anterior anchorage. anchorage. History of Molar Distalization in Orthodontics 245

5. Expansion is also possible all the same time supplies only 30 g of force on the molars. The as the distalization of the molar, and is springs are placed as far gingivally as possible achieved by changing the angulations of the to minimize crown tipping and to cause molar tubes in relation to the sagittal plane. movement without Irritation. 6. Repair is easy. The removable appliance exerts a force, which moves the molar crowns distally, with relative Disadvantage ease. The extra oral headgear on the other hand It is a delicate appliance. The two wires must hold exerts a force of 150 g per tooth and is used to the movable part without binding. control root position. The headgear is advised to be worn for 12–14 hours/day. CETLIN APPLIANCE When using a cervical headgear, it is generally The appliance involves a combination of an necessary to elevate the outer bow to produce extra-oral force in the form of headgear and an an appropriate “force couple” that will move infra oral force in the form of a removable the roots distally, by directing the line of force appliance. In molar distalization, bodily distal above the outer of mass of the molar. movement rather than distal tipping of the maxillary molars is essential. When there is only THE LOKAR APPLIANCE a distal tipping, the molars relapse messily, The Lokar appliance was developed by Dr Loter uprighting under their apices to comeback to its In 1894. original position. To overcome these drawbacks, the Cetlin Components of Lokar Appliance appliance utilizes a removable appliance intra orally to tip the crowns distally and then an The appliance consists of two basic components, extra oral force to upright the roots. So the intra- and they are: oral removable appliance can be called the A mesial sliding component crown mover while the extra-oral force, is the A component which inserts Into arch wire tube root mover. of the molar.

ANCHORAGE NEED Design of the Lokar Appliance The anchorage for the removable appliance is by The distalizer is inserted into arch wire tube proper adaptation to the palate, an acrylic shield of the first molar and the application is around the four maxillary incisors and a modified adapted such that it is parallel to the plane of Adam’s Clasp on the first premolars. occlusion and as close to the teeth as possible tor patient comfort. EXTRAORAL FORCE A 0012" S.S. ligature wire hand twisted around the premolar bracket before the Lokar is fixed The extraoral appliance is a headgear, which to the molar tube. This ligature wire is engaged is inserted into the molar tube. The headgear around the mesial sliding component of the used in generally a cervical or a high pull type, distalizer and tightened to activate the depending on the usual consideration of appliance. skeletal pattern. The removable appliance is worn 24 hours a Force Applied and Activation of the day. The appliance also contains a bite plane Appliance to disengage the molars (to aid in rapid molar movements). The force is delivered by NiTi Coil spring, which gets compressed during activation. THE FORCE APPLIED Anchorage In the removable appliance, the spring is activated only 1 to 1.5 mm, measured along The anchorage is by a Nance appliance, soldered the occlusal surface of the molar and It to the premolars. 246 History of Orthodontics

Activation important to center the K-loop between the first molar and the pre molar. A 0.012" S.S. ligature wire is hand twisted twice – For additional molar movement, the around the premolar bracket, such that the free appliance is reactivated 2 mm after 6-S ends of the ligature face distally. One of the free weeks. The loop is easy to remove from the ends is then passed over the mesial sliding molar tube, since the distal end of the wire component of the mainframe and tightened to is not bent. In most cases, one reactivation, activate the appliance. The force is delivered by producing a total of as much as 4 m of distal the NiTi Coil spring, which gets compressed molar