\\\EI )S-ANGI >r v< -j %13'ONV'Sn^ cLOS ANGELA ./, .OKAI.IF(% ;ZB *J- ^ V ~ m >*^ j %HV^ail^ ^7130NV-S01^ %'M, ^lOS-ANGELfj^ ^UIBRARYfl/ : ^OJTO-JO^ %0: TREATMENT OF MALOCCLUSION OF THE TEETH AND FRACTURES OF THE MAXILLE./ ANGLE'S SYSTEM. Sixth Edition, Greatly Enlarged and Entirely Rewritten, With Two Hundred and Ninety-nine Illustrations. BY EDWARD H. ANGLE, M.D., D.D.S., Former Professor of Histology, Orthodontia, and Comparative Anatomy of the Teeth in the Dental Department of the University of Minnesota ; former Professor of Orthodontia in the American College of Dental Surgery and in the North- western University Dental School, Chicago, 111., and in the Missouri Dental College, St. Louis, Mo.; former Surgeon for the Treatment of Fractures of the Maxillre to the Great Northern R. R. and to the Asbury Hospital, Minneapolis, Minn. President of the Angle School of Orthodontia, St. Louis, Mo. ; Member of the New York Society of Stomatology ; Member of the American Dental Associa- tion ; Honorary member of the American Dental Society of Europe ; Surgeon for the Treatment of Fractures of the Maxillae to the Wabash R. R. PHILADELPHIA: THE.S. S. WHITE DENTAL MANUFACTURING COMPANY. Copyright, 1898, by EDWARD H. ANGLE. Copyright, 1900, by EDWARD H. ANGLE. Wo S tfffO To all those who have been perplexed by cases of malocclusion of the teeth and have not become discouraged thereby, but rather stimulated to a keener interest in, and a broader study of, this most beneficent, fascinating, and pro- gressive branch of dental science, this book is respectfully dedicated. PREFACE. THE issuance of this sixth edition of this work in its enlarged form, intended by the author as a culmination of his labor in this line, is inspired by various considerations. The system of appli- ances and methods of treatment introduced in the former editions have been well received, as is evidenced by the number of editions issued and by their translation into the French, German, Dutch, Scandinavian, and Spanish languages by writers in the countries where these languages prevail. As a result of busy years devoted to teaching and the exclusive practice of orthodontia, during which the science has been an absorbing study and the subject of most painstaking investigation, the author has been more and more impressed with its far-reaching importance and possibilities. He is actuated in the present instance not alone by the earnest solicitation of teachers, students, and practitioners, but also by an appreciation of the necessities of this science and the hope that the principles herein recorded may be instrumental in promoting its advancement. The subject is treated far more comprehensively in this edition than in those which have preceded it, they having been limited to the mechanical phases of the subject. Much of this early matter has been rewritten, some of it being eliminated superseded by better methods, the object always being to keep simplicity and efficiency foremost. There has been a studied effort for condensa- tion and systematic arrangement. It is believed that lumbering volumes, like multiplicity of appliances and methods, serve rather to leave the student in hazy bewilderment than to equip him for useful practice. On the other hand, a mere recital of the achievements of others, by divers means, without system or de- tail, presupposes a knowledge on the part of the student which if possessed would render the slight information imparted but a yi PREFACE. possible matter of interest, instead of a necessity of study. That this work will be found radically different in many particulars from the usual work on orthodontia is certain, especially in that many devices for regulating the teeth, which have been familiar pictures from the earliest remembrance of the subject of our oldest practi- tioners, will be found missing; not that they are eliminated on account of their antiquity, but because, analyzed never so care- fully, they fall so far short of the present requirements of a regula- ting appliance. It is believed that instead of the student being longer hampered by such crudities, they are entitled to only such respect as by right awaits them in history. It has long been the effort of the author to perfect a system which should be complete within itself a system which should include the simplest and best methods not only for the treatment of all forms of malocclusion, but for the study and diagnosis of cases, as well as for the teaching of the subject in its entirety. The degree of his success must be determined somewhat by time and the intelligent, unbiased judgment of others. In the illustrations, which are all original, the art of the photog- rapher and the skill of the engraver have been severely taxed to accurately represent cases from actual practice, with appliances and methods of treatment employed. No fanciful pen-sketches of imaginary and improbable cases, created to illuminate theoreti- cal, complicated, and impractical devices, will be here found. The ideas expressed and the lines of practice laid down are also, except as is otherwise stated, original with the author, and he accepts full responsibility for them. A conscientious effort has been made to give proper credit for all inventions of acknowledged merit. To fair minds recorded dates are usually sufficient evidence of priority. This work is designed primarily for the instruction of students in colleges, and secondarily as a guide and ready-reference-book for practicing dentists who have not devoted special study to the subjects of which it treats. It has been said that "order is heaven's first law." Order im- plies exactness, thoroughness. Not only is an effort made to impress these principles throughout the following pages, but they have prompted the manner of doing it. Literary style has been subordinated to clearness of expression and precision of detail. PREFACE. Vll This may explain a frequent repetition of terms and methods which would be inadmissible in a narrative, but which is here indulged for the convenience of the student, that the necessity for back- reference may be reduced to the minimum. A poverty of terminology has long been felt in the science of orthodontia, but it has been deemed better to expand the meanings of terms employed, in many instances, to meet requirements than to increase the vocabulary by introduction of new words. Thus the term "malocclusion" is often used, for convenience, to ex- press the condition of malposition of a tooth which has no occlu- sion at all with other teeth. "Elevating" is a term employed with similar license. We may speak of elevating a tooth in the upper arch when we really pull it down, and so with other usage the meaning of which should be clear. The author expresses obligations to Professor Black for some suggestions in regard to the arrangement of the subject-matter, and to Professor Noyes for the use of selections from his valuable col- lection of microscopical slides of the peridental membrane, and also for actual work in the preparation of the new and excellent engrav- ings prepared especially for this work to illustrate the chapter on the peridental membrane; also to The S. S. White Dental Mfg. Co., for the excellent illustrations which they have cheerfully pre- pared and for the painstaking thoroughness of their work as pub- lishers. CONTENTS. ^ PXCE INTRODUCTION i PART L ORTHODONTIA. CHAPTER I. OCCLUSION 5 Forces Governing Normal Occlusion Forces Governing Maloc- clusion Line of Occlusion Nomenclature. CHAPTER II. FACIAL ART. LINE OF HARMONY 15 CHAPTER III. ETIOLOGY OF MALOCCLUSION 23 Premature Loss of Deciduous Teeth Prolonged Retention of De- ciduous Teeth Loss of Permanent Teeth Tardy Eruption of Permanent Teeth Supernumerary Teeth Habits Disuse Nasal Obstructions Abnormal Frenum Labium. CHAPTER IV. CLASSIFICATION AND DIAGNOSIS OF MALOCCLUSION 34 Class I Class II, its Divisions and Subdivisions Class III and its Divisions. CHAPTER V. ALVEOLUS AND PERIDENTAL MEMBRANE 45 CHAPTER VI. MODELS THEIR CONSTRUCTION AND STUDY 57 Material for Impressions Method of Taking Impressions The Trays Taking and Removing the Upper Impression Taking and Removing the Lower Impression Pouring and Separating the Model Value of Good Models Photographs of Patients. CHAPTER VII. REGULATING APPLIANCES PRELIMINARY CONSIDERATIONS 67 The Old and the New Methods Epochs in the History Requisite Qualifications of Appliances Materials for Construction. CHAPTER VIII. THE AUTHOR'S APPLIANCES 81 General Description of Tools and Instruments. CHAPTER IX. SOLDERING ^ 95 Plain Bands, their Construction and Attachments Clamp Bands and their Adjustment. ix X CONTENTS. CHAPTER X. PAGR ANCHORAGE 109 Principles Details. CHAPTER XL COMBINATIONS OF APPLIANCES 1 16 Jack-screw Lever Traction Screw Expansion Arch, its History and Combinations Miscellaneous Combinations. CHAPTER XII. RETENTION 150 Time Required Temporary and Permanent Devices Principles and their Application. CHAPTER XIII. TISSUE CHANGES INCIDENT TO TOOTH MOVEMENT 166 Alveolus Membrane Pulp. CHAPTER XIV. OPERATIVE SURGERY 173 Immediate Movement Alveolar Section Resection of Peridental Fibers Section of Frenum Labium Double Resection of Maxilla. CHAPTER XV. PHYSIOLOGICAL CHANGES SUBSEQUENT TO TOOTH MOVEMENT 184 CHAPTER XVI. AGE APPROPRIATE FOR TREATMENT 188 Time Required for Treatment. CHAPTER XVII. TREATMENT 192 Direction of Efforts Correction of Malocclusion Harmony in Rela- tions of Jaws Harmony of Facial Lines Treatment of Class I. CHAPTER XVIII. TREATMENT OF CASES. CLASS II, DIVISION i 234 CHAPTER XIX. TREATMENT OF CASES. CLASS II, DIVISION 2 263 CHAPTER XX. TREATMENT OF CASES. CLASS III, DIVISION 268 CHAPTER XXI. TECHNIQUE 280 CHAPTER XXII. GENERAL SUGGESTIONS 281 PART II. FRACTURES OF THE MAXILLA. TREATMENT 285 INTRODUCTION. MALOCCLUSION of the teeth is found in all races and even oc- casionally among the lower animals, and has in all probability been one of man's afflictions from time immemorial, but that it is becoming more common as civilization progresses is very generally agreed. The real growth of dentistry is of comparatively recent years, and along lines having little in common with orthodontia, so that this branch received little attention until within the last half-cen- tury, and it is probable that more real interest has been awakened and more real advancement made in the last thirteen years than in its entire previous history. Much has been written upon the subject of orthodontia, and its various lines have been quite broadly and ably studied. It has passed through marked evolutionary stages to its development as a distinct science, the broad possibilities of which are even yet but dimly comprehended by those who have not given it careful study. In the light of our present knowledge much of the theory, as well as of the practice, of even a few years ago seems strikingly crude. Of such theory and practice was the common advice to young patients to "let the teeth alone and trust to Nature to straighten them," or to wait until the permanent dentition should be complete before making any effort toward their correction. Of such was the unfortunate sacrifice of teeth with a mistaken view of relieving the crowded condition of the arches, but with the result often of ag- gravating the malocclusion and giving rise to a serious train of evils, as shown in the chapter on etiology. So also the use of huge 2 MALOCCLUSION. plates combined with springs taken from clocks and various strange mechanisms as a means of tooth movement, which now seems more in accordance with many of the teachings of medicine during the period of history known as the "dark ages." Until within a very few years the teaching of orthodontia in dental colleges was very superficial, even ofttimes being wholly omitted from the curriculum. Now, however, in some of our col- leges separate chairs are established and the subject is far more comprehensively taught. Yet it must be apparent to all thoughtful observers that there is great opportunity for further improvement in this direction. In some colleges this branch of the science is still made entirely subservient to others, notwithstanding the fact that it is regarded by all to be the most difficult and exacting of any of the branches of dentistry, if not of medicine. In fact, so exacting are its requirements, both in teaching and in practice, that, unlike the general practice of dentistry, the mere smatterer can never hope for even moderate success, for often apparently very simple cases of malocclusion are in reality only symptoms of condi- tions whose management requires the broadest knowledge and mature judgment. Orthodontia is a subject so great, so important, and offering such possibilities and rewards, that it is ample in itself for the life- work of the best minds, and it is the author's firm belief that it should be regarded as a distinct specialty, and that it should be taught and practiced as such. The tendency in this direction is gratifying, and should receive encouragement from the fact that most lines of science are rapidly passing into those of specialties, with far more rapid progress as a result. Where now there are but two or three specialists in the world who give their entire time to orthodontia, there should be as many in at least every large city, for no one can doubt that there is a great demand for such service. Every dentist who is endowed with a natural ingenuity and who is studiously devoted to his profession should find an absorbing INTRODUCTION. 3 interest in this study. His adaptability to its mastery will be de- termined by conscientious application, and if successful his efforts will be amply rewarded. He will, in any event, find gratification in the consciousness that he will have deepened his conceptions of the science, will have widened the scope of his practice, and will at least have avoided many of the disastrous errors now common in dental practice. The importance, however, of the proper breadth and thoroughness in the preparatory study, before attempt- ing operations in orthodontia, cannot be too strongly impressed. Malocclusion of the teeth has become so common that it is now almost the rule, rather than the exception. Go where we will, wander down the village street or the crowded avenues of great cities, in churches or theaters, or wherever humanity congregates, and we will be confronted by these deformities in such numbers that we are amazed at their prevalence. And in proportion as malocclusion exists so are the functions of the teeth and speech im- paired, and the facial lines marred. The opportunities and pos- sibilities of improvement of the features by proper treatment of mal- occlusion are so great, and the appreciation of the patients and their friends so genuine when the work has been quickly and intelligently performed, that we wonder that a closer study and keener interest in the subject by practitioners was not long ago awakened, and are surprised that so few have any conception of the possibilities of orthodontia for the improvement of the human face. Unfortunately in the past, and still to a large extent, the progress of orthodontia has been seriously handicapped by the apparent belief that the science consisted in the designing and con- structing of regulating appliances. The instructions that many students still receive on this subject would seem to be in harmony with this belief. In reality the regulating appliances are only secondary to many more important considerations. They are only a means to an end, and are no more to the orthodontist than are the colors to the artist, whose success depends upon the breadth of 4 MALOCCLUSION. his knowledge, the purity of his conception, and his skill in their use. It is not enough to simply move into correct alignment irregular teeth. We should have a proper conception of the influence of the malocclusion in arresting or modifying the development of the alveolus, jaws, and muscles, and in shaping the contour of the face. We must consider the numerous possible changes which may follow the movement of teeth into correct positions, with the restoration of the natural functions of the occlusal planes, and the assistance the changes will lend to nature as they stimulate her to efforts for the continuation of normal growth and development of all the related parts, that they may be in best harmony with Nature's plan, as well as with each other in their new relations. It is now well known that the structural changes which follow the correction of malocclusion are often pronounced. In many cases there can be no intelligent diagnosis or plan of treatment unless the change probabilities be fully considered. PART 1. ORTHODONTIA. CHAPTER I. OCCLUSION. THE term "irregularities of the teeth," as it is usually applied to express the condition of abnormal arrangement, does not, in the author's opinion, properly express the full meaning of these de- formities. It would seem that the term malocclusion would be far more expressive; for in studying the subject we must fully ap- preciate the importance of the dental apparatus as a whole and the important relations, not only of the two arches to each other, but of each individual tooth to all other teeth in both arches. The shapes of the cusps, crowns, roots, and even the very struc- tural material of the teeth and their attachments, are all designed for the purpose of making occlusion the one grand object, in order that they may best serve the purpose for which they were intended, namely, the cutting and grinding of food. Examined carefully it will be seen that perfect occlusion is in- compatible with any degree of irregularity, but that the arrange- ment of the teeth must be even and regular, each contributing sup- port to the others, all in perfect harmony. Not only this, but the jaws, the muscles of mastication, the lips, and even the facial lines will then be in best harmony with the peculiar facial type of the individual. Therefore, we should be constantly impressed with the impor- tance of perfect occlusion in the study and treatment of these de- formities, instead of making occlusion secondary, or even losing sight of it entirely, as has been too much the practice in the past. The author has become firmly convinced that occlusion is the i 5 6 MALOCCLUSION. very basis of the science, and that in the treatment unless occlusion be established the results will be largely in the nature of failures, for the correction of malocclusion is but the establishing of har- mony of the occlusal planes. So in the pages that are to follow he will make occlusion the central thought, and on it base the classification of malocclusion, as well as the nomenclature, and will define orthodontia (from the Greek o>#?, straight, oVW, 9 , tooth) as being that science -which Ms for its object the correction of mal- occlusion of the teeth. Malocclusion is but the perversion of normal occlusion, and in order to intelligently comprehend it it is of the utmost importance that we first thoroughly consider normal occlusion and the princi- ples which are operative in establishing and maintaining it. Occlusion, as the basis of the science of orthodontia, is the stu- dent's most important lesson. Its proper comprehension pre- supposes a knowledge not only of the normal relations of the occlusal surfaces of both permanent and deciduous teeth, but of their forms, structure, and attachments, their growth and develop- ment, and as well of the jaws and related muscles. His perceptions of the subject should be broadened also by a comparative study of the occlusion of the teeth of the lower animals. The limits of this work will not permit the extended consideration of these funda- mental requisites, for which the student is referred to the following excellent works: "Anatomy and Histology of the Mouth and Teeth," by Professor I. N. Broomell; "Dental Anatomy," by Pro- fessor G. V. Black, and "Comparative Anatomy of the Jaws and Teeth," by Professor A. H. Thompson. By referring to Figs. I and 2, which represent the teeth in ideal normal occlusion, it will be seen that each dental arch describes a graceful curve, and that the teeth in these arches are so arranged as to be in greatest harmony with their fellows in the same arch, as well as with those in the opposite one. The lower arch is somewhat smaller than the upper, so that in occlusion the labial and buccal surfaces of the teeth of the upper jaw slightly overhang those of the lower. The key to occlusion is the relative positions of the first molars. In normal occlusion the mesio-buccal cusp of the upper first molar is received in the buccal groove of the lower first molar; the teeth posterior to the first molars engage with their antagonists in a OCCLUSION. precisely similar way; those anterior interlock with one another in the interspaces till the incisors are reached; of these the upper over- E.H A. FIG. 2. ZYGOMA hang the lower about one-third the length of their crowns, usually, though the length of the overbite varies, being greater in the teeth 8 MALOCCLUSION. indicating the bilious and nervous temperaments, and less in the sanguineous and lymphatic types. The upper central being broader than the lower, it necessarily extends beyond it distally, overlapping in addition about one-half of the lower lateral; the upper lateral occludes with the remaining portion of this tooth and with the mesial incline of the lower cus- pid ; the mesial incline of the upper cuspid occludes with the distal incline of the lower cuspid, the distal incline occluding with the mesial incline of the buccal cusp of the lower first bicuspid. In the same order the series of buccal cusps of the bicuspids occlude, the mesial incline of each occluding with the distal incline of the corresponding lower tooth. The distal incline of the second upper bicuspid occludes with the mesial incline of the mesial cusp of the lower first molar. The mesial incline of the mesial cusp of the upper first molar occludes with the distal incline of the mesial cusp of the lower first molar; the distal incline of the mesial cusp of the upper first molar oc- cluding with the mesial incline of the distal cusp of the lower first molar; the mesial incline of the distal cusp of the upper first molar occludes with the distal incline of the distal cusp of the lower first molar, the distal incline of this cusp occluding with the mesial in- cline of the mesial cusp of the lower second molar. This same order is continued with the second and third molars, the distal incline of the distal cusp of the upper third molar having no oc- clusion. It will thus be seen that each of the teeth in both jaws has two antagonists or supports in the opposite jaw, except the lower central and the upper third molar. As the inclined planes match and harmonize most perfectly in the bucco-occlusal relations of the teeth, so there is a similar ar- rangement in the linguo-occlusal relations, except that the lingual cusps of the lower bicuspids and molars project beyond the upper into the oral space. Likewise in the transverse arrangement, the buccal cusps of the lower molars and bicuspids pass between the buccal and lingual cusps of the upper molars and bicuspids, and the lingual cusps of the upper molars and bicuspids between the buccal and lingual cusps of the lower molars and bicuspids. The grinding-surfaces are thus enormously increased in extent OCCLUSION. 9 and efficiency over what would be possible if they consisted of a single row of cusps or of plane surfaces. But increase of masticating- surface is not the only, perhaps not even the most important, reason for this complex interdigitation of the cusps and inclined planes of the teeth, but its main office is to provide for the teeth a mutual support. The sizes, forms, in- terdigitating surfaces, and positions of the teeth in the arches are such as to give to one another, singly and collectively, the greatest possible support in all directions. Forces Governing Normal Occlusion. An important part played by the inclined planes of the cusps is in influencing the direction of the teeth while erupting and taking their positions in the arch. If, however, their influence be perverted, they may become mis- chievous factors in the production of malocclusion. When the teeth first emerge from the gums considerable dis- placement is often noticeable, but this need occasion no uneasiness, provided as eruption progresses their cusps pass into the normal influence of the inclined planes of the opposing cusps ; but once passed beyond the normal influence into the abnormal they will not only be' deflected from their proper relations in the arch, but they will assist in the displacement of the opposing teeth as well, and oftentimes of those which are to follow in eruption. So there may be times when the dividing line between harmony and in- harmony of occlusion is very slight. Hence the importance of careful attention during the important period covering the erup- tion of the permanent teeth, especially the beginnings. Harmony between the upper and lower arches and their teeth is also powerfully promoted by their normal action and reaction upon each other. As the teeth of the lower arch erupt before those of the upper, and are consequently to an extent fixed in their posi- tions before their antagonists appear, it follows that the lower arch is the form over which the upper is molded. In other words, the lower arch exerts a controlling influence over the form of the upper and the positions of the teeth therein. Of course, the upper re- acts upon the lower, but it is unquestionable, in the author's opinion, that the lower arch is the more important factor, not the upper, as has hitherto been taught. It will thus be readily seen how greatly one arch contributes to the other in maintaining its form and size, so that pressure, as for IO MALOCCLUSION. example on the labial surfaces of the upper incisors, would be resisted not only by all the upper teeth acting as blocks of stone in an arch of masonry, but also by the teeth of the lower arch acting through occlusion. Inversely, then, one arch cannot be altered in shape without modifying that of the other, nor can it be altered in size without soon exercising a marked effect on the other. This important fact is of the greatest interest to us as students of orthodontia, namely, that in a case of perfect occlusion, as in the illustrative case shown, each tooth is not only in perfect har- mony with every other, but helps to maintain it in its harmonious relations, for the cusps interlock and each sloping plane serves to not only keep the tooth in position, but to prevent it from sliding out, and to wedge it into position if slightly malposed, that is if not beyond the normal influence of the inclined planes. A careful study of the relations of the inclined planes and the marginal, triangular, and oblique ridges, in connection with the movements of the jaw, cannot fail to impress thoughtful persons not only with the influence which these exert in maintaining each individual tooth in correct position, but as well their wonderful efficiency for incising and triturating the omnivorous food re- quired by man, and with their marvelous arrangement for self- cleansing and consequent self-preservation. Harmony in the sizes and relations -of the arches is further as- sisted by another force, namely muscular pressure, the tongue act- ing upon the inside, and the lips and cheeks upon the outside of the arches. The latter, if normal in development and function, serve to keep the arches from spreading, as do hoops upon the staves of a cask; the former prevents too great encroachment upon the oral space. I am satisfied that this muscular pressure is a far more important factor than is generally recognized. So it will be seen that the occlusion of the teeth is maintained, first, by the occlusal inclined planes of the cusps; second, by the support given by the interdependence of the arches due to their harmony in sizes when in normal relations; third, by the influence of the muscles labially, buccally, and lingually. The illustrations show the result where these forces have acted normally, a har- moniously aligned and occluded denture. Forces Governing Malocclusion. These forces not only con- OCCLUSION. II tribute to maintaining the teeth in their normal positions and to harmony in the sizes of the normal arches, but they are equally powerful in maintaining inharmony in the sizes or relations of the arches and malocclusion of the teeth, when once established. In a large percentage of cases of malocclusion the arches, are more or less contracted, and as a result we find the teeth crowded, bunched, and overlapping, or, as crudely designated by one author, "jumbled." In these cases the lips serve as constant and powerful factors in maintaining this condition, usually acting with equal effect on both arches, and effectually combating any influence of the tongue or any inherent tendency on the part of Nature toward self-correction. In other words, the narrow and diminished sizes FIG. 3. of the arches are fixed, and they are prevented from enlarging by the lips with a force equal in power to that exerted when the arches are of normal size and the teeth in normal occlusion. Likewise, each inclined plane of the cusps out of harmony in the occlusion serves to maintain it in its malposition, or to wedge it still farther out of position, upon each closure of the jaw. It is interesting and instructive to note the result of these forces even in the earliest in- dications of malocclusion. Fig. 3 illustrates a developing form of malocclusion, very com- mon and familiar to all observing dentists. The case is that of a child where the four lower permanent incisors are fully erupted, but one of them (the left lateral) has been deflected lingually, Fig. 4. The arches being thus deprived of the wedging and retaining in- 12 MALOCCLUSION. fluence of this tooth, the external pressure of the lips has closed the space and diminished the size of the arch. At the same time pressure of the lips and cheeks (aided by the occlusal planes) is gradually molding the upper arch to conform to the abnormal size of the lower. It will thus be seen how effectually the maintenance of the mal- occlusion has been provided for, and how hopeless it is to expect Nature to correct this deformity unaided. As well might we ex- pect the self-cure of strabismus of the eye or curvature of the spine. How absurd, even pernicious, then, is the common advice of many FIG. 4. dentists to parents to "Let Nature alone and the teeth will straighten themselves." These same influences may be traced in a similar manner in any case of malocclusion. Recognizing the potency of these influences it must be apparent to every thoughtful observer that cases of this kind, instead of being self-corrective, will become more and more complicated as time goes on and as each succeeding permanent tooth shall be erupted. In all such cases the positions of the incoming perma- nent lower incisors should be guarded with zealous care, and should be maintained by corrective procedure if necessary. Then, unless there be unusual influences or tendencies toward malocclusion, the positions of the teeth in the upper arch will be directed normally. On the other hand, for the reason previously stated, if the teeth of the lower arch be permitted to remain in malposition even to the slightest overlapping of one or more of the incisors or cuspids, OCCLUSION. 13 the normal size of the arch will be diminished to that extent, with a corresponding contraction of the size of the upper arch and some form of bunching, as a result of the influence of the lips. So we can with much confidence, by examining a model of either the upper or lower arches of a case belonging to Class 1 of malocclusion, determine the extent of malocclusion in the op- posite arch. The length of overbite of the teeth in the upper arch will, of course, modify this rule, though but slightly. The con- forming of one arch to the other seems to be Nature's plan of patching up her deformities in order to render the teeth as efficient as possible, even in malocclusion. If the reader will turn to the figures illustrating Class II, Division 2, and Class II, Division 2, Subdivision, he will find even more striking illustrations of the in- fluence of the muscles in molding the upper arch to conform to the lower. Finally, recognizing the influence of the muscles and of the in- clined planes of the teeth in establishing and maintaining harmony in the sizes and relations of the arches and in the occlusion of the teeth, the folly of correcting the malpositions of the teeth in the upper arch alone without equal attention to those of the lower, as is so often done, becomes apparent. Line of Occlusion. When the teeth are in normal occlusion their greatest number of points of contact will be found to lie along an imaginary line passing over the points of the buccal cusps of the molars and bicuspids, and the cutting-edges of the cuspids and incisors of the lower arch, and along the sulcus between the buccal and lingual cusps of the upper molars and bicuspids, thence for- ward, crossing the lingual ridge of the cuspids and the marginal ridges of the incisors at a point about one-third the length of their crowns from their cutting-edges. This we shall call the Line of Occlusion, and will define it as being the line of greatest normal occlusal contact. This line describes more or less of a parabolic curve, and varies somewhat within the limits of the normal, according to the race, type, temperament, etc., of the individual, therefore the normal form of this line must be determined in any given case by the judg- ment of the operator after a careful study of the features, facial lines, forms of teeth as related to temperament, etc. In the diagnosis of cases it is important that we should have 14 MALOCCLUSION. this definite line as a more accurate base from which to reason and note variations than the less definite outline as indicated by the incisive and occlusal ends of the teeth. All teeth found out of harmony with the line of occlusion may be sard to occupy positions of malocclusion, and each tooth may occupy any of seven malpositions or their various deviations and combinations. The malpositions of teeth consist principally in the variation from the normal of the positions of their crowns, with usually little displacement of the apices of their roots, so that they incline at an angle more or less oblique from the normal. In some in- stances, however, there is some displacement of the apices as well as of the crowns, they having either developed in malpositions, or having, as in most instances, been forced from their normal posi- tions by the eruption of more powerful teeth in juxtaposition, as for example the crowding lingually of the lateral incisors by the development and eruption of the cuspids, as in Fig. 210. Yet even in such cases the displacement of the apices is more apparent than real, the marked malpositions which the crowns occupy lend- ing to the appearance of displacement of the points of their roots. Nomenclature. A definite nomenclature is as necessary in orthodontia as in anatomy. The coarse outlines and mere phrases heretofore often used are totally inadequate. The terms for de- scribing the various malpositions should be so precise as to con- vey at once a clear idea of the nature of the malocclusion to be corrected. The author therefore suggests the following, which, while perhaps not perfect, still seems to be a great improvement over present usage. For example, a tooth outside the line of occlusion may be said to be in buccal occlusion; when inside this line, in lingual occlu- sion; if farther forward, or mesial, than normal, in mesial occlusion; if in the opposite direction, in distal occlusion; if turned on its axis it would be in torso-occlusion. Teeth not sufficiently ele- vated in their sockets would be in infra-occlusion, and those that occupy positions of too great elevation would be in supra-occlu- sion. These different malpositions, in their modifications and com- binations, form the basis for limitless variations of occlusion from the normal, from the simplest to the most complex, in which may FACIAL ART. LINE OF HARMONY. 15 be involved not only the malpositions of all the teeth, but even the relations of the jaws, resulting in marked deformities and produc- ing appearances even repulsive. In order to better comprehend the varying peculiarities of cases of malocclusion it will be necessary to consider another important phase of the subject, namely, the relation of the features to the occlusion of the teeth. CHAPTER II. FACIAL ART. LINE OF HARMONY. ONE of the evil effects of malocclusion is the marring or dis- torting of the normal facial lines. It follows that, in the applica- tion of the principles of orthodontia, our efforts should be so directed as to mold and modify these lines of inharmony to those of harmony and facial beauty so far as lies within the range of the possibilities of art, and of the type and temperament of the indi- vidual. Our opportunities for benefiting humanity are very great in this field, far exceeding those offered by any other branch oi dental science, for patients with facial lines so distorted as some- times to be a marked deformity and a source of constant humilia- tion to themselves and their friends may now be so treated as to bring about a complete transformation of the facial expression, even to the establishment of lines of beauty. But, lacking a proper appreciation of the true purpose of orthodontia, we may work in such utter ignorance of the requirements of facial art, as is often done, as to not only fail to improve the appearance, but even to produce results still more unpleasing than the original condition. In order to work intelligently it is important that we shall have first fixed in our minds the- outlines of the perfect face, so that we may ever have an ideal which, like teeth in normal occlusion, shall serve as a pattern from which to note deviations and to guide us in our efforts toward the establishment of the normal. For this perfect face we shall look in vain among the people we meet. Although we may find many having more or less of the characteristics of beauty, all will be found to possess one or more lines not in harmony with the ideal face. 1 6 MALOCCLUSION. Raphael, the great artist, said, "There is nothing so rare as perfect beauty in women."* When painting the head of Galatea, he was unable to find in the faces of the living a sufficiently perfect type of beauty to serve as his model, and was compelled to substi- tute for nature a certain ideal inspired by his fancy. In proceeding to define beauty, all that the writers on art have been able to do is to affirm the expression of Albrecht Durer, that "beauty is the reverse of deformity. The more remote from de- formity, the nearer the approach to beauty." We must have recourse, then, to the purely ideal, to suggest, to guide, to vary in imitation, but never to rigidly copy. "A profile well chosen, all the features will be made to harmonize with it; and according to the profile will correspond in form the beauty of all the other features. No face was ever repulsive where the profile was beautiful, and no face can be made beautiful while the profile is ugly." Fig. 5 represents the profile of a face so perfect in outline that it has long been the model for students of facial art. It is that of Apollo, one of the Grecian mythological gods. It is supposed to be so faultless in form that to change it in the least would be to mar the wonderful harmony of proportions ; as Fuseli puts it, "Shorten the nose by but the tenth of an inch and the god would be destroyed." All the essentials of beauty found in this face can be traced with but minute variations in all other masterpieces of art representing ideal facial beauty, as the Psyche, Sistine Madonna, Medusa, Venus de Milo, etc., and consist in a short, finely curved, and prominent upper lip; a full, round, but less prominent, lower lip, with a strongly marked depression at its base, giving roundness and character to the chin. These characteristics of the lower part of the face are 'elements" of beauty wherever found, regardless of race, type, or temperament. At the present day the pure Greek type is rarely seen, but we nevertheless do see in all handsome profiles very much the same outline in the lower part of the face as has been indicated, the variations being in the upper half of the face and not in the lower. In studying the perfection of the profile it will be seen that it is in perfect harmony with a straight line at three points, namely, the most prominent points of the *Bell's Anatomy of Facial Expression. FACIAL ART. LINE OF HARMONY. l"J frontal and mental eminences and the middle of the ala of the nose. As a convenience we shall call this the line of harmony. It will be found of great value as a basis of diagnosis, serving the same purpose in the esthetics of the face as does the line of occlu- sion in indicating the variations of the teeth from the normal alignment. FIG. 5. Fig. 6* shows the application of this line to another face of much beauty, which, it will be seen, is in harmony at the three points above indicated. Fig. 7* shows still another very beautiful face, in which it is easy to note how nearly the line of harmony approaches the ideal ; while Fig. 8 shows another face in many respects quite perfect, *Copyright, Morrison, Chicago. 3 i8 MALOCCLUSION. FIG. 6. FIG. 7. FACIAL ART. LINE OF HARMONY. FlG. 8. FIG. 9. 20 MALOCCLUSION. but when measured by the line of harmony we may quickly detect its variations from the ideal and the consequent unpleasing effect. Fig. 9 shows the profile of still another face in which the variation from the line of harmony is very great, and the result a real de- formity. As we readily find that any variation in any region of the profile may be easily detected upon application of this line, we will apply the terms pro- or sub-, according to development and location, to designate these variations, as for example sub-intermaxillary, de- FIG. 10. noting an arrested development in the region of the intermaxillary bones; or pro-intermaxillary, to describe the opposite, or exces- sive development: pro-inferior maxillary and sub-inferior maxil- lary, to designate excessive or deficient development or protrusion or retrusion of the maxilla ; or pro-mental and sub-mental develop- ment, to denote excess or deficiency in the development of the chin; or pro- and sub-dental, to denote the excessive inclination outward or inward of the incisors, etc. In like manner prominence or deficiency in the development of the lips may be indicated. Fig. 10 illustrates sub-mental development ; Fig. 1 1 illustrates pro- labial and sub-mental development. These terms seem to the author to far more nearly meet our FACIAL ART. LINE OF HARMONY. 21 requirements than the very limited and commonly employed terms, prognathism and orthognathism, which were introduced by the craniologist for describing the variation of the facio-cranial angle of man and the lower animals, but which are wholly inadequate for expressing the variations caused by malocclusion of the teeth and asymmetrical development of the bones and muscles of the face. FIG. ii. Judgment and practice are necessary in making use of this line in order not to mistake the mal-condition of one region for that of another. As for example in that class of cases of malocclusion represented by Fig. 12, the mistake is commonly made of supposing it to be pro-intermaxillary development, while in reality the devel- opment is, in nearly every case, sub-inferior maxillary, as is proven by Fig. 13, which represents the same face after treatment. This consisted principally in sliding the lower jaw forward to obtain normal occlusion of the teeth, which was made possible by first establishing harmony in the line of occlusion, as described under 22 MALOCCLUSION. treatment of cases of malocclusion belonging to Class II, Divi- sion i. FIG. 12. FIG. 13. All who hope to attain real success in the correction of malocclu- sion should cultivate a love for art and the beautiful, and form the habit of observing and carefully studying the normal and abnormal lines of the human face, together with their relations to and de- pendence upon the occlusion of the teeth. An appreciation and ETIOLOGY OF MALOCCLUSION. 23 intelligent application of the principles of art must ever go hand in hand with the successful practice of orthodontia. The ease and certainty with which teeth are now moved by means of modern regulating appliances has opened up great possi- bilities in this field of facial art, and there can no longer be just excuse for ignoring this most important phase of the subject. CHAPTER III. ETIOLOGY OF MALOCCLUSIOX. THE causes which are operative in producing malocclusion, many of which are as yet imperfectly understood, are usually divided into inherited and acquired. Interesting and common observations of every one are inherited peculiarities of children, such as voice, gestures, gait, traits of character, etc., and, of special significance to us, peculiarities in the form, structure, or arrangement of the teeth which are often striking. A misshapen central or cone-shaped lateral of, diminu- tive size has been frequently traced through several generations. So may the arrangement of the teeth in the arches, like the family likeness in faces, be traced to the father, mother, or grandparents, and doubtless often to remote ancestors. It is the author's ob- servation that when malocclusion is inherited the deformity is often intensified in the patient. The intermarriage of different races is commonly regarded as a prolific cause of malocclusion of the teeth, especially if the parents present marked differences physically or mentally, the supposed effect being the inharmonious development of the offspring, with malocclusion of the teeth as one of the results. For example, if one of the parents has large jaws and large teeth, while the other has small jaws and small teeth, the child might inherit large teeth from one and small jaws from the other, the result being necessa- rily a crowded and malarranged condition of the teeth. But this possibility, though seemingly plausible in theory, is open to seri- ous doubts to all students who study the question carefully, as Nature's plan is to harmonize the proportions of the anatomy. It is, however, a well-known fact that many children, while in- 24 MALOCCLUSION. heriting no direct peculiarities of the teeth or jaws, yet receive by transmission tendencies to physical degeneracy which may be manifested in irregularities of the teeth and asymmetrical develop- ment of the jaws, as well as in derangements of other parts of the anatomy. But far more numerous are the causes which are operative after birth, which act mechanically, and which are principally local. Premature Loss of Deciduous Teeth. Nature has designed for the deciduous teeth not only the important function of masticating the food required by the child up to the period of their normal loss and their replacement by the succeeding -permanent teeth, but also that of assisting in a mechanical way in the develop- ment of the alveolar process, and as well, probably, the develop- ment of the jaw. The permanent teeth being larger and more numerous than the deciduous, the greater space required by them is provided prin- cipally by the lengthening of the lateral halves of the dental arches. This is influenced largely by the development and eruption of the permanent molars posterior to the deciduous molars. If the mesio-distal diameters of the deciduous teeth be not impaired by caries and the teeth remain the normal period, the first permanent molar in taking its position in the arch must force its way between the second deciduous molar and the ramus of the jaw if below, or the maxillary tuberosity if above. Coincident with the development of the jaw the deciduous teeth are carried forward, and the normal mesio-distal lengthening of the process takes place. If, however, one of the deciduous teeth be prematurely lost, as for example the lower first molar, the in- coming permanent molar will exert its wedging influence only distally to the lost tooth ; it will occupy a portion of the space, and will not cause any forward movement of the anterior teeth. If, meanwhile, no teeth have been lost in the same side of the oppos- ing arch the wedging process will have pushed forward the decid- uous teeth and the normal development will have occurred. There will thus be an inequality between the jaws on the affected side, with the establishment of malocclusion. And this is not the only evil, for, the space occupied by the lost tooth having been closed or greatly diminished, the eruption of the succeeding permanent tooth (first bicuspid) will be prevented entirely, or it will be forced ETIOLOGY OF MALOCCLUSION. 25 into buccal or possibly lingual occlusion, as in Fig. 131. The shortened lateral half will not develop and the lower arch will con- sequently be smaller than normal, which must result in protrusion of the upper incisors by the lower lip being forced beneath them, or, as we have already noted, in an irregular arrangement of the teeth in the upper arch through the effort of Nature to restore harmony in the sizes of the two arches by lip pressure. A similar result from the premature loss of the deciduous cuspid may be seen in Fig. 273 ; also, of the incisors and cuspids, Figs. 206 and 208. While probably the greatest harm results from the premature loss of the second deciduous molar or cuspid in either arch, yet the principle applies to the loss of any of the deciduous teeth, the difference being only in degree. This is only another lesson in occlusion. Rare instances have been reported where no evil effects have followed the premature loss of deciduous teeth, especially the upper incisors and cuspids, yet this not only indi- cates that in those cases there was unusually good natural develop- ment of the jaw, but proves the absence of any unfavorable tenden- cies, either acquired or inherited. Had there been any such tendency, in all probability malocclusion would have resulted. The mechanical influence of the deciduous teeth in the develop- ment of the dental arches is so important that they should not only by all means be retained their full normal period, but if they be- come affected by caries their full mesio-distal diameters should be restored by suitable fillings after sufficient separation. Likewise, if a deciduous tooth be lost through the premature absorption of its root, the full space occupied by it should be main- tained by some suitable retaining device. This may be easily and quickly effected by making small pits in the approximal surfaces of the teeth mesial and distal to the space and inserting the ends of a section of the wire G therein, after which the wire may be lengthened by a few pinches of the regulating pliers, or as in Fig- H5- Prolonged Retention of Deciduous Teeth. For reasons not always clearly recognized, one or more of the deciduous teeth are occasionally retained beyond the normal period. This is due to failure of absorption of the root, resulting from death of the pulp or other cause. In this event the succeeding tooth will either be prevented from erupting or will be deflected to a malposition. 26 MALOCCLUSION. Deflection may also be caused by the survival of even a small portion of the root. Loss of Permanent Teeth. What we have already said in re- gard to the mechanical influence of the deciduous teeth in assist- ing the normal development of the dental arches and promotion of harmony of the facial lines is equally applicable to the teeth of the permanent set up to the period of their full eruption, or until the last of the molars have taken their positions. This is a point of such importance that it should be carefully considered by all teachers and students. If one or more of the permanent teeth anterior to erupting molars be extracted, the wedging process so necessary in developing the arch serves only to close the space thus made, and there will be no carrying forward of the teeth and pro- cess. The evil effects already enumerated as arising from unequal development of the two arches will follow. It should also be borne in mind that the interdependence of the teeth is so great at all times that the loss of one or more at any period in their history must have a marked influence upon the remaining teeth. Each tooth is such an important part of occlusion that its loss should be seriously considered before deciding upon its removal. Occasionally we hear of some one advocating the sacrifice of the first molar (one or more) as a prevention or cure for malocclusion. The author has yet to see a single case where the loss of this tooth has not been followed by malocclusion, or aggravations of it if formerly existent, often of a far-reaching and serious nature. The loss of no other tooth is followed by so many and so marked evil effects as that of the first molar, especially the lower. The size, position in the arch, and the relations of this tooth to the others are such as should entitle it to the greatest care with a view to its longest possible preservation. If unavoidably lost, it should be immediately replaced by some form of artificial substitute. The author has seen one patient where all of the first perma- nent molars were extracted at the age of nine years, with a view of preventing developing malocclusion of the incisors. The result was shortening of both of the arches anterior to the spaces, greatly deforming the patient, who, although a young lady of but sixteen years, yet had an undeveloped, sunken appearance about the mouth similar to that of an edentulous person, while apparently no relief had been given to the crowded arrangement of the incisors. ETIOLOGY OF MALOCCLUSION. 2/ Fig. 14 shows a case of malocclusion, the cause of which was directly traceable to the unwarranted extraction of several of the permanent teeth. First, the two lower first molars were extracted between the ninth and tenth years of age. The main support and guide as to the normal length of bite being thus removed, the oc- clusal edge of the lower incisors impinged upon the linguo-gingival inclines of the upper, rapidly forcing them into labial protrusion, the tendency also being to force the entire lower jaw distally and prevent its normal development. This condition was further inten- sified, first, by the normal lengthening of the upper arch and FIG. 14. arrested development of the lower ; and second, by the pressure of the lower lip, which habitually rested between the upper and lower incisors. Later followed the loss of other teeth by extraction, which only augmented the untoward conditions already enumerated, the re- sult being the establishment of such marked malocclusion as to make the dental apparatus almost useless, as well as the alteration of the features of the patient into a real deformity; and this, too, with facial lines and form and structure of teeth naturally much above the average. Similar cases with like results are only too common. The evil effects arising from extraction of the upper lateral incisors in order to provide space in the crowded arch for the cus- 28 MALOCCLUSION. pids are so apparent that arguments against the practice seem out of place in a modern text-book. The abnormal appearance given to the face in the region of the nose consequent upon the dimin- ished size of the upper arch, together with the carnivorous appear- ance of the mouth by the resultant prominence of the cuspids, is a deformity as inexcusable as it is repulsive, and must ever reflect the ignorance and incompetency of those resorting to the practice. For a further discussion of this point we would refer the reader to the chapter on Treatment of Cases belonging to Class I (see also Figs. 208, 215, and 216) and to the classical articles of Drs. Bogue and Davenport in the Dental Cosmos, December, 1899, and Inter- national Dental Journal, 1892, respectively. Tardy Eruption of Permanent Teeth. It occasionally hap- pens that a tooth, with or without apparent cause, fails to erupt and remains imbedded in the alveolus for months, or even years. Usually the space is partially or wholly closed by the ad- joining teeth. The impaction of the cuspid is the most common of that of any of the teeth, owing to the fact that it erupts after both its mesial and distal associates and must in all cases meet more or less resistance from them. If, later, efforts toward eruption occur, the tooth must necessarily be deflected or force other teeth into malposition. It is quite probable that so-called "third dentitions" are only instances of tardy eruption of some one or more of the permanent teeth. Supernumerary Teeth. Supernumerary teeth, as their name implies, are anomalies, or extra teeth above the normal number of thirty-two. In outline they rarely resemble any of the typical tooth forms, being most commonly peg-shaped or conical. Although they may occur in any part of the dental arches, or even nearly cover the entire vault of the upper arch, as shown in a model in the author's collection and also in two or three other well-known cases, their favorite location is between the central incisors, in the region of the laterals, or in the bucco-embrasial spaces between the molars. The reason for their appearance is not clearly established. It is now, however, quite commonly attributed to atavism, or the occasional effort on the part of Nature to re-establish original conditions. The typical number of mammalian teeth is supposed to have been forty-four, man in his evolution having lost four ETIOLOGY OF MALOCCLUSION. 