movement is sufficient. during activation. The best activation is achieved – The palatal Nance button, held in place by by compressing the spring by 2–3 mm. wires extending from bands on the first premolars or first deciduous molars, is Re-activation of the Appliance primarily responsible for preventing anterior Re-activation is done at 5–6 weeks interval. movement of the first premolars. The button should be large enough to, provide adequate K-LOOP MOLAR DISTALIZER anchorage and prevent tissue impingement, but should be kept away from the teeth. The The K-loop molar distalizer was developed by acrylic should not be built up so that the Vamn Kalra. The K-loop molar distalizer consists button acts as a bite plane. of: – The premolars moved forward by about ‘1 A K-loop—to provide the forces and moments mm’ during ‘4 mm’ of molar distalization. A Nance button—to resist anchorage. If necessary, the anchorage can be – The K-loop is made of 0.017- x 0.025" TMA reinforced by attaching a straight pull or wire. Which can be activated twice as much high-pull headgear with a force of 150 g to as stainless steel before it undergoes the premolars. permanent deformation. A loop made of ‘TMA’ also produces less than half the force Advantages of one made with stainless steel. – Each loop of the ‘K’ should be 8 mm long The K-loop molar distalizing appliance has the and 1.5 mm wide. The legs of the ‘K’ are following advantages: bent down 20° and inserted into the molar Simple yet efficient tube and the premolar bracket. The wire is Controls the moment-to-force ratio to produce marked at the mesial of the molar tube and bodily movement, controlled tipping or the mesial of the premolar bracket. Stops uncontrolled tipping as desired are bent into the wire ‘1 mm’ distal to the Easy to fabricate and place distal mark and ‘1 mm’ mesial to the mesial Hygienic and comfortable for the patient mark. Each stop should be well-defined Requires minimal patient co-operation low- and about 1.5 mm long. These bends help cost. keep the appliance away from the mucobuccal fold, allowing a 2 mm THE DISTAL JET APPLIANCE activation of the K-loop. The distal jet was designed by Akto Carano and – The 120° bends in the appliance legs Miiuro Testa in 1996. produce moments that counteract the tipping moments created by the force of the Appliance Design appliance, and these moments are reinforced by the moment of activation as The appliance consists of bilateral tubes of the loop is squeezed into place. Thus, the 0.036" internal diameter which are attached molar undergoes a translatory movement to an acrylic name button. NiTi Coil spring instead of tipping. Root movement and screw clamps are slide over each tube. continues even after the force has The wire extending from the acrylic, through dissipated. If an extrusive or intrusive force each tube ends in a bayonet bend that is against the molar is not desired, it is inserted into the lingual sheath of the first History of Molar Distalization in Orthodontics 247

molar band. An anchor wire from the Nance 1. Conversion to Nance holding arch. button is soldered to the bands on the 2nd 2. Double set screw distal Jet appliance. premolars. 3. Incorporation of helical loops into bayonet wire far molar rotation and up-fighting. Components 4. Incorporation of Jack screws for maxillary expansion. 1. The transpalatal connectors—rigidly immobilize the premolars and provide a THE CROZAT APPLIANCE support to the Nance button. 2. The Bayonet director unit: Lumen of the tube The crozat appliance is similar to the crickett portion supports the molar bayonet, while its appliance but has palatal and lingual bars instead outside diameter supports the spring and the of stainless steel wire components. activation lock. Dr Crozat viewed the appliance as acting in a 3. The molar bayonet: It is drawn out of the truncated cone or funnel. As the molars are being bayonet director unit during distalization and translated distally in a divergent direction, inserted into the lingual sheath. The distal step expansion must be placed in the appliance to avoid prevents the spring from riding on the vertical the more roots striking the lingual cortical plate, arm of the molar bayonet while activating the blocking movement. Over-expansion can also appliance. impede distal movement by emerging the roots 4. NiTi springs: NiTi coil springs of 150 gm are against the buccal plate. used for children and 250 gm used for adults. Treatment of a bilateral class II malocclusion 5. Stainless steel springs: The appliance can also with a good lower arch is begun with rotation be fabricated with stainless steel springs. adjustments of the upper molars. First the 6. Activation locks—to compress and activate the measurement is made between the lingual arms; springs. and each crib clasp complex is rotated to increase 7. Lock wrench: To engage and tighten (the screw this measurement ½ mm per side. Once the of the activation lock). rotation adjustment is begun every third rotation adjustment, the molars are expanded to keep the Activation teeth tracking back into a more divergent portion The distal jet is activated by sliding the damp of the arch. Once the molars are derotatad, class II closer to the first molar once a month. elastics are added to continue distal movement. Once the distalization is complete, the Similar unilateral class II can also treated, with appliance can be converted to a Nance retainer crozat appliance. simply by replacing the clamp-spring Dr Crozat introduced this appliance in 1919. assemblies with light-cured or cold cure acrylic Dr Crozat’s goal was to solve crowding by the and cutting off the arms or the promoters. distal movement of molars. As he moved molars distally, expansion of the appliance was Advantages necessary because the bony dental arch itself is wider in the posterior regions. The advantages of the distal-jet appliance are listed below: MOLAR DISTALIZATION BY MAGNETS Minimal patent discomfort Minimal or no molar tipping Magnets have been used intra-orally for a Ease of fabrication variety of reasons. More often for retention of Ease of insertion prosthesis. In contemporary orthodontics, Esthetically acceptable light continuous force (75 to 100 g) are Well-tolerated by patients commonly used to correct malocclusion with Ease of conversion to a Nance holding arch to typical tooth movement of 0.5 mm/week. maintain the distalized molar position Miniature Samarium-cobalt (Sm-Co) magnets It can be used with a full-fixed appliance are used and they have been proved to be There are several modifications to the distal- effective and efficient force delivery systems. jet appliance, for different purposes. They are: Ferrite, Ainico or platinum cobalt have been 248 History of Orthodontics

tried but left out due to their very low magnetic facilitates buccolingual adjustment of the springs strength and hence larger size. in the vestibule and aids patient comfort. The The magnets can either be used in the attractive springs can be readily removed for adjustment or or the repelling state. The repelling state is activation. There have been no studies to date preferred. It was found that the Sm-Co magnet; documenting results achieved with this appliance. when used, exert very high forces of more than 200 omi at small separations, while optimum Availability of the Appliance orthodontic forces were generated (75 to The appliance comes in two sizes: 180 g), when separation was 0.5 to 1.00 mm. 27 mm primarily designed for extraction cases n n Magnetic Force = (Separation) = (d) and The force exerted by the magnets decrease from 40 mm for non-extraction cases. 200 gms at contact to about 409 gms at 2mm, The springs are paired for left and right sides. with a rapid decrease of force at greater separations. Indications The magnets used showed good biocompatibility when they were coated. 1. Dental Class II malocclusion.