29 incisors and eight premolars. It is believed that these supernu- meraries are some of these suppressed teeth reappearing in a rudimentary form. These teeth frequently take their positions, especially in the incisive region, just before the eruption of the permanent teeth, with the effect of deflecting erupting permanent teeth from their normal course. Fig. 15 represents a model in the author's collection in which two supernumeraries are clearly shown, one between the centrals FIG. 15. and the other distal to the cuspid and somewhat resembling it Another irregularity is also here shown in that the right central is greatly oversized. Habits. The habits of sucking the thumb, lip, or tongue, so frequently formed by young children, while rarely causing dis- placement of the deciduous teeth, will if persisted in during the eruption of the permanent incisors, cause marked malocclusion. In the case of thumb-sucking fortunately the habit is usually broken before any marked evil effects result, so that cases where malocclusion has really resulted from this habit are rare and easily recognized. The upper incisors and cuspids are always drawn forward and to one side, according as the thumb of the right or left hand has been used, while pressure from the back of the thumb 30 MALOCCLUSION. upon the lower incisors causes their marked displacement lin- gually. These cases are frequently confounded with those of pro- trusion belonging to Division i of Class II. The conditions and results are very different, the latter being mouth-breathers, the former never, as such action would be a physical impossibility. This is illustrated in the difficulty which infants experience in nurs- ing while suffering from temporary obstruction of the nasal pas- sages resulting from colds. The pernicious habit of biting the lower lip, or pressing the oc- clusal edges of the upper incisors against its outer surface, has a FIG. 16. tendency to move the upper central incisors forward, thus lessen- ing their natural resistance to the narrowing of the lateral halves of the arch. Such a case is shown in Fig. 16. In this case the malocclusion was easily reduced, but the habit of biting the lip was still persisted in for a period of nearly two years, necessitating the continued wearing of the retaining device for that length of time. This habit is more common than seems to be generally supposed, is often extremely difficult to overcome, and probably accounts for many ultimate failures in tooth regulating. It is always a marked accompaniment of cases belonging to Division i of Class II and its subdivision, and unless it be overcome and the normal functions of the lips regained the incisors cannot be kept in their ' ETIOLOGY OF MALOCCLUSION. 3! normal positions. The device described and illustrated in Fig. 164 is apparently the most useful in combating this habit. This same device may also be used to successfully overcome the habit of thumb-sucking. The other habit, though quite rare, that of resting the tongue between the upper and lower incisors, produces the effect shown in Fig. 17. The pressure upon the incisal edges prevents full eruption and holds the teeth in infra-occlusion, while the molars, FIG. 17. being held apart much of the time, lengthen into positions of supra-occlusion from lack of resistance. Disuse. According to a well-known physiological law, the use of a part tends to stimulate its growth and development, as illus- trated in the well-known example of the blacksmith's arm, while disuse tends toward lack of development, or even atrophy, as illus- trated in the wings of domestic fowls as contrasted with those of wild fowls. The structure and history of the jaws and teeth show that they were intended for much use. There can be little doubt that modern methods of food preparation have a marked general effect in causing malocclusion from the lack of the development of the jaws through diminished use. 32 MALOCCLUSIOIST. Nasal Obstructions. When there is normal nasal respiration and normal relations of the dental arches, the teeth, and the muscles, the conditions are such as to perfectly maintain the equilibrium and the mutual support necessary to the normal development of the teeth and jaws. Should nasal obstruction occur in the developing child, inducing habitual mouth-breathing, immediately the equi- librium is disturbed, the lips and muscles are placed on a different FIG. 18. tension, and pressure upon the arches, instead of being equal, is localized, being greater than normal at some points and less at others. No matter how strenuously it may be denied, malocclu- sion of the teeth and abnormalities in the formation of the bones of the jaws naturally follow. The undeveloped nose and adjacent region of the face, the vacant look, the short upper lip, the open mouth, and irregular teeth of the mouth-breather are common sights familiar to all. See Fig. 18, also Fig. 24. One has but to observe those who pass on the street to be ETIOLOGY OF MALOCCLUSION. 33 convinced of the great prevalence and deforming effects of mouth- breathing, or to examine the patients in a large clinic to be con- vinced of the frequent close association of the practice and mal- occlusion. Abnormal Frenum Labium. A somewhat common form of malocclusion is distinguished by a space between the upper central incisors, Fig. 19, and occasionally, though very rarely, between the lower centrals. This space varies in width, the distance being from one to four, and even five millimeters, always presenting an unpleasing appearance and interfering with speech in proportion to its width. FIG. 19. The cause of the deformity is abnormal development and attach- ment of the frenum labium, which, instead of being normal in size and ending in its attachment to the gum about five millimeters above the gingiva, not only reaches the gingiva, but passes di- rectly through between the teeth and is attached to the likewise overdeveloped mesio-lingual tuft. This strong fibrous ligament keeps the teeth separated, not only by its passive presence, but as well by its action mechanically, as may be easily proven by gently grasping the lip between the thumb and finger and moving it from side to side in imitation of its normal movements. Whether this abnormal condition of the frenum results from an abnormal suture of the bones is not clear, yet it is probable that it is nearly always an accompaniment, although the author has seen some cases where the union of the bones seemed to be normal. A more exact knowledge, to be gained through the use of the X rays in a satisfactory number of these cases, is much needed. 34 MALOCCLUSION. In some cases there is not only a space between the upper in- cisors, but the entire alveolus seems to be drawn upward and out- ward, causing more or less of a space between the upper and lower incisors similar to the result produced by sucking the tongue. CHAPTER IV. CLASSIFICATION AND DIAGNOSIS OF MALOCCLUSION. IN every case of malocclusion presented for treatment, the im- portance of a thorough study and a correct diagnosis cannot be overestimated. Otherwise any plan of treatment will be very un- certain as to results; in fact, is most apt to lead to failure, with all of its embarrassments. From an extensive intercourse with dentists and students the author is impressed with the belief that although diagnosis is the question of greatest importance, it is yet apparently the least intel- ligently studied and comprehended. In the beginning we wish to thoroughly impress the necessity for complete separation of diagnosis from treatment. This state- ment seems necessary for the reason that we have so frequently noted a mental conflict in the endeavor to consider the two to- gether, the consideration of such questions as regulating appliances and extraction apparently preceding or being confused with diag- nosis before the facts upon which treatment should be based have had due consideration. As a matter of fact, if the diagnosis of any given case be first thoroughly mastered, the line of treatment and the appliances necessary to bring about the various tooth move- ments required are, in nearly every instance, clearly indicated, even to the devices necessary for retaining the teeth when correctly placed. In order to diagnose any case of malocclusion correctly it is necessary to be familiar with, first, the normal or ideal occlu- sion of the teeth; second, the normal facial lines. These must be so fixed in the mind as to form the basis from which to reason, all deviations from the normal being intelligently noted; and it must follow that in the absence of clear, fixed, and definite ideas as to CLASSIFICATION AND DIAGNOSIS OF MALOCCLUS1ON. 35 the normal, the limits or boundary lines of the abnormal must also be vague and indefinite, and the line of treatment be the merest empiricism. As already stated, there are but seven distinct positions which teeth in malocclusion can occupy. These, with their inclinations, form combinations practical!}- limitless in variety, to the casual observer presenting differences very pronounced. Failure to grasp the underlying principles of occlusion has given rise to the belief that each case differs radicallv from all others, necessitating- - " o the invention and construction of an appliance to meet its special requirements. In reality all cases of malocclusion may be as readily arranged in well-defined classes as plants, animals, or the elements, and having a thorough knowledge of the distinguishing characteristics of occlusion and of the facial lines peculiar to each class, the diag- nosis of any given case is greatly simplified. At the same time, familiarity with the possibilities of tooth movement and the changes necessary in each distinct and separate class to attain harmony in occlusion and in the facial lines, and acquaintance with the standard appliances best suited to produce these changes in each special class, will reduce the time and difficulties of treatment to the mini- mum. In diagnosing cases of malocclusion we must consider, first, the mesio-distal relations of the jaws and dental arches; second, the individual positions of the teeth. For convenience of diagnosis two points have been selected from which to note variations from the normal in the arches. These points are represented by dark lines in the engravings, and indicate the normal mesio-distal rela- tions of the cuspids and of the mesio-buccal cusps of the upper first molars, Fig. 2, or their relative relations, as in Figs. 22, 25, and 30. Of course, in determining the mesio-distal variations, all of the teeth are to be taken into consideration, but the points indicated have long been favorites with the author in beginning the diag- nosis of cases, for the reason that the first molars and cuspids are far more reliable as points from which to judge. This is due to the fact that they are found to occupy normal positions more often than any of the other teeth, the molars being less restrained in taking their positions, and the cuspids, owing to their history and great 36 MALOCCLUSION. size, force their way, usually, into relatively normal positions in the arches. In diagnosing all cases it is important that the occlusion of both the lateral halves of both arches receive equal and careful attention. FIG. 20. FIG. 21. A CLASSIFICATION AND DIAGNOSIS OF MALOCCLUSION. 37 Class I, represented by Fig. 20. Relative positions of jaws and dental arches mesio-distally normal, with first molars usually in normal occlusion, although one or more may be in lingual or buc- cal occlusion. (Exceptions resulting from extraction noted later.) Cases belonging to this class far exceed in number those of all other classes combined (see table), ranging from the simple over- lapping of a single incisor to the most complex derangement involv- ing the positions of all the teeth of both arches, Fig. 21. The average case is where the arches are more or less reduced in size, with a corresponding bunching of the teeth, usually confined to the incisors of both upper and lower arches. Fig. 20 represents an average case. The molars of each side are in normal mesio-distal relations, the arches shortened and the anterior teeth crowded. Class II. Relative mesio-distal relations of jaws and dental arches abnormal, all the lower teeth occluding distally to normal FIG. 23. the width of one bicuspid tooth and producing very marked inhar- mony in the incisive region and in the facial lines. This great class has two divisions, each having a subdivision. THE FIRST DIVISION is characterized by more or less narrowing of the upper arch and lengthened and protruding upper incisors, Figs. 22 and 23, accompanied by abnormal functions of the lips and some form of nasal obstruction and mouth-breathing, Fig. 24. MALOCCLUS10N. FIG. 24. FIG. 25. MM 468 468 "% *i|***^n ,-v-v-y 468 468 CLASSIFICATION AND DIAGNOSIS OF MALOCCLUSION. FIG. 26. 39 4O MALOCCLUSION. In the subdivision of the First Division one of the lateral halves only is in distal occlusion, the relation of the other lateral half of the lower arch being normal, all as shown in Fig. 25. THE SECOND DIVISION is characterized by less narrowing of the upper arch, lingual inclination of the upper incisors, and more or less bunching of the same, as in Fig. 26, and is associated with normal nasal and lip function, Fig. 27. FIG. 28. The peculiarities of the subdivision of the Second Division differ from those of the main division, just described, in that one of the lateral halves of the lower arch only is in distal occlusion, the other being normal, as in Fig. 28. Class III. The relation of the jaws and dental arches is ab- normal, the lower being more or less mesial to the upper. There is one division and a subdivision. CLASSIFICATION AND DIAGNOSIS OF MALOCCLUSION. 4! THE DIVISION comprises cases in which all the lower teeth oc- clude mesial to normal the width of one bicuspid tooth, as shown in Fig. 29, or even more in extreme cases, Fig. 30. The arrange- FIG. 29. FIG. 30. ment of the teeth in the arches varies greatly in this class, from that of quite even alignment to considerable bunching and overlapping, especially in the upper arch, Fig. 275. There is usually a lingual 42 MALOCCLUS1ON. inclination of the lower incisors and cuspids; which becomes more pronounced in proportion to the age of the patient, due to the pres- sure of the lower lip in the effort to close the mouth. The inharmony in size of arches is usually due to the asym- metrical development of the maxillary bones, the angle of the lower jaw being more obtuse than normal, but it may be the re- sult of overdevelopment in the body of the jaw. This seems to be in some cases limited to certain localities, as in Fig. 175. Another model in the author's collection shows local overdevelopment of both the lateral halves between the bicuspids, one space being greater than the width of one bicuspid tooth, the other not quite so great. In other cases the jaw seems to be normal in form, the protrusion apparently being caused by the temporo-maxillary articulation being farther anterior than normal, this probably being due to the gradual sliding forward of the condyles and to modification of the fossa. In all cases of malocclusion belonging to this class the marring of the facial lines is most noticeable, amounting in some instances to pronounced deformities, Fig. 9, also Fig. 279. In the subdivision the general characteristics are the same as those of the Division, except that the inharmony is less in degree, in that one of the lateral halves of the arch only is in mesial occlu- sion, the other being normal, as in Fig. 31, the arches crossing in the region of some of the incisors. It is quite probable that all cases met with will be found to be embraced in the above classification. There still remains, how- ever, one possible class, viz, where one of the lateral halves of the lower arch is in mesial occlusion while the other is in distal, but cases having these characteristics are so rare that no further refer- ence to them is necessary. In diagnosing cases according to the above classification it will be seen that each of the lateral halves of the arches must be con- sidered as distinctive, yet of equal importance. In developing cases the full mesial or distal relations of the opposing lateral halves of the arches may not be complete, but the teeth may be in transition, apparently occluding upon the points of the cusps, suggesting at first sight either of two classes, but upon careful inspection it will be found that a majority of the CLASSIFICATION AND DIAGNOSIS OF MALOCCLUSION. 43 inclined planes favor either one or the other of these classes, the co-relation of the first molars being of course the most important factor. , ! FIG. 31. The loss of a tooth by extraction or otherwise is usually fol- lowed by such marked changes in the positions of the remaining teeth that diagnosis is sometimes greatly complicated. There- fore great care and judgment should be exercised, making allow- ance for the tipping of teeth and other changes which have taken 44 MALOCCLUSION. place as a result of extraction, in order to determine their original positions. The classification of malocclusion is here given in brief, for con- venience of study and for ready reference. Class I. Arches in normal mesio-distal relations. Class II. Lower arch distal to normal in its relation to upper arch. DIVISION i. Bilaterally distal, protruding upper incisors. Usually mouth-breathers. Subdivision. Unilaterally distal, protruding upper incisors. Usually mouth-breathers. DIVISION 2. Bilaterally distal, retruding upper incisors. Normal breathers. Subdivision. Unilaterally distal, retruding upper incisors. Normal breathers. Class III. Lower arch mesial to normal in its relation to upper arch. DIVISION. Bilaterally mesial. Subdivision. Unilaterally mesial. Out of several thousand cases of malocclusion examined, the pro- portion per thousand belonging to each class was as follows: Class 1 692 Class II. Division 1 90 Subdivision 34 Division 2 42 Subdivision 100 Class III, Division 34 Subdivision 8 i coo ALVEOLUS AND PERIDENTAL MEMBRANE. 45 CHAPTER V. ALVEOLUS AND PERIDENTAL MEMBRANE. BEFORE entering upon the consideration of the treatment of malocclusion it will be necessary to consider the alveolus and peri- dental membrane, as their importance is perhaps greater in ortho- dontia than in any other branch of dentistry, in fact, is only FIG. 32. secondary to that of the teeth themselves, and it is owing to our intelligent comprehension and management of these tissues that we are enabled to correct inharmonious positions of the teeth. Alveolar Process. The alveolar process, Fig. 32, is that portion of the maxillary bones formed for the reception and support of the roots of the teeth, which are lodged in alveoli or sockets accurately 46 MALOCCLUSION. fitting their surfaces. The alveolar process seems to be wholly subservient to the uses of the teeth, as it does not appear befort their eruption and slowly disappears by absorption after their re- moval. It conforms to whatever position the teeth arrange them- selves in, regardless of regularity, and in correcting their mal- positions the process readily forms itself about their roots in their new positions, so that a crowded and greatly diminished arch may be much enlarged and the alveolus will become completely re- formed and modified, as will be shown in numerous cases hereafter. In health the alveolar process surrounds the roots of the teeth FIG. 33- to nearly the height of the gingival line. The thickness of the process on both the labial and lingual surfaces varies gr.eatly over different portions of the roots and in different individuals, but perhaps in each case the distribution is best suited to resist the force of mastication. It is usually very thinly distributed over the labial surfaces of the roots of the upper incisors and cuspids and upper thirds of the bicuspids and molars, always presenting more or less of a fluted appearance which is readily detected by pressure of the finger, and is very noticeable in carefully made models, enabling us to trace quite accurately the exact positions of the roots of these teeth, Fig. 33. At the immediate margin of the process it is thin, but ALVEOLUS AND PERIDENTAL MEMBRANE. 47 abruptly thickens, and on the buccal surfaces of the molars and bicuspids amounts to a well-defined ridge, in some instances fully one-eighth of an inch in thickness. The alveolus on the lingual surface of the upper teeth is also very thin at the margin, gradually and evenly thickening toward the ends of the roots, an exception being on the lingual surfaces of the roots of the second and third molars, it there assuming a quite uniform thickness in order to form the groove and fossa for the posterior palatine artery. The alveolus covering the buccal roots of the lower teeth is thin at the margin, gradually and evenly becoming thicker toward the center of the body of the jaw, while the labial plate covering the roots of the incisors and cuspids is thickest near the margin, the remaining covering being very thin and sometimes even missing in portions, especially if the root be markedly prominent. The distribution of the alveolus over the lingual surface of the roots of the lower teeth is thin at the margin, gradually thickening toward the mylo-hyoidian ridge. The sockets are quite loosely formed about the teeth during their eruption and for some time after, so that considerable movement of the teeth is possible without bone displacement. The sockets, however, gradually become diminished in size and fit the roots and neck of the teeth more closely with advancing age, greatly limiting tooth movement without displacement of the process. The broad, funnel-shaped opening of the anterior palatine for- amen is situated in the median line just posterior to the central incisors. The septum of bone between this and the root of the tooth is often slight, therefore care should be exercised not to injure the artery when it may be found desirable to surgically remove a portion of the process in this region in order to expedite the lingual movement of malposed centrals. The alveolar process has an external and an internal plate. The outer plate forms the external surface of the bone; the inner plates form the sockets or alveoli of the teeth. The structure of both the external and internal plates is quite compact, but is freely perforated by minute openings for the transmission of nutrient vessels. Between the external and internal plates the bone is far less compact, being very cancellous and similar to the internal structure of the larger bones. This cancellated structure, Fig. 34, MALOCCLUSION. permits of considerable bending of the process without breaking, especially in the case of young patients. As age advances the bone becomes more dense and unyielding. FIG. 34. Strongly adherent to, and closely covering, the external plate of the alveolar process is the periosteum, which in a modified form dips down into the alveoli to form the peridental membrane. Peridental Membrane. The peridental membrane is a strong, fibrous membrane forming a close, cushion-like investment of the roots of the teeth, and is the medium of attachment between the alveolus and cementum. It is composed largely of inelastic fibers of connective tissue, and is richly supplied with nutrient vessels, nerves, cells, and glands. Its function is three- fold : ALVEOLUS AND PERIDENTAL MEMBRANE. 49 First, vital, for the formation of the alveolus on one side and the cementum on the other. Second, sensory, being the seat of the sense of touch of the tooth, through which the most delicate contact with the tooth is recog- nized. Third, physical, holding the tooth in position in the alveolar socket and resisting the movements of teeth in the various direc- tions incident to occlusion and mastication. Cells. Of the cells found in the peridental membrane there are five kinds: First, the fibroblasts, for formation of fibers of the membrane. These are spindle-shaped cells found lying between the fibers. Second, osteoblasts. These are cuboidal cells for formation of the alveolus, and are found close to the layer of bone or imbedded therein. Third, cementoblasts, or formative cells of the cementum. These flattened and irregular cells are found in close contact with the surface of, or partially inclosed in, the cementum. Fourth, osteoclasts, or cells whose function it is to disintegrate calcified tissue, found to vary greatly in numbers and location. Fifth, glands, the function of which is yet imperfectly under- stood. Arrangement of Fibers. The arrangement of fibers of the peri- dental membrane is very complex. More than a general descrip- tion is here impossible. The course which the fibers take varies greatly in different portions of the root. Figs. 35 and 36 show a longitudinal section of the tooth, membrane, alveolus, and gum, which will give a general idea of the arrangement of these fibers. It will be seen that the fibers about the neck of the tooth pass outward more or less at right angles, some blending with the gum, other branches curving up to support the gingiva, while others blend with those at the beginning of the alveolus. Still others anastomose with those from the gingival portion of the adjoining teeth, forming a tough ligament known as the dental ligament. The manner of attachment of the fibers to the alveolus at its beginning is noteworthy. Not only are they attached to it at points nearest the cementum, but some are attached at the top of the bone while others pass over to form attachment with the alveolus on its outer surface (well shown in the microscopical sec- 5 5O MALOCCLUSION. tion illustrated in Fig. 36), thus making the strongest possible attachment to prevent lateral strain. At the beginning of the alveolus, and a little below, the fibers are at right angles to the long axis of the tooth. They soon, FIG. 35. A drawing of a longitudinal section of an incisor of a kitten with crypt of permanent tooth. The labial is to the right and the lingual to the left. The bone is represented in the light stippling. The thinness of the labial plate of the process is shown, with the periosteum and the muscle attached. The lingual plate of the bone is much thicker. ALVEOLUS AND PERIDENTAL MEMBRANE. FIG. 36. Longitudinal section of the peridental membrane, showing the gingival and upper third of the alveolar portion. B. dentin, showing the light band at the outer border. C, cementum, show- ing at the occlusal extremity a thickening where the fibers which pass up to support the gingivae are attached. D, bone of the alveolar process. The short, strong fibers which support the tooth against lateral strain are seen stretching from the cementum to the bone. A blood-vessel cut longitudinally is seen crossing these fibers. 52 MALOCCLUSION. however, begin to incline, and a little farther down their course is oblique until we have neared the apex of the root. These serve to suspend the tooth in its socket. As we near the apex of the root the fibers again assume a direction more or less horizontal, while at the apex their course is at right angles with the surface. Fig. 37 shows a transverse section in the alveolar portion, in which the general arrangement of the fibers from this aspect is well shown, and it will be seen that some of the bundles of fibers pass out from the cementum at right angles to its surface and pursue the shortest course to the alveolus, while other bundles are sent out at different angles and cross on their way to the alveolus. Others still curve laterally, this course being more pronounced at the angles of the root, especially the labial angles, to prevent the turning of the tooth in its socket. The course of these latter is especially well shown in the reproduction of the microscopical section in Fig. 38. The fibers soon after springing from the cementum break up in smaller fibers which pursue more or less of a parallel course, or in some instances pass around the numerous nerves and blood- vessels in their course outward. These again unite into larger and coarser fibers as they aproach the alveolus. In young sub- jects a large portion of the alveolus is often missing between the teeth, as in Fig. 38, in which case the fibers pass directly across to unite with those of the adjoining teeth. The attachment of the fibers to the cementum and bone is most secure, the ends being literally built into the bony substance, actually penetrating the cementum to its union with the dentin. while the alveolar portions, in addition to the strong attachments gained by the numerous bay-like excavations in its surface, also penetrate the very substance; in reality the bone has been deposited about the fibers. Although the fibers are composed of inelastic tissue and their attachment is most secure, yet it is known that the teeth admit of slight movement normally. This wise provision doubtless often prevents shock or fracture, and probably renders more efficient their occlusal planes in masticating food. This slight movement is probably due to the bundles of fibers pursuing different directions in their course, so that none are on actual tension. No thoughtful person can study the arrangement of the fibers ALVEOLUS AND PERIDENTAL MEMBRANE. FIG. 37. 53 Drawing of a transverse section of the peridental membrane in the upper third of the alveolar portion, showing the thickness of the labial plate, with periosteum and muscle attached, and the fibers resisting rotation. The tooth shows two layers of cementum. The bone is represented by the lighter stippled part, which shows its spongy character. On the mesial side (to the left) the septum is not complete and the fibers pass to the distal of the incisor, which is not shown. The labial plate of bone (above) is very thin, and shows the periosteum with its two layers and the muscle attached to it. 54 MALOCCLUSION. of the peridental membrane without being impressed with their wonderful perfection for resisting the various tooth movements incident to occlusion and mastication, and a knowledge of this arrangement is of peculiar interest to the orthodontist, enabling FIG. 38. Transverse section of a lateral incisor and its membrane from the occlusal third of the alveolar portion. A, the pulp, showing blood-vessels and nerves. B, dentin. C, cementum, showing two layers. The outer of the two layers of cementum shows at several points greater thickness, where cementum has been built up arounji fibers to attach the strong bands that resist rotation. D, bone of the alveolar process. E, dark spots representing indifferent fibrous tissue surrounding and accompanying the blood-vessels and nerves, or fibers which run in a plane at right angles to the section. On the right side the fibers are seen passing from the mesial of the lateral to the distal of the central, the septum of bone not coming between at this point. At the left the fibers are seen passing from the cementum to the bone of the alveolar process. ALVEOLUS AND PERIDENTAL MEMBRANE. 55 him to better comprehend not only the difficulties and possibilities in tooth movement, but as well the anchorage to be gained from teeth in the operation. Of the seven possible tooth movements it is well known that depressing a tooth in its socket is the most difficult. This is readily explained from the fact that by far the largest number of fibers the suspensory fibers directly resist the teeth in mastication, and consequently in the movement of depression. The next most difficult movement is that of rotation. While probably most of the fibers indirectly tend to prevent the tooth from turning in its socket, there are an unusual number at the four angles so arranged as to directly resist such action. The lingual and labial movements, less difficult to perform, have less resistance from the fibers, while to the movement of elevation very little resistance is offered by the fibers, only by those at the extreme apex of the root, and experience proves that this is by far the easiest movement to accomplish. Thickness. The thickness of the peridental membrane varies greatly in different periods of life, being much thicker in child- hood and gradually becoming thinner as old age advances. This is brought about largely by the deposition of bone around the entire internal plate of the alveolus, similar to the lamellar arrange- ment in the large bones. The membrane is sometimes further encroached upon by increase in the thickness of cementum by deposits by the cementoblasts around the ends of the fibers. This becomes especially marked in that pathological condition, hyper- cementosis, and is well shown in Fig. 39. Blood Supply. The peridental membrane is freely supplied with blood, which is derived from three sources : First, from branches of vessels given off from the gums. Second, from numerous branches from the alveolus. Third, from one or two large branches entering through the apical space and which immediately divide and subdivide, some being given off to the pulp and others to the membrane, forming a rich plexus throughout these structures. The advantage of these various supplies of blood is apparent, for if from disease or pressure the supply be interfered with from one source, that derived from the remaining sources is still ample. The question is often asked, "In the rapid movement of teeth 50 MALOCCLUSION. is the blood-supply to the pulp shut off?" As minute branches of vessels are supplied to the pulp through the foramen from the peri- dental membrane, as well as from the large branch entering the FIG. 39. Transverse section of the peridental membrane, showing the fibers passing from the cementum to the bone, taken from the disto-lingual corner of Fig. 38. B, dentin. The light band next the cementum shows the first formed layer, or granular layer of Tomes. C, cementum, showing two layers, the inner or first formed darker and more even in thickness ; the outer, or newer, lighter, and showing a hypertrophy at the disto-lingual corner, where the cementum is being built up around the fibers to attach the strong bands which resist rotation and which are seen stretching across to the bone of the alveolar pro- cess, D. D, bone of alveolar process. F marks a spot where absorption is going on in the bone. The small dark spots next to the surface of the bone are osteoclast cells. MODELS THEIR CONSTRUCTION AND STUDY. 57 apical space, it is not probable that strangulation could result unless preceded by inflammation. The vessels supplying 1 the peridental membrane, for the most part, are found midway between the bone and cementum. In old age, however, they are found nearer to the bone, even partially imbedded therein, so that their course may often be traced on the surface of the inner plate. When force is exerted upon a tooth by the regulating appliance, as for example in rotation, there is a slight springing of the process, and the fibers directly resisting the movement are immediately placed on tension, which causes a feeling of discomfort, owing to the pressure upon the nerves of the membrane. This gradually subsides, due probably at first to the temporary partial paralysis of the nerves by the pressure, and later to the gradual relinquish- rnent of the pressure by the further movement of the teeth. As a result of this pressure a greater number of the osteoclasts are developed and stimulated to activity. They immediately begin the work of absorption of that portion of the alveolus which offers greatest resistance to the moving teeth, as well as dissolving a portion of the bone and fibers which are on greatest tension. Such a point is well shown at F, Fig. 39. The cementoblasts and osteoblasts are also stimulated to activity, and as soon as opportunity offers begin the work of repair, depositing bone about the ends of the fibers which have been severed and filling in bone in the space made by the moving tooth. As the fibers of the membrane pursue different courses only a small proportion of them are on direct tension at the same time, some being dissolved while others are being replaced, so that only a por- tion of them are detached at one time unless the normal rate of re- pair is interfered with by inflammation or a too rapid movement. CHAPTER VI. MODELS THEIR CONSTRUCTION AND STUDY. Material for Impressions. In deciding upon a proper course of treatment in any given case, it is of the first importance to obtain very accurate articulating models of both arches. Such models 58 MALOCCLUSION. not only assist us in determining the variation from the normal and the class to which the case belongs, but also aid in deciding the proper plan of treatment, and are exceedingly valuable as refer- ences during its continuation. From such models accurate meas- urements may be taken from time to time for comparison with the natural teeth on each visit of the patient. In this way one may not only judge of the exact movements of the malposed teeth, but any unfavorable movement of the anchor teeth may be de- tected. The reliability and value of these models is only in proportion to their accuracy, and the nearest approach to accuracy is in models made from plaster impressions. These models must show not only both arches and the relative positions of the teeth and cusps, as well as the vault of the arch, rugge, and gums, but must also correctly show as much of the roots and positions of the same as are indicated by the gums and alveolar process up to the point where the attachment of the muscles renders obscure the further shape of the jaw. It is frequently stated by those writing on this portion of the subject that models sufficiently perfect can be made from impres- sions taken in modeling compound or other of the plastics. There is no fact better known in dentistry, however, than that an im- pression of the teeth made with modeling compound or any of the plastics can only remotely approach accuracy even where they are in normal position. The shape of the jaw, together with the shapes and inclinations of the teeth, make the removal of a plastic impression, without change of form, impossible. The degree to which arrest of de- velopment of the alveolus has taken place, especially in the region of the roots of the incisors, so important to accurately record in the model, can only be the merest supposition in a model made from a plastic impression. From the large number of models of this kind which the author receives each year from dentists, none of which have even ap- proached accuracy, it is evident that the value of correct models is not sufficiently appreciated. It is quite probable that those who object to plaster impressions have never taken the time to properly learn the correct method of taking them, otherwise they would find but little, if any, more MODELS THEIR CONSTRUCTION AND STUDY. 59 trouble to themselves, or objection from the patient, than if one of the plastics were used. Method of Taking Impressions. If the reader will carefully ob- serve the following simple plan for taking impressions and making models he will find, after a little experience, that the method is easy and the most perfect results certain. He must, however, observe extreme care and accuracy in each stage of the operation. We may as well remark here that a careless operator could never hope to be successful, and had better remain content with the unreliable results of plastics. First, the teeth should be thoroughly cleansed from all tartar or soft deposits. For this the little soft-rubber cup disk, used with pumice, is excellent. Care should be taken not to wound the gums, as any bleeding prevents sharpness in the outline of the gingiva. The Trays. The trays shown at Fig. 40 are essential. There are five sizes. They were especially designed by the author, in accordance with the anatomy of the parts, for taking impressions of complete or partial dentures, the rims and vaults being much higher than in the ordinary trays, which were all designed for tak- ing impressions of edentulous jaws. It is very important that they should always be kept thoroughly smooth, bright, and clean. When not in use they should be wrapped in clean cotton flannel, to prevent marring by contact with each other. In taking an impression care should be observed to select a suf- ficiently large tray, which should be bent to conform more per- fectly to any peculiarity in the shape of the jaw. This will not injure the tray. The proper size and shape will be best determined by trials in the mouth. Taking the Upper Impression. Good impression plaster is mixed in the usual way and carefully distributed, as shown in Fig. 41, the shape and height of the trays making but little impression material necessary. It will be observed that the greater amount is placed in the anterior part of the tray and made to extend over the outer edge of the rim, none being allowed in the vault of the tray. It is now placed squarely in position and the plaster allowed to rest evenly in contact with the occlusal edges of all the teeth, but not to be forced up into position. The lip is then raised and the plaster extending outside of the rim of the tray is carried high up underneath it with the finger; this is to insure expulsion of air, as 6o MALOCCLUSION. FIG. 40. MODELS THEIR CONSTRUCTION AND STUDY. 6l well as a high impression. The tray is then forced up evenly until the points of the teeth touch, or nearly touch, the bottom of the tray, and steadily supported upon the end of the index finger only. To expel the air from the cheeks they are now gently manipulated, but not drawn down, as to do this would 'expel a portion of the plaster and prevent one of the important objects, viz, a very high and accurate impression. There being no surplus plaster in the vault of the tray, little, if any, can be forced in contact with the soft palate, to cause nausea. The patient will therefore not be inconvenienced and the impres- sion may be allowed to remain until it has become thoroughly set, which is very important, as the harder the plaster is allowed to be- come the more perfect will be the impression. If removed too quickly a film of the plaster will be found adhering to the surfaces of the teeth. The tray must now be loosened and taken away, leaving the impression in the mouth. It is essential that the tray should loosen easily from the impression, hence the importance of its being kept clean, bright, and smooth. Removing the Upper Impression. All superfluous pieces should be carefully removed with a pair of pliers, and the saliva and re- maining soft portions should be thoroughly removed by means of numerous pledgets of cotton of generous size. Two grooves are then scraped or cut in the hardened plaster on a line parallel with the cuspid teeth, but should not, however, be cut quite through. Then with a quick pry with the point of a pen- knife the anterior plate is loosened and laid, together with all sub- sequent pieces, on a clean blotting pad. The lateral pieces are then broken off with the thumb and finger, when the large piece covering the roof of the mouth alone will remain. This may be readily worked loose, and if the operation has been carefully per- formed the impression will consist of four pieces (although to have a much greater number would in no way injure it). Great care should be observed to save all small pieces, having them as clean as possible, and to immediately place them near their original posi- tions in the large pieces. Uniting the Pieces of the Upper Impression. After removing the pieces of the impression, they should be laid away and thoroughly dried before uniting. 62 MALOCCLUSION. Patience and care should be exercised in uniting the pieces. If skillfully done, the line of fracture can hardly be detected. The pieces are best united by means of wax made quite hot on the spatula and flowed over the outside, the clean, united ends being held so perfectly in contact that none will flow into the fracture. They should never be united in the tray, as accuracy by this method is impossible. In uniting the impression the smaller pieces should first be joined to the larger, instead of attempting to force them into correct FIG. 42. position after union of the large pieces. The minute pieces are best held in position with celluloid cement.* In uniting the pieces they should be placed in actual contact only once, and immediately secured. The habit of frequently trying pieces together should be avoided, as the fine serrations are thus destroyed. This method of taking impressions preserves the fine points of *Pieces of ordinary celluloid plates dissolved in equal parts commercial ether and strong alcohol. MODELS THEIR CONSTRUCTION AND STUDY. 63 the interdental spaces. We believe it to be the only practicable way of taking an impression. After the impression is united it should present the appearance illustrated in Fig. 42. Taking the Lower Impression. In like manner the impression of the lower arch is secured, being carefvil to observe the essential points, namely, carrying the impression material which has been built up and outside of the anterior part of the rim of the tray, well down beneath the lip i^ith the finger before forcing the tray home, then expelling the air by gradually working the cheeks while the tray is steadily held by the ends of two fingers of the left hand, one to rest on the top of each lateral half. The handles of the trays are only used for insertion and removal of the tray. While thus supported the folding in of the cheeks between the gums and distal portion of the tray should be guarded against by gently forcing them outward and backward with the ringer. To guard against the infolding of the tongue it should be raised and gently drawn forward, then allowed to settle back into an easy position. Removing the Lower Impression. In removing the lower impres- sion, in addition to the labial grooves parallel with the cuspids, it is often desirable to make two other grooves in the plaster parallel with the lingual surfaces of the cuspids Sometimes a single groove between the central incisors will be sufficient. The exact number and location of grooves in both impressions should vary according to the requirements of the irregularities, and should be carefully planned before inserting the impression material. Removing Impressions from Arches with Spaces, due to Loss of Teeth. In the case of an impression where one or more of the teeth are missing, the difficulty of removing it by ordinary methods is greatly increased. There are two plans, however, by which this difficulty can be easily overcome and accurate impressions of the most difficult partial dentures secured. The first is by cutting a deep additional groove in the impres- sion mesio-distally between the nearest points of the adjoining teeth. The lateral halves of the segment are then readily sprung apart and the pieces dislodged. The peculiarities of these spaces should be carefully studied before inserting the impression in the mouth. 64 MALOCCLUSION. Another excellent plan for weakening the impression at ex; the same points is to insert a piece of thin metal or tough c board in the space of the missing teeth, the pieces being held by nearest approximal surfaces of the teeth at either end ; the lo edge resting upon the gum, while the upper edge should be c line about parallel with the occlusal surfaces of the teeth. By method grooving will be nearly or quite unnecessary. Varnishing the Impression. The impressions being united ; thoroughly dried, they should be coated with shellac varnish ; the expiration of half an hour, or when the varnish shall have come hard, a second coat should be applied over the tooth-surfa> only, avoiding the gum surface in front. Dry again thorough and then apply over the entire impression, with the exception of the gums of the incisors and cuspids, an even coat of sandarac varnisl Pouring the Model. After drying for half an hour the impre sion will be ready for filling, which may be best accomplished, in order to insure expulsion of air-bubbles, by quickly and careful painting the plaster into the tooth-cavities with a small camel's-ha brush, then rapidly filling with a spatula, gently shaking the whi (never jarring) ; after which it should be turned bottom upwat on a glass slab. Separating the Model. After the plaster shall have thoroughl set, the pieces of the impression may usually be very readily sepa rated in the same order in which they were removed from th mouth. Should any air cavities be found in the model they ma be filled by packing in white oxyphosphate of zinc and pressin; it home by replacing the corresponding piece of the impressic.i which should be allowed to remain until the cement is thoroughl; hardened, when it will readily separate, leaving a very perfec surface. A cusp or broken tooth may in like manner be repaired or these defects may be remedied by the artistic use of a delicate brush in the application of plaster of a creamy consistence. The models may now 7 be trimmed ; and not only will there be a surface as smooth as polished marble, but each cusp, all the inter- *It is important that both of these varnishes shall be of the proper con- sistence, which is difficult to describe. If too thin the hard, glossy surface will be wanting, and it will be difficult to separate the impression without injury to the model. If too thick all fine tracings of the impression will be obliterated. MODELS THEIR CONSTRUCTION AND STUDY. 65 dental spaces, and the rugae, as well as the inclinations of the roots, and even the minute "stipples" of the gum and the developmental lines of the enamel, will all be accurately and beautifully shown. Any coating of paint or varnish only detracts from the beauty of such models. FIG. 43. I lit!-.:'* * ... '*H*I mm-m mmmmm mmmmmmmm mmmmmmmmmm mmmmmmmmmm mmmmmmmmmm mmmmmmmmmm mmmmmmmmmm mmmmmmmmmm mmmmmmmmmm ******* ff 91 mmmmmmmimmm mmmmmmmmmm mmmmmmmmmm They should now be carefully articulated after comparison with the natural teeth, and the articulation indicated by two or more pencil markings, so the proper points of contact may afterward be readily found. These serve the purpose much better than any form of an articulator. The models should also be neatly labeled and placed in a suitable cabinet, for protection from dust and injury. 6 66 MALOCCLUSION. to serve for study and reference, and, on occasion, be valuable as legal evidence. Fig. 43 shows a very convenient form of case designed by the author for this special purpose. As soon as the teeth have been completely moved, another impres- sion should be taken and models made. This is done after all appliances have been removed and the teeth thoroughly cleansed, and immediately previous to adjusting the retaining devices. These models are valuable for comparison with the natural teeth during the period of retention, as well as for future reference. It is also of advantage to have "study models" occasionally made during treatment and retention by pressing a piece of softened wax, about three-eighths of an inch deep, onto the occlusal edges of the teeth, to accurately show their positions and such appliances as may be upon them only. Value of Good Models. A collection of fine accurate models is not only an incentive to keener interest and better work, but is a most valuable form of "library" in itself, in which many valuable phases of the subject are recorded which can never be reduced to writing. , Models should never) be mutilated by the fitting of bands and appliances. While they may serve as a basis for general measure- ments for the appliances, yet the fitting should always be done to the natural teeth. Photographs of Patients. As one of the principal objects of the correction of malocclusion is to improve the facial lines of the patient, it is quite as important that accurate photographs of the patient be secured before treatment is begun, as well as at its com- pletion. By occasional careful comparisons of the original photographs with the face of the patient during the progress of treatment, a better understanding of the true conditions of the case, as well as much valuable knowledge in facial art, will be gained. In photographing the patient should sit in the easiest and most natural position, with the jaws lightly closed and teeth in natural occlusion. One full profile and one full front view of the face should be obtained. From such negatives numerous blue prints may be easily made at slight expense. REGULATING APPLIANCES PRELIMINARY CONSIDERATIONS. 6? CHAPTER VII. REGULATING APPLIANCES PRELIMINARY CONSIDERATIONS. REGULATING appliances are devices for exerting pressure upon malposed teeth in order to place them in harmony with the line of occlusion. Two plans are now followed in the designing and construction of regulating appliances, the first acting upon the belief that each case so radically differs from all others that an appliance must be invented and constructed from raw material to meet its special requirements. The second plan recognizes the division of mal- occlusion into a few clearly-defined classes, having requirements of treatment clearly indicated, with fixed, standard forms of ready- made regulating appliances acting upon definite principles, which amply provide for all requirements of all cases belonging to each class. The first plan is the one which has been most universally em- ployed, and has come down to us from the earliest history of ortho- dontia; indeed, much of the literature of the science consists of descriptions of appliances which have been invented to accomplish tooth-movements in special cases, until some thousands are re- corded, one author alone boasting of many hundred. Where much may be accomplished in the following of this plan, in devising and constructing appliances, yet it should require no argument to prove that there are many reasons why the plan is most defective and unscientific. First, it necessitates that each dentist shall be an inventor, and it is well known that the inventive faculty is rather a natural gift than an acquirement, and can be exercised success- fully only by a very few. As all inventions, if perfected, must be experimented with, it must follow that each case so treated must be largely in the nature of an experiment, often necessitating many changes in the plan and construction of appliances. Hence all treatment upon such theory must be, and, in fact, has ever been, tedious and costly, and often of doubtful result. Second, another objection is that, following this plan, the con- struction of appliances must necessarily be more or less crude and lacking in requisite proportions, for any instrument only reaches 68 MALOCCLVSIOX. perfection as to size, proportion, temper, strength, and finish after much experimenting and repeated efforts toward perfection in manufacture. Finally, another objection, more serious than all, is that, as the plan is empirical, with only a vague and indefinite basis from which to reason, the difficulties in teaching and practice become very- great and the results greatly limited. After a life of practice the dentist following this plan must still be in a maze of experiments, and unable to impart information that could be of much assistance to those who may begin the practice after him. This, we think, is abundantly proven by some of the elaborate works which have recently been written on the subject. Such teachings may be said to "begin nowhere and end nowhere,"" and the attempted correction of malocclusion with such appliances has been most appropriately termed "tinker regulating." The second plan, as we have already stated, recognizes the practi- cability of fixed, standard forms of devices for the requirements of tooth movement necessary in all the various classes of malocclusion,. the proper forms having been, arrived at as a result of careful ex- perimentation and close observation in a very large number of cases, embracing the greatest variety of malocclusion. Instead of hand-made productions by the dentist, which, with his limited experience and meager facilities, must always fall far short of the ideal in delicacy of proportion, temper, accuracy of fit, and inter- changeability of parts and in finish, they, like fine watches, are made upon elaborate machinery by the most skillful workmen, who have become experts, not only through natural ability, but from close study and long practice, insuring the most perfect product at the minimum of expense. Dr. Farrar long ago predicted the possibility of this plan, for he says in Vol. XX, page 20, of the Dental Cosmos, "It has for some time been evident to me (though by most people- thought to be impracticable) that the time will come when the regulating process and the necessary apparatus will be so systema- tized and simplified that the latter will actually be kept in stock, in parts and wholes, at dental depots in readiness for the profession- at large, so that it may be ordered by catalogued numbers to suit the needs of the case ; so that by a few moments' work at the blow- pipe in the laboratory the dentist may be able, by uniting the parts,. REGULATING APPLIANCES PRELIMINARY CONSIDERATIONS. 69 to produce any apparatus, of any size desired, at minimum cost of time and money." If such appliances are practicable, it must become apparent to all thoughtful minds that the advantages from their use must be very great over the first plan, for, instead of being confronted with a confusing and almost limitless number of devices, which can at best serve only as general, vague, and often delusive patterns to him, the dentist has but to thoroughly familiarize himself with a few standard devices and their combinations, which he may ever keep in stock in readiness for immediate demands, and which may be quickly and easily applied, thus obviating the great disadvantage of delays, so often necessary in the former plan. Again, familiarity with and repeated use of the standard appli- ances adds greatly to the possibilities of development of skill and judgment in their use, as in the case of the frequent use of favorite patterns of pluggers or excavators. Finally, instead of being compelled to puzzle himself in invent- ing and experimenting until a suitable and efficient instrument has been devised, he has the advantage of being able to thoroughly rely upon standard forms of devices, as he should, and as he does in other operations of dentistry and surgery. He is thus enabled to direct his energies to a more thorough and intelligent study of the case in hand, such as the problems of occlusion, art relations, anchorage, retention, physiology, etiology, etc., the consideration of which is too often sacrificed for the problem of devising and constructing of appliances. And whether or not ideal standard regulating appliances have yet been reached, the possibilities and positive advantages of the principle over the first plan are so marked that we think all teachers who are interested in this branch should make efforts toward that direction, rather than assisting in per- petuating a principle which is so obviously defective that it must be apparent to all that it is a positive hindrance to the real progress of orthodontia. In no other branch of medicine, nor in any other science that we know of, is there such inclination to perpetuate this fossilized principle. Even machinists deem it no longer worth their while to make the tools they use. Then imagine a modern surgeon teaching his students to invent, forge, and construct from raw material instruments for each operation, or an up-to-date dentist /O MALOCCLUSION. grinding the clays and pigments for the artificial teeth he shall use, or "designing and forging a special instrument for each case or operation." Such was once the practice, but it is now well known that most real progress that has been made in dentistry or surgery has been since the dentist or surgeon was relieved of this impracti- cal task by experts, who have produced instruments so perfect in design, construction, and finish as to be often even far in advance of his comprehension and skill. A few of the writers and teachers, it is true, are still linking the present with the past in commending to dental students the acquirement of skill in the construction of implements and appliances, but the custom is archaic and illogical ; and the long, tedious hours which students are usually compelled to devote to the making of regulating appliances, crude at best, should be directed by a more advanced standard of teaching to purposes more in keeping with the modern requirements of ortho- dontia. It is the author's opinion that, while the practice of den- tistry involves the exercise of mechanical skill, the dentist should feel no pride in classing himself as a mechanic. Let us hope that the day is forever past when every man shall be his own shoe- and garment-maker. The author's regulating appliances, the description, plan of appli- cation, and operation of which will be given farther on, are in direct keeping with the second plan just described. In fact, the second plan may be. said to have originated in the introduction of this system some fourteen years ago. The author's appliances are now extensively used in all countries where dentistry is practiced, and their efficiency and universal application are recognized. Like most valuable and popular pieces of mechanism, they have numer- ous imitations, but if intelligent comparison be made with all others from the basis of efficiency, simplicity, and delicacy, their supe- riority is at once apparent. Epochs in the History. To the real student of orthodontia the history of regulating appliances is a most interesting and instruc- tive study. It shows that their beginnings, like those of other sciences, were crude ; the unfolding slow, and ofttimes marked by steps backward as well as forward, with the perpetuation of much, even into the present, which should have been left far behind. Of necessity, the history of appliances is closely associated with the history of the science, and measures its progress to a consider- REGULATING APPLIANCES PRELIMINARY CONSIDERATIONS. /I able extent, clearly telling of the apathy manifested by the profes- sion in general on this subject. One surprising feature of the his- tory is the frequency of rediscovery of identical principles, their materialization differing only in minutiae of manufacture. While the study is of much interest to the student of orthodontia, yet the limits of this work will not permit of other treatment than the brief mention of such steps in the history as may be regarded as epochs in the evolution of appliances. This will involve the consideration of principles only, and of those whose value is attested by their survival or present universality of use. Mere improvements in methods of applying these principles, however ingenious and valuable, cannot here be noted. The actual principles embodied are few. The form of the first regulating appliance, or by whom employed, is not known. It may have been, like the substitution of the natural by artificial teeth, far back in the history of man, but the first appli- ance which was destined to mark a distinct step in the written his- tory was that given to us by Fauchard, of France, in 1726, and which we will call the expansion arch, for it is the form of the ideal arch, and its chief function is to expand the dental arch, although it has been variously named as bandeau, bow, long band, bande- lette, etc. Unquestionably the conception of this device was the one greatest step in the invention of appliances. That which may easily take rank as second in importance was the invention of the band for the attachment of appliances to the teeth. Of bands there are two kinds, the clamp and the plain, for different uses, yet of equal importance. The first was the invention of J. M. A. Schange, also a Frenchman. We find it illustrated, as in Fig. 44, in a book of one hundred and eighty pages published in Paris in 1841.* He used it chiefly upon the malposed teeth, rather than for anchorage. It is only fair, however, that the honor of the invention should be accorded to him, as its inception is commonly thought to be of later date.f It consisted of a ribbon of metal in length sufficient to nearly encircle the crown of the tooth, each end bent sharply at right angles, thickened and perforated, one threaded, the other smooth. A threaded shaft with perforated head was *"Precis sur le Redressement des Dents." Par J. M. A. Schange, Medi- cin-Dentiste, membre de plusieurs Societes savantes. Troisieme edition. Paris, 1841. fFarrar, first volume. 72 MALOCCLUSION. made to engage the perforation in the band shanks. By turning the shaft the band was diminished in circumference and securely clamped upon the crown to prevent displacement, as shown in the engraving, in principle identical with Farrar's of 1876. Fie. 44- To all students of orthodontia another very important epoch in the history of regulating appliances should be mentioned in con- nection with Schange's clamp band, and also with his improvement of the expansion arch, for it is in these connections that the screw first makes its appearance in regulating appliances, the honor of the introduction of which has been erroneously* divided between Dwindle, of New York, and Gaines, of England. Their recorded dates of using the screw were, however, eight years later than that of Schange's. The plain band consisted of a ribbon of metal fitted to the cir- cumference of the crown, the ends being united by brazing. Although such bands, of gold, were used by the ancients for secur- ing artificial crowns and bridges, it is not clear by whom they were first used for regulating purposes. Desirabode (1726) speaks of them as "bracelets" or "little rings." Thomas Evans, of Paris, again mentions them in 1854, and Dr. A. H. Fuller, in the Missouri Dental Journal, January, 1872, describes a novel form of plain band. It was constructed by closely wrapping a plaster model of the tooth to be banded with fine platinum wire, over which was flowed 20- carat gold, to which the desired attachments were made. The real value of the plain band, however, dates from its attach- * Farrar, first volume. REGULATING APPLIANCES PRELIMINARY CONSIDERATIONS. /3 ment to the tooth crown by means of oxychlorid of zinc cement, which was accomplished at about this time by Dr. Magill,* of Erie, Pa. This effectually prevented its' displacement under the ordi- nary strain necessary in tooth movement. Magill's method of making the band was to encircle the crown with a thin ribbon of platinum, slightly overlapping the ends and uniting by brazing. He was probably not at this time aware of previous use of either plain or clamp bands. By the use of bands the direct, firm attach- ment of appliances to the teeth was gained, so that loss of power by slipping was reduced to the minimum, thus greatly increasing the efficiency of the appliances and lessening the time necessary for treatment. The regulating jack-screwf was invented in 1848 by Dr. Dwi- nelle, of New York. This invention marks two important steps: First, the introduction into orthodontia of one of the most compact, yet powerful, forms of mechanism for exerting force known to mechanics ; second, the beginning of fixed, standard forms of regu- lating appliances with interchangeable parts and kept in stock at the dental supply houses. It consists of a threaded steel shaft with conical head, perforated for the reception of a turning tool, and a rounded nut, also of steel, with long, parallel flanges joined at their extremities, which were of fish-tail form. Although difficult to keep in position and somewhat expensive, three sizes being re- quired, it was at the time regarded as a boon to the profession, and is still in favor with many practitioners. Lee and Bennett, some time in the 8o's, attached a washer of elliptical form with perforated ends below the head of the jack- screw, and, attaching ligatures to this and the fish-tail, used the appliance for pulling instead of pushing. The author's traction screw was inspired by this adaptation of the jack-screw, as were probably various other devices' that have been used for traction. *At the meeting of the Western Pennsylvania Dental Society, Pittsburg, March, 1896, in a conversation with the author, Dr. Magill said he could not remember the exact date in which he first began attaching the bands by means of cement, but believed it was in 1871 or 1872. tSome attempt has been recently made to change the name of this appliance to Screw-jack. But as it has been known, since 1849 as Jack-screw, and is defined in Webster's and the Standard dictionaries, being illustrated in the latter in position against the teeth, and as the term seems more appropriate, this innovation is not regarded with favor. 74 MALOCCLUSION. The traction screw* may, in any event, be regarded merely as a modification of the jack-screw, and not as the application of a distinct principle. The force derived from the elasticity of rubber has been exten- sively used in tooth movement. It was introduced by Dr. E. A. Tucker, of Boston, in 1846. Although an immense amount of harm has resulted from its improper application, and it is now far less commonly used than formerly, yet it is, and doubtless will long remain, a valuable adjunct to regulating appliances under suitable conditions. The application of force for the reduction of protruding anterior teeth, gained through occipital anchorage by means of the use of the head-gear, which originated with Dr. Norman W. Kingsley, of New York, in 1866, was the introduction of a principle of much value. The introduction of piano-wire by Dr. Seldon Coffin, of England, some forty years ago, marked another step in regulating appliances. On account of its great elasticity, it has been extensively used, but far less now than formerly, as it has been largely supplanted by German silver. The introduction of vulcanite for the construction of regulating plates records, in the author's opinion, a step of doubtful value, for the reason that the same results by means of far more delicate forms in metal were previously accomplished. The introduction of tubes f by the author, in 1886, may, we hope not immodestly, be said to have been another step in the evolution of appliances, as it provided a ready means of attachment between bands and working appliances which greatly simplify the neces- sary operations. The tubes were cut in desired lengths from a crude form of unbrazed tubing known as joint wire, composed of a silver alloy ; but far more suitable' tubes, of special manufacture, are now employed. The measure of value attributable to this in- vention may be determined by the reader upon observation of the various appliances shown in the literature since its advent. It *This has been denominated "drag-screw," but the name seems neither so appropriate nor euphonious as the other, and has not been adopted. tTransactions of the Minneapolis Dental Society, December, 1886, of the Minnesota State Dental Society, May, 1887, and of the International Medical Congress, September, 1887. Also Ohio Dental Journal, October, 1887. REGULATLNG APPLIANCES PRELIMINARY CONSIDERATIONS. 75 seems to have entered into the formation of all appliances of note, and has a varied application. In 1886 the author made an attempt to group all necessary regu- lating and retaining appliances into a simple, yet complete, system, with interchangeable parts admitting of ready combination. This system has been gradually improved, until it is believed that now it is very nearly perfect. The advent of a complete system is of such great importance in comparison with the hitherto fragmentary methods, that it is believed it is worthy the distinction of being classed among the epochs in the history of regulating appliances. The introduction of German silver (the valuable properties of which are more fully discussed elsewhere) by the author in 1887* for the manufacture of regulating appliances has to such a large extent revolutionized their manufacture that it must take rank as an important step in their history. The introduction of soft brass wire for ligatures is of such great practical value that the author believes it should here have honor- able mention. REQUISITE QUALIFICATIONS OF APPLIANCES. Efficiency. As the object of the regulating appliance is to per- form tooth movement, efficiency should precede in importance all other qualities. The reason for this is obvious, for at best the correction of malocclusion is to a greater or less degree an un- pleasant and protracted operation ; and unless the appliance be efficient, so that the various tooth movements may be accomplished as rapidly as is consistent with the physiology of tooth movement, the operation will be unnecessarily long and tedious, sacrificing valuable time of both patient and operator, and frequently leading to discouragement and failure. A very large number of the appliances recorded in the literature are so obviously defective in plan of operation, application of force, and anchorage, as w r ell as in construction, proportion of parts, and manner of attachment, that the period of wearing must necessarily have been extended to many times what would have been necessary had they possessed the requisites of truly efficient appliances. Simplicity. Next to efficiency in importance, the regulating Archives of Dentistry, September, 1888. 76 MALOCCLUSION. appliance should be simple in form and plan of operation. It is well known that the best forms of mechanism are those freest from complication, simplest in design, and most direct in application of force. It is also known that most valuable machines possessed but limited utility until they had passed through certain evolution- ary stages, in which the original plans of greater complexity gradually gave place to those of simpler principles. For example, the electro-magnetic mallet and the sewing machine. In fact, many modern inventions are but the discovery of simpler methods in the application of long-known principles ; and where complexity may be admissible in some machines, as, for example, the printing press, yet we must remember that it performs numerous functions, and the limits of space and weight are very broad, with the freest scope for application of mechanical principles. But in the regulating appliances the restrictions of the lips, cheeks, tongue, gums, and occlusion make simplicity and freedom from bulk of great impor- tance. The invention of a simple yet efficient machine is a much greater achievement than is the invention of one that is complicated. It should be remembered that each additional piece composing a regulating appliance usually augments in a more than proportionate ratio the liability to derangement, as well as the care and time required in its operation, the expense of its construction, and the inconvenience to the patient. And yet the complexity of design and number of parts of many of the regulating appliances which have come down to us through the literature are such that it would seem that their originators must have believed these qualities to be of the first importance. Many of these appliances are in reality curiosities, and doubtless in the future will be pointed out as such. Such an appliance is shown in Fig. 45. Delicacy. An appliance which is delicate of size and proportion, and from which all unnecessary material has been eliminated, possesses such important advantages as should be readily appre- ciated, for not only is the annoyance to the patient often largely in proportion to the bulk of the appliance, but also in the same pro- portion are the functions of the mouth interfered with. Another disadvantage from a bulky appliance is the difficulty of cleansing it. It forms ready lodgment for particles of food, which, REGULATING APPLIANCES PRELIMINARY CONSIDERATIONS. // at the temperature of the mouth, soon undergo fermentation, ren- dering the breath most offensive and necessitating the frequent removal of the appliance from the mouth (either by the patient or dentist, according to its plan of construction) for the purpose of cleansing. Thus the operation is prolonged. But, worse than all, the relinquishment and reapplication of pressure is. the principal cause of pain in moving teeth, the alternate forward and backward movements so interfering with the tissues involved as to be the most potent cause of inflammation. For these reasons a skeleton form of appliance, with direct, stable attachments to the teeth by means of the plain or clamp bands, should invariably be used in preference to devices in combi- nation with plates, a remarkable illustration of which is shown in Fig. 46. It is not so much a wonder that such crude, bulky, inefficient, and most uncleanly appliances have been used in the past, for that was but natural in the evolutionary stages through which orthodontia has passed ; but why such devices should find place in modern text- books and be advocated by modern teachers is most difficult to *Transactions Ninth International Medical Congress, Vol. V, p. 577. Washington, D. C, 1887. 78 MALOCCLUSION. comprehend. The fact is, there is no longer any use for the plate forms in regulating appliances. They are as much out of harmony with the requirements of orthodontia in its present development as would be the Mexican ox-cart for the uses of a modern speeding sulky. FIG. 46.* Inconspicuousness. As any devices upon the teeth attracting attention are, to patients of sensitive nature, a source of more or less annoyance, it is important that the regulating appliance shall be made as inconspicuous as possible ; and yet we insist that effi- ciency in an appliance is of so much greater importance that it should be kept foremost in view, even though the form of appliance best suited to the case be conspicuous. The wearing of appliances has in recent years become so common that it no longer attracts such attention and comment as formerly. The degree of unsightliness is increased largely by the manner in which a given appliance is constructed and fitted to the teeth. If gracefully proportioned, with skillfully made attachments and the most perfect finish of parts, the appliance, although noticeable, may not be really objectionable in appearance; while if, as is too often the case, the same form of appliance be unnecessarily bulky, badly proportioned, unskillfully attached, with little attention given to finish of parts, its appearance is most repulsive. Stability of Attachments. No matter how perfect the design and construction of an appliance, if the attachments to the anchor and moving teeth be not such as to insure its stability the appliance becomes worthless, for if it slip or give at the point of anchorage or deliverance it will either become entirely inoperative or the force *Essig's "American Text-book of Prosthetic Dentistry." REGULATING APPLIANCES PRELIMINARY CONSIDERATIONS. 79 will be wrongly directed, according as the power may be derived from a screw or spring, thus prolonging the operation and sacrific- ing the time of both operator and patient, with the added pain, annoyance, and expense necessitated by the removal and repair of the appliance. Owing to the slipperiness and irregularity of the surfaces of the teeth, stability of attachment of appliances has always been one of the problems of tooth-regulation. Since the introduction of the plain and clamp bands, firmly cemented or clamped upon the teeth, as well as the wire ligatures, the certainty of firm, immovable attachments is assured, with consequent perfect control of the ap- pliances and direction and intensity of force, making it possible to compute with considerable accuracy the time necessary for tooth movement in each given case. The great advantages of this form of attachment have rendered practically obsolete attachments by means of plates, clasps, cribs, etc., and it again becomes difficult to understand why such forms of appliances, with their crude and necessarily unstable attachments, should still find advocates. Materials for Construction. Gold, silver, platinum, platinous gold, platinous silver, iridio-platinum, platinoid (so called), alumi- num, and several of the baser metals and alloys, as brass, copper, aluminum bronze, steel, and iro'n, and also vulcanized rubber, may all be used in the construction of regulating appliances, and each possesses properties of more or less value ; yet, after experimenting with all of these, as well as with several other metals and alloys, the author is thoroughly convinced that the one most nearly filling all requirements is German silver.* Since being introduced for the manufacture of regulating appli- ances by the author, some fourteen years ago, it has largely sup- planted all other metals for this purpose. Its great practical value becomes more and more apparent to the unprejudiced practitioner as the peculiar working properties and possibilities of this ideal material are revealed by familiarity of use. It is very susceptible to skillful working, and may be developed to possess great strength and rigidity, as demanded by the jack and traction screws. Again, it may be given great elasticity, as required by the expansion arches. Again, when properly annealed, it is very malleable, yet sufficiently *German silver, or nickel silver, is an alloy of copper, nickel, and zinc pre- pared in varying proportions according to the use for which it is intended. 8O MALOCCLUSION. rigid to give it the excellent qualities so necessary in retention and reinforcing anchorage, as exemplified in the wire G. But its excel- lent qualities are perhaps best shown in the construction of the plain bands to be placed upon the teeth for securing the attachments of the appliances. If of proper quality and properly treated in the manufacture it is very soft and pliable, yet possessing great strength. It may be drawn by the band-forming pliers so tightly about the tooth as to conform to its surface with great accuracy without tearing, even though the thickness be but .003 of an inch (F) ; and yet it is suffi- ciently rigid to withstand driving to place upon the tooth with- out crimping or changing form if care be used. All this is in striking contrast with the properties of gold, platinum, or other metals used in the same thickness for this purpose. Its surfaces may be readily united with solder, and its fusing point is so high that any of the various grades of gold or silver solder, or even pure gold itself, may be employed, if the proper flame be used and care be taken, without fear of injuring the band by overheating. So slow a conductor of heat is it that the excellent method of soldering* by holding many of the pieces with the fingers may be employed, again in sharp contrast with any of the other metals we have enumerated. It is susceptible of a high degree of polish, which should always be given the band after setting, and which in most mouths will remain durable, often assuming a delicate bronze-like color, pleas- ing in appearance. The author has known these bands to be worn for three years with no apparent change. In a small percentage of mouths, however, it is true that it does become discolored, even to unsightl.iness. This fact has given rise to the only prejudice against its use that we know of, but this objection seems trivial in view of its many points of superiority, which should far outweigh it. If the orthodontist will insist upon a reasonable degree of cleanliness on the part of the patient while wearing the appliances, or will occasionally devote a moment or two of attention to them himself with the soft-rubber disk and pumice, followed by a bur- nisher, there need be no occasion for complaint. And, lastly, its inexpensiveness brings it again in sharp contrast *Introduced by the author in the first edition of this work. THE AUTHOR'S APPLIANCES. 81 with gold and platinum; yet we insist that it is its ideal character, not its inexpensiveness, that makes it so preferable for the manu- facture of regulating appliances. The oft-repeated fallacy that gold is the one suitable metal for the construction of regulating appliances should, with many other fossilized inconsistencies in orthodontology, be relegated to the past, for unquestionably it has been a real hindrance to progress. CHAPTER VIII. THE AUTHOR'S APPLIANCES. IN the descriptions of these appliances which have appeared in the different editions of this work, they have been divided into sets and designated as Nos. i and 2, with a few auxiliary parts. As some of the parts are more frequently demanded in use than others, the grouping into sets has been discontinued and the parts will hereafter be designated separately. All parts of a kind are thoroughly inter- changeable and each accurately fits the part to which it belongs, but as they only fit the parts for which they are intended, and as they will be referred to often in the pages which sEall follow, it is very important that the student memorize their sizes and shapes, as well as the letters or figures by which they are designated. FIG. 47. H F and H, Fig. 47, are coils of band material from which are made plain bands to be placed upon the teeth to be moved, to serve as mediums of attachment for the regulating appliances, as well as forming part of the retaining devices. Each coil is twenty-four inches in length and will furnish a considerable number of bands. F is narrower and thinner than H, and is usually used for banding the lower incisors and upper laterals. H is for forming bands for the cuspids and upper central incisors. 7 82 MALOCCLUSION. Fig. 48 represents six adjustable clamp bands for encircling the molars and bicuspids, usually used for attaching the appliances to the teeth used as anchorage. FIG No. i. X Band. DBand. Nos. I and 2 are plain. Nos. 3 and 4 are provided with strong headed pins, soldered to their sides. These two bands were espe- cially designed for the treatment of fractures of the maxillae, and their use, therefore, is fully described in that portion of this work devoted to the treatment of such fractures. They are also useful in the attachment of ligatures in the regulation of teeth, described later. X and D are provided with tubes of smooth bore, soldered to their sides, into which the ends of the arches, described later, accurately fit. FIG. 49. The retaining wire G, Fig. 49, consists of a section of very soft, smooth wire. Its uses are numerous, chief of which are the rein- THE AUTHOR'S APPLIANCES. 83 forcing of anchorage, the formation of spurs upon bands for the at- tachment of ligatures, the retention of teeth, and the moving of teeth. The latter purpose is effected by securing one end of a short section against the tooth to be moved, with the other end suitably anchored, then lengthening the wire by pinching with the regulating pliers, Fig. 90. This wire is provided with ten delicate tubes known as retaining tubes, R, Fig. 50, which slide closely on its surface. These tubes are used in detachable connections, in reinforcing anchorage, in re- tention, etc. FIG. 50. * 7 -i * Fig. 51 represents the jack-screw, E and J (enlarged to better show the parts), consisting of a threaded shaft provided with a nut and incased in a tube of smooth bore accurately fitting the shaft. Two lengths of these tubes are provided to meet varying require- ments. If the base of the screw be made to rest against a suitable anchor tooth with proper attachments and the flattened end made to engage with suitable attachments on a tooth to be moved, by turn- ing the nut the appliance will be lengthened and force exerted upon the moving tooth. FIG. 51. A valuable improvement has recently been added to this useful device, consisting of a friction sleeve or extension flange forming part of the nut, which accurately telescopes the end of the sheath enlarged for its accommodation, as shown in the engraving. It is more particularly described in Chapter XI, in connection with the expansion arch. A and D and Y, Fig. 52, is a traction screw. It consists of a shaft A, bent sharply at right angles at one end and at the other threaded and provided with a nut, with three accurately fitting tubes of smooth bore, one long, Y, and two short, D. If the long and 8 4 MALOCCLUSION. one of the short tubes have been soldered to tooth bands upon the anchor and moving teeth respectively, and the angle of the screw made to engage the tube D, as in Fig. 53, by tightening the nut, a pulling force will be exerted upon the moving tooth. If the nut be placed against the other end of the tube and tightened, it will push. This device is indispensable, although its use is chiefly limited to the retraction of the cuspid, as shown in Fig. 53.* FIG. 52. E.H.A FIG. 54. Fig. 54 shows a bundle ,oi spring levers L, in four different sizes. These levers are still made from piano-wire, on account of its superior elasticity ; yet because of its tendency to rapid corrosion, no matter how heavily plated, and the consequent discoloration of the teeth, its ordinary use is objectionable. This has led to the discovery of new combinations of other appliances, described later, which have obviated the necessity for its use to a large extent, yet not wholly. The principal use of the levers is in the rotation of teeth in their sockets. *In the former editions of this work a traction screw similar to the one here shown, but smaller, was advocated. As new combinations of other devices hereafter described better serve the purpose for which the smaller screw was designed, the author has dispensed with its use in his own practice, and has therefore thought it advisable to omit it from these pages. THE AUTHOR S APPLIANCES. 85 Fig. 55 illustrates a small wrench of universal application to all the various nuts and appliances ; it is nickel-plated and finely finished. Fig. 56 represents the expansion arch E. It is a very elastic round bar bent to conform approximately to the outside of an ideal dental arch. The sides of this arch are threaded and provided with friction sleeve nuts, which, with the threaded portion of the arch, accurately fit the smooth-bore tubes of the X or D bands. It has the widest range of uses in tooth movement. With its attachments FIG. 55. FIG. 56. it is ample for the treatment of a large percentage of cases, and in combination with the traction screw, to be described later, this percentage is considerably increased. Its principal use is for the movement of teeth singly or en masse in any or all of the various directions, except distally. For this movement it is unsuited for important reasons given later. The teeth to be moved are attached to it by means of ligatures. 86 MALOCCLUSION. The arch B, Fig. 57, is a smooth, threadless arch, similar in form and temper to E. It is also always used with the clamp bands D or FIG. 57. X, and in addition the traction bar and head- gear with heavy elastic bands, described later and shown in Fig. 59. This combina- tion of appliances is for shortening the den- tal arch, or moving distally en masse pro- truding incisors and cuspids. The anterior part of the arch B is prevented from sliding up or down upon the surfaces of the incisors by being made to rest in notches in plain bands, C C, made from F or H, Fig. 47, cemented upon them. The traction bar A, Fig. 58, is provided with a standard in its center, having a socket for the reception of a delicate ball on the center of the arch B. The hooked ends of the traction bar receive two heavy elastic bands on each side, which exert force from the head-gear upon the moving teeth, as shown in Fig. 59, the arch being carried distally, its ends sliding through the tubes of the bands on the molars. As the traction bar and head-gear cannot be worn constantly, the THE AUTHOR'S APPLIANCES. 87 teeth, during these interruptions, are prevented from springing back by two delicate rubber ligatures tied in front of small, immovable FIG. 59. collars on the arch by means of floss silk. These ligatures are stretched distally and slipped over the ends of the anchor tubes, as 88 MALOCCLUSION. in Fig. 60, thus exerting- a constant, gentle force which automatic- ally retains the teeth at any point in their progress. FIG. 60. The head-gear, Fig. 61, is a cap of silk netting covering the back of the head and laced to a metal rim for the even distribution of force exerted by the heavy elastic bands. This cap is strong, E.H.A. artistically made, and presents a very neat appearance. It is non- collapsible, and may be easily and quickly adjusted to fit any size of head. The chin retractor, Fig. 62, is used only in connection with the head-gear. It is made of aluminum, is light, neat, and highly THE AUTHOR'S APPLIANCES. 89 polished. It will fit all cases, it being only necessary that the fit be approximately accurate. A layer of absorbent cotton should always be placed between the metal and the chin. As auxiliaries to the appliances already enumerated, ligatures and strips of rubber are used. FIG. 62. Ligatures. Of these there are three kinds. First, the rubber, which is best made by punching a hole in thick rubber dam or a thin elastic band with a rubber-dam punch, then trimming the outside down to the desired size. Ligatures made in this way are much superior to those cut from tubing, as any desired size and strength may be quickly made and a better quality of rubber is insured. Their use, however, in this system is greatly limited. Second, knitting or floss silk. The latter should be waxed. Third, wire. Each possesses advantages in certain cases, wire being by far the most useful. It was introduced in the fourth edition of this work, for use in connection with the expansion arch, and has proved to be one of the most valuable additions made to orthodontia in recent years. Its advantages and uses are described in Chapter XI, in connection with the arch. The different forms of wire ligatures are shown in Fig. 63, and should be carefully studied. 90 MALOCCLUSION. The wedges of rubber are principally used for exerting pressure upon some tooth of overprominence or to intensify the force of the lever or expansion arch in rotating teeth, one of the strips, Fig. 64, of suitable thickness being stretched nearly to its limit and drawn FIG. 63. 1 /8 IN. WIDE 3/16IN. WIDE mi between tooth and appliance, the tension then released and super- fluous ends cut off, as in Fig. 65. The rubber conforms so perfectly to the shape of the tooth and appliance that the annoyance of slip- ping is entirely obviated and much added force is given to the ap- pliances. THE AUTHOR S APPLIANCES. 91 It will be seen that the appliances, independent of their attach- ments, are but five in number and very simple of form, consisting of the jack-screw for pushing, the traction screw for pulling, and the lever for rotating, the arch E for enlarging the dental arch in any or all directions, and the arch B for shortening the dental arch. The appliances being so few in number, it has been doubted by some in the past whether they were sufficient to meet all require- ments in the correction of malocclusion. They are now so widely used and their efficiency is so thoroughly established that this question need not here be discussed. Not only are they adequate for all cases, from the simplest to the most complex, within the range of treatability, but their saving in time and expense to the dentist and in discomfort to the patient are qualities widely ap- preciated. Another advantage is the ready convertibility of certain of the parts into simple, delicate, yet very efficient devices for the retention of teeth. Constant effort toward improvement has resulted in the discovery of new methods of manufacture whereby, with specially constructed machinery, the production of more uniform, better proportioned, stronger, and finer tempered appliances has been secured, as well as heavier plating, finer finish, and greater accuracy as to fit of parts, insuring in their uses, singly or in proper combinations, the greatest strength, firmness, and efficiency. All the parts of appliances used in this system, with the exception of the levers L, the retraction cap for the chin, and the wire liga- tures, are made of a very fine quality of German silver, the adopted formula for which has been determined upon after much careful experimenting. It is much superior to the ordinary German silver of commerce. Tools. For uniting the different parts of the appliances to form the various combinations, and for placing them in position upon the teeth, only a few tools are necessary, but it is important that they should be of the best selection, and some of them of special design. First, a pair of soldering pliers. Those shown in Fig. 66 are most suitable, their delicate proportions and peculiar form making them especially suited for holding bands and small pieces. Second, another pair of pliers, as in Fig. 67, for placing pieces of solder in position, picking up small pieces, etc. Third, band-forming pliers. Those shown in Fig. 68 were de- MALOCCLUSION. signed especially, and are indispensable for band-making. They are also very useful for most other purposes for which ordinary FIG. 66. FIG. 67. FIG. 68. FIG. 69. flat-beaked pliers are used, and are provided with grooves for holding the small square nuts and round wire. THE AUTHORS APPLIANCES. 93 Fourth, wire-cutters. The style shown in Fig. 69 is preferable. Fir,. 70. Fir.. 71. 94 MALOCCLUSION. Fifth, the regulating pliers shown in Fig. 70, for lengthening or shortening wire. They are most useful. FIG. 72. FIG. 73. Sixth, a pair of scissors, Fig. 71, for trimming bands, clipping ligatures, etc. SOLDERING. 95 Seventh, pliers for twisting ligatures and for general uses, as shown in Fig. 72. Eighth, an ordinary hand mallet and band driver, as in Figs. 73 and 74. FIG. 74. FIG. 75. And last, and very important, a suitable lamp for soldering, Fig- 75- CHAPTER IX. SOLDERING. As many of the parts of these appliances are very delicate, it is important that a fine, sharp, steady flame shall be used in effecting their union by solder. A large or uneven flame would injure and might ruin them. The author greatly prefers the Herapath blow- pipe, Fig. 75, operated with the ordinary foot-bellows, as it pro- g6 MALOCCLUSION. duces the proper flame, Fig. 76, of most intense heat, yet under the most perfect control, while both hands of the operator are left free. FIG. 76. Fig. 77 shows a bracket table devised by the author as a con- venience in this work. It is covered by a glass slab and holds the blow-pipe, connected by tubing with the foot-bellows. The drawers are receptacles for tools and appliances. Notwithstanding many ingenious spring clamps and other de- vices have been invented for holding such small work, yet the plan introduced by the author in the second edition of this book is far preferable in most cases. It consists in holding the pieces with the fingers while being soldered. The metal of which these appli- ances are made is most favorable for soldering in this way, it being so poor a conductor of heat that all such attachments as E, F, H, I, and K, Fig. 100, can be so held without any perceptible communication of heat to the fingers, provided the flame be suit- able. Where union of a small tube with a band is desirable, as in Fig. 76, the tube is best held in contact with the band and flame by means of some delicate instrument which will absorb but little heat. One of Gates's nerve-drills, with the point broken off, is nearly the ideal. Where two of the small tubes are to be united, as in Fig. 78, the pliers may be used in supporting one of them. This method of soldering is not difficult, most students learn- ing it readily. The only point which may seem at all difficult to the beginner is the holding of the pieces in fixed position just at the time the solder is congealing. This is accomplished by touch- SOLDERING. 97 ing one or more of the fingers of one hand with those of the oppo- site hand, as in Figs. 76 and 78, to steady them, at the same time holding the pieces gently, not rigidly, just as a good penman holds a pen. After a little practice any of the various soldered attach- ments may be easily and quickly made. All of those shown in FIG. 77. Figs. loo and 101 are made in this way. In such attachments as E, F, H, and K, Fig. 100, the pieces of solder may be kept from flying off by being gently held in position between the pieces to be united. Where the ends of small tubes are to be united, as in C and D, Fig. 100, it is best to fuse the solder upon the band, then hold the small tubes by means of the straight pliers, Fig. 67, in contact with the solder and again apply heat, as otherwise the solder would usually be drawn into the tube. 98 MALOCCLUSIOX. The solder best adapted for uniting the different parts of these appliances is ordinary jewelers' silver solder (easy flowing), al- though any of the various carats of gold solder may be used, with cream of borax for a flux. Never use more solder than is neces- sary, especially in all small attachments just enough to make the union. Always avoid overheating apply just sufficient heat at the right point from a fine sharp flame to thoroughly fuse the solder. In every instance avoid heating the screws or nuts. This is to be especially observed with the jack and traction screws, as great care FIG. 78. is used in their manufacture to preserve their stiffness and strength, and this fine temper would be ruined by heating. The arches E and B, which are manufactured in such a way as to give them the greatest possible spring, second only to steel, might also be easily ruined by heating. Soft-soldering. It is often necessary to attach spurs to the arches B, which are manufactured in such a way as to give them the ertion of force in the desired direction. If these spurs be attached by means of the ordinary soft solder used by jewelers the temper of the arches will not be injured, provided only a very small passive flame be used, just sufficient to melt the low-fusing solder. The best plan for making these spurs is to fuse a very small piece of the solder upon the end of a section of the ligature wire (first having dipped the end of the wire in soldering fluid), then holding the solder and end of the wire in contact with the arch SOLDKRIXG. 99 in the flame. This gives a fine, conical spur with brass center, which, is very strong, yet inconspicuous. Fig. 79 shows the spur before and after the surplus wire has been cut off. Another plan is to bend the wire over the labial surface of the expansion arch in the form of a half collar, secure it with solder, and trim down the ends. This is stronger than the other spur, but is more conspicu- ous. FIG. 79. The soldering fluid for making these attachments may be of two kinds : first, that known as jewelers' soldering fluid (nitro-muriate of zinc), second, the ordinary phosphoric acid used in the oxy- phosphate cements. The latter, which we prefer, is cleaner and does not discolor the gold-plating of the arches. With this the soldering is somewhat more difficult, but after a little experience is easily accomplished. It being highly important that appliances worn in the mouth should always present as neat an appearance as possible, only as much solder should be used in attaching these spurs as is absolutely necessary. The spur should be no higher than the diameter of the ligature it is intended to support, as it would be unsightly, and would abrade the lips or interfere with their movements. IOO MALOCCLUSION. All these points should be carefully considered. See further instructions in Chapter XXI, on Technique. Plain Bands. As the plain band forms such an important part in so large a percentage of modern regulating appliances, and especially in this system, it is important that proper methods be employed, not only in the making but in the setting of the same. So erroneous are many of the directions given by authors and so- crude are some of the different methods of making these bands, that it may not be amiss to here point them out. First, it is the plan of some to adjust the appliance to the plaster model, forming the bands over the plaster teeth, and then to transfer it to the mouth. A more crude or inaccurate method could hardly be devised, as it is impossible to pinch or burnish band material about a plaster tooth so that its final fit to the natural tooth will be at all accurate, and it must soon loosen under the necessary strain of tooth movement. Another but slightly less crude method is to cast the form of the tooth in metal, around which the band is hammered and molded to the desired form. Another method is to make a band in a similar way and then to- cover it, forming an entire crown for the tooth. This of all methods is the most absurd, for unless the tooth be mutilated such a band must be imperfect of fit, bulky, and occupy valuable space, and also often directly interfere with occlusion, while the firm- ness of attachment is no greater probably less great than with a plain or clamp band correctly made and properly set with suit- able cement. Still another method, much better, but never admitting of any considerable degree of accuracy, is to burnish a short piece of band material about the tooth, overlap the ends, and solder. One author directs that the band shall be made larger than the tooth in order to provide space for the cement. The error of this is obvious, for, notwithstanding the greatest care and accuracy possible in the fitting of the band, there will still be room for suffi- cient cement if it be properly mixed. The chief disadvantage of a- band larger than the tooth is that its attachment will be far less firm than if the fit were accurate, and it will almost invariably loosen under the strain necessary in tooth-movement. The last method to be here considered is the use of a strip of metal SOLDERING. IOI in length not quite sufficient to encircle the crown and having soldered upon its outer surface, near the ends and at right angles to them, two small buttons, around which ligature wire is wound in the form of the figure 8, thus completing the union of the ends of the bands by tying. This form of band possesses no ad- vantages over the brazed band, but on the contrary has many disadvantages. It is bulky and uncleanly and will loosen under the .strain of tooth-movement far more easily, besides being more ex- pensive and requiring more time in tying than is needed in brazing. We have already stated our reasons for preferring German silver for the making of regulating appliances, and especially for the making of bands, in Chapter VII, yet this metal varies greatly in quality, not only on account of differences in the formulae from which it is made, but also on account of the manner of manipulation in manufacture. It is important that it shall be of the proper fineness, diameter, and temper, or it will be harsh and unyielding and difficult or im- possible of proper adaptation to the form of the tooth, in which case it will loosen more readily under the strain of tooth-move- ment, will occupy unnecessary space between the teeth, and pre- .sent a less pleasing appearance. To simply pinch a short piece of band material about the tooth, as has been recommended by some authors, is to make a loose fit and an imperfect band, Fig. 81. Pieces of generous length should be used, sufficient to firmly grasp with thumb and fingers after it has been slipped around the tooth to the desired point, so that considerable force may be exerted by the hand alone in drawing the loop firmly about the tooth at the time when the band is pinched by the band-forming pliers, Fig. 68. By this method sufficient pressure is brought to bear to make it fit with the greatest accuracy the surface of the tooth around which it is drawn, and if the surplus ends be cut off so they will still be united, as in Fig. 80, there will be very little waste to the strips of band material and ample length for a firm grasp will always be insured. By exercising the proper care a considerable number of bands can be made from one of the coils of band material, either F or H. No one should expect other than a very crude band if rough and loose-fitting pliers be used for pinching, for the junction of the IO2 MALOCCLUSION. pinched portion will then be rounded, as in Fig. 81, instead of sharp and at right angles, as in Fig. 82. FIG. 80. FIG. 82. Many advantages will be found in the use of the new band-form- ing pliers, Fig. 83, which so perfectly meet the requirements and which are so easy of access to all surfaces of any of the teeth, so that the seam can be as readily made on the lingual surface as on the labial, insuring a smooth, unbroken joint when soldered, Fig. 80. In soldering a band either gold or silver solder may be used. A portion about one-eighth of an inch square wet with borax cream is placed between the angles of the band and held by means of the new band-soldering pliers, Fig. 84, over the sharp flame of the Herapath blow-pipe. With these pliers uniform pressure *Essig's "American Text-book of Prosthetic Dentistry." SOLDERING. 103 is exerted at the exact points necessary to insure the seam being even and perfect, while the minimum amount of heat only is ab- sorbed by the pliers, consequently no change of form or injury to them is possible. A further advantage of their use is that their points rest in contact with the band material in such position as to be shielded from the solder, so that none will be fused upon the points, thus avoiding an annoyance of no small moment that ;s FIG. 84. often encountered in the use of ordinary pliers, their contact with the solder being almost a necessity. They will be found to be a great improvement over those heretofore used for the purpose. To insure the flowing of the solder in the seam only, plenty of borax should be placed there but none on the inner surface of the band, as otherwise the solder would be drawn from the seam and there would be faulty union or a thickening of the band, either of which would render it entirely useless. When soldered the band IO4 MALOCCLUSION. should present a continuous, even inner surface. Any other union is imperfect and should not be used. The band being properly fitted, it is ready for any attachments which may be required. Let us again insist upon the importance of a very hot, fine, sharp- pointed flame in the making of all these attachments, as neatness in such delicate soldering is impossible with a coarse flame. With the proper flame such attachments may be made almost instantly Fir, 85. FIG. 86. without injury to the delicate pieces of the appliances, and before the heat can be transmitted to those portions held by the fingers. The flame from the ordinary blow-pipe is wholly unsuited. The principal soldered attachments to the plain bands are tubes R, spurs and staples. The two latter are made from the wire G, as shown in D, E, G, and H, Fig. 85, and B, Fig. 63. The attachment of a spur is best accomplished by heating the smoothened end of the wire G, touching it to a large piece of borax, holding it in contact with a small piece of solder in the flame until it is partially fused, then bringing it in contact with the band at the desired point and again holding in the flame. After it is fused. SOLDERING. 