The stainless steel coated samarium-cobalt 2. Deep bite with retroclined mandibularincisors. magnets can be recycled and showed good Contraindications biocompatibility. 1. Cases predisposed to root resorption. THE MAGNETS 2. Dental and skeletal open bites. 3. Vertical growth with high mandibular plane The magnets are four in number and they are angle and excess lower facial height. encased in a steel sleeve with a finely machined hole in the center and coated with a HERBST APPLIANCE biocompatible polymer to avoid leaching out of products. The Herbst bite jumping mechanism was Two of the magnets are pre-set in regulation developed by Emil Herbst in the early 1900’s.The (on each wire) for easy insertion bilaterally. original banded design of this appliance was Both repelling magnets on each wire are introduced at the international dental congress clamped together to avoid possible loss of in Berlin (Germany) by Herbst in 1905. It was magnet. introduced by Pancherz. Pancherz used a banded Herbst design that involved the: THE KLAPPER SUPERSPRING Placement of bands on molar This appliance is an auxiliary which is fitted to and premolar Maxilla fully banded upper and lower fixed appliances Bands are connected by copper (ORTHO design, 744 Falls Circle, Lake Forest, lingual wire Illinois 60045, USA). Bands on lower right first premolar and lower right first premolar Mandible Design of the Appliance Bands are connected by a lower lingual arch wire The appliance consists bilaterally of a length multi-flex nickel-titanium which is bent back on it Herbst Appliance attaching to the upper first molar tube and The Herbst appliance is a fixed functional attaching to the lower arch wire by means of a orthopedic appliance having passive tube and helical loop. The springs lie in the buccal vestibule. plunger system with the exact length of the tube The effect of the spring is to place a distalizing determining the amount of anterior mandibular and intrusive force to the upper first molar. development. The tube is attached to a maxillary posterior root, whereas the plunger is fixed Latest Design of Klapper Super Spring anteriorly to the mandibular dentition and slides The latest design of the spring requires a special through the tube during opening and closing oval tube to be fitted to the upper first molars. This movements. History of Molar Distalization in Orthodontics 249

THE MANDIBULAR ANTERIOR 7 and REPOSITIONING APPLIANCE (MARA) 10 mm. The Mandibular Anterior Repositioning Pre-requisites of the Spring Appliance (MARA, Allesee Orthodontics Appliances, PO Box 725, Sturtevant, WI 53177, No longitudinal research studies on this auxiliary USA) MARA consists of cams made from 0.060 are available in the literature to date. Starnes square wire attached to tubes (0.062 square) on (1998) recommends that for successful treatment upper first molar bands or stainless steel crowns. to be carried out the prerequisites are as follows: A lower first molar crown has a 0.059 arm Prior correction of deep bites; projecting perpendicular to its buccal surface, Stabilization of each arch with a large which engages the cam of the upper molar. The rectangular arch wire; appliance is adjusted so that when the patient Direction of force as horizontal as possible; closes, the cam on the upper first molars guides Sufficient resistant torque (lower incisor the lower first molars and repositions the lingual crown torque); mandible forwards into a Class I relationship. Perfect fit of bands; There have been no studies to date documenting Proper placement of hooks for spring results achieved with this appliance. The attachments. developers of the appliance recommend a 12- month treatment time to achieve a bite jumping or THE ‘FASTBACK’ APPLIANCE FOR MOLAR orthopaedic effect. Stabilization of the lower DISTALIZATION molars is assisted by the fitting of a lingual arch Modern Orthodontic Science is constantly and on the upper arch a transpalatal bar to exploring new non-extraction therapies through stabilize the upper molars is placed. This research carried out employing appliances that appliance does not require the placement of will allow the Orthodontist to gain space both attachments on teeth other than the first molars. transversally and distally. Consequentially, in recent times we have observed an increase