1 05 Fig. 86, it is clipped off with the wire-cutters to the desired length, which should never be greater than one-thirty-second of an inch, and the roughened end made smooth with a file. But little solder should be used, as a large amount would form an incline, which would not so well hold the ligature. If a staple is to be made the end of the wire is bent into the form of the letter U, the solder is flowed upon the surface of the band first, then the convex portion of the staple is held in contact and the solder re-fused, after which the ends are clipped to about one-sixteenth of an inch in length and smoothed with a file, as in E and H, Fig. 85. The jaws of the staple should be close enough together to prevent much play of the piece it is to engage. When an oval loop, as in D and G, Fig. 85, is to be attached, the solder should be flowed first upon the band and only in suffi- cient quantity to secure the loop at the given point. A larger amount is unnecessary, and might be drawn into the cavity of the loop. The attachment of one of the tubes R, as in C and D, Fig. 100, and B, Fig. 101, should be made by also first flowing a minute portion of solder upon the band, then holding the end of the tube in contact with it and re-applying heat. If the side of the tube is to be soldered to the band, as in Fig. 167, it should be done in the same manner as shown in Fig. 76. It is desirable that all attachments, both for moving the tooth and in anticipation of retention, shall, if possible, be made before first setting the band, in order that the pain and trouble of removal and substitution of a new band, after the teeth have become .tender, may be avoided. The untrimmed ends of the band serve the useful purpose of a handle for holding it in the flame and in contact with the piece to be attached, as in G and H, Fig. 85, and Fig. 86. After the attach- ments have been made the ends of the bands are trimmed off, leaving them long or short, as desired. If a niche is to be formed, as in C C, Fig. 57, or A, Fig. 85, the ends are left about one-six- teenth of an inch long, but if they are not to serve as a means of attachment they may be trimmed still shorter, though it is never desirable to trim them even with the surface of the band. The sharp corners should be rounded by means of a fine flat file. The united ends may be further strengthened by an extra piece of the 106 MALOCCLUSION. band material held between the jaws at the junction when soldering; this, however, is rarely necessary. When the band is ready to be cemented upon the tooth it is first boiled in a few drops of dilute sulfuric acid, in a small test- tube or other suitable vessel, then washed and dried, or dipped in phosphoric acid and held in contact with the flame until the fluid is partially evaporated -by boiling, then washed. This is the author's favorite method of deoxidizing most small pieces. The tooth is cleansed with pumice, followed by alcohol or ether, then dried with the chip-blower and protected from moisture by a small roll of cotton or bibulous paper. The band is filled with oxyphosphate of zinc of creamy consistence, then carried on the end of the finger to the tooth, upon which cement and band are pressed. With the fingers alone the band is carefully worked nearly to its desired position and then driven down by a few 7 gentle taps from the mallet and band-driver (Figs. 73 and 74). The burnisher is now quickly applied to the edges of the band only, and the surplus cement wiped off. When the cement has thoroughly hardened the band should be carefully polished and burnished, as it is well known that discoloration is far less liable with a smooth, polished surface than with a rough one. The polishing is best effected by means of the ordinary leather polishing wheels, delicate of size and sharp of edge, with pumice. A band so made and set will fit with the most glove-like accuracy, will present a very neat appearance, and will not loosen under strain. It should be remembered, however, that only a perfectly fitting band can be firmly attached. If it is defective in any par- ticular, as too large, weakened by crimping, or slightly torn when driven into position, it should be immediately condemned and a more perfect one substituted, for sooner or later it will surely fail and cause annoyance. \Yhen it is desired to loosen the band, never attempt to do so with forceps or pliers. That is a clumsy way and involves too great risk. The band should be cut with the delicate point of a sharp knife, gently worked between enamel and band. In banding a tooth where there is much crowding of the teeth, sufficient space may usually be made between the tooth to be banded and those adjoining by stretching and working a strip of band material between the teeth on one side and allowing it to re- SOLDERING. lOJ main in position a few moments, after which the opposite side of the same loop may in like manner be worked between the teeth on the opposite side. The loop is then drawn tightly about the tooth with the fingers only, and if lateral pressure be considerable it is best to trim off the surplus ends of band material and allow this wedging band to remain in position over night before band- ing in the usual way. Usually, however, by exercising a little care and patience, the banding may be done at one sitting if, upon pinching and removal of the band, pieces of band material be im- mediately worked into the spaces already gained and allowed to remain while the band and its attachments are being completed. The cuspid is the most difficult of any of the teeth to band, but by forming the seam on the lingual incline and firmly burnishing the outer surface while it is being pinched, an accurate fit can in most instances be made. Another plan is to pinch a fold in the band on the lingual incline, while it is being firmly pinched and drawn with the fingers on the opposite side. The band is then removed and a little solder flowed into the fold. It is then re- placed and the seam made upon the labial surface by pinching, burnishing, etc., in the usual way. Adjustment of the Anchor Clamp Bands. The clamp bands were designed to be used upon the molars and bicuspids, as the shapes of these teeth and their positions in the mouth make it substantially impossible to fit plain bands to them so that they will not soon loosen under the necessary strain of tooth-movement. The clamp bands are easily and quickly adjusted upon these teeth, and may be readily removed and replaced without injury, when necessary. In adjusting a clamp band the nut should first be loosened suf- ficiently to allow ample size for the crown over which it is to slip. The band should then be shaped between the flat beaks of the band- forming pliers until it conforms approximately to the shape of the crown of the tooth, the shaft of the screw being also bent if neces- sary. It should then be carefully worked over the crown with the fingers and made to slide between gum and enamel to the desired point. It should then be alternately clamped and bur- nished until it be made to conform accurately to the shape of the crown. One of the greatest blunders made in adjusting these bands is to trim or file the band on its edge in order to prevent supposed IO8 MALOCCLUSION. interference with the gums. Such procedure only ruins the band. Besides, it is essential that this portion of the band shall pass be- yond the swell of the crown and be clamped and burnished to the neck of the tooth to prevent its slipping off. Another blunder frequently made is to begin the clamping or burnishing before it is well over the crown. In this case part of the band must bear the entire strain and will be stretched or torn. It is a mistake to allow the screw to stand out at too great an angle. The band should be turned before clamping until the screw be in close contact with the adjoining tooth. It cannot then interfere much with the movements of the tongue or lips. The bands are made to endure the greatest possible strain con- sistent with their nearly ideal proportions. They will therefore bear considerable tightening of the nut, yet if this be carried too far they may be easily broken. Judgment, not mere brute force, is required in their adjustment. It is usually best not to clamp the band too tightly at first, but to occasionally inspect and grad- ually clamp to the desired tension. The clamping of the bands is ample to so secure them in position that cement is unnecessary except in effecting stationary anchorage, as in the use of the trac- tion screw, as shown in Fig. 89. If the bands are to be worn for three or four months it would be desirable to use cement, but only as a means of preventing the possible disintegration of the enamel which they cover. FIG. 87. Fig. 87 shows a D band which has been properly adjusted to the crown of a molar. It will be noted that it accurately conforms to the swell of the crown. A small portion of the upper edge has been burnished over the distal marginal ridge, to prevent the possi- bility of the working of the band too far over the crown. ANCHORAGE. ICX} In order to gain sufficient space between crowded teeth for the reception of the bands, the directions for placing the plain band in similar cases should be followed. The points for any attachments which are to be made should be indicated by a small mark after the band has been made to conform accurately to its desired position, and before removing it from the tooth. CHAPTER X. ANCHORAGE. Principles of Anchorage. In the application of force for the movement of teeth, the crowns are the only portions available for effecting the necessary attachments. Force is usually exerted at right angles, or nearly so, to the long axes of their roots, and their changes of position may be said to be partial or complete. In the first instance the change is principally in the crown end of the tooth, it being tipped into position, thereby changing its angle of inclination, with little or possibly no apical displacement. In the second case the tooth is moved bodily, its coronal and apical displacement being more or less equal, and in the same di- rection. Whether the movement shall be partial or complete depends upon the manner of attachment, which determines the distribution of the applied force. In the first instance the attachment must be in the nature of a hinge or pivot, so as to admit of tipping, as would follow the use of a ligature made to exert force substantially at right angles to the long axis, or the jack-screw attached by means of a pit in the enamel of the crown, A, Fig. 100, or by a notched band cemented on- the crown, Fig. 88, or from the traction screw in pulling, as in Fig. 89. To effect the second form of movement necessitates that the at- tachment to the crown shall be rigid, as well as the appliance, so that tipping will be impossible, the force being then distributed equally to the root. Prof. Calvin S. Case, of Chicago, invented the first appliance to successfully accomplish this movement, exercis- ing in its construction much ingenuity and skill. His high standing no MALOCCLUSION. in the profession entitles his claims to respectful consideration, yet in the opinion of the author the movement is of uncertain utility in ordinary practice. It necessitates the use of a complex appliance, obtrusive in appearance, inconvenient to the patient, and trouble- some to the operator. The author believes it is wholly unnecessary, for reasons which he gives in the chapter on Changes Subsequent to Tooth -Movement. The movement of the malposed tooth depends upon two im- portant things: first, that the force exerted shall be sufficient to effect the movement, and second, that the anchorage shall be suf- ficient to resist this force. FIG. No.S Details of Anchorage. As has before been stated, there are but seven distinct malpositions which teeth can occupy. In accordance with laws of physics, their movement into harmony with the line of occlusion can only be accomplished by the application of force from a fixed base of anchorage in one of three ways, pulling, pushing, or twisting. As "for every action there is an equal and opposite re- action," it must follow that the same amount of force will be exerted upon the anchorage as upon the tooth to be moved, and if the anchorage offer no greater resistance than that offered by the tooth to be moved, equal displacement of both must follow. For moving teeth we have two principal sources of anchorage, first, that which may be derived from the teeth themselves ; second, that gained from suitable attachments to the top and back of the head. An accurate knowledge of the forms and surfaces of the teeth and their occlusion, the surfaces, lengths, and inclinations of their roots, ANCHORAGE. 1 1 1 and the structure, density, and distribution of the alveolar process and peridental membrane, is essential to an intelligent comprehen- sion of its requirements and possibilities. The resistance offered by different teeth varies greatly according to their position, size, length, and number of roots, the direction from which force is exerted, and also, as we have said, in the manner of mechanical attachment. Of the many improvements in the methods of tooth regulation perhaps none have been greater than the modern devices for secur- ing anchorage. The former bulky and insecure devices for this purpose, in the form of vulcanite or metal plates or cribs, have practically become obsolete since the introduction of the plain and clamp bands for the teeth, which make possible much greater control of the anchorage, as well as firmness and stability. The force should be as direct and positive as may be possible with the conditions at our disposal. The ideal anchorage would of course be that from an immovable base. This, however, is probably never fully possible in the mouth, owing to the slight spring of the alveolus and cushion-like function of the peridental membrane. Some displacement of anchor teeth is admissible, provided they be kept within the limits of final restoration by means of the inclined planes of the occluding teeth ; but if greater displacement than this occur, malocclusion of the anchor teeth, most difficult or even im- possible to overcome, may be established. Hence they should be closely watched, and careful measurements and comparisons with the original models be frequently made. Any movement perceived should be promptly combated. The embarrassment following any considerable displacement of the anchor teeth is so serious that ample anchorage should always be secured in the beginning. The anchorage available to us may be said to be of five kinds. They are more or less intimately associated and are used in combi- nations or separately, according to the exigencies of requirement. We will designate them as Simple, Stationary, Reciprocal, Occipital, and Occlusal. Simple Anchorage is that in which the resistance of the moving teeth is overcome because of the larger size or more favorable lo- cation of the anchor tooth, as in Figs. 90 and 91, the form of at- tachment being hinged or pivotal, admitting of the tipping of the anchor tooth in its socket. This form of anchorage, though often primarily unreliable in itself, may be reinforced by enlisting the 112 MALOCCLUSION. resistance of other teeth in the same arch, near or remote in location. Fig. 92 shows the first bicuspid in simple anchorage, reinforced by all the incisors, in order to overcome the resistance of the firmly implanted cuspid to labial movement. FIG. 90. FIG. 91. FIG. 92. Stationary Anchorage is that in which the form of attachment is essentially rigid, so that tipping of the anchor tooth is impossible, and if moved at all it must be dragged bodily through the alveolus in an upright position. Fig. 93 shows an illustration of stationary anchorage to a molar in the retraction of a cuspid. The long sheath of the screw is soldered to a clamp band rigidly cemented and clamped upon the molar, while the angle of the screw engages a tube soldered horizontally to a plain band on the cuspid. The attach- ANCHORAGE. 113 ment to the cuspid is hinged and designed for tipping, while that to the molar is rigid, to prevent tipping. If displacement of the molar should occur, it would be equal its entire length. It will be seen that the anchorage is thus enormously increased over the simple form. So efficient is it that the retraction of a cuspid has been accomplished by anchorage to a bicuspid alone, with but little displacement of the latter, while by ordinary anchorage all three molars and one bicuspid have been known to be tipped for- ward in the effort at retraction of the cuspid by means of a '"long clamp band" made to encircle the five teeth. Skill and judgment are necessary in the use of this form of anchorage, for its success depends, first, on the absolute rigidity of the attachment and appliance, and second, upon care that the FIG. 93. force exerted be not at any time so great as to strain or injure it. This is of vital importance, for any loosening or straining of it would change it to ordinary anchorage. (See directions for adjust- ing clamp bands for stationary anchorage, Chapter IX.) This valuable form of anchorage is somewhat limited in its range of usefulness because complete rigidity of both appliance and at- tachment is not always possible. We shall, however, employ it many times in the pages that are to follow. It was introduced by the author in the first edition of this book* (see also Items of In- terest, December, 1887). Reciprocal Anchorage is the pitting of one malposed tooth against another, the tendency of the force, correctly applied, being to move both into the line of occlusion, as in Fig. 94, where double rotation of the centrals is being accomplished by one appliance and widening *Stationary anchorage was first employed by Dr. Barrett, by means of a vulcanite plate entirely covering the molars; but this, of course, did not admit of strict rigidity of attachment. 9 114 MALOCCLUSION. of the arch by another, the rubber ligatures connecting the two being used merely as a convenience, to expedite the movement of the centrals, though not necessary to it. FIG. 94. FIG. 95. FIG. 96. Reciprocal force in anchorage admits of the widest range of ap- plication and is of the greatest value. Each case should be care- fully studied with a view to its use whenever possible, either in its simplest forms, as in Figs. 95 and 96, or when a greater number of teeth are to be moved, as in widening the arch, as in Fig. 94, or in combination with other forms of anchorage. It will be found ap- ANCHORAGE. 115 plicable to a very large percentage of cases, and is an important principle in many of the combinations of appliances in this system. FIG. 97- Occipital Anchorage is that in which the resistance is borne by the top and back of the head and transmitted by means of the head-gear and heavy elastics to attachments upon the teeth, as in Fig. 97. Il6 MALOCCLUSION. This very useful and well-known form of anchorage is principally applicable in the treatment of cases belonging to Division I and its subdivision, Class II, and to Class III. Occlusal Anchorage is so designated by the author because the principle involved would seem to require distinction. The tooth- anchorages already described depend primarily upon the lateral resistance of the alveolus to the roots of the teeth. In the present form of anchorage, while the alveolus affords more or less lateral resistance, the anchorage is principally due to the direct or indirect resistance of the opposing teeth through the occlusal planes, as in Figs. 98* and 99, where impacted cuspids were drawn into the line FIG. 98. of occlusion by means of rubber ligatures attached to the opposite jaw. This form of anchorage is direct and powerful, and may often be employed to much advantage. Dr. Baker's modification of this form of anchorage, shown in Fig. 255, is of such great value that it is the author's opinion that it may be classed among the marked steps in the progress of tooth regulation. It will be dis- cussed more fully hereafter. CHAPTER XI. COMBINATIONS OF APPLIANCES. THE hundreds of appliances that have been used in different hands in the various periods of dental history might be classified into a very few groups, each group representing merely variations of a single mechanical principle. Therefore the very common prac- tice of advocating indiscriminately every appliance that has ever ^Dental Cosmos, 1891, page 743. COMBINATIONS OF APPLIANCES. 1 17 been made to serve a purpose is, we believe, not only unnecessary, but misleading and fruitful of much harm. The author early became convinced that a very few appliances, in harmony with the simple laws of mechanics, of suitable propor- tions and interchangeable parts, would, in combination, meet all re- quirements. It has been his constant aim to simplify and minimize the number to the limit consistent with the necessities of practice. While the variety of combinations possible in the assembling of the several parts comprised in the system of appliances devised by the author and bearing his name is substantially limitless, yet a very few of these possible combinations are in reality sufficient for all purposes of orthodontal practice. Several writers, in commending, from time to time mechanisms constructed by practitioners along lines of these models, have, perhaps unwittingly, introduced many unnecessary combinations, which must be misleading to the student or inexperienced practitioner. Thorough familarity with, and experience in the use of, a few appliances of desirable form will reveal possibilities of accomplish- ment which would never follow in the case of a large variety each of which might only occasionally be used. The best success can be achieved only by persistent concentration of mental effort, and success will be modified as the attention shall be divided, however great the earnestness of application. We cannot too strongly urge the minimizing of the number of appliances to the absolute requirements of use. Those appliances which the author has found from much ex- perience to be the most useful will be chiefly specified in the de- scriptions of treatment in the following pages, but that there may be ample range of choice a number of others will also be mentioned as being possibly desirable in certain cases. Let it be remembered that the functions of regulating appliances consist in the movement of teeth from their seven malpositions into harmony with the line of occlusion by the exertion of force in pulling, pushing, and twisting, singly or in combination. The varied requirements in the establishing of occlusion and in harmonizing the sizes of the arches necessitate that the appliances shall not only move teeth singly in these several directions, but that they shall, on occasion, move them collectively and often in various directions simultaneously. For example, it may be required to n8 MALOCCLUSION. move buccally one or both of the lateral halves of one or both arches, or to lengthen or shorten one or both arches in front, or to lengthen or shorten one or both of the lateral halves of one or both arches, and in rare instances to move lingually one or both of the lateral halves of one or both arches. A FIG. ico. C D Jack-Screw. In employing the jack-screw for exerting force upon teeth to be moved the base of the sheath may be secured in various ways, as shown in Fig. 100. First, by means of a small dowel, made by soft-soldering a piece of the wire G into the end of the sheath, which is made to rest in a pit in the anchor tooth, as in A. COMBINATIONS OF APPLIANCES. 1 19 Second, by means of a similar dowel made to engage a tube R soldered to the anchor band, as at C. In this way the length of the sheath may also be increased in the rare instances where a longer sheath may be required. Third, by means of a spur made from the wire G soldered to the anchor band, over which the end of the sheath of the jack-screw may be slipped, as in B. Fourth, by pointing the end of the sheath with a file and letting the point rest in a tube on the anchor band, as in D. Fifth, by soldering the sheath directly to the anchor band, as in E and F. Sixth, by notching the end of the sheath, and resting it against a wire, as in G. Seventh, by soldering the end of the sheath directly to another sheath, as in H. Eighth, by means of a spur made from the wire G soldered to the sheath and engaged with a tube R soldered to the anchor band, as in I. Ninth, by slipping the end of the sheath over the screw of an anchor band, as in J. Of these various ways of attaching the sheath, those shown in B, E, F, and J, are preferable. The point of the jack-screw is held firmly in position in six prin- cipal ways, as shown in Fig. 101. First, by engaging a notch in its end with a similar notch in the united ends of the band, as at A, the notches to be made with a separating file. Second, by pointing the end of the screw and engaging it with small tubes R soldered to the band, as at B. Third, by a mortise in the band to engage the point of the screw, as in C. Fourth, by an elliptical ring soldered to the band, as in D, and engaging the point of the screw. Fifth, by means of a staple soldered to the band, as in E, and engaging the notched point of the screw. Sixth, by resting the screw, suitably pointed, in a pit formed in the enamel, or in a filling, as in F. Of these various ways those shown in D and E are preferred. Fig. 1 02 shows the jack-screw effecting the labial movement of I2O MALOCCLUSION. the upper cuspid teeth, which are provided with plain bands ce- mented upon their crowns. To the mesio-lingual angle of one is soldered a spur which engages the base of the sheath of the jack- screw (as in B, Fig. 100), while the notched point of the screw en- FIG. 102. gages a staple soldered to the mesio-lingual angle of the other cus- pid. By tightening the nut the teeth are moved in opposite direc- tions. The tubes R, in anticipation of reinforcing anchorage, are also shown, one upon the side of the sheath of the screw, the other upon the lingual surface of a band encircling the first bicuspid. As the right cuspid will probably be moved into position first its further COMBINATIONS OF APPLIANCES. 121 progress will be arrested, as well as its anchorage reinforced, by a ligature inclosing the reinforcement tubes, drawn tight and the ends twisted. Tubes R soldered to the labial surfaces of the bands upon the moving teeth are also shown. These are in anticipation of reten- tion by means of a section of the wire G to be slipped through them, its ends to bear against the labial surfaces of the adjoining teeth, as described in the chapter on Retention. Fig. 103 shows a combination in which the jack-screw is made to exert force in moving labially an inlocked cuspid. The point of the screw engages a pit in the enamel, the base of the sheath having FIG. 103. been previously slipped over a spur (B, Fig. 100) soldered to the mesio-lingual surface of the anchor band No. i clamped upon the first bicuspid. Reinforcement of the anchorage was gained by means of a section of the G wire, the ends of which were hooked into tubes, one being soldered near the base of the jack-screw, the other upon the mesio-lingual angle of a band encircling the lateral incisor. Later experience has proved that an easier and better way of attaching the reinforcement wire is to omit the tube from the band, soldering the straight end of the wire directly to the band. The other end of the wire, before bending, is passed straight through the tube in the direction of the anchor tooth, then bent around in the direction of the point of the screw and the surplus wire cut off. The bending of the wire should be the last part of the operation, or after the cementing of the band upon the lateral and complete adjustment of the screw. 122 MALOCCLUSION. A modification of a similar combination of the jack-screw is shown in Fig. 104, in the labial movement of an inlocked lateral, the point of the screw engaging a staple on the lingual surface of a band on the malposed tooth. The base of the screw engages a spur on the anchor band. Reinforcement of the anchorage was gained by a loop made from the wire G which engaged a tube R soldered at right angles to the sheath of the screw on its palatine surface. The FIG. 104. G, -NO. 2 ends of the wire, bent in the form of hooks, engage wire ligatures encircling cuspid and central incisor. This combination is quickly and easily made, and the reinforcement through the ligatures is quite as efficient as would be if bands were used, which, besides requiring more time and trouble in adjusting, would occupy valuable space. Of course such ligature reinforcement would be useless with fibrous ligatures, as slipping and stretching would render them inoperative. Fig. 105 shows a combination of the jack-screw where reciprocal COMBINATIONS OF APPLIANCES. 123 anchorage was used to accomplish the lingual movement of the lateral and labial movement of the cuspid, the sheath of the jack- screw being cut short to allow it to travel forward over the spur as the nut was turned until its base finally rested against the anchor band, when the lateral was drawn into place and reinforced the anchor tooth in resisting the moving cuspid. The extra tube on the sheath of the jack-screw was in anticipa- tion of further reinforcement of anchorage, if it should be found necessary, by hooking another piece of the wire G into the tube after soldering the other end to a band upon the first bicuspid. It was not found necessary in this instance, but it is always well to anticipate the possible need of spurs, tubes, etc., in order to avoid the trouble of removal and readjustment of appliances, the evil ef- fects of relinquishment of pressure, etc. FIG. 106. Fig. 106 represents a combination of two jack-screws for moving labially, out of inlock, two central incisors (one also being in torso- occlusion), the patient being a child eight years of age. The inci- sors were encircled by plain bands, the union of the bands being at their disto-lingual angles and notched (as in A, Fig. 101) to hold a straight section of the wire G, against which rested the notched points of the jack-screws. The bases of the sheaths were slipped over the ends of the screws of the anchor clamp bands (as in J, Fig. 100) and force was exerted by tightening the nuts of the jack- screws. Rotation of the central was accomplished at the same time, by occasionally tightening the wire ligature (A, Fig. 63) encircling the tooth, its looped ends engaging the wire and union of the band. 124 MALOCCLUSION. Retention was effected principally by the occlusion with the lower teeth, the bands, however, having been removed and soldered at points of contact and re-cemented in position. In using the jack-screw it is always best to employ as long a sheath as possible, turning the nut close up to the chisel end, in order that there may be ample length of the screw to effect the necessary movement. Formerly some annoyance was occasioned by the nut being loosened by the tongue. This is, happily, now wholly overcome by the latest improvement to the jack-screw, the extension flange or friction sleeve, as already described. Two sheaths are provided for the jack-screws, to afford ample length for all cases. They should, of course, be cut shorter if the case demand. The author has occasionally found it necessary to use this screw and sheath combined only one-fourth of an inch in length, as might be found necessary in restoring to an upright posi- tion a molar which had inclined into the space made vacant by the loss of another tooth. Lever. In the movement of rotation of a single lateral incisor by means of the lever L, shown in Fig. 107, the plain band, with a FIG. 107. tube on its mesio-labial angle, was cemented upon the lateral. One end of the lever engaged the tube, the other end being sprung around and made to engage a hook on the buccal surface of an anchor band on the second bicuspid, which was reinforced by a section of the wire G passed through the tube R on its lingual sur- face, the ends of the reinforcement wire being made to bear against the lingual surfaces of the first molar and the first bicuspid. Additional reinforcement may often be gained by ligatures made to encircle lever and teeth intervening between the moving tooth and COMBINATIONS OF APPLIANCES. 125 the main anchor tooth. The lever should be occasionally removed and straightened to intensify the force. The various sizes of the levers furnish ample range for the needs of larger teeth, but as the force exerted by the lever is so great the smallest sizes are usually preferable. Fig. 108 shows a combination of the lever for rotating a central and lateral incisor and moving labially a lateral incisor. The re- sistance end of the lever is passed through a tube R soldered to the disto-lingual angle of a band on the lateral. The power end, bent in the form of a hook, is secured by a wire ligature made to engage FIG. 108. the nut on the anchor band on the first molar. This is the author's favorite method of securing this end of the lever, as the strongest anchorage and greatest control of the lever are thus secured. Additional force is applied to the rotating lateral by allowing the end of the lever to bear against the labial surface of the cuspid, and it is further intensified by an intervening wedge of rubber. At the same time the other lateral is being moved from lingual occlusion and the central rotated by means of wire ligatures, band, and spur, as would be similarly employed if the expansion arch were used in- stead of the lever. Fig. 109 shows a combination where two levers were used in rotating two superior cuspids, the ends of the levers engaging tubes R soldered to bands upon the moving teeth. The power ends of the levers engaged hooks soldered to an anchor band upon the first molar, the anchorage being reciprocal. 126 MALOCCLUSION. Fig. no shows two central incisors being rotated in opposite directions at the same time by means of the lever. Upon the in- cisors have been cemented plain bands having soldered at their disto-labial angles tubes R. One end of a section of the smallest size of lever wire was inserted into one tube and then into the other by springing and sliding, as a door-bolt is slid into position. FIG. 109. FIG. no. FIG. in. Fig. in shows a view from the labial aspect of the appliance in position. The spring of the wire exerts pressure lingually on the mesial angles, while the ends of the lever operate in the opposite direction on the distal angles of the teeth. As the teeth are turned it may be necessary to occasionally remove the lever and straighten it in order to maintain the pressure. Should one tooth be rotated sufficiently before the movement of the other is complete, its further movement should be arrested by a spur soldered to the disto-lingual angle of its bands and made to bear against the lateral incisor. If COMBINATIONS OF APPLIANCES. 127 .the teeth show a tendency to separate as they rotate, this should be prevented by a wire ligature which should inclose the ends of the lever on the labial surface. Although this is a simple and efficient method of performing double rotation of the incisors, yet it must be remembered that in most instances these positions of the teeth are only the result of lateral pressure from narrowing of the arch, which must be widened to provide room for their occupancy. In such cases the expansion arch is better suited for accomplishing the movement of double ro- tation of the incisors while widening the arch at the same time, yet where there is sufficient room for the incisors it would be difficult to find a more ideal method than the use of the lever, as here de- scribed. This would be peculiarly true in cases where the teeth after regulation by enlargement of the arch have, from neglect or enforced absence of patients, partially relapsed into their former malpositions during the period of retention. FIG. 112. E.H. A. When opposite movements of incisors in double rotation shall be found necessary it may be accomplished by means of the lever L, made to rest in notches in sections of the wire G soldered to the disto-labial angles of the bands, while a wire ligature encircling spurs soldered to the mesio-lingual angles passes between the teeth to inclose the center of the lever, as in Fig. 112. The ligature should occasionally be tightened by twisting. After the teeth have been sufficiently rotated, temporary retention may be effected by means of a ligature inclosing the spurs only. Traction Screw. Although there are many possible combinations with the traction screw, yet in reality its uses should be limited to two, or possibly three. Its most important use is that of retraction of that most obstinate tooth, the cuspid, as shown in Fig. 1 13. This it accomplishes so easily and so perfectly, when properly adjusted and managed, that it easily takes rank, we believe, over all other appliances for this purpose. We shall use this combination many 128 MALOCCLUSION. times, singly or with other appliances, in the pages that are to follow, and will here only describe its correct adjustment. The cuspid and anchor teeth are carefully banded after the man- ner described for adjustment of the plain and anchor bands in the chapter on Band-making. The traction screw is then held in position, and the short and long sheaths made to touch the bands at the exact points they are to occupy when soldered. With a suitable instrument the anchor band is scratched parallel with the long tube to indicate its alignment. The side of the long sheath is then filed to permit of close contact with the band and to give increased sur- face for the solder, filing through being carefully avoided. The band is then replaced, and the exact point of contact of the edge of the short sheath with the band on the cuspid is located and indicated FIG. 113. A Y E.H.A. 'H No.2 by a suitable mark. Lest this be obliterated upon soldering, the band may be perforated at this point with a small drill. Having noted as accurately as possible the angle at which this tube shall stand to properly line with the right angle of the shaft, minute notches are made in the edge of the band mesially and distally, to line with the end of the tube, Fig. 114. The bands are now re- moved from the teeth and the sheaths from the screws, and a minute piece of solder partially fused upon the edge of the short tube at the point intended for attachment to the band. The tube is then held with the solder-placing pliers, Fig. 67, in the left hand, the band being held by its untrimmed ends in the right hand, the end of the tube lining with the notches A and B, Fig. 1 14, and the solder fused by contact with the flame at the proper point. Only sufficient solder to form the union should be used. A little experience will enable the operator to make this the most difficult of all attachments in this system easily and quickly, yet it is highly essential that the tube shall be attached at the right COMBINATIONS OF APPLIANCES. 129 point and at the proper angle, or the angle of the screw will not fit. The beginner may, therefore, probably better temporarily wax the tube in position and invest and solder as he would in attachments to be made in bridge- or crown-work. Be it remembered that the tube attached to the cuspid band must always stand at right angles to the long axis of the tooth, that a free hinge-like movement of the tooth in retraction may be gained ; not parallel with the long axis, as some will persist in attaching it, with resultant binding and prevention of free movement. FIG. 114. A The surplus ends of the bands are now trimmed off and smoothed, and the band deoxidized and cemented in position. While the cement is hardening the long sheath is soldered, according to align- ment, to the No. 2 band, using plenty of solder, a piece one-fourth of an inch square and of the usual sheet thickness. It is then cleansed and slipped upon the screw and the nut adjusted, the angle is hooked into the tube upon the cuspid band, and the clamp slipped over the crown of the molar and gently tightened. It is allowed to remain a day or two before cementing, in order that this operation, so important to thoroughly perform, may be accomplished without interference by pressure from the approximal teeth, and also that both the cuspid and the anchor tooth may slightly move and become more perfectly adjusted to their relations with the two bands. The proper length of the screw having been determined, it is cut 10 130 MALOCCLUSION. off behind the nut. Never shorten the screw and then attempt to screw the nut upon it. Heat must in no instance come in contact with any portion of the shaft of the screw. Before finally cementing the band in position, it should be re- moved and cleansed and dried. The crown of the molar should also be thoroughly cleansed and dried, the final cleansing being with a pledget of cotton moistened with alcohol or ether. The crown being properly protected from moisture, cement is quickly mixed to the proper consistence and the interior of the band nearly filled. The angle of the traction screw is then inserted into the short tube and the anchor band and cement carried down over the crown with the thumb and finger, forcing the cement well down about the crown by pressure from the thumb. The band is quickly worked to the de- sired position, and the nut of the band tightened until it is firmly clamped. The superfluous cement is then wiped off and the patient dismissed until the next sitting before tightening of the nut of the traction screw is begun, in order that the cement shall become thoroughly set and the most rigid possible attachment gained. If the operation so far has been carefully performed, the nearest approach to stationary anchorage will have been gained, so that the cuspid may be moved distally without changing the relation of the occlusal planes of the anchor tooth with those of the opposite jaw. It is very important, however, not to strain the attachment by overtightening the nut of the traction screw at any time. One- half a revolution of the nut each day, or just enough to exert a slightly snug feeling upon the cuspid, is all the force that should be exerted at any one time. Very often patients may be provided with wrenches and intrusted to tighten the nut regularly each day themselves. This movement, of all, however, should be conducted with the greatest regularity, and unless the patient can thoroughly comprehend and carry out instructions he should not be depended upon. It is nearly always best to operate the screw on the outside of the arch, placing the tube engaging the angle of the screw in the region of the mesio-lingual angle of the tooth, or in the same man- ner as shown on the right of Fig. 115. It is very important that the angle of the screw be passed into the tube its full length, otherwise it will be broken when force is exerted. COMBINATIONS OF APPLIANCES. If it is desired to rotate the cuspid as it is moved distally, it may be accomplished by using a staple instead of a tube for engaging the angle of the traction screw, as shown on the left of Fig. 115. In this instance the angle of the screw is parallel with the long axis of the tooth, instead of at right angles to it, as when the tube is FIG. 115. used. In this manner force is exerted on one side of the band only, and rotation, as well as retraction, takes place. In some instances it may be desirable to operate the screw on the lingual side of the arch, as in Fig. 116, although the anchorage is not so secure on account of the shape of the crown not admitting of so strong attachment of the tube to the band. The shifting of the cuspid lingually or labially in its distal movement may be accom- plished by bending the screw where it enters the sheath, as in Fig. 132 MALOCCLUSION. 117. As the nut is tightened the screw is gradually straightened as it is drawn into the sheath, thus arranging the teeth in proper alignment. A method of reinforcing the anchorage is also shown in this engraving, by enlisting the resistance of the lateral incisor. The tooth is banded and provided with one of the tubes R soldered at its disto-lingual angle, which engages a straight section of the wire G, the other end resting in another tube R soldered at an obtuse angle near the end of the sheath. The fine adjustment of this wire may be effected by means of the regulating pliers. FIG. 117. FIG. 118. Fig. 1 18 shows the use of a traction screw in effecting rotation of a bicuspid tooth, in combination with the clamp bands Nos. I and 2. The angle of the screw engages a staple made of the G wire soldered to the mesio-lingual angle of the band encircling the bicuspid. By tightening the nut at A traction force is exerted on one side only, while resistance in the opposite direction is offered by the intervening bicuspid. It is necessary in the treatment of many cases to rotate one or more of the bicuspid teeth in order to gain the full size of the arch, so that it shall harmonize with the other arch and establish normal relation of the occlusal planes. It is also well known that COMBINATIONS OF APPLIANCES. 133 rotation of these teeth is difficult by ordinary methods. This method of rotation is very efficient and most desirable in all such cases. In Fig. 119 is shown another use of the traction screw, in ef- fecting the labial movement of a lateral and at the same time pro- viding space for its movement. A strip of band material F is looped around the lateral, the ends resting on the labial surfaces of the adjoining teeth. To one end is soldered vertically one of the short tubes D, while on the other end is a similar tube attached horizontally. Into these tubes the traction screw is placed, being bent to conform to the proper curve of the arch, and pushes the ends of the band farther apart as the nut is tightened. FIG. 119. Although efficient, it requires frequent tightening, and is trouble- some on account of its liability to work loose. It is now rarely used by the author except in the quick readjustment of teeth which have partially relapsed toward their original malpositions through accident during the period of retention. Expansion Arch: History and Combinations. Its wide range of application in tooth-movement easily distinguishes the expansion arch, with its attachments of bands, spurs, and ligatures, as shown in Fig. 1 20, as the most universal of all regulating appliances. Not only may it be used for the movement of teeth singly, but also col- lectively, and it is equally applicable to both arches. In its use it is made to occupy a position external to the dental arch, lying in more or less close proximity to the labial and buccal surfaces of the teeth, as shown in Fig. 121. The ends of the arch are supported by the accurately fitting tubes of the strong anchor bands. The front of the arch is firmly supported by resting in niches formed for this purpose in the united ends of bands on one 134 MALOCCLUSION. or more of the anterior teeth, as occasion may require, although the brass wire ligatures alone may in some instances be sufficient for its support in this region. In accomplishing the various tooth-movements the expansion arch is first made to conform to the shape of the ideal dental arch, or as we wish the teeth to be arranged when the movements are completed. It therefore becomes a guide and pattern for the FIG. 120. FIG. 121. E.H.P" proper alignment of the teeth, as well as the means of effecting their movement by reason of its elasticity and the use of the wire ligatures. The adjustment of the size of this pattern for the re- quirements of the teeth to be moved into proper alignment is con- trolled by the nuts in front of the anchor tubes. For the inception of this valuable device, as we have said, we are indebted to Fauchard, who introduced it in 1726. Unques- COMBINATIONS OF APPLIANCES. tionably its introduction marked the most important step in the history of regulating appliances. Originally the appliance was very crude, clumsy, and unsightly, and its uses greatly limited. It was composed of a flat ribbon of FIG. 122. FIG. 123. FIG. 124. FIG. 125. metal, perforated for the reception of ligatures by means of which attachments to the teeth used as anchorage, as well as to the teeth to be moved, were effected. It has undergone many modifications by many practitioners since Fauchard's time, only a few of which we have here space to consider. Four of these are represented in Figs. 122, 123, 124, and 125. 136 MALOCCLUSION. It is doubtful if Fox's plan of nearly a century later was any im- provement over Fauchard's. It consisted principally in the addi- tion of that most useless absurdity, the gag, in the form of blocks of ivory to prevent the closure of the jaws and interference from the moving teeth. A marked improvement in the anchorage of the arch was given us by Schange in 1841, in the form of a skeleton crib attachment to the molars. We greatly question whether Harris's supposed improvement of the expansion arch in 1850 was an improvement. Metal caps were swaged to cover the crowns of the molars to whick the arch was soldered, and in order to keep these crowns in position Upon the anchor teeth they, in turn, were soldered to a metal plate covering the vault of the arch. This necessitated the frequent removal of the device for the purpose of cleansing a fatal weakness in any appliance, as the moving teeth are thus frequently sprung back and forth by the relinquishment and reapplication of force, which action is a certain means of inciting inflammation. Desirabode's modification of the expansion arch was very simi- lar to that of Harris. To describe any considerable number of the later modifications would require so much space that the author has thought it best to omit them all to avoid any inference of invidious distinction, their characteristics differing mostly in their proportions and in their manner of attachment, they being combined usually with some form of plate. The author's improvements may be briefly said to consist in change of metal, modification of form and proportions, delicacy of temper, greater length of threading of sides for universal adjust- ment of size, in the material, style, and proportions of the parts entering into the anchor clamp bands, and in the various attach- ments, some of which are modified and others newly devised. Im- portant among these is the addition to the clamp band of the long tubular sheath for the reception of the ends of the arch, which not only protects the cheeks from abrasion by the threaded portion of the arch, but gives greater stability to the anchorage. Another is the delicate style of spur and means of its attachment to the arch, its use controlling the direction of force exerted by the ligatures. Still others deemed very important are the friction sleeve of the COMBINATIONS OF APPLIANCES. 137 nut, the wire ligature and the reinforcement arch, descriptions and properties of which follow in connection with instructions for their use. Unquestionably the greatest modern improvement in connection with the use of the arch is the adoption of wire for ordinary ligatures, in place of rubber and the fibers. (Fourth edition.)* This improvement has greatly extended its range of uses, making easy much that was impracticable or even impossible before. Its great strength, cleanliness, and freedom from stretching or slipping place it easily ahead of all other ligatures. It is easily and quickly applied, and is unobtrusive in size. Its most valuable quality, however, is that it may be tightened by twisting, without renewal, possessing thereby, in addition [to its primary usefulness, the ideal power of the screw, and obviating the necessity for relinquish- ment of pressure on the moving tooth, as must follow the use of other ligatures. Its force is direct and positive. It is very im- portant, however, that only wire of the proper metal, quality, and size be used. After much experimenting brass has proved by far the most satisfactory, the most useful size being No. 26. If larger it will be unyielding; if smaller it will not possess sufficient strength. It is also important that it shall be in temper very soft, so made during its manufacture. Wire of spring temper is entirely useless. Uses of the Arch. If a single tooth is to be moved buccally or labially, it is effected by a plain ligature being made to inclose it and the arch (A, Fig. 120), and being occasionally tightened by either twisting or renewal. If a number of teeth are to be moved forward simultaneously, the result is attained by ligating the teeth to the arch and tightening the nuts in front of the anchor tubes. The wire being inexpensive, a ligature of generous length (about one foot) should be employed, to afford a ready grasp for both hands, that strong tension may be exerted while giving it the twist, which should never be more than three-fourths of a turn at first. The surplus ends are then clipped off, leaving projections one-eighth of an inch long. These ends are then curled under, as *The author is unable to find record of any use or mention of the wire ligature in connection with the expansion arch previous to his introduction of it in 1895, although he had thoroughly tested its value for two years be- fore publication. 138 MALOCCLUSION. shown correctly in Figs. 120 and 126. It is very important that this point be remembered, for by observing this special way of pro- viding for the sharp ends a smooth, easy surface is presented to the lip. Never attempt to bend the twisted portion of the liga- ture out of the way, as by so doing the entire strain would be brought on one strand and the ligature in almost every instance be broken. In tightening the ligature a very excellent plan is to firmly press the tooth and arch between the thumb and finger while giving the ligature another half turn with suitable pliers. It should be remembered that the spring of the wire arch, when used in con- nection with the wire ligature, is constantly acting, so that as a rule tightening of a ligature need be done only occasionally. Rotation is accomplished by firmly cementing to the tooth n plain spurred band and encircling the spur and arch with a tightly drawn ligature (B, Fig. 120), much force being exerted, upon the moving tooth at its diagonally opposite corners, in reality the arch operating as two levers combined, the power ends acting in opposite directions. No tooth can resist the combined rotating force of these levers, while at the same time the relative position of the tooth is perfectly controlled. Let us further study some of the uses of the expansion arch in a most complex case, Fig. 126, necessitating force from all direc- tions to be exerted upon the badly malposed teeth, and offering the severest test to a regulating appliance. The delicate wire loop lying lingual to the teeth will be ex- plained later. The dental arch requires much widening, while both centrals and both laterals are to be carried forward and outward and rotated, and the cuspids are to be elevated in their sockets. It will be noticed that wire ligatures are looped over spurs on the disto- lingual angles of bands upon the incisors, thus exerting pressure as they are occasionally tightened by either twisting or renewal. This tends to rotate the teeth, as well as move them forward and outward into harmony with the pattern of the expansion arch. The exact direction of this force is controlled by little spurs at- tached by soft solder at the desired points to the expansion arch, which thus prevent the ligatures from slipping down the sides of the arch, as is clearly shown in the engraving. (See also chapter COMBINATIONS OF APPLIANCES. 139 on Soldering.) The nuts in front of the anchor tubes are occa- sionally tightened as more room for the moving teeth is re- quired, thus carrying all four teeth forward with the positive force of the screw. The action is practically that of two jack-screws united. As the expansion arch is very elastic, it exerts a powerful lateral force upon the sides of the dental arch, through the anchor bands and the ligatures upon the bicuspids. By studying this figure it will be seen how perfectly force is being distributed to accomplish these various tooth movements, and how, as in all fine mechanisms, each part assists and harmonizes with each other part. For ex- ample, note how perfectly the force is reciprocated from one mov- ing tooth to another, or from one lateral half of the arch to the other, and how this is intensified by the pressure on the center of the arch in front, the tendency being when pressure is exerted at this point, as in all arches, to widen the lateral halves. One lateral incisor reciprocates its force to the other, one central to the other, all in perfect harmony. Note also what complete control we have over the teeth, singly or collectively. As we shall see later, in the 'Treatment of Cases," we may widen the arch on one or both sides, or we may lengthen one or both of the lateral halves or any portion of them. This 140 MALOCCLUSION. appliance is not, hozvever, suited for narrowing or shortening the arch or cither of its lateral halves. The modifications of form and directions of spring, plus the modifications in ligature attachments, make it possible to derive wonderful combinations and results, and in its use it is possible to cultivate a very high degree of skill. It typifies efficiency and simplicity. It is easily applied, and is so stable in its attachment that there need be no slipping or loss of power. It is cleanly, and occupies a position in the mouth that is of the least inconvenience to the patient. If this device be intelligently managed it need interfere but little with the normal functions of the mouth. On the contrary, if improperly managed it becomes a constant annoyance and one of the most wobbly and useless of devices. In its proper use the widest range for reciprocal anchorage is possible. \Ye may also gain simple, and a considerable degree of stationary, anchorage by reason of the tubes and firm attach- ment of the anchor bands to the teeth used as anchorage. The necessary direction and distribution of force should be carefully studied in each case, as well as the effect upon the anchor teeth and all that are in proper position. The arch should always be made to lie approximately close to the teeth, so as to interfere as little as possible with the functions of the lips. Again, as its force in tooth movement is exerted usually by its elasticity, its careful bending, in order to secure the proper de- gree and direction of force, is of much importance. To make the most of this possibility, and at the same time avoid interference with desired movements or with teeth already in correct position by binding, is the most difficult problem in its management, and yet is easily solved if intelligently studied in each case. The author's latest improvement to the expansion arch is the extension flange, or friction sleeve, of the nut, which accurately telescopes the end of the sheath ] on the anchor band, the shoulder of the nut bearing against the end of the sheath, while the end of the sleeve bears against the shoulder formed by the smaller diam- eter of the sheath, as shown in Fig. 127. One of the advantages of this style of nut is greater length and consequently greater strength of thread without increase of bulk, but its chief advantage is that it prevents the annoyance of the COMBINATIONS OF APPLIANCES. 14! loosening of the nut by the movements of the tongue and lips an annoyance which has existed as long as small screws and nuts have formed parts of regulating appliances. After long and persistent experimenting in the use of the arch the author believes he has succeeded in eliminating all weaknesses and in gaining very nearly the ideal in its size, proportion, and elasticity, as well as in the size and proportionate strength of each part of the anchor bands for its attachment, Fig. 127. A frequent FIG. 127. mistake in the adjustment of the anchor bands is in not placing them in correct position upon the crowns of the teeth, usually in not forcing them sufficiently over the crowns, in which case they will soon loosen ; but if properly placed, as in Fig. 87, and thor- oughly burnished and clamped to conform to the surface of the crown, displacement is impossible. (See Directions for Setting Clamp Bands in Chapter IX.) There are two sizes of anchor bands used for securing the ends of the expansion arch, namely, the D and X bands. The larger (D) are most frequently used, and preferably upon the first molars, as on account of their superior size and favorable position they 142 MALOCCLUSION. ordinarily afford by far the best anchorage. It may, however, be found desirable to employ one of the bicuspids for anchorage, and for this purpose the band X was added. The sheath is set farther back, to afford room for the nut as the curve of the arch is reached. Occasionally the tooth which it is desired to use as anchorage may be found to incline forward at such an angle that the sheath on the D band will not properly line with the expansion arch, in which case the band should be removed and the sheath be de- tached and resoldered at the proper angle. This may be readily effected by placing a small piece of solder and borax at the union of the band and sheath, applying heat and turning the band as desired. It is, however, rarely necessary, as by slightly bending the arch and shifting the band, it can in most instances be properly adjusted without changing the position of the tube. The proper alignment of the sheaths is best effected by slipping the ends of the arch into them before firmly clamping the bands. In order that the patient may become gradually accustomed to the appliances, the bands should be worn for two or three days loosely clamped about the teeth, then the arch added without ligatures for three or four days more, and finally all carefully and thoroughly adjusted and the ligatures applied for the movement of the teeth. They should be very light of tension at first. If this bf. done, the patient will be more tolerant of conditions during the progress of the movement. The elasticity of the arch is sufficient to exert ample force for widening either of the dental arches, yet in some instances where the patient has reached maturity the force may not be sufficient to accomplish the desired movement as rapidly as may be wished. To meet this limitation we have devised the reinforcement arch L, which should be adjusted to exert pressure upon the lingual sur- faces of the anchor bands, as in Fig. 128; also Fig. 126. Attach on each side in the manner following: unite two short tubes at right angles, R and D; slip the longer one over the end of the screw of the clamp band D; bend the end of the lever sharply at right angles and engage it with the short tube. Any desired degree of force may be easily gained with this simple method of reinforce- ment. A cheaper and quite as efficient way of securing the ends of tha COMBINATIONS OF APPLIANCES. 143 reinforcement spring is to finely point the ends, bent sharply out- ward at right angles, and insert them into fine perforations made in the anchor bands at their mesio-lingual angles, as in Fig. 223. The perforations should be made with the finest pointed excavator or a delicate drill, made to pass through the band and a little beyond by gently working it between band and enamel. A large perforation would weaken and injure the band. FIG. 128. Combinations of the Expansion Arch and Traction Screw. As we have already stated, the expansion arch is not suited for shorten- ing the anterior part of the dental arch or its lateral halves, for the reason that it is impossible to gain complete stationary anchorage in its use, the spring of the arch and attachment of ligatures de- feating the possibility of complete rigidity of anchorage and ap- pliances ; but by combining it with the traction screw, perfect results are possible. Fig. 129 shows a very important combination of the traction screw and expansion arch for shortening one of the lateral halves of the arch and at the same time correcting malpositions of teeth. The traction screw should be first adjusted as already described, and as shown in Fig. 113. In addition it should be provided with one of the tubes D soldered to the side of the sheath Y near its mesial end. This is for the reception and support of one end of the expansion arch in place of the usual D or X band. The nut of the expansion arch is to bear against this tube, and when so used should be reversed, the friction sleeve turned mesially. The other end of the expansion arch is supported in the usual way, as 144 MALOCCLUSION. in Fig. 126. As the cuspid is retracted into the space made vacant by the loss of the first bicuspid the malposed incisors are rotated by means of the ligatures, bands, and spurs, as is well shown in the engraving, and also in Fig. 126. The general control of the incisors is gained by tightening or loosening the nuts of the expansion arch, as in Fig. 129, in accom- plishing the movements of the incisors. FIG. 129. A similar combination may be used on the opposite side of the arch when it is desirable to shorten both of the lateral halves. Similar combinations of the traction screw with the B arch will often be found necessary. These, however, will be described in the treatment of cases belonging to Class II, Division i. Miscellaneous Combinations. Fig. 130 shows a combination for widening and lengthening the arch. The notched ends of the jack- screws engage a section of one of the levers L held in position by notches formed in the united ends of bands upon the lateral in- cisors. The sheaths of the screws were secured to anchor clamp bands No. 2 upon the first molars, as in F, Fig. 100. The incisors were moved forward by turning the nuts of the jack-screws, \vhile the arch was widened by the spring of a lever L, the ends bent sharply at right angles and made to engage delicate holes bored in the sides of the sheaths of the jack-screws, all as clearly shown in the engraving. A modification of this plan is to exert pressure laterally by means of a third jack-screw in place of the spring, this screw being COMBINATIONS OF APPLIANCES. 145 notched at each end and made to rest in contact with the other screws, anterior to their nuts. This plan, however, is rarely as desirable as the first. Another combination is shown in Fig. 131, in which the torso- labial movement of the laterals was effected by means of two jack-screws and two levers. The points of the jack-screws en- gaged mortises in bands on the disto-lingual angles of the laterals, FIG. 130. their bases resting over spurred bands on the anchor teeth. As the teeth were moved labially by tightening the nuts of the screws, they were also rotated by the two levers L, which were crossed In front. The resistance ends of the levers were inserted in tubes soldered to the labial portions of the bands. One of the power ends was secured by being latched into a hook soldered to the buccal surface of one of the anchor bands, the other being bent sharply at right angles and engaging a tube soldered at right angles to the tube on the band on the opposite lateral, thus exerting - a certain amount of reciprocal force. Although this combination is 146 MALOCCLUSION. sometimes useful, it is rarely as desirable as the expansion arch would be in such cases. , Another combination for effecting the lengthening of the arch by moving forward all of the incisors by means of two jack-screws, the points of which engage staples soldered to the disto-lingual angles of bands on the lateral incisors, is shown in Fig. 132. FIG. 132. The necessary rotation of the incisors was accomplished at the same time by means of a section of one of, the levers L, sprung into tubes upon the disto-labial angles of the bands upon the laterals. The central incisors were laced to the lever. As the nuts of the jack-screws were tightened all of the incisors were carried forward. At the same time they were rotated by the elas- ticity of the lever. Fig- 133 shows a combination for retraction of the cuspid and labial movement of the lateral incisors. While the traction screw COMBINATIONS OF APPLIANCES. 147 was accomplishing the distal movement of the cuspid it was as- sisted by the loop and traction screw device, as in Fig. 1 19, operat- ing upon the incisor, while the other incisor was being moved labially by means of a jack-screw, the base of which rested over a spur soldered to the sheath of the traction screw operating upon the cuspid. Figs. 134, 135, and 136 show simple and convenient methods of moving single teeth that are lingually or labially displaced. In FIG. 134. FIG. 136. Fig. 134 anchorage is gained for the force exerted by the wire or rubber ligature by the short sheath of one of the jack-screws being slipped over the end of the screw of the No. 2 band upon the first molar. In Fig. 135 the screw was lengthened by an additional piece of metal soldered to its end. In Fig. 136 a piece of the wire G, or a section of the lever L, was bent sharply at right angles and made to engage a tube R soldered to a clamp band No. 2 upon the first molar. 148 MALOCCLUSION. Fig. 137 shows a method of making a long clamp band which is sometimes useful in closing spaces between incisors. To the ends of a section of band material of suitable length are soldered tubes D, one horizontally and one perpendicularly, which engage the angle and screw ends of the traction screw. By tight- ening the nut the size of the band is diminished and force exerted. Figs. 138 and 139 show efficient devices for widening the arch in the region of the bicuspids. Force is exerted by a lever L of FIG. 138. FIG. 139. suitable length, its ends being secured by engaging in tubes R, soldered at right angles to sections of wire. G, which have been soldered to the lingual surfaces of the anchor bands, as in Fig. 138, or in a closed-end tube attached directly to the anchor band, as in the left of Fig. 139, or the tube may be soldered to a side of the nut of the clamp band, as on the right. This form of device is often useful in widening the arches of children to release lateral pressure upon the centrals, to be followed by a delicate vulcanite plate covering the vault of the arch, for retention, as in Fig. 158. A new combination of appliances for effecting double rotation of the central incisors is shown in Fig. 140. It consists of bands having spurs soldered at their mesio-labial angles to engage a COMBINATIONS OF APPLIANCES. 149 tightly drawn and twisted wire ligature. Between the bands is stretched a strip of rubber. By the occasional renewing of the ligature a powerful force is exerted which will turn the teeth readily. Temporary retention is effected by the application of a fresh wire ligature and dispensing with the rubber. Fig. 141 represents a very neat and convenient method of forc- ing the eruption of a cuspid which had become impacted by the too long retention of the deciduous cuspid. The first upper bicus- pid was encircled by a Xo. i band; to its labial surface, parallel FIG. 140. with the long axis of the tooth, was soldered a tube R which en- gaged a section of the wire G bent sharply at right angles, the other end being flattened and bent to engage the occlusal edge of the lateral. A common pin was set in the enamel of the impacted tooth. One had also been soldered to the anchor wire. A ligature was made to connect both pins, which exerted constant pressure. While this simple and delicate device is perhaps the nearest to the ideal for simple cases where the forcing of the eruption of a tooth that is not greatly deflected from its normal incline is de- sired, yet in such pronounced cases of deflection as indicated by Fig. 141 the anchorage is not sufficient to overcome the resistance necessary in turning a tooth so thoroughly imbedded in such I5O MALOCCLUSION. strong encasement of bone. The expansion arch, as in Fig. 273, is better, and in some cases even the combining of all the anchorage attainable in this manner with that gained from occlusal anchorage, as in Fig. 97, is necessary, as we have found in some four or five cases. CHAPTER XII. RETENTION. AFTER malposed teeth have been moved into the desired positions it is of the greatest importance that they be mechanically supported until all tendency to return to their former positions has subsided, but it cannot be too strongly insisted upon that unless such occlu- sion has been established as will enable the inclined planes of the cusps to act in harmony for mutual support, and unless perfect har- mony as to sizes of arches be gained, permanency of the teeth in their new positions after the retaining devices have been removed cannot be hoped for. It should be borne in mind that all retaining devices are only temporary assistants to the permanent establish- ment of the normal functions of the occlusal planes of the teeth. Time Required for Retention. The time required for mechani- cal retention varies, according to the age of the patient, occlusion, conditions, tooth movements accomplished, health of tissues, etc., from a few days to a year or longer, while perhaps in rare instances retention may be required for an indefinitely greater period. Upper incisors which have been moved from lingual to normal occlusion, as in Fig. 205, require retention for a few days only, as the occlu- sion with the lower incisors permanently supports them in their new positions. Again, the support of teeth that have been directed into cor- rect positions during the period of eruption is usually required for a few months only, while a much longer retention (for at least a year) would be required for the same teeth if moved after the full development of their alveoli. Again, owing to the great disturbance of the fibers of the peri- dental membrane of a tooth which has been rotated, its retention re- RETENTION. 151 quires a far longer time than if the movement of elevation had been accomplished. A few months for the latter is sufficient, where at least a year, and sometimes two, if the patient have reached ma- turity, may be necessary for the former. A rule of general application may be made, that twice as much time will be required for retention of the teeth of patients aged twenty-one as for those of patients aged twelve, the same tooth movements having been performed. There is usually a temptation to remove the appliances before the teeth have become thoroughly established, and many are the failures from this cause of otherwise well-conducted cases. As so much depends upon this part of the operation, it is far better that the appliances should be worn longer, even, than necessary, rather than that they be too early removed. It should ever be borne in mind that unless the conditions which have been operative in producing or maintaining malocclusion be removed or modified, the establishing of permanent normal occlu- sion can rarely be hoped for. As for example, if the arches have been narrowed and the teeth forced to take malpositions as a result of mouth-breathing, due to pathological conditions of the nasal passages, it will be very improbable that the teeth will remain in correct occlusion after removal of the retaining device, regardless of the time it may have been worn, unless normal breathing be es- tablished so that the mouth may be closed and the teeth not de- prived of occlusion and the normal restraint and support of the lips the requisite amount of time. (See chapter on Normal Occlusion.) Or if the malpositions of the teeth be due to pathological con- ditions of the gums or peridental membrane, unless the condition be changed by proper treatment permanent normal occlusion cannot be. hoped for. Or if, by the loss of some one or more teeth, as for example the first molars, faulty occlusion be resulting from the tipping of the remaining teeth, the further unfavorable movement of these teeth must be permanently arrested by crowns or bridges, or other methods of replacing the missing teeth by artificial substitutes, Fig. 216. Again, if irregularities of the upper teeth have followed as a result of the diminished size of the lower arch, from an overlapped or irregular condition of the lower teeth (see Figs. 206 and 208), 152 MALOCCLUSION. it would be folly to expect the teeth of the upper arch to be per- manently maintained in their new positions unless occlusion be es- tablished by harmonizing the proportionate sizes of the arches by correction of the positions of the lower teeth. Retaining Devices. Before adjusting the retaining devices it is often best to allow the regulating appliances to remain passively in position upon the teeth for a few days, in order that the tenderness of the teeth may somewhat subside. Yet upon the removal of the regulating appliances there is usually found to be more or less sore- ness, as well as mobility, in the teeth. It is, therefore, difficult or impossible to form and fit bands with any considerable degree of accuracy without occasioning pain. It is best to adjust a temporary device on exactly the same principles as if it were to be permanent, with looser fit of bands, which may be gently worked into position with the fingers alone. If a good quality of cement be used the device will be firmly held in position for a few weeks, until all soreness will have subsided, when a device with bands and all other parts of the most perfect fit and finish may be substituted for the first. As the retaining device is to be worn for considerable time, some authors prefer its construction from gold instead of German silver, on account of the tendency of the latter to discolor in some mouths, but it is a fact which any one may verify by experiment, that bands of the same delicacy will give far less trouble by loosen- ing if made of German silver than if made of gold, platinum, or of any other of the alloys. It may, however, be desirable in some cases to use spurs of platinized gold. The appliances necessary for retaining the teeth need never be bulky nor complicated, nor comprise a large number of pieces. We must remember that the patient is doubtless already wearied with the inconvenience of the regulating appliances, so it should be our aim to make the retaining device as delicate, compact, and incon- spicuous as possible, always, however, consistent with the main ob- ject perfect support. The more securely the teeth are held, the more rapidly will they become firm in their new positions. For this reason, and that it may be as little as possible under the control of the patient, the appliance should be made stationary by the at- tachment of accurately fitted and cemented bands whenever prac- ticable. It should also be readily cleansable by the patient, with the RETENTION. 153 brush, that it may in no way injure the teeth, no matter how long worn. It is remarkable how compact, simple, and yet efficient, the retaining devices may be made, even for the most complicated con- ditions. Principles of Retention. As the tendency of teeth that have been moved into occlusion is to return to their former malpositions, the main principle to be considered by the designer of the retaining device is the antagonizing of this force in the direction of its ten- dency only. Very slight antagonism is required, but its exercise must be constant. If the reader will keep this principle in view he will realize that only delicate devices are necessary, and will be impressed with the utter uselessness of much of the bulk and ma- terial composing so many of the retaining devices shown in our literature. With this in view, each corrected case should be carefully studied in connection with the original models, noting the various direc- tions in which the teeth are inclined to move, the difference in their sizes, and the proportionate force they will exert. To secure retention we have at our disposal support or anchorage from the following sources : first, reciprocal, or the pitting of one tooth against another, their tendencies being to move in opposite or different directions ; second, teeth already firm in the arch ; third, occipital, as shown in Fig. 97 ; and fourth, and most im- portant of all, the occlusion of the teeth. Application of Principles of Retention. The simple band and the short projecting wire, which for convenience we will call a spur, form the base of a principle which is applicable to nearly all the requirements of retention in all the various classes. It is sur- prising to find in what number of combinations the band and spur may be employed. If a single tooth have been rotated into its oc- clusal position it may be prevented from returning to its former position (or antagonized in the direction of its tendency) by the band and spur, the spur being so placed as to bear against an ad- joining tooth, as in Fig. 142, the spur being attached to the band by means of a small tube* and key-pin. It is usually preferable to have a band with two spurs, as in Fig. 143. These may be soldered directly to the band. Unnecessarily *Transactions Ninth International Medical Congress, September, 1887. and Ohio Dental Journal, October, 1887. 154 MALOCCLUSION. long spurs should never be used, as they are cumbersome and unsightly. Even shorter spurs than those shown in the engraving may be employed. Much care should be exercised in placing the points which shall bear against the adjoining teeth so that they will not cause displacement of the tooth retained. If placed as shown in the engraving, the elevation of the lateral in its socket would be inevitable. The point of the spur should bear upon the gingival ridge of the central, while the point of bearing upon the cuspid should be above the swell of the crown. The fine adjust- FIG. 142. Author's Retainer. ment of the spurs should be left until the cement has hardened after setting the band, when they may be bent until their ends touch at the exact points required. In some instances where the period of retention is to be pro- tracted, or where bands would be unpleasantly conspicuous, spurs may be set in fillings, as in Fig. 144, to be drilled for the purpose, or newly placed if any convenient cavities exist. In rare instances it may even be desirable to form minute cavities in the enamel to be properly filled upon the removal of the spur. In the case of de- ciduous teeth, soon to pass away, the drilling may be considered merely a matter of convenience and they may often be used in this way in preference to the setting of bands, for short periods of re- tention. A method often desirable when the space of a lost tooth is to be preserved is to connect two bands by a short section of G wire, RETENTION. 155 the ends being engaged in tubes R soldered to the bands, as in T- : 45- Fie, 145. E.H.A. Another excellent modification of this plan is shown in Fig. 146, in which one band is dispensed with, one end of the section of wire G being bent in the form of a goose-neck to engage the mesial surface and sulcus of the first bicuspid, the other end being sol- dered directly to a plain band on the lateral incisor. FIG. 146. . H. A If two approximating teeth have been rotated in opposite di- rections the firmest support is given by union of the bands by solder (Guilford). The author now prefers uniting the bands by means FIG. 147. of a spur soldered to the lingual surface of one of the bands and engaging a tube R soldered to the lingual surface of the other band, as in Fig. 147. Or the ends of the spur may be united to the lin- gual surfaces of both bands by solder, in which case it becomes 150 MALOCCLUS1ON. two bands and two spurs united. The spring of the spur makes ease and greater precision in the adjustment of the bands possible, with less liability of subsequent loosening. The tendency to rotation of the central and lateral, plus the lingual tendency of the central and the mesial tendency of all, is FIG. 148. effectually resisted by two bands connected by a spur, with an ad- ditional spur made to bear upon the mesio-labial angle of the lat- eral, as in Fig. 148. The engraving shows the ends of the wire G secured by engaging tubes soldered to the lingual surfaces of the bands. Direct attachment of the ends of the wire to the bands by solder may of course also be used, and is often preferable. By studying the tendency of the teeth it will be seen how effectually they are resisted by this device. Fig. 149 shows where the union of two bands by a section of G wire is employed to antagonize the tendency of two lateral incisors FIG. 149. FIG. which have been moved labially into the line of occlusion, while another combination of bands and spurs, Fig. 150, attached to the centrals would accomplish the same result. RETENTION. 157 Another plan for accomplishing the same result is by bands and double spurs, as in Fig. 151.* These consist of sections of wire G slipped through tubes R which have been soldered to the labial sur- face of the bands in anticipation of retention, as in Fig. 102, the ends being long enough to rest on the labial surfaces of the ad- joining teeth. The fit of the tube should be so perfect as to prevent the loosening of the wire, but if a dent be given it on each side of the tube with the regulating pliers, it will be effectually prevented from loosening, or a minute hole drilled through both tube and side of wire in which is placed a delicate pin will serve the same pur- pose (Fig. 142). If a number of teeth require support it may be readily accomplished by the same principle extended to include the union of two bands by a spur. FIG. 151. FIG. 152. Fig. 152 shows the union of two bands by a section of G wire which not only accomplishes the same result, but would also resist lateral pressure or rotation of one or both of the cuspids if re- quired, while an additional spur soldered to the long spur, as in Fig. 153, forms another combination for antagonizing the various tendencies of the incisors and cuspids. By the addition of two spurs to this combination, as in Fig. 154, the lingual and buccal tendencies of the first bicuspids are also re- sisted in a complicated case of malocclusion. It will be seen that any or all of the incisors and cuspids may be firmly supported by combinations of the band and spur, and that the bicuspids and molars may be included by extending the prin- ciple, but its greatest usefulness is limited to the incisors and cus- pids, or at most extended to include the first bicuspids, as in Fig. 154. If, however, a single bicuspid shall have been rotated, or if a single molar or bicuspid shall have been moved lingually or buc- cally, the band and double spur made to bear against the adjoin- ing teeth, the same as already described for retention of an incisor, will be most efficient. *Transactions Ninth International Medical Congress, September, 1887. 158 MALOCCLUSION. For the retention of cuspids that have been retracted of course nothing could be more efficient than to allow the traction screws to remain in position as retainers, which should usually be done for at least two months. This is only another form of the principle of FIG. 153. FIG. 154. two bands and spurs united. As the device is more bulky than is necessary, it may be removed after the time stated, and what is now the author's favorite plan for protracted retention of these teeth be employed. A delicate plain band is made to encircle the bicuspid, having two tubes R soldered, one to the mesio-lingual and one to the mesio-labial angles of the band close to the gum. RETENTION. 159 Ends of a section of the ligature wire are passed through these tubes and the wire drawn tightly against the mesial surface of the cuspid. The ends are then bent sharply around and clipped off. Twisting is unnecessary. All is correctly shown in the en- graving, Fig. 155. FIG. 155. By means of this device ample support is gained and the bulk and conspicuousness reduced to the minimum. It is important that the tubes shall be close to the gum, so the mesial end of the wire loop cannot slide off the cuspid crown. FIG. 156. FIG. 157. Retention of a number of teeth may be effected by a union of bands encircling them, as in Figs. 156 and 157. This method, however, is not advisable, as much unnecessary space between the teeth is thus monopolized, while it is impossible to hold all so rigidly together but that one or more will become uncemented. In the use of all bands in retention we would caution that thev l6o MALOCCLUSION. be inspected at least once in two months, for if they should be- come loosened they would act as receptacles for food particles, the fermentation of which might injure the enamel. The retention of molars and bicuspids is usually confined to resisting their lingual tendency after the arch has been widened by the buccal movement of one or both of its lateral halves. A neatly fitting vulcanite or metal plate, as in Fig. 158, partially covering the palatine arch and bearing against the teeth that have been moved, is, in the author's opinion, by far the most simple and practicable device for the purpose yet produced. This device has been employed for this purpose for many years, and would probably suggest itself to any artificial plate-maker. Its origin is lost in obscurity. FIG. 158. In order to gain the greatest accuracy of fit this little plate should always be constructed over a plaster impression, only enough plaster being used to take the imprints of the surfaces needed. The plate should not, during the early stage of retention, extend far enough forward to rest in contact \vith the incisors or cuspids, for owing to their sloping surfaces the plate is wholly unreliable for their support and would only interfere with other appliances, be- sides being superfluous bulk. It may be necessary to secure the plate in position in some instances, which may be done by springing each lateral edge under a lug soldered to a band encircling a tooth. Such bands may usually be dispensed with after a short time, when the plate has become better settled in position and the force exerted by the teeth has become less marked. During the last stage of retention, or when the tendency to resumption of malpositions shall have nearly subsided, the bands and spurs upon the incisors may be removed and a plate extending forward and made to accurately fit their lingual surfaces may be RETENTION. l6l used, as in Fig. 159. In this engraving is shown how a portion of the side of a stay plate has been removed and a piece of the wire G bent in such a way as to bear upon the teeth, the ends of the wire engaging cavities in the plate. By this means pressure, if desira- ble, may be brought to bear upon the teeth by occasionally remov- ing the staple and pinching it with the regulating pliers. A similar plate may be used for resisting the lingual tendency FIG. 159. of the inferior bicuspids and molars. If plates be required for both arches the upper one may be dispensed with a considerable time before the lower, provided the proper occlusion shall have been established, as the occlusion will then be sufficient to support the upper teeth. Where labial protrusion of the incisors shall have been reduced, as in Class II, Division i, it must be remembered that their tendency is not only to move outward but also downward FIG. 160. in most cases, so it is difficult to secure them by any device having for its anchorage the remaining teeth in the arch without their lengthening more or less or the anchor teeth being gradually drawn forward. The little device shown in Fig. 160, if intelligently managed, fully meets the requirements. It consists of a delicate vulcanite plate covering the labial surfaces of the incisors, as well as their cutting-edges, and about one-fourth of their lingual surfaces. It 1 62 MALOCCLUSION. is also often well to let the plate extend to bear against the mesio- labial surface of the cuspids. It is used in connection with the head-gear and traction bar, having a spur imbedded in the center to engage the standard on the traction bar, and is worn only during the night, with much lighter elastics than were employed in the retraction of the teeth, or only sufficient to give the teeth gentle support. FIG. 161. A similar device, but of skeleton form, made from metal, shown in Fig. 161, may also be used, although it is less satisfactory. It consists of a segment of the arch B to which two short pieces of the wire G have been soldered at right angles, at points opposite the centers of the central incisors. They are long enough so that the ends may be flattened and bent over the cutting-edges of the centrals, the hooks so formed preventing the appliance from sliding FIG. 162. upward against the gum. The device is prevented from sliding laterally by a spur soldered to the segment, the end resting in the depression between the centrals. To compel the jaw to close forward so that the teeth of the entire arch will be shifted from distal to normal occlusion, as in one plan of treating cases belonging to the first division of Class II, the device shown upon the molars in Fig. 162 is very satisfactory. No. 2 RETENTION. 163 clamp bands are firmly clamped and cemented upon the first molars on one side. Upon the buccal surface of the lower band has been soldered a strong spur, which is bent upward in order to close in front of a strong plane of metal which has been firmly soldered to the buccal surface of the band upon the upper molar. This piece of metal should be about one-fourth of an inch in width and three- eighths of an inch in length, and should extend outward at right angles to the long axis of the tooth, so that the jaw when closing must be brought forward to the point required for normal occlu- sion. The spur should be of sufficient length to extend at least one-fourth of an inch above the plane of metal when the jaws are closed. The positions are well shown in the engraving. FIG. 163. Another device for accomplishing the same result is shown in Fig. 163. D bands are placed upon the first molars on one side, the tubes on the bands having been reduced to about one-fourth inch in length. Into these tubes are sprung two engaged open links, made from one of the heavy levers L or of hard German silver wire. It renders all distal movement of the jaw impossible, while permitting free lateral movement by the turning of the links in the tubes. It also admits the separation of the jaws the full normal distance by the sliding of the links upon each other, at the same time offering no resistance to the desired forward extension of the jaw. This device is the author's modification of one made by Dr. McDowell, which consisted of a long upright link soldered rigidly 164 MALOCCLUSION. to the lower band and engaging a staple soldered to the upper band at right angles, the model of which is in the author's possession. This device did not permit any considerable opening of the jaws, as sufficient length of link interfered with the buccinator muscle, and it prevented all lateral movement. The author has not tested this device in a sufficient number of cases to be certain of its complete practicability. While it possesses the requisites for compelling normal closure of the jaw, yet it may be found to require more attention than that of simpler construc- tion, in Fig. 162. Another device for compelling normal position of the jaw when closed in these cases, and also for resisting the labial and lengthen- ing movements of the upper incisors, is shown in Fig. 164. A cap FIG. 164. of metal is swaged to accurately fit and cover collectively the crowns of the lower incisors. Soldered to its labial surface is a square bar of metal one-sixteenth inch in diameter, on a line with and corresponding to the occlusal surfaces of the upper incisors. To the labial surface of this bar are soldered small spurs which pro- ject upward about one-eighth of an inch and bear against the middle of the labial surfaces of the upper central incisors when the jaws are closed, as shown in the engraving. A better modification of this principle is to place upon the lower central incisors plain bands, having soldered to their labial surfaces strong spurs, which project forward and are bent upward sharply at right angles to engage the labio-occlusal edges of the upper incisors. The stability of the teeth used as anchorage should be reinforced by a section of the G wire soldered across the lingual surface of their bands and made to bear against the adjoining lateral incisors. Sometimes it may be desirable to place the bands upon the cus- RETENTION. pids, instead of upon the incisors, and connect them, as shown in Fig. 164, by a bar of metal containing the retaining spurs. If the reader will study this device he will observe that not only is normal closure of the jaw compulsory, but that the incisors are kept compressed in their sockets and prevented from moving la- bially, as well. Still another advantage of no small importance is gained in preventing the lower lip from being drawn against the lingual surfaces of the upper incisors, a habit which seems to be almost universal in these cases, and difficult but most necessary to overcome. Figs. 165 and 166 show Dr. Baker's method of retention, by what he terms "hygienic retaining plates," referred to in Chapter XIX. FIG. 165. FIG. 166. The upper one consists of a vulcanite plate limited to cover only a sufficient portion of the palatine arch to give it proper support by suction. For the support of the bicuspids and molars flattened wire projections radiate from the plate and bear against their lin- gual surfaces. The metal may be of German silver or platinous gold. To insure their being kept in the proper position during the packing and vulcanizing of the rubber the wires should be sharpened at their palatine ends, bent sharply at right angles, and made to pene- trate the plaster model to a depth of one-eighth of an inch or more at points corresponding with the margin of the air chamber. After the plate has been vulcanized these imbedded palatine projections are clipped off even with the palatine surface of the plate. An advantage, in addition to the cleanliness of such a plate, is that the projections may be lengthened by beating or by means 1 66 MALOCGLUSION. of the regulating pliers, or they may be shortened, or bent to exert slight pressure upon the mesial or distal angles of the teeth, for the finer adjustment of the positions of the teeth. To resist the labial movement of the incisors a loop of wire is made to bear against their labial surfaces, the ends passing be- tween the lateral incisors and cuspids and imbedded in the plate. This latter attachment, however, was original with Dr. N. W. Kingsley.* The same general plan is followed in the construction of the lower plate. In addition to projections for the support of the teeth, hook-like projections are made to engage the lingual grooves of the molars to prevent the plate from working down upon the gums. To prevent elevation of the anterior part of the plate, pro- jections are sprung under bands cemented upon the first bicuspids. CHAPTER XIII. TISSUE CHANGES INCIDENT TO TOOTH MOVEMENT. IN adjusting malposed teeth into harmony with the normal line of occlusion there are seven distinct movements possible: first, labially or buccally ; second, lingually ; third, mesially ; fourth, dis- tally ; fifth, elevation ; sixth, depression ; seventh, rotation. These can only be accomplished in accordance with the physiological laws which govern the changes possible in the alveolus and peridental membrane. The peculiarities of the tissues involved and the rich- ness of their vascular supply admit of much disturbance of these tissues with a very reasonable assurance of nature's complete restoration, provided these movements be properly conducted. While the movement of a single tooth only is frequently neces- sary, as the movement labially, or rotation of an incisor, more often it is necessary to combine two, three, or even four movements, as for example, a prominent cuspid may require elevation, rotation, lingual, and possibly distal movements, all of which may be accom- plished at the same time with a suitable appliance. But, as there *Kingsley's "Oral Deformities." TISSUE CHANGES INCIDENT TO TOOTH MOVEMENT. 167 is so much disturbance of the tissues involved in so great a change in the position of the tooth, more time should be employed than in a single movement. Again, the movement of a number of teeth, and in various direc- tions, not only in one arch but both, may often be necessary and may be accomplished simultaneously. When force is exerted upon the teeth to be moved, two principal changes take place in the alveolus. First, a bending of the process ; second, absorption of the process in advance of the moving tooth and deposition of bone behind it. These changes vary greatly according to the age of the patient, in different patients of the same age, in the direction of movement, and also in the rapidity of move- ment. In youth, or before the bone has become dense by a preponderance of inorganic substance, it permits of much bending, so that incisors may be moved out of inlock in a few hours, or the lateral halves of the arch widened in a very few days, OF- before much absorption could have taken place in advance of the moving tooth. In further proof of this the process will be found upon examination to be intact about the roots, not only on the labial side, or in front of the mov- ing tooth, but on the lingual, or opposite side, as well, it having been dragged after the moving tooth. This is easily explained when we remember the cancellous structure of the bone, the inelasticity of the fibers of the peridental membrane, and their very strong attach- ment to it. Another striking illustration of the bending of the bone occa- sioned by the strong attachment is in the distal movement of the cuspid into the space made vacant by the removal of the first bi- cuspid. The author has frequently noted that not only the septum of bone just mesial to the cuspid closely follows the moving tooth, but in some instances even the lateral incisor is dragged in the same direction to quite an extent, owing probably in the main to the strength of the fibers composing the dental ligament. While more or less springing of the bone is probably always an accompaniment of tooth movement, yet in proportion as the bone becomes dense with age so the modification of the process attend- ant upon tooth movement changes from springing to the slower action of absorption and the still more slow deposition of bone. Coincident with the changes in the bone there are also pronounced l68 MALOCCLL'iSION. changes taking place in the peridental membrane. As force is exerted on the moving tooth the membrane is compressed in front of it, between it and the alveolus, while a greater tension of the fibers of the membrane takes place on the opposite side. As a result of this tension and compression the nerves of the membrane are impinged upon, causing a greater or less sense of pain, which, as a result of the slight movement of the tooth and temporary paralysis of the nerves from pressure, subsides more or less quickly, accord- ing to the amount of inflammation present. As a result of this pressure the absorbent cells, or osteoclasts, are stimulated to increase in number and activity. They immedi- ately engage in the absorption of the portion of bone most involved in the movement, as well as of the bone attachments of the fibers on greatest tension. . While these changes are taking place, the osteoblasts have become active and have begun filling up the depression and re-attaching the fibers by the redeposition of bone; but as this is a much slower process than that of absorption the tooth is found to be more or less loose in its socket at the completion of its movement, as well as long after, necessitating its being supported by means of the retaining devices until the deposition of bone shall be complete and a perfect socket reformed for its support in its new position. If a tooth be elevated in its socket the principal change involves the peridental membrane. The fibers at the end directly resisting this movement are severed, and the oblique or suspensory fibers are stretched and recurved upon themselves. The result of the partial withdrawal of the conical root is increased space, not only at the end but also on the sides of the root, so that there is considerable freedom of movement of the tooth, necessitating the deposition of bone over the entire surface of its socket, as well as increase of height of margin. In the movement of depression the bone must be absorbed by the osteoclasts over the entire surface of the alveolus to allow for the advance of the root of conical form. The fibers of lateral support are stretched and placed on different angles, while the suspensory fibers are also stretched and severed at their points of attachment to the bone, thereby necessitating more disturbance of tissues and re- quiring more force and time than any other of the seven move- ments. TISSUE CHANGES INCIDENT TO TOOTH MOVEMENT. 169 In the rotating of a tooth in its socket little change by springing or bending is probable, the principal change being absorption of the fibers and bone involved along the entire length of the root. In all cases of tooth movement a large number of the fibers of the membrane remain on tension long after the movement is com- plete, the force they exert tending to draw the tooth back to its original position, thus necessitating considerable support from the retaining devices until the tissues have become thoroughly re- established in harmony with the tooth in its new position. In accomplishing the movement of teeth lingually, labially (or buccally), mesially, or distally, the principal change is in the position of the crown of the tooth, it being tipped into its correct position. The usual supposition is that the tooth in the alveolus acts as a lever, the crown, or long end of the lever, moving in 5ne direction, the apex of the root in the opposite direction. To make clear these supposed changes, and especially the extent of the move- ment of the apex, writers have frequently used the illustration of a post driven into the earth about one-third of its length. If force be exerted at right angles to a side of the post near its top the post will act as a lever in the displacement of the soil, the two ends of the lever moving in opposite directions and the pivotal point being somewhere near the beginning of the last third of the imbedded portion. The illustration is a poor one and very misleading, as the me- chanical conditions are very different. Doubtless this would be the result if the tooth, like the post, had but one resistant substance and that equally distributed in all directions about its root, but as we have already seen in the study of the alveolus, the bone varies greatly in thickness over different portions of the root and in different teeth, so the amount of displacement of the apex of the root of a tooth de- pends, ofttimes, upon the location and movement of the tooth and whether one tooth or a number in the same region are being moved in the same direction. In reality there may be little or no displace- ment of the apex, or there may be considerable. In the first place, the alveolus is not a level plane, like that in which the post is implanted, but a projection or high ridge, of elastic structure, and admits of some bending laterally, its susceptibility to this action increasing proportionately as we approach .the top. It would be especially favorable in the labial movement of the incisors, I/O MALOCCLUSION. as in Fig. 167. The pronounced bending of the process is a matter of common observation in efforts at extraction. Again, the mechanical difference in the attachment of the post to the soil and the tooth to the alveolus is such as to still further add greatly to the difference in the results of their movements. As the apex of the root is implanted deep in the bone, which is greatly thickened in its lingual direction and reinforced by the strong cortical layer of the alveolus, its movement lingually could not well take place as a result of springing. This movement is further strongly resisted by the innumerable inelastic fibers that encapsule the apex, radiating in all directions for its firmest possible attachment to the bone, their ends being inclosed in its structure. FIG. 167. So in the labial movement of the crown the lingual movement of the apex of the root is not only resisted by the bone in front, but also behind and on each side, by reason of its attachment, while with the end of the post little, if any, resistance is offered by the soil behind or on either side, but only by that in front. Another difference. The force for the movement of the post is applied remote from the fulcrum, while the force exerted on: the tooth by the ligature is applied close to the fulcrum, or at a point best calculated to facilitate the bending of the alveolus in the labial direction. Again, unlike the single post, several teeth may be associated in the movement, which adds still further to the possibilities of the labial, as well as adding correspondingly to the impossibilities of the lingual, movement of their apices. TISSUE CHANGES INCIDENT TO TOOTH MOVEMENT. I/I In the lingual movement of incisors there is often considerable labial movement of the apices of the roots, owing to the lesser re- sistance offered by their thin covering of bone and the much greater thickness of bone on the lingual surfaces of the roots. The result is often noticed following the reduction of protruding incisors, as in those cases belonging to Division I of Class II. In the similar movements of the upper cuspids and bicuspids, practically the same changes in the positions of the roots follow. In the movement buccally of the upper molars there is bending or absorption of the outer plate, the palatine roots are elevated in their sockets to make easier the tipping of the crown, with probably no movement at the apices of the buccal roots, unless it be that they are forced deeper in their sockets. In the lingual movement of the same teeth there is more or less bending of the process, the forcing deeper in its socket of the palatine root, with perhaps some elevation in their sockets of the buccal roots. FIG. 168. In the same movements of the lower molars there is greater dis- placement of the apices of the roots in the opposite direction from which the crowns are moved, owing to the great thickness of the buccal plate of the alveolus. In the movement of teeth mesially or distally there can be little or no bending of the labial and lingual plates, the chief resistance now being offered by the septse and the peridental attachments, and the movement of the teeth more nearly resembles the move- ment of the post, the apex moving slightly in the opposite direc- tion from the crown, as in Fig. 168. And yet the displacement of the apex in these movements may be considerably diminished by proper surgical operations on the tissues, of which we shall speak in the next chapter. While the pulp of the tooth is a tissue more or less involved in tooth movement, yet when the operation is properly performed this 1/2 MALOCCLUSION. tissue is practically undisturbed and should suffer no real injury. On the other hand, its normal function may be so interfered with as to cause it to suffer marked disturbance and even complete devitali- zation, especially if the movement be conducted too rapidly or the force be applied too abruptly. The principal danger, however, arises from congestion and inflammation of the tissues of the apical space, causing the partial or complete strangulation of the vascular supply to the pulp. In view of these facts it should be our aim to prevent, as far as possible, all tendency toward inflammation. If the pulp becomes partially congested, as is usually evinced by a slight change in color, as shown through the enamel, and by sensitiveness to thermal changes, the tooth should be allowed to remain passive for several days, when, usually, these symptoms will subside. The author has noticed several instances where these symptoms have been markedly manifest and have wholly subsided under palliative treatment. Sometimes, however, complete devitalization will fol- low, and while the death of the pulp under these conditions is to be regretted, yet the consequences are not of sufficient importance to occasion any more regret than when found necessary in the treat- ment of teeth for caries. The principal evil following the death of the pulp in these cases is the possible permanent discoloration of the crown, which is more liable to follow the speedy death from strangulation than the slow devitalization from the encroachment of caries. For this reason, whenever complete devitalization of the pulp shall be apparent it should be immediately removed and the canal repeatedly washed out with tepid water, sterilized and carefully filled in the usual way, when the further movement of the tooth may be conducted without greater fear of inflammation than if the pulp were intact. In like manner, if it be desirable to change the position of a tooth having an already devitalized pulp it may be resorted to without hesitancy, provided the surrounding tissues be healthy and the pulp-canal be first properly cleansed and filled. It is often desirable to perform tooth movement soon after the eruption of the teeth, or at a time before the root is fully formed, the end of the root then having a broad, funnel-shaped opening. If the movement be intelligently performed the pulp at this age should suffer no greater disturbance than when the root is fully calcified. In fact, there is less probability of strangulation and death than later when the foramen is greatly diminished in size. OPERATIVE SURGERY. 173 CHAPTER XIV. OPERATIVE SURGERY. WHILE all tooth movement is essentially surgical, that by the use of appliances may be properly called Conservative Surgery. To distinguish the more bold or aggressive operations involving the use of cutting instruments we will designate them as Operative Surgery. While such operations should probably be employed only as auxiliary to the conservative method, they are doubtless destined to play a more important part in the practice of the future, and will be briefly considered. Immediate Movement. As the changes in the tissues incident to tooth movement are as a rule necessarily slow, requiring that the operation shall be more or less protracted, different writers* from time to time, among whom may be mentioned Tomes, Stellwagen, and Bryan, have advocated that sufficient force be exerted by suit- able forceps to effect the immediate movement of teeth into cor- rect positions. Dr. Bryan, of Basle, Switzerland, was first to improve on the operation by surgically removing, with suitable instruments, a por- tion of bone in advance of the moving tooth, t The immediate movement of teeth has usually been resorted to only where one, or at most two, teeth were to be rotated or moved from inlock. The operation has never met with much favor and *J. Lefoulon, who wrote a work in 1841 (French), which was trans- lated and published in the American Library of Dental Science, says on pages 132 and 133, "Almost all the writers who have treated on this subject, i.e., regulating, have spoken of artificial luxation. This is a means which we have already condemned, and which we cannot too frequently disapprove. The ancients, and some of the moderns, yet imitate them, employing the 'pelican' for this purpose; a violent maneuver, which exposed them to the risk of breaking the tooth at the neck, and thus to replace a deformity by a mutilation a hundred times worse. Besides it is a cruel operation, which should be rejected the instant mild means can be employed which, at least, are equally efficacious." tDescribed in a paper read before the American Dental Society of Europe in August, 1892. 1/4 MALOCCLUSION. doubtless never will, for it is a practice as inexcusable and imprac- ticable as it is barbarous. First, it is so formidable that naturally but few would care to submit to it. Second, the risk to the tooth and pulp, as well as to the other tissues involved, is so great that it is wholly unwarrantable. Third, as the malposition of one tooth is nearly always but a marked symptom of a more general malocclusion, often involving several teeth in the same arch, as well as in the opposite, so that its proper placement must necessitate the enlargement of the dental arches and the correction of the positions of the other teeth, espe- cially of those on either side of it, the immediate movement is utterly ineffectual. And last, it is wholly unnecessary, as in such cases as would seem most favorable for this operation a suitable appliance will in a very short time effect by the conservative method the desired result, without risk and with but little more than inconvenience to the patient. Alveolar Section. The removal of bone in advance of the mov- ing tooth, if properly performed, may, we think, be desirable in many cases if connected with the conservative method. The author has in a large number of cases found it expedient. While it is probably never indicated in the movement of teeth of young chil- dren, in patients of more advanced age, where the bone is dense and of considerable thickness and absorption slow, it may be resorted to with advantage, especially in the reduction of labial protrusion of incisors, as in Fig. 250. Yet it does not in practice lessen the amount of force required, nor hasten the movement of teeth to a degree proportionate to the plausibility of the theory. Doubtless if the only obstacle to tooth movement were the resistance of the bone the operation would be greatly hastened by its removal, but when we remember the firm resistance offered by the fibers of the peridental membrane by their attachment to the plate of bone in the rear of the moving teeth, as well as on all sides, this is readily un- derstood. The surgical removal of bone should always be performed with care, judgment, and skill. It is highly important that only sharp, clean fissure-burs of medium diameter, with end cut, and which have been thoroughly sterilized, be employed, and that the peri- OPERATIVE SURGERY. 175 dental membrane shall not be injured in the operation. To insure this a thin septum of bone should be allowed to remain between the membrane and the cavity formed. The cavity should be crescent- shaped, of somewhat greater length than the diameter of the tooth., when practicable, and in depth about two-thirds the length of the root. Eesection of Peridental Fibers. After a careful study of the fibers of the peridental membrane, the direction in which they ex- tend, and their distribution and attachment, and knowing the strong resistance offered by them to tooth movement and that they must often be forcibly severed or slowly absorbed at their points of at- tachment in order to permit of tooth movement, it occurred to the author that it would be but reasonable and wholly in keeping with good practice to surgically sever them. Acting upon the belief he has adopted the practice in a number of cases with, he thinks, real success, for the force and time necessary in tooth movement were much lessened and as yet no evil results have appeared. He would earnestly caution conservatism, however, advising the severance of only such fibers as would most probably be severed by absorption. The only unpleasant result seemingly conceivable is a possible invitation to the development of a degeneracy of the membrane and the formation of septic pockets. But this is only, a possibility, and then, perhaps, only in cases especially susceptible by reason of heredity. We must remember, too, that many have advocated the complete severing of all of the attachments by extraction and re- placement of the tooth for the cure of pyorrhea alveolaris. At first thought it might seem to be a painful operation. In reality it is very simple and nearly painless, provided it be properly performed, with suitable instruments. The form of instrument is of much importance. The author experienced much difficulty in finding those of sufficient delicacy and proper temper. He knows of no suitable form of knife or bistoury used in dentistry or in surgery, until we reach that of the eye, and then only those used in the most delicate of all surgical operations, that upon the iris, or for removal of cataract, the instruments known as the iris needle and cataract knife. These seem to be most perfectly adapted for operations on the peridental membrane as well. They are extremely sharp and delicate. They are illustrated in Fig. 169. 176 MALOCCLUSION. In their use, if we wish to sever the principal obstructing fibers of a tooth, as for example those which resist rotation, Fig. 170, we have but to pass them down along the angle of the root with but FIG. 169. FIG. 170. little more effort, and perhaps causing no greater pain, than would follow the insertion of a fine, smooth broach. In their use it has OPERATIVE SURGERY. 177 been found better to first adjust the regulating appliances and allow them to exert tension for two or three days, that the fibers might be well tightened by stretching. This facilitates insertion of the delicate blade and makes the severing of the fibers more complete. In retraction of the cuspid the severing of the fibers in the rear of the tooth to the depth of one-third the length of the root seems to be sufficient to greatly expedite the movement. We believe that in suitable cases the duration and difficulty of the movement may be lessened fully one-half by the intelligent combination of methods, the surgical severing of fibers and re- moval of bone, in connection with the use of the regulating appli- ances. Section of Frenum Labium. A form of malocclusion character- ized by a space between the upper central incisors (and rarely be- tween the lower centrals) is quite frequently encountered. This space may vary from one to four or even five millimeters, and always attracts unfavorable attention and interferes with speech in proportion to its width. The closing of this space by drawing together the incisors is a comparatively simple operation, requiring only a few hours, or days at most. But notwithstanding the ease with which these spaces may be closed they are yet well known to be unsatisfactory and annoying cases to treat, on account of the difficulty of permanently estab- lishing the teeth in their corrected positions. For it is usually found, even after months of the most perfect support by the retain- ing device, that following its removal the teeth will rapidly separate and assume their former positions. By a more careful study of these cases the reason for this becomes obvious, the cause has not been removed, which, as we have shown in the chapter on Etiology > is usually due to abnormal development and attachment of the frenum labium, Fig. 171. It is evident that the portion of the ligament passing between the teeth must be removed, or so modified that it will no longer act mechanically upon them. The author has derived partial success by the mere severing of the ligament with a pair of delicate scissors, union of the ends while healing being prevented by occasional manipulation. But the plan now followed by him,* and which offers promising results, is *Dental Cosmos, November, 1899. 