in the Indication number of appliances for the distalization of the Skeletal Class II with mandibular deficiency. upper molars. Italians have been particularly prolific in this area, probably on account of many Contraindications of our young patients being reluctant to follow the therapeutic indications that come with extra- 1. Dolichofacial growth pattern. oral tractions. The common goal for all those 2. Cases predisposed to root resorption. involved in developing new distalizing 3. Dental and skeletal open bites. appliances appears to be the ability to provide a 4. Vertical growth with high mandibular plane dental movement that is bio-mechanically angle and excess lower facial height. controlled and generated by adequate forces, while keeping undesired contramovements to a SAIF SPRINGS minimum., the ideal Distalizer should occupy the Design of the Appliance smallest possible space, interfere as little as possible with function and provide bodily distal These are long nickel-titanium closed coil springs movement of the dental elements involved with that are used to apply Class II inter-maxillary traction minimal (or absence of) patient compliance. Distal when fully banded fixed appliances are in place movement should occur in the patient with (Saif Springs, Pacific Coast Manufacturing Inc, 18506 minimal damage to the surrounding tissues and 142nd Ave, NE Woodinville, WA 98072, USA). The function, generating minimal (or absence of) springs are tied in place with steel ligatures and are contra-movements. The appliance used should be worn in place of inter-maxillary elastics. engineered in such a way that would make therapy management easy and safe. Availability of the Saif Spring The ‘Fastback’ Molar Distalizer is now fully The springs are available in two lengths: established as a ‘reference’ appliance in the 250 History of Orthodontics

Orthodontic field. A growing number of Reduced or minimal loss of anchorage Professionals, having had the opportunity to fully Reduced or minimal contra-movements evaluate and appreciate the ease and safety of use Bodily Distalization occurs, no risk of as well as the bio-mechanical development undesired movements provided by this device, are now prescribing it Easy, non-frequent Activation regularly whenever they need to gain space in the Checks every 4/6 weeks, cost-effective patient posterior region. At the time of writing, 6 years management have passed since the initial prototypes of Spherical or long ends ensure the appliance ‘Fastback’ devices were introduced. stops when not activated, should the patient skip FEATURES OF FAST BACK APPLIANCE one or more appointments Fast back features are as follows: The ‘Fastback’ can be used in conjunction with Easy to plan and assemble fixed Reduced bulk Buccal appliances (brackets). Minimal patient discomfort There are three versions of the ‘Fastback’ Good aesthetics appliance: Continuous, constant forces are at work at all FB1 (Monolateral FB with ‘Tripod’ Anchorage times unit) with or without ‘Nance’ button Intensity and direction of the forces applied FB2 (Bilateral FB ) with ‘Nance’ button can be FB3 (Bilateral FB ) with ‘Nance’ button and Accurately controlled Extensions, or Rests, to the Canines. SSuSuuggggggeeesssttteeeddd RReeeaaadddiiinnnggg

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Page numbers followed by f refer to figure and t refer to table

A Arch Camper’s angle 136 length analyses 146 Canine Adam’s clasp 162 wire 114 guidance 181 with incorporated helix 163 bends 177 retractors 165 with soldered hook 163 Argon lasers 50 Carbon dioxide laser 50 with traction hook 163 Artistic positioning bends 177 Care of deciduous dentition 18 Adult orthodontics 19 Carey’s analysis 123 Advantages of B Caries lasers in soft tissue surgery 52 control during orthodontic Baker’s anchorage 25f, 33f metal brackets 107 treatment 57 Ball end clasp 162 removable appliances 161, removal 51 Base plate 162, 166 162 Carpenters syndrome 203 Begg appliance 179f Aesthetic component 218 Case-angle controversy 70, 148 Benefits of orthodontic treatment