13 178 MALOCCLUSION. to take advantage of the contraction of tissue resulting from actual cautery, as rhinologists do in operations on the nose for deflected septum. F IG - I " 1 - FIG. 172. With a suitable lancet or bistoury a deep incision is made between the teeth, splitting the ligament, after which an electro-cautery knife, Fig. 172, at white heat, is passed through the incision. No pain will be occasioned if, preliminary to the opera- tion, the tissue be locally anesthetized with a proper solution of cocain, applied by means of a pledget of cot- ton for about ten minutes. Great care should be exer- cised in the use of the cautery instrument, which should come in contact only with the abnormal tissue, the wounding of the peridental membrane being rigidly avoided, and for this reason the clean incision is first made to simplify the operation. The teeth should be drawn together and mechanically supported for several weeks or months. The author's favorite method of closing the space is by the exertion of pressure by means of a wire ligature occasionally tight- ened by twisting or renewal, it being made to encircle two spurs one-thirty-second of an inch long, soldered to the mesio-labial angles of accurately fitting bands cemented upon the teeth to be moved, Fig. 173. The bands should be in position before the operation. This same device is very satisfactory for retention, or the bands may be removed and replaced by similar bands OPERATIVE SURGERY. 179 joined by solder. Retention may also be effected by a plate cover- ing- the anterior part of the vault of the arch, having finger-like projections of metal bearing against the distal surfaces of the central incisors. Although the contraction due to the cicatricial tissue is con- siderable, yet when we remember the character and structure of the peridental membrane and the immense number of normal fibers acting to combat this tendency, and that they are practically double in these cases, for two teeth are involved, the necessity of support for a considerable length of time (a year and a half in some cases) -should occasion no surprise. Double Resection of Maxilla. Several years ago the author be- came convinced that no operation depending upon tooth move- ment alone could establish proper relations of the teeth or ma- terially improve the facial lines in certain cases of pronounced over- development of the inferior maxilla. It seemed to him that such cases might be successfully treated by the removal of a section of bone from each of the lateral halves, although the operation was not contemplated except as a remedy for the most aggravated condi- tions, as illustrated in Figs. 174 and 175. The removal of a single complete section of the jaw had been reported in numerous operations for the relief of ankylosis, tu- mors, gunshot wounds, etc., but a search of the literature failed to reveal any instance of the removal of complete sections from each of the lateral halves. The author's proposition was discussed with surgeons and den- tists, and was decided to be feasible. It was as follows : Careful i8o MALOCCLUSION. photographs should be first taken of the patient, and two accurate models be made of the lower dental arch and one of the upper FIG. 174. FIG. 175- E.H.A OPERATIVE SURGERY. 181 which should show the forms of gums and jaws as far as possible. One of the plaster models of the lower jaw should then be sawed through and the sections removed. The positions and extent of these sections should be carefully experimented with until the three remaining sections of the model could be made to best harmonize with the upper arch, that the teeth might be in best possible oc- clusion with those of the upper jaw. These sections of the plaster model should then be cemented or waxed together, and over this reconstructed model a vulcanite or metal splint should then be formed, as shown in Fig. 176, and by careful comparisons and meas- FIG. 176. urements of the reconstructed model with the unchanged model the exact size and form of both sections of bone to be removed should be determined, so that there might be no guessing as to the relations of the bone, and complete apposition of the ends be made possible. As there is more or less lingual inclination of the lower incisors in all of these cases (most pronounced in some), it is certain that the sections of bone to be removed must not be parallel on their sides, but more or less wedge- or V-shaped, if we would gain the best positions for occlusion of the incisors, as well as for appearance of the chin. The degree of variation from the parallel of the lines of section must be determined by the conditions, perhaps never to l82 MALOCCLUSION. so great an extent as indicated by the dotted lines in Fig. 175, which were exaggerated in the engraving. The teeth having been thoroughly cleansed just previous to the operation, and the splint in readiness, the sections of bone corre- sponding accurately to those determined upon, as already de- scribed, should be removed, the anterior section placed in apposi- tion with the posterior sections, and the splint fixed in position upon the teeth with thinly mixed oxyphosphate cement. If the operation be skillfully performed the most rigid support should be given to the reconstructed jaw, far more efficient and more in keeping with modern aseptic surgery than is possible with that crude, unstable, and unmechanical plan of wiring the ends of the bone together, so often employed in the reduction of fractures. The question most often raised by dentists in discussing the practicability of the operation as here outlined was the uncertainty as to union of the bones and as to impairment of vitality of the teeth in the middle segment. These doubts have' since been set at rest by two operations. June 23, 1897, the author assisted the late Professor Henry H. Mudd in one of these operations performed at St. Luke's Hospital, St. Louis, upon Miss M. J., of Arkansas, a delicate girl thirteen years old. She had suffered, when a child aged three years, with some acute inflammation of the mouth, probably septic in character. She had exfoliation of some portion of the lower jaw at that time,, and a number of the teeth dropped out. She had also an abscess on the index finger, with loss of bone, and some sores developed on the legs. There was no history of any specific trouble. As a result of the inflammation of the mouth the lower jaw be- came fixed and firmly closed by cicatricial contractions. At the time of admission to the hospital there was some slight motion of the temporo-maxillary articulation on each side. There was, how- ever, scarcely a perceptible movement of the body of the jaw. The upper jaw was perhaps normal as to size, with arch some- what narrowed and containing the full complement of teeth, though somewhat irregular as to positions. The lower jaw was deformed ; the ramus of the jaw on each side passed downward and back- ward so that the angle of the jaw came a little behind rather than in front of a vertical line dropped from the lobe of the ear. The arch of the lower maxilla was broadened, and the incisor teeth were OPERATIVE SURGERY. 183 pressed up inside of the arch of the upper jaw so that the mucous surface of the palate was injured. The teeth of the lower jaw were irregular as to number and positions, and the molars undersized and defective in development. The deciduous first molars, very diminutive in size both as to crowns and roots, were still intact. The permanent cuspids and incisors, however, had developed nor- mally, and the incisors occluded distally to the upper incisors fully an inch. The widening of the arch and the pushing back of the angle of the jaw were, it is thought, produced by the suction action of the child in the endeavor to get food into the mouth. The only point of entrance for food was the opening under the arch of the hard palate above the incisor teeth of the lower jaw. This suction of the jaw cultivated very markedly the extrinsic muscles of the larynx, as well as the depressors of the jaw. In order to free the body of the jaw so that the mouth might be opened, a triangular segment with the base downward, the apex upward and forward, was removed from the angle of the jaw on each side. A complete section of the bone was thus removed in order to secure false joints at the junction of the ramus and the body of the jaw. When the bone was separated, the tongue and jaw dropped down so markedly that respiration was difficult and obstruction marked. Tracheotomy was made in order to insure free respiration; the breathing was not relieved by simply holding forward the tongue, but it improved when the jaw was held upward and forward. This was easily accomplished by means of wire ligatures made to encircle the buttons on the fracture bands No. 3, which had been placed upon the four cuspid teeth, as described in the treatment of frac- tures of the maxilla, and illustrated in Fig. 285. The ligatures were occasionally removed and movement of the jaw made, in order to establish a hinge joint instead of osseous union of the bone. The patient made a rapid recovery and left the hospital in a few weeks, when further record of the case was lost. At that time there was no indication of the circulation or vitality of the anterior teeth or segment of bone having been impaired. Double resection for the purpose of shortening the jaw was recently performed successfully at the Baptist Hospital, St. Louis.* *Dental Cosmos, July and August, 1898. 184 MALOCCLUSION. Such an operation might at first seem formidable, but there is no reason why, if skillfully performed according to modern aseptic methods of surgery and the plan first indicated, the clean, smooth ends of the bone would not unite at least as readily as they do in the common cases of double fractures, and the result be nearly ideal. But the author would earnestly plead against the practice of wiring the ends of the bone together after the usual plan of surgeons, as the most serious results must certainly follow. One such failure has already been reported. CHAPTER XV. PHYSIOLOGICAL CHANGES SUBSEQUENT TO TOOTH MOVEMENT. So far we have considered the physiological changes which take place in the tissues during tooth movement, but we must remember that certain changes also occur subsequent to tooth movement. To better understand these changes we must keep in mind the condi- tions previously existent. The development of malocclusion is gradual, and in proportion as the functions and positions of the teeth deviate from the normal is necessitated a corresponding deviation in the development of the alveolus, and, to a greater or less degree, in the bones of the jaws, vault of the arch, the nasal tract, and the muscles of the face. All being out of harmony, the tendency is usually to favor still greater inharmony, or departure from the nor- mal, as growth and development progress. After the crowns of the teeth have been moved into correct posi- tions in the line of occlusion and harmony of the occlusal planes established, the positions of the teeth and function of the occlusal planes have been so changed as to exert a different influence upon the bones and muscles. The tendency now is to assist and stimu- late Nature to efforts toward the rearrangement of these tissues and their normal growth and development, in accordance with the demands of the teeth in their new positions and with her original design. Evidences are common throughout surgery of Nature's wonderful inherent power to remedy her defects, and of her prompt response as soon as favorable conditions for self-assertion have PHYSIOLOGICAL CHANGES SUBSEQUENT TO TOOTH MOVEMENT. 185 been established. The natural changes following the intelligent correction of malocclusion are often pronounced and gratifying. The cognizance of the possibilities of these changes should, in many instances, modify our plan of treatment from what it would be were we in ignorance of them. Very frequently where there has been change of position of a number of teeth, especially in both arches, some may occupy planes of greater elevation than others, or the cusps of some may not occupy exactly normal mesio-distal rela- tions, but if we have succeeded in placing the teeth so that the inclined planes of their occlusal surfaces favor their normal posi- tions, their proper heights and relations will become established as a result of occlusion. In some cases the incisors may apparently FIG. 177. FIG. 178. be too short, but after a few weeks or months, when the teeth shall have become settled in their new positions, the length of overbite of incisors may be normal. Another noticeable and important change is that following the movement labially of the crowns of a number of incisors, as in Fig. 177. The crowded and bunched positions of the incisors have necessitated marked arrest in the development of the alveolus in the region of their apices, so that after correction they are found to stand at a very pronounced angle, with an abnormal depression in the region of the apices of their roots, Fig. 178, and an apparent overprominence of the lip, often suggesting the impossibility of their being maintained in such positions and the desirability of ex- traction in order to reduce this prominence ; but in all probability, at least in a large percentage of cases, the apparent prominence is due to lack of development of the alveolus and the lingual posi- tions of the apices of the roots, which have developed thus in ac- cordance with the demands of the teeth in malocclusion. 1 86 MALOCCLUSION. The crowns of the teeth now being in normal occlusion, nature is stimulated to continue the development of the alveolus, and to shift labially to normal positions the apices of the roots, so that in due time there will be the full normal contour of the alveolus and the teeth will stand at a normal angle, the result being a corresponding improvement in the contour of the face in the region of the base of the nose, a far better result than could have taken place had extraction been resorted to. The changes here outlined are shown to have taken place in Fig. 179, which represents a model of the corrected case three years later than that shown in Fig. 178. FIG. 179. The same changes also followed in the cases shown in Figs. 184, 1 86, 189, and 209. It is quite probable that while the development of the alveolus was progressing a change in the positions of the crowns of the teeth of both arches was also being effected, there being a slight movement distally on account of the increase of lip pressure due to the more prominent positions of the incisors. This, however, could not have occurred unless there had been full normal function of the lips, accompanied by habitual nasal breathing. The author would not be understood as asserting that extrac- tion in cases of this character is never necessary. This phase of the question will be discussed under the chapter on treatment of cases belonging to Class i. What we especially wish to impress is the careful consideration of the possible changes following tooth movement in all such cases, and the requirements of the facial lines. PHYSIOLOGICAL CHANGES SUBSEQUENT TO TOOTH MOVEMENT. l8/ Again, where one or both of the lateral halves of the upper arch have developed with the teeth in lingual occlusion, the result is to prevent the normal development and width of the arch, as in Fig. 1 80. It will be observed that force incident to mastication is brought to bear upon the crowns at an abnormal angle to their axes. In- stead of being received upon the buccal cusps of the lower molars it is received upon the lingual cusps, the tendency being to cause a gradual divergence of the roots of these teeth at their apices, while the opposite is the effect in the upper arch, the force being FIG. 180. received upon the buccal cusps instead of the lingual, the tendency being to cause convergence of the apices of the roots of the molars of the lateral halves, with pronounced perversion in the develop- ment of the alveolus and of the jaws, and with abnormal height of the vault of the arch. Following the labial tipping movement of the crowns of the up- per molars and the lingual tipping movement of those of the lower. as described in the last chapter, the force of occlusion will be re- ceived at the proper angle with the axes of the teeth, or principally upon the buccal cusps of the lower molars and lingual cusps of the upper molars, the tendency being to cause divergence of the apices of the roots of the upper molars and convergence of those of the lower, nature being thus permitted to continue the development normally of the bones. In the case described marked changes fol- 1 88 MALOCCLUSION. lowed. The width of the face in the region of the upper jaw was perceptibly increased, and diminished in that of the lower, with a corresponding improvement in the vault of the arch and function of the nose. There are also noticeable changes following the reduction of marked prominence of the upper incisors, as in those cases belong- ing to Division i of Class II. As the crowns of the incisors are moved lingually the apices of the roots, as we have already noted; are moved to some extent in the opposite direction, which is evinced by more or less of a fluted appearance of the alveolus in the region of their apices, and to some extent, a greater prominence of the lip in the region of the base of the nose ; but if normal functions of the nose and lip have been established there will follow a return of the apices to their normal positions, with corresponding normal de- velopment of the alveolus surrounding them and a corresponding lessening of the prominence of the tissues at the base of the nose. We will have occasion to mention other changes following tooth movement in connection with cases discussed under treatment. CHAPTER XVI. AGE APPROPRIATE FOR TREATMENT. THE age at which the correction of malocclusion may be accom- plished extends over quite a wide range of years. All agree that the positions of teeth may be more readily changed in early child- hood (from seven to twelve years of age) than in any other period, yet it is argued by many authors and practitioners that this is a most unpromising age for treatment, as a young child will not endure suffering or inconvenience, and is lacking in the power to appreciate our efforts in its behalf. Much is recorded in the litera- ture favoring the period of life between the ages of twelve and seventeen years, it being argued that as the operation is such a long and painful one it is useless to begin treatment before the child has arrived at an age when pride begins to assert itself. Then, it is argued, the regulating appliance would be worn, the inconvenience AGE APPROPRIATE FOR TREATMENT. 189 tolerated, and the pain endured, consequently the hope of success would be greater than with children younger. Again it is argued that as the operation is such a painful one this age has its dis- advantages, especially with girls, being a critical period in their history, the physical economy being already severely taxed. Doubtless there has been some reason for the above arguments in the past, for the awkward, bulky, and inconvenient appliances generally used always caused much annoyance and often real suf- fering to the patient. Owing to their faulty principles of construc- tion they were necessarily very slow in bringing about desired re- sults, often prolonging the operation over a period of many months, or even years. It is therefore but little wonder that young children refused to endure them that only those pushed on by pride could be induced to persist in their use and that patients of delicate con- stitution were deterred from wearing them altogether, for fear of permanent constitutional injury. The author believes there is no longer just reason for such arguments, except as they may apply in connection with the similar appliances to some extent still in use. A properly constructed appliance, properly adjusted and oper- ated, should occasion but little more than inconvenience and should bring about desirable results, usually, in a very few weeks. The inflicting of real pain and suffering is not only unnecessary, but is reprehensible. Any young miss may undergo an operation for the correction of malocclusion, even though extensive, without any fear of impairing her health. The author has constantly in his practice a large number of young misses, many of them quite deli- cate by nature, and he has yet to notice that they have in any way sustained physical injury or that they have been made more nervous or irritable by wearing the regulating appliances. And instead of finding young children lacking in appreciation he greatly prefers such patients to all others, for if they are not hurt and can see satisfactory results taking place they become our most willing and appreciative patients. The ease and rapidity with which their teeth can be moved at this tender age should make it the one most desira- ble time of life for the correction of malocclusion. The author is more and more impressed with the advantages of beginning the treatment early, just as soon as the irregularities are manifest and the teeth have emerged from the gums sufficiently to admit of mak- 190 MALOCCLUSION. ing suitable attachments. Then nature is putting forth her best ef- forts; then growth and repair are most rapid and the surrounding tissues most yielding; then slight force is sufficient to gently direct each erupting tooth into its correct relation with the line of oc- clusion. Unless some unusual physical condition of the patient exist it is unquestionably a serious mistake, without the least argument in its favor, to defer the operation until all the teeth shall have erupted, as is still so often advocated. By this time the whole dental ap- paratus will have become greatly complicated, the teeth fixed in their malpositions, the facial lines badly marred, and the lips and muscles modified to work in harmony with the complicated mal- occlusion, all of which, in most cases, might have been easily avoided had the operation been begun when irregularities \vere first manifest. There is another reason, it would seem, in favor of early treat- ment. We have already seen in the study of the alveolar process and peridental membrane, that in young patients the sockets of the teeth are large and the intervening septa of bone often lacking to a considerable extent, nature seemingly waiting until the posi- tions of the teeth shall be determined before completing her work. Now, if the teeth be moved at this time into correct position the normal deposition of bone and development of the socket about the root of the tooth will follow, while if movement be delayed until the complete development of the alveolus, it necessitates extensive ab- sorption, as well as greater force in effecting the movement, and the redeposition of bone may be less stable in quality, or even lack- ing entirely, as we believe in some instances. From experience in a few cases of attempting to correct malocclusion which had been years before unsuccessfully treated, the author has been strongly impressed with the abnormal instability of the teeth which had been used for anchorage. This fact, together with the great diffi- culty in some cases of maintaining in their new positions teeth that have been corrected, even after a long period of retention, strongly suggest the possibility that the secondary deposition of bone may never be as stable as that deposited in the normal period of devel- opment of the alveolus. Histological investigations on this point are greatly needed. While, as we have noted, the period for the treatment of mal- AGE APPROPRIATE FOR TREATMENT. 19! occlusion may extend to maturity, or, in favorable cases, much later, yet we think it may be regarded as a law that in proportion to the age of the patient are the time required for treatment, the obstacles to be overcome, the inconvenience, the period of retention, and uncertainty as to prognosis increased. We have pointed out elsewhere the uselessness of delaying treatment with the hope that nature will correct the deformity. Time Required for Treatment. One of the questions usually asked by patients, as well as by dentists, is as to the length of time required to complete the treatment of given cases of malocclusion. The author believes it is a mistake in most cases to attempt to fix other than in a general way a definite time, as the conditions and requirements in orthodontia vary greatly even in very similar cases, and it must be remembered that the time for full completion em- braces not only the period of regulation, but the often protracted period of retention. One principle should be borne in mind, ap- plicable more especially to the treatment of the teeth of young chil- dren, that our efforts should be only to assist nature in her efforts to place the teeth in normal occlusion. It is now a quite generally accepted theory that nature requires periods of rest in the growth and development of the brain and other portions of the physical economy, probably in all, including jaws and teeth. So our efforts in the correction of malocclusion may with profit, we think, be marked by periods of rest and retention. For example, if an erupting tooth be found deflected, with no probability of self-cor- rection, it should be moved into position and the arches, one or both, be made to harmonize with the normal position of the tooth. Delicate, though efficient, retaining devices should then be ad- justed, followed by absolute rest from all interference, but with oc- casional inspection, until other erupting teeth may require our attention. Or, if an arch be found too narrow to accommodate the erupting incisors and they be assuming malpositions, the arch should be widened, which may usually be done in a few days. It should then be stayed by a delicate retaining plate, with no atten- tion to the incisors other than occasional inspection, for, being re- lieved of lateral pressure, they will often assume normal positions unaided. Later, however, if interference be found necessary their correction may be effected. So there may be several periods of activity and rest, which pos- IQ2 MALOCCLUSION. sibly in some instances may extend from the time of eruption of the lower permanent central incisors until the upper cuspids shall have grown firm in their new positions. It should also be borne in mind that long and indefinite periods of wearing regulating appliances, besides being unnecessary, may be fruitful of harm. A very few weeks will usually be sufficient, with good appliances intelligently managed, to accomplish all that will be required for any one period. While what we have said ap- plies more especially to the treatment of teeth of young children, we believe that the same plan is advisable in many cases of older patients. After the eruption of the teeth, and especially if the cases be complicated, the treatment should be divided into periods of activity and rest. During the period of activity the tooth movements undertaken: should be fully accomplished, and as rapidly as may be consistent with the physiology of tooth movement. This should be followed by retention, with careful regard to cleansing, and complete rest for several weeks, or even months, when the remaining malposed teeth mav receive attention. CHAPTER XVII. TREATMENT. BEFORE beginning the treatment of malocclusion each case should be carefully studied, noting the type and temperament of the indi- vidual, the relations of the two jaws and dental arches in compari- son with the normal, determining the location of the line of normal" occlusion, and noting such teeth as are in normal, and also such teeth as are in abnormal, relations therewith ; also such teeth as may be missing through extraction, non-eruption, or non-development; the facial lines, their variation from the normal and how modified by the occlusion. To intelligently understand these conditions may, in complicated' cases, often require several visits from the patient, in connection with a careful study of accurately made models, and in some in- stances photographs, which, studied in connection with the models,. TREATMENT. 193 may suggest points for consideration in subsequent studies of the case. Skiagraphs, now so easily and quickly made, are often of great value in settling all doubts as to whether teeth be missing, or their exact locations and forms if merely imbedded. While these points may be determined in the majority of cases by careful inspection of the contour of the alveolus and digital pressure, together with the use of the exploring needle, yet where any doubt exists the skia- FIG. 181. FIG. 182. FIG. 183. graph should be resorted to. Fig. 181 illustrates a case as revealed by the skiagraph where the cuspid is so deeply imbedded in the alveolus as to baffle the ordinary methods of diagnosis. Fig. 182 shows the rare case of a missing permanent cuspid, the deciduous cuspid being nearly ready to drop out, its root having been almost wholly absorbed. The first bicuspid is about to erupt. 14 194 MALOCCLUSION. The skiagraph showed in the opposite side of the arch that the per- manent cuspid and first bicuspid had failed to develop and were entirely missing. The deciduous cuspid, like its fellow on the op- posite side, was also about to be lost through absorption of its root. Fig. 183 shows another case, that of a young lady aged sixteen, where the left lateral incisor is entirely missing. Additional in- terest is given to this case in the fact that in a cousin of this patient on the father's side the left upper lateral also failed to develop, while the paternal grandfather and a sister have diminutive, mal- formed laterals, the father's teeth being normal in development. In the treatment of all cases of malocclusion our efforts should be toward the accomplishing of three main objects : First, correction of malocclusion ; Second, establishment of harmony in the relations of the jaws; Third, improvement of the facial lines. In the accomplishment of these our efforts should be toward the ideal, where normal occlusion, normal relations of jaws, and har- mony of facial lines are combined. While the -ideal is not always possible to gain, yet the best attainable results cannot be hoped for with a lesser standard. Correction of Malocclusion. It has already been pointed out that teeth are held in their correct positions when in normal occlusion by the harmonious relations of their inclined occlusal planes. It there- fore becomes of the greatest importance in the treatment of cases of malocclusion that harmony be established in these inclined planes, so that their interlocking will eventually keep each tooth firmly in its corrected position. Recognizing this powerful influence, then, it is but folly to ex- pect teeth that have been moved into harmony with their lines of occlusion to remain longer than a few weeks or months after the removal of the artificial support given by the retaining devices, un- less harmony of the inclined occlusal planes shall have been estab- lished and consequent mutual support of the arches gained, or the inclined occlusal planes at least placed in such relations that the final settling of the teeth will bring them into normal relations. Even the slight torso-occlusal position of a single tooth, for example a lower cuspid, must not be overlooked, but must be readjusted and made to occupy its full normal mesio-distal space in the arch ; other- wise there must necessarily follow a corresponding diminution in TREATMENT. 195 the size of the opposite arch, evidenced by some form of bunching, crowding, or overlapping of the teeth. Let this be remembered as a law in the correction of malocclusion. We should aim, as far as may be consistent with conditions found to exist in each given case, to place the teeth in normal occlusion. This, however, is not always possible or advisable, for to do so the full complement of teeth must be retained, which in rare instances would result in giving too great prominence to the teeth and lips, thereby creating a condition probably quite as unpleasing as the original. In some instances with the full complement of teeth it may be impracticable to establish harmony in the occlusal inclines, as for example in the subdivisions of all of the classes. Therefore it becomes necessary in some cases to sacrifice some of the teeth in order that we may have the best attainable degree of occlusal and facial harmony, in which case the result may be defined as im- proved occlusion, as distinguished from normal occlusion. Harmony in Relations of Jaws. The jaws are often found in abnormal relations, and the ideal in occlusion of the teeth and har- mony of facial lines cannot be attained without establishment of normal relations of the jaws as well. Yet the limitations of present knowledge do not, in most cases, permit any great improvement in their relations. We are chiefly limited to operating upon the jaws indirectly through the teeth, but recent progress in orthodontia and surgery encourages us to hope for greater future achievements in this direction. Much can be accomplished, however, even at present, in suitable cases and at the proper age, that coincident with growth and development. In favorable cases belonging to Classes II and III we may change the position of the lower jaw by moving it forward or back- ward until the teeth are in normal or improved relations. By main- taining it in this position it will in time become modified or changed in form, from the influence of the changed tension of the muscles and changes in the temporo-maxillary articulation, to harmonize with its new conditions. Just to what extent the form of the jaw changes is not known, but there are many instances in orthopedic surgery to prove that bone can be bent and that it is frequently so modified. After maturity we are limited to the shortening of the jaw by the surgical operation of double resection already described. With the upper jaw the limits of modification are still greater, by JC)6 MALOCCLUSION. reason of its immobility. We may, however, by the proper appli- cation of force to the teeth, separate the superior maxillary bones at the suture, thereby perceptibly increasing the width of the jaw in either the anterior or posterior region, thus improving its re- lation with the lower jaw, as well as the consequent improvement of the features. While but little has yet been done along this line, only a few cases having been reported, yet there is little doubt that the scientific possibilities are promising and that with the advance of surgery there will be gratifying results from systematic efforts. The operation on the cleft palate, principally through the jaw, as in the Brophy operation, is one indication of the possibilities in its modification and improvement. Another source of improvement of their relations is the develop- ment of the jaws subsequent to the correction of the positions of the teeth and the establishment of normal functions of their occlu- sal planes, as discussed in the chapter on Changes Subsequent to Tooth Movement. Harmony of Facial Lines. Often the desire for improvement of the features is one of the impelling motives for seeking the cor- rection of malocclusion, and although perhaps secondary in im- portance to the restoration of the normal functions of the teeth, yet as symmetry of the facial lines is of much consequence, especially to womankind, the possibilities of improvement being so great are worthy of our highest efforts. The form of the face may be modi- fied by enlarging or diminishing in size one or both of the dental arches, thus often greatly altering the relation of the lips with the line of harmony, or in favorable cases the lower jaw may even be moved bodily forward or backward and permanently established in its new position, as already stated and illustrated in Figs. 13 and 280,. thereby placing the entire lower part of the face in greater harmony. The author would not be understood as advocating that the ef- fort should be made to make each face rigidly conform to the line of harmony. The great variation of facial types and the limits of the region over which we may exercise control, together with the peculiarity of conditions of the teeth, make impracticable such a course. We should, however, always have this standard of beauty toward which to direct our efforts, and should approach it as nearly as is consistent with all the condiiions found to exist in each given case. TREATMENT. IQ7 Having made a thorough study and diagnosis of each case and noted the class to which it belongs, and the desirable, possible, and practicable changes, we may then direct our attention to the consid- eration of other questions, such as anchorage, the appliances best suited for producing the changes, the probable time necessary for effecting them, together with the anticipation of the requirements of retention, the probable adequate remuneration for services, etc., which can only be approximately arrived at after the most honest and thorough consideration of all the lines we have enumerated re- lative to diagnosis. Treatment of Cases Class I. As we have already noted in the classification of malocclusion, the number of cases belonging to this class is the greatest and comprises by far the largest variety, the distinguishing characteristic of the class being relative normal re- lations of the jaws, with molars in correct relation mesio-distally, although one or more may be in buccal or lingual occlusion. The malposed teeth are usually, however, confined to those anterior to the molars and more commonly to the incisors, the dental arches being smaller than normal and the teeth crowded and overlapping. Both arches are usually involved, and sometimes quite similarly. As the mesio-distal relations of the lateral halves of the dental arches are normal in this class, it must follow that if the teeth of each arch be moved into harmony with their lines of occlusion both arches must then be in perfect harmony as to size and the teeth be in normal occlusion. 'Fig. 184 represents a very common form of malocclusion belong- ing to this class. It will be seen that the mesial and distal inclined planes of the mesio-buccal cusp of the first upper molar on the right is received between the inclines of the mesio- and disto-buccal cusps of the first lower molar, or that the relations of the first molars are normal. (The molars of the opposite side were also in normal relation.) The arches are diminished in size and the teeth, espe- cially the incisors, occupy positions lingual to normal. What is then clearly indicated is that the arches be enlarged and each tooth moved into its correct position in the line of occlu- sion, as shown in the case when completed, Fig. 185, and in the plan of treatment of any case belonging to Class I it makes but little difference what positions the malposed teeth may occupy. They are always subject to the one general requirement. In the com- 198 MALOCCLUSION. pleted case, as shown in the engraving, it will be seen that each tooth has been placed in harmony with its line of occlusion and is therefore now in best position to support and be supported by all FIG. 184. FIG. 185. the remaining teeth, as well as to be in nearest harmony with the muscles and the normal facial lines. The establishment of normal occlusion may and should be the result in by far the largest percentage of cases belonging to this TREATMENT. 199 class, but this is only possible with the full complement of teeth. There are cases, however (though the author believes they are very few), in which extraction is necessary. Aside from those rare in- stances of supernumeraries or malposed teeth, or where extrac- tion may be necessary to harmonize conditions in the arches re- sulting from previous losses or failure in development of teeth, which conditions cannot be discussed according to any general rules, but must be determined alone by the judgment of the opera- tor after a most thorough consideration of all the peculiarities, the author can conceive of but two reasons for extraction in this class. First, where the jaws are so small, either naturally or because of arrested development, that the angles of inclination would be too great if all the teeth were placed in line. Such a case is shown from both sides in Figs. 186 and 187. It will be readily seen from a study of this case that the upper jaw was naturally diminutive in size, giving marked labial inclination to all. FIG. 186. FIG. 187. of the anterior teeth, even in their crowded condition, and that if moved into correct alignment their protrusion would be exagger- ated and the result impracticable. Second, where extraction is necessary from the requirements of the facial lines, for the development of the arches may be such as to afford an abundance of room for the malposed teeth, and yet the placing of them in the line of occlusion may result in marked dental or labial prominence, and the facial result be more unpleasing than 2OO MALOCCLUSION. if the teeth had been allowed to remain in malpositions. Such a case is shown in Fig. 188. The author believes such cases are much more rare than seems to be commonly supposed, for often where such results at first seemed probable, yet the conservative method being followed, after all was completed and the teeth had settled to mesio-distal contact, the features were not too prominent. We should also take into con- sideration in connection with these cases the possible changes in the development of the jaws, as noted in the chapter on Changes Subsequent to Tooth Movement. FIG. 188. It is difficult to lay down any precise rule regarding extraction, but it is a matter which involves the broadest consideration and closest study of each case, often taxing the judgment as much as does any problem in orthodontia. A rule which the author has fol- lowed for some time, when at all in doubt, is to pursue treatment according to the conservative method, studying the relations of the dental arches and features carefully, until a certainty in the matter shall become apparent. Very often by pursuing this course we shall find that where ex- traction seemed at first imperative, its necessity was only apparent, and disappeared as treatment progressed. If, however, it develop that extraction be necessary, no harm will have resulted from pursuing the conservative course first. But if extraction be re- sorted to hastily or ill-advisedly, and afterward prove to have been TREATMENT. 2OI a mistake, as would in most instances be found to be the case, the final effect on the occlusion or facial lines, or both, may be such as to cause serious regrets and embarrassments. The study of such cases as represented in Figs. 184, 189, and 197, together with that of the tissues, and of changes subsequent to tooth movement, should, we think, be evidence not to be passed lightly over by those who have so freely advocated extraction. There seems to be much difference of opinion as to choice of teeth in case a sacrifice be necessary. Either the first or second bicuspids are usually advised, some writers advocating the first molar, especially if it be affected with caries, while some have extracted the lateral incisor. Probably defective appliances have done much in the past toward shaping the decision as to the sacrifice of teeth, such extraction being resorted to as would best facilitate adjustment of the re- maining teeth, regardless of their comparative value. The present ease and certainty of tooth movement by the use of proper appli- ances makes inexcusable the extraction of teeth as a help to the accomplishment of results that will not accord with the demands of the best possible occlusion and facial harmony, which alone should be our guide. We cannot understand how those who have made a careful study of the occlusion of the teeth and know their interdependence could ever advise the removal of the first molar, even though far ad- vanced with caries; for its loss not only could not benefit the crowded condition of the incisors, but would probably be followed by other forms of malocclusion even more serious ; while the re- moval of a cuspid or lateral incisor, unless the root be malformed in such manner as to make its adjustment impracticable, the author believes to be no longer excusable even in a country physician. As between the first and second bicuspids, their resemblance in form is so close as to make the choice for sacrifice a matter of in- difference were it not that the loss of the second bicuspid greatly increases the difficulties of treatment. To remove one tooth in this class is to necessitate removal of the corresponding tooth in the opposite arch, as otherwise there would be a resultant inharmony in the sizes of the arches, with all its evils. To extract the first upper bicuspid and one of the lower incisors, as advocated by some, would only lead to a similar result of less degree, besides making impos- 202 MALOCCLUSION. sible the establishment of real harmony between the occlusal planes of the remaining teeth. If it be necessary to sacrifice a bicuspid from a corresponding lateral half of each arch in this class, it by no means follows that similar sacrifices must be made from the opposite side. In fact, such cases are extremely rare. Of course, extraction from one of the lateral halves of each arch necessitates the slight shifting of the FIG. 180. FIG. 190. incisors from the median line as the arches diminish in size. But arches with lateral halves equally developed are rarely found. One of the sides will usually be found to be the more favorable to extrac- tion. And again, after completion of the case and after all the teeth have become settled in their new positions the lateral inclination of the incisors is rarely noticeable, and weighs naught in comparison with the general occlusal and facial results. Figs. 189, 190, and 191 illustrate a case in its labial, buccal, and TREATMENT. 203 occlusal aspects, and from the positions of the cuspids and mesio- buccal cusps of the upper first molars it will readily be recognized as a typical case belonging to the first class. FIG. 191. It will be seen that the arches are much shortened and reduced from the normal size, with marked lingual positions of all the in- cisors, the left upper lateral being in contact with the first bicuspid, causing almost complete labial displacement of the left cuspid, while at least one-half of the space necessary for the right cuspid is occupied by the right lateral, the influence of the lips effectually 204 MALOCCLUSION. maintaining the diminished size of the arches and the malocclu- sion. The effect, as might be supposed, was very noticeable in the facial lines of the patient, as shown in Fig. 192, producing a pinched and flattened appearance about the mouth. As so much space would be required for admission of the upper cuspids into the line of occlusion, the extraction of one first bicuspid in this arch might at first suggest itself, but the de- velopment of the alveolus and demands of the facial lines were such in this case as would have made such a course inexcusable. What was clearly indicated was the restoration of all the teeth to normal FIG. 192. occlusion by slightly widening both arches, moving labially all the incisors into line, and performing elevation, rotation, and a slight lingual movement of the cuspids. Fig. 193 shows these various movements being accomplished in both arches simultaneously by means of expansion arches, spurred bands, and wire ligatures, adjusted as described in the use of the expansion arch, Chapter XL The anchorage was effected by means of D bands placed upon the first molars in the lower arch, while in the upper arch a D band upon the first molar was used on the right side and an X band on the first bicuspid on the left side, it being found necessary after a few days of treatment to transfer the anchorage from the left first molar to this tooth, as the molar showed displacement distally in resisting the strain of the labial movement of the incisors. It will be noticed that there are two ligatures upon the left lateral incisor. One is a plain ligature, as in A, Fig. 63, for effecting the TREATMENT. 205 labial movement ; the second, as in B, Fig. 63, encircles the arch and a spur soldered low down upon the lingual surface of the band upon the lateral. The office of this ligature was partly to assist in carrying the incisor forward, but principally to effect its rota- tion. A spur is seen upon the expansion arch to prevent this liga- FIG. 193. ture from sliding forward and to direct the movement of the tooth laterally, the arch being so bent that in shape and spring it bears to the left and favors this movement, assisted reciprocally by the band, spur, and ligature upon the right lateral. The reason for the spurs being placed well toward the gum, as is important in all such cases, is that it resists the tendency of the arch to slide toward the 2O6 MALOCCLUSION. occlusal edges of the teeth. This tendency is further opposed by the crossing of the ligature near the spur. The right lateral is encircled by the loop style of ligature, as in C, Fig. 63, being prevented from sliding off by the band. The form of the expansion arch was occasionally modified by bending to meet the requirements of the moving teeth and prevent bunching. Xot until the incisors had been moved labially sufficiently for tlu full admission of the cuspids into the line of occlusion was any effort made toward elevating them in their sockets. This was also effected by enlisting the spring of the expansion arch. Wire ligatures were carefully worked beneath the gum and above the gingival ridges of the cuspids and given one full twist on the labial surface, followed by a final one-fourth twist from the grasp of the pliers. One of the long ends was then made to encircle the arch, a second twist given, and the ends clipped down to the usual length, as described in directions for adjusting ligatures, Chapter VIII. This period in the treatment is shown in the engraving, Fig. 193, made from. a study model taken in wax with the appliances in position. Tension on the cuspids by the spring of the expansion arch was occasionally intensified by an additional twist in the ligatures, first always pressing upward upon the arch with the finger in order to relieve the strain upon the ligature while twisting. The movement of rotation being the most difficult, it was de- layed until the teeth were fully erupted to the line of occlusion, when the spurred band, wire ligature, and wedges of rubber were applied after the usual manner for accomplishing the movement and soon brought about the desired results. Owing to the lingual inclination of the crowns of the lower incisors no bands were necessary, the ligatures simply encircling the expansion arch and crowns of the teeth. The lateral pressure from the teeth prevented the ligatures from sliding off. It will be noted that a spur upon the arch directed the movement of the cuspid laterally as well as labially. The slight necessary rotation of the left second bicuspid was ac- complished by bands, spurs, ligatures, and rubber wedges, as al- ready described, as soon as the teeth anterior had been moved into correct position to reduce the crowding and permit it to turn. TREATMENT. 2O7 The teeth of the upper arch were retained in their new posi- tions by a section of wire G soldered to the mesio-lingual angles of bands on the cuspids and made to bear against the lingual surfaces of the intervening incisors, as in Figs. 152 and 212. The lateral tendency of the lower cuspid and lingual tendency of the incisors were antagonized by a similar device, and the cuspid was retained by a band and spur, the end bearing upon the lingual surface of the first bicuspid, as in Fig. 154. A combination of the jack-screw, as in Fig. 132, might have been employed in the movements of the incisors, though perhaps with not quite such perfect control of the teeth. FIG. 194. FIG. 195. Fig. 194 shows the upper model of the case soon after its com- pletion; Fig. 195 nearly two years later. And it is interesting to 208 MALOCCLUSION. note, by comparing the two cuts, what a marked change has oc- curred in the alveolus in the region of the incisors. Nature un- aided has shifted the roots of these teeth to closely approximate their ideal positions. Fig. 196 represents the face of the patient at this time, and the improvement in the facial contour is very noticeable and gratifying. FIG. K Fig. 197 shows another case similar to that just described. The main peculiarities are almost identical, the difference really con- stituting only one of the ever-varying combinations in the mal- positions taken by the incisors, with the same general require- ments. Fig. 198 shows the upper model from the occlusal aspect with the appliances in position at the beginning of treatment. It will be noted that each arch is greatly diminished in size, and that there is marked arrest in the development of the alveolus in the region of the incisors. These teeth were moved labially in the usual way, and similar to that in the case last described. The same plan was. also followed in the correction of the positions of the lower teeth. TREATMENT. 2O9 Fig. 199 shows the occlusion of the case after correction, with retaining bands upon the cuspids. All four cuspids were banded and connected by sections of G wire, as inrFig. 152. FIG. 197. FIG. K Figs. 200 and 179 represent the upper model of the case from the labial and occlusal aspects three years after the removal of all appliances. By comparing these with Figs. 178 and 199 (which also represent the same case), it will be noted what a remarkable change has taken 15 2IO MALOCCLUSION. place in the development of the alveolus in the region of the incisors. There has also been a shifting labially of the apices of the roots of the incisors until these teeth occupy ideal positions and inclinations, with an equally gratifying change in the contour of the face. FIG. 199. FIG. 200. Before leaving this case one point of interest should be men- tioned. It will be seen in Fig. 199 that the bicuspids are in slight infra-occlusion, but, as they are perfectly placed in other respects, the author deems it good practice, as in all such cases, to allow any TREATMENT. 211 slight shortness of the teeth to be adjusted by nature lather than to prolong treatment beyond the period necessary to the accomplish- ment of the essential principles in the establishment of occlusion, knowing full well that this will soon be effected and that the in- clines of the cusps will certainly guide them into correct positions. Figs. 201 and 202 show the malocclusion of the teeth from the labial and occlusal aspects in the case of a patient ten years of age. From the position of the deciduous cuspids it will be readily diag- nosed as belonging to the class under consideration. FIG. 202. All of the permanent incisors have fully erupted and occupy positions lingual to normal, while the upper laterals and left cen- tral are in torso-occlusion as well, the central occluding lingually 212 MALOCCLUSION. to the opposing lower central. The external muscular pressure is gradually narrowing the arches, as a result of the diminished sup- port of their lateral halves, and ever-increasing complications must follow delay of treatment, while the occlusal edges of the teeth must be injured by abnormal contact. The line of treatment which should be followed is practically the same as in the case first described. By placing each tooth in proper position, by means of expansion arches, spurred bands, and wire ligatures, we establish normal occlusion. Retention was effected by resisting the torso-lingual tendency of the incisors by two bands united by solder and placed upon the left central and lateral. Projecting from the disto-labial surface of the band on the lateral was a spur made to bear against the mesio-labial surface of the cuspid. Projecting from the mesio- lingual surface of the band on the central was another spur which extended across the lingual surface of the right central and lateral, and terminated in a pit in the mesio-lingual surface of the tem- porary cuspid. The lingual tendency of the lower incisors was resisted by the same device as in the case last described, shown in Fig. 152. Fig. 203 shows another more or less common type of malocclu- sion belonging to this class, as will readily be recognized by the FIG. 203. FIG. 204. position of the molars. All of the upper incisors are in lingual occlusion, while the lower have been forced into slight labial oc- clusion. The upper incisors were laced to the expansion arch with wire TREATMENT. 