Aims of orthodontic treatment Cast versus wrought metals 116 19 15, 16f Cephalometric Bleaching 51 Alignment of incisors 152f analysis 139 Bolton’s Altered passive eruption of developmental pattern analysis 125 management 51 and facial morphology study 125 American in cleft palate 85 Bondable brackets 109, 109f Board of Orthodontics 15 radiography 137 Bonded rapid maxillary Orthodontics 29, 30 roentgenography 27f expansion appliances 157, Anchorage design of Ceramic brackets 108, 108f 157f M-pendulum appliance 242 Cetlin appliance 245 Andrews’ straight wire appliance Branches of orthodontics 16 Characteristic 98 British Society facial appearance 202 Angell’s palatal expansion device for Study of Orthodontics 37t of ideal arch wire 177 placed on maxillary teeth of Orthodontists 15 Choice of teeth for extraction 150 155f Broca’s occipital angle 136 Circumferential clasp 162 Anterior movement of dental Broussard bracket 112 Classification of Buccal arche 178 archwires 117t self-supported retractor 166 Apert’s syndrome 203 canine retractors 166t sweep 177 Aphthous ulcer 51, 56f malocclusions 27 Cleft Apicoectomy 52 C Application of laser in lip and palate formation 200 bonding orthodontic bracket Calculation of of anterior 54 DAI scores 222 and posterior palate 201 orthodontics 53 final scores 220 primary palate 201 260 History of Orthodontics

of posterior secondary palate Dentistry in Enamel 201 eighteenth century 10 hypoplasia 203 palate 202 sixteenth and seventeenth reduction in orthodontics 223 Cobalt-chrome-nickel alloy 118 centuries 7 Encephalocele 203 Common syndromes associated Dentoalveolar and facial Erbium-YAG laser 49 with cleft lip and palate asymmetries 141 Esthetic harmony 15, 16 203 Dentofacial orthopedics versus Etiology of cleft lip and palate 201 Components of removable orthodontics 79 Evolution of orthodontic appliance 162 Denture stomatitis 52 bracket 174 Comprehensive orthodontic Depigmentation of gingiva 57, cephalometrics 140 treatment 19 57f clasp design 162 Contraindications of Design of molar distalization 239 edgewise buccal tubes 174 removable orthodontic appliance 248, 249 orthodontic appliances 106 appliances 161 Lokar appliance 245 Expansion Correcting malocclusions of Destructive scanner 231f orthodontic appliances 159, dental origin 19 Determination of 159t skeletal origin 19 anterior ratio 125 screw 157, 159 Correction of arch Exposure of cleft palate 24, 25 length 123 impacted tooth 53 curve of Spee 225 width 123 teeth 52 Corrective orthodontics 16 discrepancy 123 Extensive hypodontia 219 Craniofacial overall ratio 125 External skeletal fixation 194 anomalies 219 Development of removable Extraction of second premolar syndromes 203 orthodontic appliances 161 123 Craniometry 133 Dewel’s method 151, 151t Extraoral Crouzon’s syndrome 203 of serial extraction 152f force 79, 245 Crowding of mandibular incisors Different types of appliances 17 224 canine retractors 166t traction 25 Crown expansion screws 158f, 159t Eyelet clasp 162 angulations 180, 181 labial bows 163t inclination 180, 181 Diode laser 50, 51 F lengthening procedure 57, 58f Disadvantages of removable Crozat Fabric of human body 22 appliances 162 appliance 247t Facial clasp 162 orthodontic appliances 162 angle 135 Curing light-activated resins 51 Distal jet appliance 246t axis Current clinical use of dental Down syndrome 203 angle 91 lasers 51 Drawback of of clinical crown 180 Curve of Spee 181 lingual 185 point 180 Cusp embrasure contact 181 Pont’s analysis 124 deformities 27 Factual period 77, 78 D E Failure of buttresses 176 Debonding of brackets by laser E-arch appliance 27, 68, 68f, 171, Fastback appliance for molar 57 171f distalization 249 Deciduous Early Father of dentition 18 mixed dentition 18 American Orthodontics 24, teeth 52 permanent dentition 18 25, 31 Deficient lower anterior facial Ectopically erupting teeth 203 expansion appliances 25 height 90f Edgewise modern Definition of orthodontics 14 appliance 69, 70f, 172, 173f dentistry 23 Dental brackets 110, 110f orthodontics 20 aesthetic index 221 technique 27 orthodontics 27 and skeletal cross bites 141 Edward Hartley angle 67f Features of fast back appliance contour appliance 227 Elimination of abnormal oral 250 health component 218 habits 18 Fictional period 77 Index 261

Film position and enlargement retention-joint appliance 155 J 140 High labial bow 163 Jack expansion screw 159 Fixed History of Jackson’s orthodontic appliance 17, 17f arch wires 114 clasp or full clasp 162 prosthetics/cosmetics 51 cephalometrics 133 triad 16 rapid maxillary expansion cleft lip and cleft palate 197 James McNamara analysis 88 appliances 156 dental lasers 47 Jumping bite 24 Focused versus defocused beam dentistry 1 48 expansion appliances 154 K Force applied and activation of extraction in orthodontics 145 appliance 245 fixed orthodontic appliances Kernahan’s stripped ‘Y’ Founder of modern dentistry 23 167 classification 201 Frankel appliance 189 interproximal enamel Kesling model analysis 131 Frankfort mandibular reduction 223 Kingsley’s incisor plane angle 143 malocclusion indices 205 extraoral traction appliance plane angle 143 model analysis 122 155f Frenectomy 51 molar distalization in incline plane 155f Functional orthodontics 238 Korkhaus’ analysis 124 mandibular displacements orthodontic materials 120 141 orthodontics in L orthopedic magnetic Greece and Rome 44 Labiolingual appliance 112f appliance 82, 83 united states of america 28 Lack of incisor prominence 146 study of palatal and removable orthodontic Lang brackets 112 pharyngeal structures 85 appliances 160 Laser Functions of teeth 23 surgical orthodontics 193 ablation of surface enamel for Fusion of teeth 203 Hixon and old father method orthodontic bracket 128 placement 54 G Howe’s analysis—1954 124 beam interaction with tissue Gaining access for bracket Huckaba’s analysis 127 48 placement on partially Hyperplasia 51 classification 52 erupted teeth 55 Hypothetical period 77 medium 47 Gingival safety 52, 58 contact 219f I use in dentistry 51 Late mixed dentition 18, 239 retraction 51 Impeded eruption of teeth 219 Gingivectomy 51 Lateral Incisor mandibular plane angle borer of tongue 56f Gingivoplasty 51 143 Goldenhar syndrome 203 set-back bends 177 Index of Latest design of Klapper super Grewe’s method 153 complexity 220 spring 248 Growth and development of orthodontic treatment needs Lattice imperfections and jaws 23 218 dislocations 116 Indications of H Law of canines 138 removable orthodontic Limitations of straight wire Haas expansion appliance 159 appliances 161 appliance 182 Hard various types of Frankel Linder Hart’s measurements 124 lasers 49 appliance 189 Linderharth index 124 tissue Interceptive orthodontics 16 Lineae cephalometricae 135 applications 51 Intercuspal position 181 Lingual evaluation 89 Intermaxillary elastics 25, 25f brackets 110f Healing of aphthous ulcer 56 Internal structure of teeth 23 technique 183, 183f Heavy gold wire framework 161 Interproximal Lokar appliance 245 Helical canine retractor 166 decay detection 51 Long Helices of vertical holding enamel reduction 223 axis of root 165 appliance 243 Irregularities of teeth 30, 36 labial bow 163 Herbst’s Isaacson expansion appliances Looped canine retractor 166 appliance 190, 248 157f Lower pharynx 92 262 History of Orthodontics

M Non-aqueous elastomeric dental Poor impression material 121 facial appearance 15 Magnetic strength and corrosion Non-extraction philosophy 168 oral hygiene 225 of rare earth magnets 82 Nonosseous gingival surgery 51 maintenance 15 Management of Nonsyndromic clefts 202 Posteroanterior cephalometry aphthous ulcer 56, 56f Normal lower pharyngeal 141 dentofacial anomalies 19 Post-retention survey 206 Mandibular measurement 93f Potential soft and hard tissue plane angle 90 Normalization of gingival applications of laser in procedures 196 contour 224 dentistry 51 Martensitic Normative standards in Preadjusted edgewise brackets active alloy 118 McNamara analysis 89t 110, 110f stabilized alloy 118 Number of anchorage teeth 242 Premolar Maxilla 83 basal arch width 124 McNamara analysis 94t O diameter 124 Mechanism of action of Occlusal