213 ligatures, and all carried labially by tightening the nuts in front of the tubes on the anchor teeth the first molars. It will be seen in the next engraving, Fig. 204, that plain bands encircle the lateral incisors to prevent the sliding of the ligatures, while the plain ligatures are used on the centrals. The engraving illustrates a study model made after completion of tooth movement and just before the appliance was removed. The teeth were moved outward to correct positions, as shown in the case completed, Fig. 205, in just seven days. The patient was a boy sixteen years of age. The author doubts if this could have been accomplished so easily and quickly by any other known method. The appliance was allowed to remain upon the teeth pas- sive for ten days before removal, when occlusion alone was de- pended upon for retention. No effort was made to change the positions of the lower incisors, as it was known that the necessary change would be effected by occlusion. FIG. 205. In the treatment of all similar cases there is a strong tendency on the part of many to perpetuate a very old fogy notion in apply- ing some form of gag to keep the jaws apart and prevent the oc- clusion from interfering with the movement of the teeth. Such practice should be obsolete. A good appliance will effect the movement, regardless of the slight hindrance offered by occlusion, which is reduced to the minimum by the patient's natural avoid- ance of irritating the tender moving teeth. Fig. 206 represents the occlusion of the teeth of a child nine 214 MALOCCLUSION. years of age. The causes and peculiarities of this case were de- scribed in the chapter on Occlusion. The upper arch was widened and the incisors moved labially by the combination of jack-screws and section of levers L, as in Fig. 106, while the lower arch was widened and the incisors moved into correct position by means of FIG. 206. FIG. 207. E.H.A. the expansion arch, as in Fig. 193. Both upper and lower were retained as in Fig. 152. A better plan, in the case of the upper arch, would have been to place bands upon the laterals instead of upon the cuspids, thereby utilizing the reciprocal force between centrals and laterals their tendencies being to move in opposite directions. The completed case is shown in Fig. 207. TREATMENT. 215 Fig. 208 shows the occlusion of the teeth of another child who had suffered the loss prematurely of a lower deciduous cuspid, and the same natural influences produced results very similar to those in the last case. Treatment in all such cases should be immediately commenced. The lower incisors should be moved labially and the full space of the removed cuspid maintained by suitable devices until the permanent cuspid shall take its position in the arch to maintain its size, acting as does a keystone in an arch of masonry. Precisely the same plan of retention was employed in this case as in the last, with the exception that as the right lower cuspid was missing the band was placed upon the lateral and another spur at- tached to project from its disto-lingual angle and engage a small pit made in the mesial surface of the deciduous first molar, this spur being of sufficient length to maintain the full space of the FIG. 209. FIG. 208. missing cuspid. The width of the upper arch was maintained by a neatly fitting vulcanite plate, as in Fig. 158. In Fig. 209 is shown another case of malocclusion which is represented from the labial aspect, while Fig. 210 shows the occlu- sal surfaces of both arches. From the positions of the mesio-buccal cusps of the upper first molars relative to the lower first molars the case is readily diag- nosed as belonging to the class of malocclusion under discus- sion. 2l6 MALOCCLUSION. The patient was a lad aged thirteen. The strongly developed cuspids are erupting and have forced the lateral incisors lingually and the centrals into torso-occlusion, while all the lower incisors, though quite even, occupy positions lingual to normal, and the FIG. 210. cuspids are in torso-occlusion. From the marked malpositions of the incisors, especially the left upper lateral, it would seem that extraction in this case would be a necessity, as it would appear that if all the teeth were retained and their crowns moved into the TREATMENT. 217 line of occlusion they would then occupy such inclining positions as .to be unsightly and impair their functions. While this at first seemed probable to the author, he decided to proceed upon the line FIG. 211. of retaining all of the teeth, enlarging the arches in all directions sufficiently for their accommodation, and to resort to extraction only in case of ultimate necessity. Fig. 211 illustrates a study model, made with the appliances in position, and shows the upper incisors being moved labially en 2l8 . MALOCCLUSION. masse by means of the expansion arch, ligatures, and spurred bands, the spur and ligature acting upon the right central to effect the movement of rotation at the same time. It will be noted that the deciduous second molar has been removed and the anchor band X placed upon the first bicuspid, not in order to secure greater anchorage than that which would be offered by the first permanent molar, but to shift the tooth distally somewhat in order to gain much needed space for the cuspid. The loosened temporary molar was not removed and change in the anchorage made until sufficient anchorage from the firm permanent molar with a D band had been utilized to move 'the incisors forward to nearly their correct posi- tions. The arch was bent to accentuate the labio-buccal movement of the left lateral incisor, the force being reciprocated from the first bicuspid on the left through its attachment by the ligature, as shown. The disto-torso-occlusal position of the lower cuspids shown in this case is the malposition most often assumed by these teeth, not only in this, but in other classes of malocclusion, and as their movement is unquestionably one of the most difficult to perform they are too often left undisturbed. But as we now know that there must be complete harmony in the sizes of the arches in order to insure permanency of corrected occlusion, and as we also know that the lower arch is the pattern for controlling the size and form of the upper arch, how important does it appear that these teeth shall be moved forward and turned in their sockets in all cases, that they may do their part in establishing the full size of the arch. The cuspids then, as they should, not only become as keystones in the lateral halves of their own arch, but in a degree in those of the upper arch, through occlusal influence. Otherwise we must expect a corresponding diminution in the size of the upper arch, with a bunching of the teeth, through the influ- ence of the lips. It must be remembered that space for their accommodation must always be provided before rotation will be possible. They must therefore be carried forward until their distal angles shall be free from inlock with the mesial angles of the first bicuspids. To in- sure this in this case spurs were soldered to the arch to prevent the ligatures from slipping as the nuts were tightened, as in Fig. 126. TREATMENT. 219 In these cases the author has often used with advantage a double ligature ahead of the spurs. In this way the most stable attach- ment is gained and a power exerted equal to the direct application of a jack-screw. With no other form of ligature would it be possi- ble to exert pressure upon the tooth in so effective a manner. After the cuspids were moved forward sufficiently to be free from the bicuspids the rotation was expeditiously effected by occa- sional renewal of ligatures in the usual manner, the spring of the arch being made constant by wedges of rubber stretched between it and the tooth bands, as properly shown in the engraving. The author believes this to be the most powerful and practicable means known for performing these oft-needed movements. If analyzed it will be seen that the appliance is only a series of levers, made to act in the most effective manner on pure mechanical principles, combining reciprocal and simple anchorage, while per- mitting the most perfect control over the directions of movement. Fig. 212 shows the teeth after they have been moved into har- mony with the line of occlusion, the retaining devices in position. By studying the original positions of the teeth in Figs. 209 and 210, together with their corrected positions in this figure, it will be seen that the connection of the upper cuspids by bands and a section of G wire, as in Fig. 152, not only resists their torso-labial tendency, but that their infra-occlusal tendency is also resisted by the resting of the wire upon the linguo-gingival ridges of the laterals, whose lingual tendencies are in turn resisted by the wire, while their mesial tendencies are resisted by the centrals. At the same time the laterals exercise resistance to the rotation of the centrals by contact with their disto-fingual angles, while the mesial angles of the centrals are prevented from moving labially by the tension of the fibers of the peridental membrane, care having been exercised to preserve this tension by exerting force for their proper rotation only on their disto-lingual angles. Had they been moved labially before rotation there would have been mesial disturbance of the fibers, instead of distal disturbance only, necessitating their retention by two united bands. Much may often be gained by an intelligent use of the advantages offered by the peridental mem- brane. The lower right lateral and cuspid were retained each by a single band and spur, preventing their torso-lingual displacement. Of 22O MALOCCLUSION. course the same effect would have resulted from the bands being soldered together, with one spur from the cuspid only bearing against the buccal surface of the first bicuspid, but the difficulty FIG. 212. of adjusting both bands at the same time so that one of them would not become loosened and cause injury to the enamel, as they were to be worn in this case for nearly two years, made the plan ob- jectionable. There is another decided advantage in the use of spurs in all TREATMENT. 221 such cases, in that the finer adjustment of the teeth may be easily effected after the application of the retaining device by in each in- stance stretching a piece of rubber between the anchor tooth and spur, to create a leverage, and on its subsequent removal bending back the spur to hold the position. Figs. 213 and 214 represent the case three years after treatment. Attention is called to the de- velopment to normal contour of the alveolus in the region of the apices of the incisors which has followed the establishment of normal occlusion and function of the teeth. It will also be noted FIG. 213. that the retention of all of the teeth has not caused undue promi- nence of the lips, which are seen to be in harmony with the other lines of the face, but that it is a far finer result than could possibly have followed the sacrifice of one or two teeth from each arch to gain space. Fig. 215 shows the left sides of two models of a case, before and after treatment. The occlusion of the right lateral halves was nor- mal. On the left (upper model) the lateral halves of both arches were shortened, the upper permanent lateral incisor being in con- tact with the first bicuspid. There was a shrunken appearance of the .mouth, and the incisors were shifted from the median line. This condition was the result of the unfortunate and unnecessary 222 MALOCCLUSION. loss of the deciduous upper cuspid and first and second deciduous lower molars. What was clearly indicated was the lengthening of the lateral halves of both arches and the moving forward of the centrals, and the shifting of their positions to be in harmony with the median line. FIG. 214. This was accomplished in both arches simultaneously by means of expansion arches, bands, and ligatures. No bands were neces- sary on the teeth to be moved. The incisors were laced to the arch with plain ligatures, as in A, Fig. 63. The spurs for preventing the ligatures on the upper lateral incisor and lower cuspid from slip- ping were placed well forward on the arches, so that the force produced by tightening the nuts in front of the anchor tubes on the first molars exerted a direct mesio-labial movement of these teeth, TREATMENT. 223 and as the nuts were tightened only on the affected side the lateral shifting of the incisors, as the arches were lengthened, was natural and easy. See Figs. 126 and 211. The result of treatment is shown in the lower model, the sides of the arches having been sufficiently lengthened to admit of the eruption of the upper cuspid and lower bicuspids. Retention was effected as follows : A section of G wire engaged R tubes, one of which was soldered at its end to the mesial surface of a No. 2 band on the molar and the other similarly attached to the FIG. 215. distal surface of a band on the cuspid. A few pinches from the regulating pliers slightly lengthened the wire, giving a firm resist- ance to the distal tendency of the cuspid, Fig. 145. A similar de- vice, Fig. 146, was placed upon the upper lateral and first bi- cuspid. These were worn until the eruption of the teeth made their use no longer necessary. This is a very desirable method of retention in all similar cases. In the model on the right of the engraving, Fig. 216, is shown a case from which several valuable lessons may be learned, espe- cially by the odontocide. The case was that of a young lady aged sixteen years. Two years previous to the making of this model 224 MALOCCLUS1ON. her teeth were practically faultless in occlusion, and, with the ex- ception of the first lo'wer molar on the left, of excellent structure and color. At this time the molar was lost through neglect of caries, the result being the inevitable tipping forward of the second molar. The locking of its inclined occlusal planes with those of the upper second molar caused the carrying distally of this side of the lower jaw, and at the same time some forward movement of all the anterior teeth of the upper arch, the result being the gradual shifting to nearly complete distal occlusion of the teeth in this lateral half of the lower arch anterior to the space. At the same FIG. 216. time pressure from the upper lip was gradually molding the upper arch to the diminishing size of the lower, as shown by the bunch- ing tendency of the incisors. The treatment clearly indicated was lengthening of the lateral half of the lower arch, the tipping to an upright position of the second molar, the correction of the positions of the teeth in the upper arch, or the restoration of the occlusal planes to their original positions. The truing of the positions of the upper teeth was accomplished by means of the expansion arch, bands, and ligatures, in the usual way, while the lengthening of the lateral half of the lower arch was accomplished in the same manner as in the case last described. The tipping to an upright position of the molar was effected by force exerted upon the nut in front of the anchor tube, and also by bending the expansion arch at the point where it entered the TREATMENT. 225 tube, so as to give a spring or pry upward on the mesial end of the tube and a downward pry on its distal end. The result is shown in the model of the completed case on the left of the engraving. The patient was then referred back to her dentist for the insertion of an artificial substitute for the lost molar, which being provided, in the form of a bridge, served the double purpose of mastication and retention. The requirements of orthodontia and bridging are such as should induce a closer study of their relations. FIG. 217. Fig. 217 shows one of the most complicated types of cases be- longing to the first class. Both lateral halves of the upper arch are in lingual occlusion, thus greatly encroaching upon its incisive region and forcing the laterals into marked torso-lingual occlu- sion and the centrals into torso-labial occlusion. The result of the occlusion of the buccal cusps of the upper molars and bicuspids with the lingual cusps of their opposing teeth, as shown in the dotted lines in Fig. 219, is a tendency to force the apices of the roots of the lower molars and bicuspids farther and farther buccally, with the opposite effect on the corresponding upper teeth. Such a result was most noticeable in this case, both in the inclinal angles of the teeth and in the facial lines, the middle part of the face being narrowed, while the lower part was broad- ened and puffy, the condition being really a distortion of otherwise comely features. 16 226 MALOCCLUSION. The line of treatment was toward the ideal, the widening of the upper arch, the correcting of the malpositions of the incisors, and the narrowing of the lower arch. Fig. 218 shows the upper arch being widened by means of the expansion arch, adjusted in the usual way and reinforced by one of the spring levers L, all as shown and described in the chapter on Combinations of the Expansion Arch. The incisors were moved forward en masse and rotated by means of spurred bands, ligatures, etc., after the usual method. FIG. 218. The narrowing of the lower arch was effected by means of a device manufactured for the occasion, and is the only instance in the author's experience where an appliance differing from those standard forms described throughout this book has been required. The standard appliances might have been used to accomplish even this movement, but their use would have required a longer time. The device consisted of a piece of Stubb's steel wire slightly less than one-eighth of an inch in diameter, bent closely to con- form to the shape of the arch, the temper being so soft as to make this easy of accomplishment. The extreme ends were bent sharply at right angles and filed to the sharpest hook-like points, which were made to engage the buccal pits on the first molars, as in Fig. 219. If the points are bent at the proper angle and made extremely sharp no drilling of cavities in the enamel is necessary, TREATMENT. but they will readily remain in position when grasping the sides of the tooth at any point, especially just beneath the gingival ridge. After the wire arch had been tested and found to be of exactly the length and shape necessary, the ends were sprung closer to- gether, or made to conform in shape to an ideal arch. It was then tempered to extreme hardness, after which it was polished and given a spring temper by being held in contact with a sheet of thin metal over a flame until its color had changed to a light blue. It was sprung into position and the amount of force exerted upon the teeth was found to be about twenty pounds, but being so evenly FIG. 219. distributed little inconvenience was experienced by the patient and, somewhat to our surprise, the dental arch was molded into correct shape by bending of the alveolus in the short period of eleven days. After the spring of the arch had been expended it was al- lowed to remain as a retaining device for two or three weeks, held in position by an occasional ligature of the brass wire. It might be asked why a section of heavy piano-wire would not answer the same purpose. The most important reason is that the fibers infolded in the bending have little contractile power, its use- fulness as a spring being confined to its expansion or outward ac- tion. Another reason is that it is not sufficiently heavy. It is always important that the wire be tempered after it has been bent to the desired form. 228 MALO^CLUSION. Fig. 220 shows the upper arch completed and the retaining de- vices in position, while Fig. 221 shows both arches completed and the teeth in occlusion. The lingual tendency of the upper incisors FIG. 220. FIG. 221. and the torso- and infra-occlusal tendencies of the upper cuspids, as well as the lingual tendency of the molars and bicuspids, were resisted by double bands connected by a section of the wire G and a vulcanite plate, as illustrated. The bands upon the cuspids are also shown in Fig. 221. The model illustrated in Fig. 222 represents a case where one TREATMENT. 229 only of the lateral halves of the upper arch was in lingual occlu- sion, while the lateral incisors were in marked torso-lingual oc- clusion. The patient was a child eight years old, the deciduous molars and cuspids being still in position. The plan of treatment clearly indicated was widening the arch by movement buccally of the affected side only, with labial move- ment of centrals and torso-labial movement of laterals. Fig. 223 FIG. 222. FIG. 223. shows a view of this arch from the occlusal aspect, with the appli- ances for accomplishing these movements of the teeth in position. It will be seen that all of the teeth on the left side are used as anchorage and their combined resistance concentrated through the force distributed by the external and internal arches upon the left first permanent molar. But a few days were necessary to move this tooth into correct position. A wire ligature was then made to encircle the second deciduous molar and the expansion arch, thus practically transferring the force to this tooth. Later the first 230 MALOCCLUSION. deciduous molar was moved out in the same way. The object of moving the teeth one at a time was to avoid overtaxing the anchor- age derived from the opposite side of the arch. Had the effort been made to move all at the same time it is probable that the nor- mal side would have been displaced more rapidly than the ab- normal, on account of the increased resistance offered by the inlocking of the inclined planes of the cusps of the molars on the abnormal side. While the appliances were acting upon the lateral half of the arch the lateral incisors were carried forward and rotated by bands, spurs, and ligatures, with spurs on the expansion arch to prevent slipping, further assisted by the tightening of the nuts on the ex- pansion arch, as in the case last described. By studying the positions of the teeth in the upper arch it will be seen that their tendencies were similar to those in the last case, and that they were overcome in a similar manner and by the same combinations of bands and spurs. The widened arch was retained by the vulcanite plate, Fig. 158. The mesial, torsional, and lingual tendencies of the right lateral and the lingual tendencies of the other incisors were resisted by bands upon the laterals connected by a piece of G wire soldered to their lingual surfaces. FIG. 224. Fig. 224 shows a case belonging to this class in which there was marked lingual inclination of both upper and lower incisors, as well as of lower bicuspids, the latter occluding wholly inside of their upper antagonists, which were thus inclined labially. Figs. 225 and 226 show both arches from the occlusal aspect. The ex- pansion arch and ligature attachments are shown in position on TREATMENT. 231 the lower arch, which is to be enlarged by the renewal or twisting of the ligatures and the tightening of the nuts. The spurred band, ligature, and rubber wedge are shown on the right cuspid for ef- fecting its rotation. There are two points of interest in connection with the upper arch which have not been brought out in any of the similar cases described previously. The first is the prominence of the right cuspid, and the second is the torsal position of the left first molar. The rotation of the molar and reduction of the cuspid were accom- plished while the incisors were being carried forward, by bending and so adjusting the arch that it would bear with considerable force FIG. 225. FIG. 226. against the prominent cuspid. The force was increased by a strip of rubber drawn between the tooth and arch. At the same time the ligatures encircling the bicuspids on that side and the incisors in front exercised a reciprocal force upon it. The molar was rotated by the bending of the expansion arch at a point just mesial to the nut so as to exert force buccally upon the mesial end of the tube and lingually upon the distal end, this being as- sisted by the reciprocal force from the incisors as the nut was tight- ened to carry them forward. It was necessary to occasionally remove the arch and increase the tension by slightly reducing the bend at the point near the nut. Fig. 227 shows the lower arch nearing completion, and Fig. 228 shows the method of retention. A gold crown already on the first molar was utilized for reten- 232 MALOCCLUSION. tion by making a small hole in the mesio-lingual angle and insert- ing one end of a section of wire G, the other end being engaged with a tube R soldered to the disto-lingual angle of a cuspid band. This effectually resisted the lingual tendency of the bicus- pids. The lingual tendency of the cuspid on the opposite side was FIG. 227. FIG. 228. resisted in the same manner, only that a pit was made in the enamel of the molar and afterward suitably filled. The twisted ends of the ligatures are improperly shown in the illustrations of this case. They should be as in Fig. 63. Fig. 229 shows a case in which there is much space between the occlusal edges of the incisors, the result of the habit of holding the tongue between the teeth. It also shows the method of cor- recting the infra-occlusion of the incisors by means of the expan- TREATMENT. 233 sion arch. The middle of each side of the arch was made to bear against a spur soldered to a band on the cuspid, which acted as a fulcrum, the center of the arch being sprung over hooklike spurs projecting from the labial surfaces of bands on the incisors and its spring thus exerting a down-ward force upon them. The use of ligatures instead of spurred bands for the incisors, as represented in Fig. 193, is now preferred. Either of the arches, E or B, may be used. FIG. 229. FIG. 230. This is an excellent method of correcting infra-occlusion of teeth, and yet it must not be forgotten that the force also tends to elevate the anchor teeth and that they must not be overtaxed by the at- tempt to move too many teeth at once. Not more than one or two should be moved at a time. If pronounced vertical movement of the anchor teeth should occur, the bands should be shifted to other molars. It is often desirable in these cases to reinforce the molars by occlusal anchorage, by means of bands and buttons on the lower incisors, or by attachment to lower cuspids, as in Fig. 230, which are made to engage rubber ligatures stretched over spurs on the arch or on bands on the upper teeth. 234 MALOCCLUSION. The best means of retaining teeth so elevated is to allow the arch to remain in position the requisite time. CHAPTER XVIII. TREATMENT OF CASES. CLASS II, DIVISION I. IT will be remembered that the distinguishing characteristics of cases belonging to this class and divisions are distal occlusion of both lateral halves of the lower arch, sub-development of the lower maxilla, narrowed upper arch, lengthened and protruding upper incisors, and lengthened lower incisors. It will also be remem- bered that these patients are in almost every instance affected with some form of nasal obstruction, necessitating mouth-breath- ing, which usually begins at an early age, causing the mouth to be held open almost constantly and the lips and buccal muscles to act abnormally. The upper lip is drawn upward in the effort at breathing and fails to develop in size and function, exercising little, if any, restraint upon the labial movement of the incisors. Their protrusion thus becomes more and more pronounced, partially as a result of pressure from the tongue and narrowing of the arch, but principally because the lower lip is so frequently forced against their lingual surfaces in swallowing and in the effort at moistening the mucous membrane of the mouth. Both upper and lower in- cisors become lengthened, probably from lack of function, so that the occlusal edges of the lower are frequently in contact with the mucous membrane of the hard palate. It is a common mistake to suppose that this form of malocclu- sion is the result of overdevelopment of the upper jaw. The author has never seen a case where it seemed to him that this con- dition really existed. The marred facial lines and the condition of the upper jaw and teeth are but the natural results of distal occlusion, recession of the lower jaw, and the consequent modified functions of the lips and cheeks. If it were possible, in the case of any person with normal features and teeth in normal occlusion, to force the lower jaw back until the teeth were in distal occlusion, TREATMENT OF CASES. CLASS II, DIVISION I. 235 narrow the upper arch, compel mouth-breathing, move forward and slightly lengthen the upper incisors and cuspids, and shorten the upper lip, we would then have a typical case of this class of deformities. It seems quite probable that all of these conditions have been gradually brought about as a result of mouth-breathing, at least in a very large percentage of cases. It therefore becomes apparent that treatment should be first directed toward the restora- tion of normal breathing, and it is now the belief of the author, after much experience with these cases, that failure in maintaining cor- rected occlusion will sooner or later follow unless normal respira- tion be established. Treatment of the occlusion without attention to the nasal tract is but the treatment of symptoms without removal of the cause. For that reason the advice and co-operation of a competent rhinologist should early be enlisted in order that both lines of treatment may progress simultaneously, yet we are much at the mercy of the rhinologist for the success of our efforts. Treatment. There are two distinct lines of treatment which may be followed. The first has for its object merely the improvement of the occlusion and restoration of harmony in the sizes of the arches. The second is toward the ideal, the establishment of nor- mal occlusion and harmony in the relation of the jaws and facial lines. In following the first plan of treatment, in order to establish harmony in the sizes of the arches and improve the occlusion, one bicuspid (preferably the first) from each lateral half of the upper arch must be sacrificed and the arch shortened by moving distally the incisors and cuspids until the space be closed. The incisors also, in many instances, require to be depressed in 'their sockets. No effort is made to change the mesio-distal relation of the jaws, or the occlusion posterior to the space. So much force is necessary to move the incisors and cuspids back to their correct positions and depress them in their sockets, as well, that it is impossible by any known form of appliance to gain sufficient anchorage from the remaining teeth 'without effecting their serious displacement. Notwithstanding this fact the effort . is frequently made to accomplish these movements by this means of anchorage, most of the appliances which have been devised for the treatment of this class of cases depending on simple anchorage from the molars. It would seem that only a slight familiarity with 236 MALOCCLUSION. the anatomy of the parts would readily convince any thoughtful person of the uselessness of such attempts. Let the reader study the engraving, Fig. 34, and note the comparative shortness of the roots of the molars (upper), and the normal mesial inclination of their crowns, remembering their natural tendency to mesial movement. Consider, also, the very cancellous structure of the alveolus. Compare these conditions with those of the cuspids and incisors their long roots, the firm resistance offered by the bank of bone on their lingual surfaces, and the fact that in all cases of protrusion their pronounced inclination so braces them in their FIG. 231. positions as to enormously increase their resistance to movement. Then if he consider the fact that the principles of occlusion neces- sitate our guarding with zealous care the relations of the occlusal planes of the molars he will, we believe, agree that it is the merest folly to depend upon simple anchorage from the molars in the hope to effect the complete distal movement of the incisors and cuspids. Practice abundantly confirms this theory. We must therefore resort to occipital anchorage in connection with the arch B, bands D, traction bar A, and heavy elastic bands, adjusted as described in general description of author's appliances. Figs. 231 and 232 show the appliances in position. Before adjusting the arch B it is made to conform to the shape of the ideal arch, or as we wish the teeth to be finally arranged ; and TREATMENT OF CASES. CLASS II, DIVISION I. 237 as it is carried distally, even though the teeth be irregular they are forced to gradually conform to its shape, an advantage over every FIG. 232. other similar device for the purpose. The common method has been to rigidly attach the traction bar, or its equivalent, to a swaged or vulcanite cap covering and firmly resting against all the teeth 238 MALOCCLUSION. to be moved, and thus their relative positions could not be changed in the movement. For support the front of the arch may be allowed to rest in notches formed in the united ends of the bands on the incisors, as in C, Fig. 233, or in notches filed in pieces of the wire G soldered at right angles to the labial surfaces of the bands, as in Fig. 234 FIG. 233. FIG. 234. and B, Fig. 233, or against short spurs of the wire G soldered to the labial surface of the band near its upper edge and at right angles to the long axis of the tooth, as in A, Fig. 233. The latter is the author's favorite method, as it presents a neater appearance and effectually prevents the arch from sliding against the gum the only direction, in reality, toward which it tends. The small ligatures shown on the side of the arch, for automatic retention, exert a constant gentle traction and prevent the incisors from springing back at times when the head-gear is not worn. TREATMENT OF CASES. CLASS II, DIVISION I. 239 These ligatures should be delicate, and made as described under general description of ligatures. They are best applied as follows : First tie a silk ligature of generous length firmly around the arch in front of one of the little fixed collars. One of the ends is then slipped through the rubber ligature, which with a pair of delicate pliers is carried back and slipped over the end of the tube on the anchor band D. The strand of silk is then drawn forward until the desired tension upon the rubber is gained, when the ends are tied in a surgeon's knot, followed by a plain knot, and cut off as shown in the engraving. It is a mistake to use other than very . delicate rubber ligatures, as some will persist in doing in the belief that it expedites tooth movement and assists the head-gear. The only effect is to drag forward the molars and bicuspids and en- danger the relations of their occlusal planes, which cannot be too carefully guarded. Very often the author uses no ligatures, espe- cially where any lateral spring is given to the arch. Its tendency then being to slide distally through the tubes, it will be adequate for temporary retention. The arch should not be bent so as to give it too much lateral spring. The author has known embarrassing results where dentists have applied it with full lateral spring and allowed it to be worn for several weeks without modification, much buccal displacement of the molars being caused. It must be remembered that the molars in this case are not, properly speaking, anchor teeth, the office of the D bands being merely to passively support the ends of the arch, which should be so placed and bent that very little pressure need be brought to bear upon them. The dental arch needs to be widened principally in the region of the cuspids, and this is usually accomplished as they are carried distally, by the di- rection of force through the centrals and laterals. Indeed, this tendency must sometimes be modified by bending the arch to bear against their labial surfaces. Occasionally there is a tendency of the centrals to slide behind the laterals, or of the cuspids to rotate, owing to the triangular shape of their roots and the angle at which they receive the transmitted force. All such unfavorable tendencies can be easily overcome by compelling their correct relation with the arch, by bands, spurs, and ligatures placed at points best calculated to antagonize their tendencies. Usually the wire ligatures alone are ample. 24O MALOCCLUSION. The various parts of this appliance should be added at different times, that the patient may become gradually accustomed to them. The head-gear proper has been greatly improved. It is shown in correct adjustment in Fig. 232, although the position should be higher or lower on the back of the head according to the require- ments for the direction of force. A mistake is frequently made in having the head-gear worn too high on the head, the result being to shorten the teeth too much and limit the retraction force. If much shortening of the teeth be desired, it should be worn some- what higher than indicated in the engraving. The rim should be adjusted to the proper size, and be modified in form by slightly bending to fit the head. It should be in all parts of its circumference at least one-fourth inch from the head. One of the recent improvements is the form given the rim in the region of the neck, it being made to bow outward to avoid pres- sure. Another improvement is that immovable collars have been placed upon the rim, to prevent the sliding of the elastic bands toward each other. After the head-gear has been worn for some time the netting be- comes stretched, and necessitates the taking up of the slack by the lacing cord which connects it with the rim. The great advantage of this head-cap is that the rim receives the force and distributes it equally over the back of the head, thus avoiding headache, a common result in the use of all other styles because of interference with the circulation by localized pressure. Thus there may be from two to three times the ordinary degree of pressure, and con- sequently much shortening of the time of treatment. Three heavy elastic rubber bands* are shown looped to the side of the rim of the cap, the one in the center not in use, but in readiness. As the others become somewhat weakened by stretching, the center one is to be stretched forward and made to engage the end of the traction bar also. It is well to have one or more of these bands always in readiness, and the patient should be induced to wear the head-gear as much of the time as possible with good firm tension, that the work may be done expeditiously. A tedious, protracted operation is unnecessary and should be avoided. Patients and parents should be impressed with the fact that treatment is in progress only while the head-gear is worn, and *Johann Faber's oo^ and ooojHj are best suited. TREATMENT OF CASES. CLASS II, DIVISION I. 24! that every hour of omission will prolong the operation propor- tionately. The author has noticed a marked difference in the progress of treatment in case of patients who come from a dis- tance and make the wearing of the head-gear their chief purpose, in comparison with the progress in case of patients who greatly limit the time of wearing it on account of social and other duties. The operator should carefully inspect ligatures and attachments twice a week, see the patient adjust the head-gear, and test the amount of force exerted upon the moving teeth, which latter can be easily done with a delicate spring scale (such as trout-fishermen use, and which costs about thirty-five cents), by engaging the hook in the center of the traction bar and exerting tension upon the handle until the exact force is registered. The amount of force which seems to be comfortably tolerated by patients varies from four pounds to thirteen, although only the gentlest pressure should be applied in the beginning. It may be gradually increased as the patient shall become accustomed to wearing the appliances. Very light tension is given to the elastics by extending their length by loops of suitable cord, as shown in the engraving. After the patient shall have become accustomed to wearing the head-gear the loops should be dispensed with, the rubbers being stretched forward and made to engage the hooks on the ends of the traction bar. As it is desirable to hasten the treatment of these cases as much as is consistent with the physiology of tooth movement, the author has found a combination of the traction screw with the arch B, as shown in Fig. 235, a decided advantage, especially with pa- tients over the age of fifteen years. It will be seen that the cuspid teeth are being retracted in ad- vance of and independent to the moving incisors, by means of the traction screws. These should be adjusted first and operated in the usual way for performing retraction of the cuspids, as per directions in Combinations of the Traction Screw. The ends of the arch B are supported by passing them through tubes D previously soldered near the mesial end of the sheath Y of the trac- tion screw, as when in combination with the expansion arch. The delicate ligatures shown in Fig. 231 are omitted from Fig. 235 in order that the more important lines may not be obscured. The should of course be attached to the arch in the usual way, and 242 MALOCCLUSION. be made to engage the sheaths on the anchor bands. In the en- graving one of the traction screws is represented as being operated on the lingual side of the dental arch. This is rarely advisable, for reasons previously stated. The better position is on the buccal side of the dental arch, as shown on the opposite side of the en- graving. If the traction screws be adjusted and operated with the care always so necessary in retraction of the cuspids, the result of their use in this combination will be most gratifying, as the advantages FIG. 235. 2 of stationary and occipital anchorage will be combined, the result being, if intelligently managed, to greatly lessen the time of treat- ment. It may be further lessened by the surgical removal of bone in advance of the teeth to be moved, as elsewhere described. Al- together we diminish the time required by the old-style apparatus about two-thirds, and that, too, with complete movement of the anterior teeth and no displacement of the molars. Fig. 236 shows the models of the case shown in Fig. 235 at the periods of beginning and completion of treatment. As there is such remarkable similarity in all these cases, the difference being almost wholly in degree and the requirements in the treatment ac- cording to this plan so unvarying, the further illustration of cases seems to the author unnecessary. It should be remembered that TREATMENT OF CASES. CLASS II, DIVISION I. 243 this plan of treatment, although perhaps the only practicable one in a large percentage of cases, has one serious objection, in that the abnormal mesio-distal relations of the jaws are not changed, and while harmony in the sizes of the dental arches is established, yet in reality we but modify one deformity by creating another. The resultant effect upon the facial lines is sometimes very marked, but varies according to the original relations of the features with the line of harmony, principally according to the degree of devel- opment of the mental prominence. The difference in the effect on the facial lines from following this plan of treatment is shown FIG. 236. in the two profiles, Figs. 237 and 238. Fig. 238 shows the facial lines after treatment of the cases illustrated in Figs. 235 and 236. In the treatment of all cases belonging to Class II the im- portance of correct adjustment of the teeth in the lower arch must not be ignored. Usually the size of the arch and arrangement of the teeth, with the exception of the lengthened incisors, is quite normal, and yet in a very large percentage of cases it will be found that there is lingual displacement of the incisors, especially of the laterals, often accompanied by torso-occlusion of the cuspids. We have already pointed out the importance of in all cases establishing the normal relations of these teeth with their lines of occlusion. It is nearly always desirable in these cases to shorten the lower incisors about one-sixteenth inch by grinding. This will in no way injure them, but should never be resorted to until after 244 MALOCCLUSION. their correct adjustment shall have been accomplished and they shall have been allowed to settle in their sockets for at least two weeks. The movement of these teeth into their correct positions is of course accomplished by the expansion arch E, spurs, and wire ligatures, all as described in the treatment of cases belonging to the first class of malocclusion. FIG. 237. Not only are the incisors found to occupy positions of supra- occlusion, but the bicuspids and even the first molars are occa- sionally found in marked infra-occlusion, probably due to -arrested development of their alveoli. The effect is to shorten the bite and greatly intensify the protrusion of the upper incisors. In such cases the elevation of the bicuspids and first molars is necessary. Fig. 239 shows how it may be accomplished from the spring of the expansion arch. (Either the E or B Arch may be used). Elevating force is acquired by springing the arch under spurs TREATMENT OF CASES. CLASS II, DIVISION I. 245 soldered to bands cemented to the bicuspids, resistance in the oppo- site direction being gained by bands and spurs on the incisors and tubes attached to clamp bands No. 2 on the second or third molars.* Another method of securing the ends of the arch is now preferred. After drawing their temper the ends are bent carefully at right FIG. 238. angles downward and inward, and their points sharpened. Suitable spaces are made with an excavator between bands and enamel on the buccal sides of the molars, and the points engaged in them. An easier and better method of making attachments to the bicus- pids for their elevation is by means of the wire ligatures made to *Dr. Calvin S. Case was first to employ this principle in an appliance for elevation of bicuspids. 246 MALOCCLUSION. encircle their crowns below their gingival ridges, as already de- scribed in the case of cuspids, in treatment of cases belonging to the first class. The bicuspids and molars are easily elevated by this method, but the degree to which the incisors are shortened is, in the experience of the author, extremely slight. This is easily understood when we remember the structure of the peridental FIG. 239. FIG. 240. membrane. The author knows of no practical device yet produced for depressing these teeth in their sockets, owing to the great force necessary and the difficulty of securing anchorage. Fig. 240 shows the lower arch from the buccal aspect of the case last described, both before and after the elevation of the first molar and bicuspids. TREATMENT OF CASES. CLASS II, DIVISION I. 247 Second Plan of Treatment. The second plan of treatment is toward the ideal, the establishing of normal occlusion, normal re- lations of the dental arches, and normal facial lines, as we have al- ready noted. This means the retention of all of the teeth, the' restoration of each to harmony with its line of occlusion, the changing of the teeth from distal to normal occlusion by moving the lower jaw forward and compelling normal closure of the jaw by some form of device until the normal occlusion shall have been thoroughly established and the jaws and muscles, and especially the temporo-maxillary articulation, shall have been modified into harmony with this changed occlusion. FIG. 241. Copyrighted. Fig. 241 accurately illustrates a case which was treated according to this method. The patient was a boy nine years of age. It will be seen that the deciduous cuspids and molars are still in position, while the permanent centrals and laterals are fully erupted, those in the upper arch occupying positions of marked labial promi- nence. The extent of distal occlusion (indicated by the dark lines in the engraving) is equal to the mesio-distal diameter of a bicus- pid. With the exception of the somewhat lengthened condition of the lower incisors, as is usual, the arrangement of the teeth in the lower arch is normal. The narrowed and lengthened upper arch is well shown in Fig. 242, the dotted lines indicating the disto-occlusal relation of the lower teeth. The inharmony of the facial lines, as the result of such occlusion 248 MALOCCLUS1ON. FIG. 242. FIG. 243. TREATMENT OF CASES. CLASS II, DIVISION I, 249 and distal displacement of the lower jaw, is shown in Fig. 243, although not to so great an extent as was really existent, as the portrait is not a full profile. The facial lines after correction of the occlusion are shown in Fig. 244. The length and prominence of the incisors were reduced by the arch :B and occipital anchorage in the usual way, as already de- FIG. 244. scribed, the dental arch being widened at the same time by the spring of the arch B and wire ligatures. After the positions of the teeth and form of the arch had been modified to harmonize with the normal line of occlusion, as shown in Fig. 245, the widened arch was retained by a vulcanite plate. As a result of the changed form of the arch, normal occlusion was then possible, and the patient could readily close the lower jaw for- ward into normal position. In order to compel closure of the jaw 250 MALOCCLUSION. in this position only, and at the same time provide a constant re- minder to the patient of the importance of keeping the jaw closed as much of the time as possible, the device shown in Fig. 162 and already described was employed. The plane of metal anterior to which the spur is made to close is shown in Fig. 245 soldered to the buccal side of a No. 2 band. FIG. 245. The corrected occlusion and also the retaining device are shown in Fig. 246. The retaining device was alternated on opposite sides of the mouth as the deciduous teeth were lost or the permanent teeth showed indications of displacement. The patient was directed to frequently exert pressure of the upper lip upon the incisors, for the double purpose of stimulating its function and to assist in their retention. The further reten- tion of the incisors was effected after the plans already described in the chapter on Retention. TREATMENT OF CASES. CLASS II, DIVISION I. 251 Fig. 247 shows the occlusion of this case more than two years after the discontinuance of all artificial retention. There can be no question as to the permanent change in the occlusion of the teeth and relations of the jaws ; or, in other words, the so-called "jumping the bite" has been accomplished. FIG. 247. FIG. 248. This case is of additional interest, as the deciduous upper in- cisors were also markedly protruding, a condition which must be extremely rare, and which is shown in the engraving, Fig. 248, made from a photograph taken at the age of two years, and yet the cause could not be traced to the habit of exerting pressure by the lip, tongue, or finger, or to heredity. 2^2 MALOCCLUSION. Fig. 249 shows another case belonging to Division. I of Class II, and treated also after the second plan. There was complete distal occlusion, as indicated by the dark lines in the engraving, and very pronounced prominence of the upper incisors. FIG. 249. The patient was a miss fourteen years of age, and although her age seemed to be unfavorable to this plan of treatment, yet her intelligence and determination were such as to lend much encour- agement Fig. 250 shows the upper arch from the occlusal aspect, the' TREATMENT OF CASES. CLASS II, DIVISION I. 253 dotted lines showing the relation of the lower arch. The arch B, held in position by the anchor bands D upon the first molars, are also well shown, with attachments to the plain bands, as in A, Fig. 233- In order to widen the arch in the region of the cuspids and bi- cuspids so that the lower arch might be moved forward from distal to normal occlusion, the first bicuspids were laced to the wire arch, it having been first bent to give the full spring, while the cuspids were moved by that simple and most effective plan of lengthening a section of the wire G with the regulating pliers, Fig. 70. The ends of the wire were made to rest in tubes R soldered at right angles to the lingual surfaces of plain bands cemented on the crowns of the cuspids. Of course the jack-screw might have been used instead of this device, or ligatures svtrrounding the arch and teeth in the usual way, but as it was desired to accomplish the various tooth movements rapidly the former plan was employed, and the author prefers it. Only one of the delicate retaining rubber ligatures is shown in the engraving on the left. Sections of bone were removed, as elsewhere described, and as shown by the crescent-shaped markings in the engraving, in order to expedite the movement of the incisors. Force was exerted upon the incisors by means of the head-gear in the usual way, worn almost constantly for six weeks. The arch had then been changed in form to that shown in Fig. 251. Of course it was necessary to modify the form of the arch B occasionally during this period, and also to perform rotation of the lateral incisors by means of spurred bands, ligatures, and rubber wedges, in the usual way. Originally the lower incisors occupied the position of malcc- clusion which is quite uniform in all such cases, namely, ele- vated in their sockets, slightly irregular as to alignment, and with lingual inclination. They were corrected in the usual way. The teeth of both arches having been placed in harmony with their lines of occlusion, the lower jaw could then be easily moved forward and the teeth could occlude normally, as shown in Fig. 252. For compelling the normal closure of the jaw the device pre- viously described and shown in Fig. 163 was employed. A section of the wire G is shown crossing the labial surfaces of 254 MALOCCLUS1ON. the lower incisors for effecting their retention, after the plan shown in Fig. 149, and described in the chapter on Retention. The- changes in the facial lines resulting from the changed oc- clusion are shown in Figs. 253 and 254. FIG. 251. FIG. 252. Dr. H. A. Baker, of Boston, in a case belonging to this class that of his son illustrated in Fig. 255, employed a novel and valuable method of exerting force for the reduction of protruding upper incisors, using for anchorage the teeth of the lower jaw and exerting force by means of heavy elastic ligatures, one end being secured to the author's arch B in front of the small immovable TREATMENT OF CASES. CLASS II, DIVISION I. 255 collars in the usual way, the other end being drawn back and hooked over the distal ends of the tubes of the D bands on the lower second molars, these tubes also being used to support the ends of the expansion arch, which served the double purpose of correcting FIG. 253. some slight malarrangement of the teeth of the lower arch, as well as reinforcing the teeth used as anchorage. Excellent results are shown in the completed case, Fig. 256, and the very gratifying improvement in the facial lines is shown by comparing Figs. 257 and 258. 256 MALOCCLUS1ON. FIG. 254. FIG. 2$$. TREATMENT OF CASES. CLASS II, DIVISION I. 257 FIG. 256. FIG. 257. 18 258 MALOCCLUSIOX. If we will study this method of applying force we will see that it possesses several valuable features. First, it tends to harmonize the sizes of the arches by shortening the upper arch, as well as moving all the upper teeth distally, and at the same time lengthen- ing the lower arch by moving all the lower teeth mesially, or the employment to its greatest degree of that excellent form of anchor- FIG. 258. age reciprocal. Another advantage is a tendency to lengthen the bite by slight elevation of the lower molars, usually desirable in these cases. The only objection to its use which the author has so far found is, that as the force upon the protruding incisors is exerted down- ward as well as backward they are lengthened, instead of being depressed in their sockets, as they should be in so large a percent- TREATMENT OF CASES. CLASS II, DIVISION I. 259 age of cases belonging to this class. But this objection is easily overcome and the time of treatment greatly shortened by com- bining this form of anchorage with occipital by means of the head- gear and traction bar in the usual way. This combination is the author's favorite plan. Another reason for combining occipital an- chorage with reciprocal in these cases is, that it is well known that more force is required to move the teeth distally than mesially (the natural tendency of the teeth of both arches being to move for- ward), so the additional force of the occipital anchorage is needed, otherwise there will be unequal movement of the teeth in the two arches, the lower moving the faster. By such combination we have the greatest control over the movements of the teeth in both arches, and these cases which have always been regarded as so tedious and protracted are now easily brought to the period of retention in treatment in a very few weeks. In making use of this additional form of anchorage the author's plan is to adjust the appliances upon the upper dental arch in the same manner as already described, according as the plan of treat- ment shown in Figs. 235 or 250 is to be employed, but before slip- ping the arch B into final position two projecting spurs for engag- ing heavy ligatures are attached to its under surface just anterior to the small, immovable collars always found upon the sides of these arches. These spurs are best made from sections of wire G, bent as in Fig. 259, and flattened on one side for about one-fourth of an inch in order to lie in closer contact with the arch B, as well as to afford greater surface for the solder in its attachment. The arch B at its point of attachment should also be slightly flattened by filing. The solder used in attaching these spurs should of course be soft and a most delicate flame slowly applied, the same as in making similar attachments already described in the chapter on Soldering. After soldering, the surplus wire is cut off and the end smoothed, all as shown in Fig. 259. The form of elastic which has proven the most satisfactory is the red rubber band for jewelers' use, No. 20. In adjusting it it is doubled, the two sides of the rubber at the middle, B, being caught over the distal end of the sheath of the D band on the lower dental arch, the two ends, C C, carried forward and slipped over the spur on the arch B on the upper dental arch, as in Fig. 260. As the ligatures engage only the sheaths of the D bands on the lower 260 MALOCCLUSION. arch it might at first seem that these bands, or the No 2 bands with suitable spurs attached for the reception of the ligatures, or the fracture bands, would be sufficient without the addition of the expansion arch, but it is very important that it should be used in connection with the D bands for steadying and controlling the posi- FIG. 259. FIG. 260. tions of these anchor teeth, otherwise they would become rotated or displaced laterally. It is important to remember, however, that in thus using the expansion arch it must be left free from attachments by ligatures in front, that it may tip downward as the teeth are made to incline forward through the force exerted upon them by the strong elastic ligatures. If at any time, however, we wish to arrest TREATMENT OF CASES. CLASS II, DIVISION I. 26l the further tipping movement of the teeth, we have but to firmly lace the incisors to the expansion arch, when we will have changed our anchorage from simple-reciprocal to stationary-reciprocal. On the other hand, by bending the expansion arch upward at its en- gagement with the sheaths of the D bands, then springing the an- terior part downward and lacing to the incisors, we shall exert a prying influence upon the anchor teeth which will tend to tip them forward and assist the ligatures. So by taking advantage of these possibilities we may control absolutely the movements of the teeth of the lower arch, completely arresting or hastening the movements of either one or both of its lateral halves. The same principles are applicable through the arch B in controlling the movements of the upper teeth, and by studying and employing them we may bring about results in occlusion and facial lines other- wise impossible. The extent of usefulness of the Baker form of anchorage cannot be well estimated. After complete harmony as to sizes of the arches and relations of the teeth has been gained, the relations of the first molars should be carefully maintained by double bands, spur and metal plane, as in Fig. 162, which may be changed to or alternated with the plan shown in Fig. 163. Dr. Baker's method of retention is shown in Chapter XII. Class II. Subdivision of Division 1. As practically the same conditions are met in cases belonging to this subdivision as are found in the main division, just de- scribed, the only difference being the normal relations of the lateral halves of the arches on one side, Fig. 261, the plan of treatment and the appliances used must naturally be similar. As there is inharmony as to size of the two arches to the extent of one bicuspid it must follow that the plan of treatment clearly indicated, especially in fully developed cases, requires the extraction of the first upper bicuspid on the abnormal side and the movement distally of the incisors and cuspid until the space shall be completely closed. We must then have harmony in the sizes of the arches and in the rela- tions of the occlusal planes. This was accomplished in the case shown with the combination of the arch B and traction screw on the affected side, as described elsewhere and shown in Fig. 262, which accurately illustrates the 262 MALOCCLUSION. case nearing completion. The other lateral half of the dental arch being normal, the end of the arch B was supported in the usual way FIG. 261. FIG. 262. Copyrighted. TREATMENT OF CASES. CLASS II, DIVISION 2. 