interference 185 Primary distalizing appliances 240 Open bite appliance 190 incisions 51 Mesial cuspid bends 177 Opening midpalatal suture 25 palate 200 Metal brackets 107, 107f Optiflex archwire 117, 118 Principles of Metallic bonds and crystalline Oral space analysis 126 structure 116 lesion therapy 51 steriophotolithography 231 Method of screen 190 Properties of determining position of upper soft tissue pathologies 52 archwire 117 incisor 90f Orthodontia and orthopaedia of laser beam 48 straightening of orthodontic face 150 Protrusive upper incisors 92f wires 115 Orthodontic Pulse straightening 115 Mill’s retractor 163, 164 and dentofacial orthopedics Pulsed lasers 48 Modification of Adam’s clasp 162 20 Pyorrhea alveolaris 12 Modified and temporomandibular Jackson’s clasp 161 disorder 87 R ribbon arch 109f appliances 17, 186 Radiographic split labial bow 163 Orthopedic appliance 17, 18f cephalometry 134 Molar Orthosurgical teamwork 86 f study of facial deformity 138 band 24 Osseous recon touring 51 bayonet bends 177 Range of Deflection 118 Overcrowded teeth 15 distalization 239 Re-activation of appliance 246 Mouth guard 19 P Reflection 48 M-pendulum appliance 241 Removable Multiple missing teeth 203 Palatal canine retractor 166 molar distalization splint 244 Multistrand archwires 118 Pallaquium gutta 120 orthodontic appliance 17, 17f Myofunctional orthodontic Paris Society of Anthropology prosthetics 52 appliance 18f 137 Removal of Pend-X appliance 241 fibroma 51 N Periodontal regeneration granulomatous tissue 51 surgery 51 Nance redundant gingival tissue 56 analysis 129 Periodontics 51 Residual ridge modification 52 method 153 Permanent teeth 52 Retentive components 162 Narrowed maxillary arch 146 Pfeiffer syndrome 203 Reverse labial bow 163 Nasal Pierre Robin syndrome 203 Ribbon arch deformity 203 Pieter camper 135 appliance 68, 69f, 172, 172f septum 200 Pin and tube brackets 109, 109f Natural history of human teeth appliance 68, 69f, 171, 173f Risk of 23, 34, 45 technique 27 dental caries 15 Nd:YAG laser 49, 50 Placement of virtual gingiva 231f periodontal diseases 15 Nickel-titanium alloy 117, 118f Plastic brackets 107, 108f Roentgen ray anthropometry of Night guards 19 Pont’s index 123 skull 137 Index 263

Role of upper second molar Strength of wire 119 Two palatine shelves 200 extraction in orthodontic Structural balance 15 Types of treatment 78 Studies on Frankel appliance 189 Root desensitization 51 functional appliances 93 heat treatment 117 rapid maxillary expansion 95 laser 49 S TMJ 96 U Saethre-Chotzen syndrome 203 Submerged deciduous teeth 219 Scandinavian studies 206 Supernumerary teeth 219 Unfavorable sequelae of Schwartz clasp 162 System of dental surgery 29 malocclusion 15 Scope of orthodontics 18 T Upper pharynx 92 Second premolar extraction 147 Uses Secondary palate 200 Temporomandibular joint 14 in orthodontics 121 Self-ligating bracket 111, 111f, Thickness of button 244 of bionatar 190 113, 113f Timing of orthodontic Severe crowding 225 intervention 18 V Shape of teeth 225 Timm’s schedule of activation of Van der Woude’s syndrome Short labial bow 163 expansion screw 159t 203 Single width bracket 111 Tooth Variable bracket sitting Size of acrylic button 243 shape and dental esthetics 224 procedures 102 Soft size discrepancy 224 Veau’s classification 201 lasers 49 whitening 56f, 57 Velocardiofacial syndrome 203 tissue Total space analysis 130 Vertical evaluation 89 Treacher-Collins syndrome 203 holding appliance 243 modification 52 Triangular clasp 162 position of lower incisors 92 Solidification of metals 116 Tube plates for distalization of Vestibular screen 190 Southend clasp 162 molars 244 Vestibuloplasty 51 Spheno-ethmoidal angles 136 Tuberosity reduction 52 Split labial bow 163 Tweed’s W Sports guard 19 method 152 Steiner bracket 112, 112f triangle 143, 143f Wearing invisalign appliance Stereolithographic models 230f, Twin 233f 231f arch appliance 112f Weldable brackets 109 Straight wire 180 block appliance 190 Wescott’s expansion device 154, appliance 103, 180, 181, 181f brackets 111 154f