263 by the band D, with omission of the delicate rubber ligature. The ligature on the abnormal side is also omitted from the engraving. It is important, however, that it be used. It being necessary to shift the incisors to the right as they were moved lingually in order to place them in better harmony with the median line, this was effected by deflecting the force from the head-gear laterally by the wearing of a small cushion between the cheek and heavy elastics on the abnormal side, thus exerting a ro- tatory force on the arch B. The central incisor was carried laterally by being laced to the arch, the wire ligature bearing against the minute ball in the center of the arch, as shown in the engraving. The incisors were retained after the usual plans already de- scribed; the cuspid, after the plan shown in Fig. 153. It sometimes happens in these cases that the lower teeth on the abnormal side are not all in full distal occlusion, being appar- ently in the transitional stage. This does not change the plan of treatment, except that a slight forward movement of the anchor teeth may then usually be permitted, that the distal relations of the lower occlusal planes may be complete. In such cases, if the pa- tients be young, the Baker method of anchorage may be employed for shifting distally the teeth of the upper arch and mesially those of the lower, thus avoiding extraction. CHAPTER XIX. TREATMENT OF CASES. CLASS II, DIVISION 2. IT will be remembered that in cases of malocclusion belonging to this division of Class II, as in those of Division I, the teeth of the lower arch are in distal occlusion in both its lateral halves. The upper arch, unlike that of cases of Division I, which is abnormally long and narrow, is shortened, with incisors bunched and overlap- ping, as in Fig. 263, to approximately harmonize in size with the anterior part of the lower arch. Unlike the conditions of the other division, the incisors are not elevated in their sockets, owing prob- ably to their more nearly normal function, and there are normal 264 MALOCCLUSION. respiration and lip function, but the result of distal occlusion and sub-mental development greatly modifies the facial line of harmony, as in the cases of the other division, see Fig. 27, the effect being very similar to cases belonging to Division i, after treatment by the first plan, Fig. 237. As in the other division, there are two plans of treatment which may be followed in these cases. As before said, the first has for its object the improvement of occlusion only, while the second has for its object not only the establishment of normal occlusion, but the best attainable degree of improvement of the contour of the face, being an effort toward the ideal. FIG. 263. In following the first plan the extraction of two bicuspids, pref- erably the first, is clearly indicated, with the retraction of the cuspids to close the spaces, followed by the correct adjustment of the incisors. For accomplishing these tooth movements the combination of traction screws, anchor bands, expansion arch, spurred bands, and ligatures, as already described and as shown on one side in Fig. 129, should be employed. It will thus be seen that if the cuspids have been properly retracted and the incisors correctly adjusted there will then be marked improvement in the occlusion and complete har- mony in the sizes of the arches. In pursuing the second plan of treatment the expansion arch, bands D, spurred bands, and ligatures only are used, to move labially and into harmony with the line of occlusion the incisors, TREATMENT OF CASES. CLASS II, DIVISION 2. 265 after the plan already described in the treatment of cases belonging to the first class, and as shown in Fig. 126. The lower jaw is then made to close forward and the occlusion of the teeth changed from FIG. 264. FIG. 265. distal to normal in the same manner and with the same devices as already described and illustrated, Figs. 162 and 163. Fig. 264 represents the upper arch of the case shown in F% 126, while Fig. 265 shows the same arch after it had been enlarged, with the expansion arch, ligatures, etc., still in position. 266 MALOCCLUS1ON. Fig. 12 shows the profile of the patient at the beginning of treat- ment, while Fig. 13 shows the changes in the facial lines as the result of the restoration from distal to normal occlusion. As the patient was twenty-one years of age, there was some doubt as to whether the jaw and temporo-maxillary articulation would be modified to harmonize with the new conditions and in- sure permanency of the changes. A protracted period of retention, however, established the desired result. It must be remembered that in the treatment of cases belonging to this division after this plan we have much to favor us in our efforts, in that the patients are normal breathers and the mouth is kept closed, and the teeth kept in occlusion the requisite amount of time. Certainly the results are so gratifying that they are worthy of our best efforts. Should we fail no ill results will follow, and we still have the first plan of treatment to resort to. Of course what has been said in regard to the importance of the restoration of all teeth in both arches to harmony with their lines of occlusion is of equal importance in these cases, and must not be ignored. Class II. Subdivision of Division 2. In cases belonging to this subdivision the conditions and indica- tions for treatment on the abnormal side are similar to those in Division I, Class II, just described, while on the side in which the mesio-distal relation of the arches is normal any malposed teeth would require the same treatment as in cases belonging to Class I. So the treatment for the typical case, shown in Fig. 266, clearly indicated the sacrifice of the first upper bicuspid on the abnormal side in order that the arch might be reduced in size to conform to that of the lower. The distal movement of the cuspid is effected by the traction screw, while the correction of the malpositions of the incisors is accomplished by the wire ligatures and spurred bands operating in connection with the arch E in the usual way, all- as well shown in Figs. 267 and 268. On the right side is shown a block of rubber between the arch and cuspid, which is for the purpose of reducing the prominence of this tooth as space is provided for its reception by the gradual shifting to the left of the incisors by the tightening of the nut in front of the anchor tube D. The direction of force given the incisors through the spurred bands and ligatures is controlled by the spurs on the TREATMENT OF CASES. CLASS II, DIVISION 2. 267 expansion arch, as before described and as shown in the engravings. In this case the elevation of the cuspid was later accomplished by tightly twisting a ligature about its neck above the gingival ridge, FIG. 266. FIG. 267. Copyrighted. 268 MALOCCLUSION. then inclosing the arch with the ends and giving them a second twist, as before described. FIG. 268. E. HA Copyrighted. The cuspids and incisors were retained after the plans already described in the chapter on Retention. CHAPTER XX. TREATMENT OF CASES. CLASS III, DIVISION. IT will be remembered that the distinguishing characteristic of cases belonging to this class and division is mesial occlusion of both lateral halves of the lower arch, with greater or less unevenness in the arrangement of the teeth, though usually this is not extensive. As the malocclusion is, in most cases, due to the asymmetrical development of the jaw-bones, our opportunities for improving the occlusion by working upon the teeth alone are, in many cases, greatly limited, and are usually diminished in proportion to the age of the patient. These cases are nearly always progressive, and if treatment is begun very early much may be accomplished ; but if delayed until maturity, when the bone has become dense and fully formed, we are powerless to materially improve the conditions by ordinary methods, and are limited to the operation of double resection of the lower, maxilla, as shown in Chapter XIV. TREATMENT OF CASES. CLASS III, DIVISION. 269 Not only is the greatest possible degree of malocclusion reached in this class of cases, but also the greatest disturbance to the facial lines, an unpleasing appearance being always produced, even in the simplest cases as in Fig. 269, while in some extreme cases, as shown in Figs. 9 and 279, the inharmony amounts to a most pronounced deformity, constantly attracting attention and comment, and if the FIG. 269. patient be of a sensitive nature the condition becomes truly pathetic. The inability of the patient to close the lips and control sounds renders the correct enunciation of many words impossible. In order to improve the facial lines and occlusion and establish harmony in the sizes of the arches there are four different plans of treatment which may be followed, limited in their application to the conditions found to exist in each given case : First, retraction of the inferior maxilla ; second, enlarging the superior dental arch to its normal size ; third, enlarging the upper arch beyond its normal 270 MALOCCLUSION. size ; fourth, diminishing the size of the lower arch. Of course, we may often combine two or more of these plans. In employing the first plan the position of the lower jaw is modi- fied by the use of the chin retractor and occipital anchorage, as shown in Fig. 270. Where much may be accomplished by this method if employed while the patient is young and the bone yield- ing, little can be hoped for in its use after the age of fifteen, yet in some cases even later the author has been able to produce very gratifying changes with it. FIG. 270. The principal reason why more is not accomplished by this method of treatment is that the time of wearing the chin retractor is usually very limited. Could the patient be placed in surroundings where social duties would not interfere, so that pressure might be exerted in this way systematically for several months, it is quite probable that marked changes might be produced, even in case of patients at as advanced an age as twenty years; but with the wearing of the appliance for a few hours at night only, with complete removal dur- ing the remaining time, little, if any, improvement is to be hoped for. In the use of the chin retractor very light pressure should at first be employed, gradually increasing it as the patient becomes ac- customed to wearing it, always observing the greatest care to pre- TREATMENT OF CASES. CLASS III, DIVISION. 271 vent irritation of the chin by placing fresh antiseptic cotton between the metal cap and the chin at regular intervals of a few hours. Fig. 271 represents the side view of a case of a child nine years of age. The permanent incisors of the lower jaw had erupted; the superior centrals had also erupted and were twisted nearly at right angles. The deciduous cuspids were in position, although the in- ferior were loosened and nearly ready to fall out. The four per- manent first molars were present, and the first superior bicuspids were beginning to emerge from the gum. The jaw had moved FIG. 271. FIG. 272. forward so that the lower incisors closed anterior to the upper, all as correctly represented in the engraving. The patient could not retract the jaws sufficiently to bring the cutting-edges of the in- cisors in contact at any point. Double rotation of the superior centrals was accomplished by means of the lever already described in double rotation, Fig. no. They were retained by uniting the bands with solder and re-cement- ing them upon the teeth. The chin retractor and head-gear were worn almost constantly for six weeks, and at the end of this time the jaw had been retracted into almost normal position, presenting the appearance shown in Fig. 272. At the end of this time the 272 MALOCCLUSION. chin retractor and head-gear were worn at night only, with light tension, and entirely dispensed with after six months, as there was no need of further retractive force. The second plan of treatment is that of enlarging the upper dental arch to its normal size by placing each malposed tooth in correct position, which may be accomplished by means of the usual com- bination of expansion arch, wire ligatures, and spurred bands. The case shown in Fig. 273 was that of a young lady thirteen years of age. It is readily apparent from a glance at the mesio- buccal cusp of the upper first molar that it belonged to the third class of malocclusion. The condition was further intensified by the FIG. 273. contraction of the anterior part of the upper arch until the distal incline of the lateral incisor occluded with the first bicuspid, and although the inferior incisors inclined lingually, their cutting-edges were considerably labial to the superior incisors. Fortunately, the case was not further complicated by the loss of any of the teeth. Of the four possible methods of treatment two admit of appli- cation in this case. First, the enlarging of the upper arch and the shifting of the incisors laterally sufficiently to admit of the impacted cuspid being drawn into occlusion, and second, the retraction of the lower jaw. The former was accomplished by means of the appliance so well shown in position upon the teeth. As it was necessary to shift the incisors to the left in order to restore them to harmony with the median line, this was accomplished simultaneously with their move- TREATMENT OF CASES. CLASS III, DIVISION. 273 ment forward by force exerted on one side only, by tightening the nut in front of the anchor tube on the right. It will be noticed in the engraving that several short spurs have been soldered to the expansion arch, just anterior to the ligatures encircling the incisors, which serve the very important purpose of preventing the expansion arch from sliding through the ligatures and toward the left without materially moving the incisors, as would have been the result had not the spurs been so placed. The cuspid was drawn into the line of occlusion by means of a ligature made to encircle the arch and a common pin accurately fitted and cemented into a cavity made in the enamel on the labial FIG. 274. surface of the tooth, to accomplish which it was necessary to lance the gum and impact a pledget of cotton, which was worn for two or three days, in order to expose sufficient tooth-surface. The somewhat prominent first bicuspid was reduced by an inter- vening wedge of rubber, also well shown in the engraving. While the teeth in the upper arch were being drawn into the line of occlusion, the head-gear and chin retractor were being worn almost constantly. Fig. 274 shows the completed case and the only retention neces- sary, the teeth being supported in their new positions principally by occlusion, the cuspid being retained by a spur soldered to the band on the lateral incisor and made to bear upon the pin already in position. '9 2/4 MALOCCLUSION. The wearing of the chin retractor was continued with diminishing force for two or three months longer. It should be added that a slight downward spring was given to the expansion arch while the teeth were being moved outward, in order to slightly lengthen the incisors, and some depression of the molars was thus gained. The retraction of the maxilla was effected by the adjustment of the ligatures from the chin retractor to the head-gear in such manner as to exert pressure upward as well as backward, the result of all being to make a greater overbite and more effectual retention of the incisors. FIG. 275. FIG. 276. Fig. 275 shows another case from the buccal aspect of one side, and Fig. 276 accurately represents the upper arch from the occlusal aspect. The case was treated by a combination of the first and second plans, or enlargement of the upper arch in the usual manner and retraction of the lower jaw with the chin retractor and occipital anchorage, as already described. TREATMENT OF CASES. CLASS III, DIVISION. 275 At the end of two months the expansion qf the upper arch was discontinued, the teeth retained, and the patient allowed to return to her home in a distant city for a vacation of three months. This was done in order to give the upper jaw an opportunity to develop, but the wearing of the chin retractor was continued faithfully. At the end of the three months the patient returned and the expansion FIG. 277. E.H.A FIG. 278. of the upper arch was continued, at the same time the tension upon the chin being increased. Two months later the enlargement of the upper arch had been completed, and is truthfully represented in Fig. 277. The lower jaw had been moved backward, and the occluding teeth presented the appearance shown in Fig. 278. The improvement in the facial lines is shown by comparing Figs. 279 and 280. In the third plan of treatment the upper arch may be enlarged beyond the normal by lengthening one, or possibly both, of its 276 MALOCCLUSION. lateral halves in the region of the bicuspids, and the space closed by some form of artificial tooth which shall act at the same time as a retainer. This form of treatment cannot of course be employed unless the development of the upper jaw is such that the incisors and cuspids will not occupy positions of too great an angle after being moved forward. The author has followed this plan of treat- ment in two cases w r ith marked success. The fourth plan of treatment consists in reducing the size of the lower arch after extraction of the first bicuspids. This plan of FIG. 279. treatment will rarely be found practicable, as one of the character- istics almost always present in cases belonging to this class is the marked lingual inclination of the lower incisors and cuspids, due to the pressure of the lower lip in the effort to close the mouth. Fig. 281 illustrates a case in which the first, second, and fourth plans of treatment were combined. The upper anterior teeth were moved outward by means of the jack-screws, as shown in position upon the teeth in Fig. 282. After the first bicuspids had been extracted, contraction of the anterior part of the inferior arch was accomplished by means of the traction screws hooked into staples TREATMENT OF CASES. CLASS III, DIVISION. 2/7 on bands encircling the cuspids. The traction screws were assisted in moving the cuspids and incisors backward by the head-gear, FIG. 280. FIG. 281. elastics, and traction bar, they exerting pressure upon a section of the arch B, which rested in contact with the incisors and cuspids, 278 MALOCCLUSION. being held in position by the attachment of the band to the ends with solder, all as shown in Fig. 283. The combination shown in Fig. 235 would perfectly meet the requirements if intelligently adjusted and operated on the lower arch. The external force served the double purpose of assisting the traction screws in moving the teeth and of the retraction of the maxilla. The degree of success FIG. 282. FIG. 283. achieved in the last-mentioned movement was quite noticeable, as is well shown in Fig. 284, which represents the completed case. It must be borne in mind that the force necessary to carry back both cuspids and incisors is considerable, and, as we are somewhat at a disadvantage in exerting force upon teeth in the lower arch by means of occipital anchorage, more time and care are necessary than in producing the same tooth movements in the upper arch. The head-gear should be worn low upon the neck. Sometimes it is TREATMENT OF CASES. CLASS III, SUBDIVISION. 279 of advantage to use, instead of the head-gear, a broad band con- structed from cloth for the occasion, which shall bear upon the neck only, and to which the elastics are to be attached, but in every instance it must be adjusted so as not to exert pressure at such an angle upon the teeth as will elevate them in their sockets as they move distally. These cases are often troublesome, calling for our best skill, judgment, and patience, and yet the results often wholly within the possibilities are worthy of our very best efforts. FIG. 284. Class III. Subdivision. The mesio-distal relations of the arches in cases belonging to this division are normal on one side and mesial on the other, as shown in Fig. 31. As the lower arch is larger than the upper to the extent of one bicuspid tooth, the treatment clearly indicated is to extract the first lower bicuspid on the abnormal side and diminish the size of the arch by the complete retraction of the cuspid and disto-lingual movement of the incisors, which may be readily ac- complished by a combination of stationary and occipital anchorage, as in Fig. 262, operated on the lower arch. The Baker form of anchorge may be often advantageously employed to assist the devices in the various plans of treatment in both division and sub- division of 280 MALOCCLUSION. CHAPTER XXI. TECHNIQUE. IN the study of orthodontia, in addition to the lectures of the general course, which should be full and complete, covering all phases of the subject (including its relations to rhinology and com- parative anatomy) and being freely illustrated by charts and pro- jections upon the screen, we would suggest the great advisability of giving a short course of instruction in the technique. It should begin with lessons in soldering by the method we have described in the chapter embracing that subject. The student should be taught to unite various lengths of the ligature and G wires, end to end and at various angles, as well as in the form of delicate staples, hooks, loops, and ferrules, cultivating delicacy of touch and steadi- ness in holding the wires with the fingers in the operation. The proper amount of flux and solder to be used should also be consid- ered, as well as the proper degree and direction of flame best suited. After sufficient instruction in the manipulating and soldering of wire by means of both hard and soft solder, instructions may be carried further to the making of the plain bands upon teeth the roots of which have been imbedded in plaster, with variations in the positions of the seam, and to the careful formation of the few standard combinations of the system. The course should also embrace careful instruction in impres- sion and model making, as well as the full discussion and diag- nosis of conditions in actual cases according to the classification of malocclusion, the variation from the normal of the facial lines, the tracing of causes, etc. Such a course could be made very attractive to the class. In- terest in the subject would be deepened by the spirit of rivalry that would be aroused and by the better comprehension of princi- ples that would result from the object lessons. Not until the completion of this course, conducted with con- siderable thoroughness, should the plans of treatment be dis- cussed and the application of appliances and their operation be attempted. GENERAL SUGGESTIONS. 28 1 CHAPTER XXII. GENERAL SUGGESTIONS. I. AN essential preliminary to the treatment of a case is a clear conception of what is necessary. This can be acquired only by a careful study of models and natural teeth, occlusion, and facial expression, history, etc. II. If a malposed tooth be crowded by other teeth no tension should be exerted upon it until their pressure shall have been re- leased by their partial movement, which should continue during the process somewhat in advance of the movement of the tooth they would otherwise obstruct. III. One of the essentials of success of treatment is the full and cordial co-operation of patient, parents, and operator, whose instructions should be clear and explicit as to the part they are expected to perform. At the beginning definite understanding should be had as to times of visits by the patient. A few minutes two or three times per week should be devoted to each case. Both patient and operator should observe these appointments with the utmost conscientiousness. Dereliction in this respect at any stage of treatment might necessitate a repetition of work and bring about various annoying complications. This matter cannot be too strongly impressed. IV. Carefulness, thoroughness, and promptness of decision and action at each visit of the patient are imperative, doing exactly what is clearly indicated without deferring until another time. If an arch is to be changed in form, anchorage shifted, an over- twisted ligature to be renewed, a different attachment added to a band, a band replaced, removed, or a new one added, etc., it should be done promptly, only dismissing the patient after knowing with the fullest confidence that each and every part of the regulating ap- pliance is fully performing the object for which it was applied. In order to accomplish this it is essential that there be a ready supply of appliances sufficient to meet all requirements. V. Exercise such care and judgment in the adjustment of the appliances that delays from slipping, breaking, or changes will be avoided. 282 MALOCCLUSION. VI. In moving a tooth, the best result is obtainable only by recognizing the regular and prompt amount of force necessary to stimulate absorption. The practice of applying great force at- ir- regular intervals serves only to defeat the desired object, for it retards absorption and restoration, causes unnecessary pain, ex- cites inflammation, and thereby endangers pulp-life. It also strains the appliances, causing much delay and pain to the patient by repairs. The pressure should in no instance be greater than will cause a snug feeling, which is a true indication of the proper degree of force. VII. It should not be forgotten that the correction of irregu- larities in one arch only cannot be a success unless the teeth of the opposite arch properly occlude with them. The author urgently insists that both arches must be considered in the treat- ment of even the simplest cases. VIII. The cleansing of teeth and appliances during move- ment is very important; but as the brush might disarrange the appliances, the cleansing should be effected by frequent rinsing with water and antiseptic solutions. IX. The author hopes to impress two points upon those who study this book. First, the importance of occlusion, in which he would arouse a keener interest. Second, the relation that each tooth bears to all others in both arches, that there may always be careful deliberation before sacrificing a tooth. The consequences of extraction of even a single tooth are often far-reaching, and sometimes make impossible the attainment of results which other- wise might closely approach the ideal. All dentists should culti- vate the habit of observing the results following the extraction in the cases of patients in their regular practice. X. Malocclusion in any degree, however slight, should be promptly corrected. An overlapping or twisted tooth is often a blemish in an otherwise faultless arrangement. Its adjustment would not only improve the appearance of the teeth, but would refine the whole facial expression. XL In tooth movement study to avoid the recession of teeth as much as possible. The movement may be suspended as often as may be necessary if the positions of the teeth be maintained. Disregard of this principle, usually due to faulty appliances whose frequent removal for modification and cleansing was necessary, has GENERAL SUGGESTIONS. 283 been the occasion of nearly all the pain and soreness incident to regulating. If intelligently conducted, the movement of a tooth will be nearly painless. XII. Thorough familiarity with all the parts of this system of appliances, their names and uses, is very desirable to any operator who may adopt it. They will be found sufficient for the treatment of any case. If any apparent difficulty should arise it would probably be made clear by a rereading of the descriptions and uses of the parts and the treatment of analogous cases. XIII. The plate has no place in this system except rarely as a retainer after lateral expansion of the arch. As a regulating ap- pliance it should be regarded with respect only as a relic of the infancy of orthodontia. XIV. The gag, in whatever style of contrivance, is a medieval survival, an utterly valueless instrument. During the period of tenderness the patient will, without admonition, exercise all care in occlusion that will be necessary to avoid interference with the move- ment of teeth. XV. Failure to appreciate the artistic opportunities and re- quirements in the practice of orthodontia is as readily recognizable as its effect is lasting. All who hope to attain true success in practice should cultivate studious observation of normal and ab- normal facial lines in their relation to, and dependence upon, the teeth. The line of harmony as laid down in the chapter on Facial Art is an excellent guide in this respect. An intelligent apprecia- tion of the principles of art as related to orthodontia and their conscientious application must ever go hand in hand with real success in its practice. XVI. In studying a case of malocclusion, give no thought to appliances or methods of treatment until the case shall have been classified and all peculiarities and variations from the class type thoroughly understood. Then consider appliances, anchorage, and, finally, possibilities of requirement as to extraction. XVII. While the primary purpose of this work is to arouse a keener interest in orthodontia on the part of the dental profession, yet to expect that all will succeed in its practice would be as unreasonable as to expect all to succeed in the study of music. Expert knowledge and skill in the general practice of dentistry are compatible with very little study of orthodontia, the practice of 284 MALOCCLUSION. which should be confined to those who possess such aptitude and fondness for it as will lead them to study it broadly and enthusiasti- cally. Those dentists who find this uncongenial should feel it in no sense an infraction of their professional dignity to refer cases which come to their notice to specialists in whom they have con- fidence, as broad-minded physicians and surgeons now take pleas- ure in referring unfamiliar cases to those specially qualified to treat them. The procedure serves to increase the patient's confi- dence in the integrity of, and heightens his esteem for, the prac- titioner, who is not expected to possess all knowledge. On the other hand, any evasive temporizing or unscientific treatment must inevitably result in dissatisfaction and derogatory criticism. All should feel a sense of satisfaction in the upbuilding of so beneficent a science, a science which is destined to supply a cry- ing need of humanity, and which must find its highest develop- ment in special practice. XVIII. Irregularities of the teeth being so frequently associated with some pathological obstruction of ! the nasal passages or naso- pharynx, this fact should ever be present in the operator's mind and suitable examination be made; and in case (as is often found) the oral deformity be complicated by the presence of hypertrophied faucial tonsils, adenoid hypertrophies in the vault of the pharynx, or obstruction of the nasal passages, the orthodontist's work can only be made complete by the assistance of the rhinologist and laryngologist. XIX. In conclusion, to all who have derived any knowledge or inspiration from this book is commended the advice of Sir Andrew Clark to readers of any book deemed worthy of attention, read it three times. "First, to see what it is all about; second, to see what it says ; third, read it in an attitude of friendly hostility." PART II. FRACTURES OF THE M AXILLA. TREATMENT. FRACTURES of the maxillae may result from any of the numerous forms of violence and accident. Indeed, it would seem that the tendency of modern customs of civilization, with their necessity for increase in methods of travel, are promotive of increase of accidents and fractures. The common occurrence of fracture of the maxilla should incite us to look for more efficient means of treatment than have heretofore prevailed, and dentists may well devote a closer study to this branch of practice. The limits of this work will not admit of a general discussion of this subject, nor is it deemed necessary, for all the modern works on general surgery contain treatises covering the general prin- ciples of treatment; especially commendable is Hamilton on Frac- tures. Our chief purpose is to treat of methods of reduction and fixation. While fractures of the superior maxilla occasionally occur, yet they are far less common than fractures of the inferior maxilla, and are usually less troublesome to manage, for if the fractured portions be placed in apposition they require little support, owing to the immobility of the bone; while the mobility of the inferior maxilla and the many causes which tend to displace it, such as swallowing, speaking, coughing, sneezing, hiccoughing, etc., make it far more difficult to support. Indeed, Hamilton has well said, "Of all fractured bones surgeons are called upon to treat, none are so troublesome as the inferior maxilla." Although fractures may occur in any part of the bone, the most favorable locality is the body, in the region of the cuspid or the 285 286 MALOCCLUSION. second bicuspid. The next most favorable locality, in the author's experience, is in the region of the third molar; rarely in the ascend- ing ramus, probably owing to its strong encasement of muscles; still more rarely in the condyloid process; occasionally in juxta- position to. the symphysis. Where the blow is severe a double fracture usually occurs, often being in such cases in the region of the cuspid on one side and of the first molar on the other. In fracture of the jaw there is a tendency to displacement, as in cases of fracture of the long bones, owing to the stimulated mus- cular contraction. If in the body of the bone or at the angle, the digastric, the genio-hyoid, and the genio-hyo-glossus muscles tend to draw the anterior segment down and back, while the muscles of mastication tend to draw upward and close the posterior segments and to occlude the teeth. By studying these muscles we may often take advantage of their tendencies to assist in the support of the fracture. In the treatment of fractures our aim should be toward two principal ends: first, to so set and support the jaw that the result will be a restoration of former conditions, as indicated by the natural occlusion of the teeth peculiar to each case ; second, to support the bone in its normal position as immov- ably as possible. It is well known that if the bone be immovably supported, usually about twenty-one days will be sufficient for its retention, although the locality and extent of fracture may require the prolonging of this period considerably. Again, it is well known that the tendency to sepsis is far less if the bone be firmly supported than if occasional movement at the points of apposi- tion be permitted. If the fractured portions of bone be placed in careful apposition the degree of force necessary to prevent dis- placement is usually small and does not necessitate strong or bulky devices, but only requires that the device be intelligently propor- tioned and placed. The history of the different methods of securing fixation is in- teresting, as well as surprising, as to the bulk of some and the com- plexity of others. Be it said to the credit of dentists that the methods possessing the greatest merit and the most nearly in ac- cordance with the scientific requirements have been their inven- tions. Plans usually employed by the general surgeon are as crude and unscientific as they are ancient in history. This is but natural when we remember that the requirements in the support FRACTURES OF THE MAXILLA. 287 of the maxilla are very different from those in the support of other bones, and necessitate devices which the general surgeon cannot readily construct with his facilities. The three methods most com- monly employed by surgeons are, first, bandaging; second, tying the teeth together with ligatures; third, wiring the ends of the bone together. History records the use of the first since the fifth century, al- though it was doubtless employed ages before, as it is a means of support which would naturally suggest itself. Yet a more crude or unscientific method of contributing support to a fractured jaw could hardly be imagined. In the first place, the direction and distribution of force exerted by the bandage is wholly inadequate for the natural requirements. The effect of the combined wrapping is to exert force from the dome of the head, or in the wrong direc- tion. It must be remembered that the natural tendency of the fractured jaw is backward and inward. The bandage can in most instances only favor this tendency. To exert force in the requisite direction it should be applied from a point far anterior to the forehead. Another disadvantage is the frequent displacement of the bandage. It is a fact easily verifiable that a bandage placed ever so skillfully about the head cannot prevent considerable free- dom of movement of even an uninjured jaw, to say nothing of the tmsightliness of it. The second plan, that of wiring or ligating the teeth together, was practiced by Hippocrates in the fifth century B. C., and is a sad commentary on the progress of this branch of surgery. It is so crude an application of mechanics that it is surprising that it should ever be resorted to in the present day, though doubtless in its inception it was an improvement on the then prevailing methods ; for it will either slide off the crowns or work down be- neath the gums and lose its support, as well as cause much in- flammation of the gums and peridental membrane and loosen the teeth. The wiring of the ends of the bone together can at best only form a link joint, admitting ef movement. The natural absorption re- sulting from pressure of the wire upon the bone must soon lessen the support, and frictional irritation and suppuration are inevita- ble. The infliction of irritating wounds on each side of the one intended to be healed is irrational, and is as inconsistent with the 288 MALOCCLUSION. requirements of the aseptic surgery of the present day as it is cruel and unnecessary. While the fractured ends may be sup- ported by some form of intermaxillary splint, yet this is bulky and uncleanly, and is objectionable for the reason that it keeps the muscles of mastication on constant tension. The plans of fixation devised by the author in the course of his practice were described and illustrated in the fourth edition of this work. Since its publication a number of cases have been treated by him, as well as by other practitioners, both in this country and Europe, employing the methods therein set forth, with results so uniformly satisfactory as to confirm his belief in the standard value of these methods, as to efficiency, simplicity, and cleanliness. A simple and reliable guide for the placing of the fractured ends of the bone in apposition is the occlusion of the teeth. If the . jaws are closed and the teeth placed in their natural occlusal relations, it must follow that the ends of the bone are in correct apposition. If the jaw be so retained it will be in the most favor- able position for nature's work of repair. The natural locking of the cusps will be most effectual for the steady support of the injured jaw. To keep the jaw closed and the occlusal planes of the cusps in harmony we have but to firmly connect some of the teeth of both arches by suitable appliances placed upon their crowns, their roots forming the most natural and most stable attachment and support for the fractured segments of the jaw; or, in other words, the uninjured jaw is made to act as a splint to which the injured jaw is bound by means of its firm attachment to the roots of the teeth. This is accomplished by holding the jaws in fixed contact by means of wire ligatures wrapped in the form of the figure 8 around buttons attached to bands encircling suitable opposite or nearly opposite teeth, as shown in Fig. 285. The bands, which we term fracture bands, Fig. 286, are made very thin but strong; they are adjustable, and by means of the screw and nut may be firmly clamped about the teeth. Small buttons, strong and of sufficient size to admit the requisite number of wrap- pings of the ligatures, are firmly soldered to the band. Care should always be exercised to work the band well over the crown of the tooth and down upon its neck, then to tighten the nut until the band is firmly clamped, being careful not to weaken it by crimping FRACTURES OF THE MAXILLA. 289 or tearing. The fingers alone are usually sufficient, although a dull instrument and mallet, as in Figs. 73 and 74, may be used to assist. If the teeth be crowded, the directions given in Chapter IX for setting clamp bands should be observed. The wire ligatures, already described in the first part of this work, are best, although fibrous ligatures may be used. FIG. 285. FIG. 286. Bicuspid. Molar. That the reader may become more familiar with this method of treatment, as well as with a few of the many modifications of which it is susceptible, reports of a few cases from practice are subjoined, with illustrations from models made accurately in each instance after treatment. Case I. Fig. -287* On July 14, 1889, W. F., aged forty- five, was admitted to the Minneapolis City Hospital. A blow from a policeman's club had produced one simple and one compound fracture of the inferior maxilla. The first was an oblique fracture of the right side, beginning with the socket of the second bicuspid, extending downward and backward, and involving the socket of the first molar. The second bicuspid had fallen out, and the first molar was much loosened. The second molar had been lost years *The illustration is merely historical. Though the method was efficient, it has been simplified in later practice, as shown in 'following illustrations. 290 MALOCCLUSION. before, while the third molar and the remaining teeth were much abraded and much loosened by salivary calculus. The second frac- ture was on the opposite side, high up in the ramus of the jaw. 1 could not detect the exact course the line of fracture had taken, but the crepitation of the ends of the bones and the pain occasioned thereby were unmistakable evidences of fracture. The patient, as is usual in such cases, was unable to close his jaws. The fractured parts on the right side were widely separated, and the anterior piece much depressed by reason of the action of the digastric mus- cle, the posterior piece of bone being firmly drawn up and the molars occluding by reason of the contraction of the masseter muscle. He was treated as follows : Bands were made to encircle all four of the cuspids (they being most firmly attached in their sockets). The fractured ends of the bones were placed in careful apposition and the lower jaw closed, the lower teeth being correctly occluded with the upper. FIG. 287. The points on the bands where the little tubes (shown in the engraving) should be attached were carefully noted and marked. The bands were slipped off and the tubes soldered to them, after which the bands were cemented in proper position upon the teeth and two small traction screws (shown in the engraving) were in- serted in the tubes. The jaws were closed, and the nuts tightened. During an attack of coughing the following night one of the bands was loosened, but it was easily replaced the next day. No further accident or trouble occurred, the patient readily taking nourishment through the spaces between the teeth. Thus the frac- FRACTURES OF THE MAXILLAE. 291 tured jaw was firmly supported without motion for twenty-two days, when the appliance was removed, showing most excellent results. That the patient was a great lover of the clay pipe is shown in the engraving by the much-worn ends of the lateral incisors, which resulted from holding the stem of the pipe. While wearing the appliance he was not debarred from his favorite enjoyment, al- though compelled to grasp the stem between his lips instead of the teeth. Case //.December 28, 1889, T. B. was admitted to the Dental Infirmary of the University of Minnesota suffering from the effects FIG. 288. of a blow received on the left side of the jaw from a cant hook, while working in a lumber camp. The result was two fractures of the jaw. The first fracture was on the right side, beginning between the first and second bicuspids, and extending downward and backward so far as to involve the lower part of the anterior root of the first molar. The second was on the left side, directly through the angle of the jaw, Fig. 288. The accident had occurred thirty-two days previous to his admission to the infirmary, during which time noth- ing had been done to reduce the fracture. He reported that he had called upon a physician, who supposed the trouble was merely an abscessed tooth, and lanced the gum with a view of reducing the swelling. Later the patient called upon a dentist in one of the 292 MALOCCLUSION. smaller towns, who also failed to diagnose the fracture, and ex- tracted both bicuspids on the left side in the hope of giving relief. Upon examination I found considerable swelling in the region of the fracture, with the usual results ; the patient was unable to close his mouth, by reason of the anterior piece of the fractured bone being drawn down by the depressor muscles. A false joint had also become established, and could be easily moved without causing pain. At the fracture of the right side there was but little displace- ment ; the swelling was also slight. The patient was anesthetized, and, with a view to breaking up the false attachments and stimulating activity in repair, the ends of the bone were rubbed forcibly together, placed in perfect appo- sition, and the jaw closed, great care being taken to occlude the teeth correctly according to their former relations. The jaw was now firmly bound in position as described on page 288 and shown in Fig. 288, the attachment being quite as efficient and much easier to adjust than that shown in Fig. 287. Four bands were used, encircling the four cuspids, as shown in the engraving. The bands shown on the molars were not used, as they were found to be un- necessary, since the jaws were firmly supported by the four anterior bands alone. The patient made a rapid recovery, the bands being removed on the twenty-first day. Case III, represented by Fig. 289, was that of a healthy young Swede, twenty-two years of age, who, while washing windows, had fallen from the second story to the pavement. Besides receiving several minor injuries, he sustained two fractures of the lower jaw ; one extending from between the central incisors, and one posterior to the second molar, the third molar having been extracted. The right superior lateral and cuspid were knocked out, the first bi- cuspid broken off near the neck, and the alveolar process badly shattered. The centrals and left lateral were bent inward and forced deeper into their sockets. He had been treated by the at- tending physician at the City Hospital, the method employed being that of the Barton style of bandaging, with the usual result, when the bandage is employed in such cases, of aggravating the condi- tion by forcing the pieces inward and the jaw backward. Upon examination three weeks after the accident, I found much displacement. The jaw was drawn backward, and the right middle section of the bone tipped inward. No attention had been paid to- FRACTURES OF THE MAXILLAE. 293 the bent and broken condition of the superior alveoli. The teeth had become quite firm in their new, but abnormal, positions, and I allowed them to remain so. A fibrous attachment had been estab- lished in the lower fracture, which admitted of considerable move- ment and occasioned but little pain. There was much swelling, and pus was discharging into the mouth from the anterior fracture. I found it impossible to restore normal occlusion at that time. Bands were made to encircle the four bicuspids, and between the two lower bands, on the inside of the mouth, was placed one of the FIG. 289. jack-screws E and J, held in place by the staple and spur B, Fig. 100, and E, Fig. 101. The nut was tightened until the piece of bone had been tipped outward about one-half the distance to its normal position, but the operation caused so much pain that further move- ment was deferred. The jaws were then closed and the buttons connected by ligatures, but occlusion was far from being normal. On the next day, by again tightening the nut on the jack-screw and with renewed ligatures bound very tightly, I was enabled to secure nearly the normal occlusion. On the third day following, by the same means, correct occlusion was established. The jack-screw was allowed to remain in position to steady the tipping section. The abscess was frequently syringed with fresh peroxid of hydrogen. A few fragments of bone were washed out. The frac- tures readily united, and on the twenty-seventh day the jaw was released and found to be quite firm. 294 MALOCCLUSION. Case IV shows another modification, and is represented by Fig. 290. A young machinist received a severe blow from the fist of an antagonist, by which two compound fractures were sustained ; one posterior to the first molar, the other in the region of the cuspid, which was involved and greatly loosened. Occlusion was established in the previously described way. Suppuration occurred in both fractures on about the tenth day, and received proper treatment. The union of the anterior fragment was slow, as the patient was troubled by a persistent hacking cough, which occasioned a slight movement between the ends of the bone, just sufficient to interfere with the healing process. On the FIG. 290. twentieth day the ligatures were cut, a jack-screw placed in posi- tion between the bands on the inside in the same manner as in the case last described, with an additional ligature firmly connecting the two buttons on the lower bands and resting in contact with the labial surfaces of the intervening teeth. This additional support proved successful ; the union proceeded slowly, and was found com- plete when the bands were removed on the sixty-second day after the accident. Another modification is shown in a somewhat peculiar case, represented in Fig. 291. The patient, a man about forty years of age, had sustained a- complete fracture of the left angle of the jaw, as the result of a kick from a horse. The jaw was enormously large and protruding, and the occlusion so unusually faulty that I FRACTURES OF THE MAXILLAE. 295 was at a loss to determine what the patient's natural occlusion was ; but, upon questioning him, he informed me that when a boy ten years of age he had been hit with a stone, causing a fracture on the right side of the jaw, which had been allowed to heal without any treatment. This statement, with the worn facets upon the cusps of some of the teeth and the readiness with which they occluded only at these points, showed conclusively the position in which the jaw must be secured. I at first, of course, supposed that the usual number of four bands and two ligatures would be necessary, but I found the single ligature, as shown, was quite sufficient to firmly retain the jaw in this abnormal position. The jaw was set a few FIG. 291. hours after the accident. Very little swelling ensued, the fractured parts uniting rapidly. I saw the patient but four times, and re- moved the bands on the twentieth day, as further support seemed unnecessary. I admonished the patient, however, to avoid using his jaw as much as possible for at least ten days thereafter. Fig. 292 represents a case where the patient suffered in a railroad wreck two compound fractures of the inferior maxilla, one on each side, posterior to the second molar. The left side was quite badly comminuted. The full complement of teeth was present, with the exception of the third molars, and the occlusion of the teeth was close. The incisors, however, were crossed (not well shown in this engraving) ; that is, the left superior central and lateral closed just inside of the points of the lower incisor and cuspid, while the 296 MALOCCLUSION. right central and lateral closed just outside of the points of the opposing lower cuspid, central, and lateral. The teeth being so perfect and the spaces nearly closed, liquid foods only were possible. The conditions were made more un- favorable on account of the patient's suffering from severe spinal injury received at the time of the accident, but, with the exception of considerable suppuration in the left fracture, which yielded readily to treatment, nothing unusual occurred. The ligatures were removed on the fortieth day, and excellent results were ap- parent. FIG. 292. It might be urged against a method of treatment which involves the closure of the teeth and the binding of the jaws firmly together that the patient would be unable to take sufficient nourishment. Experience, however, shows that this argument has practically no foundation, for it rarely happens that a patient is found without some missing teeth, thereby providing abundant opportunity for the ingestion of all ordinary chopped foods, and more especially for the large number of foods now available in liquid form. Even when all the teeth are sound and in perfect condition, there is plenty of space between the teeth, or behind the molars and between the upper and lower incisors, for taking all the nourishment necessary. Of course, in these rare cases more time would be required for taking nourishment. This inconvenience is very slight when we consider the advantages of freedom from an uncleanly, bulky, and inconvenient apparatus within the mouth, often accompanied by the disfigurement of bandages and splints without, as well as the FRACTURES OF THE MAXILLJE. 297 great importance of the accuracy in results which it assures, so uncertain of attainment in many other methods commonly em- ployed. There is also another class of lesions in the treatment of which this plan of fixation may be employed to great advantage. I refer to excision of the lower maxilla, or those cases where a large por- tion of the jaw has been removed, as in Fig. 293. In all these cases there is a strong tendency for the remaining portion of the jaw to be drawn greatly to one side (about three- quarters of an inch, by actual measurement, in the case repre- sented), due to the contraction of the cicatricial tissues following FIG. 293. the healing of the wound. The plan I propose will prevent this contraction by securing the remaining portion of the jaw in proper occlusion, by means of the fracture bands and ligatures in the man- ner already described. The jaw thus firmly held will exert suffi- cient tension upon the healing muscles to prevent their contraction. I would also suggest the advisability of increasing the tension by the attachment of a plumper, by means of a clamp band, to one of the molars in the upper jaw on the side from which the section has been removed, allowing the shield or plumper to extend downward and outward, to occupy somewhat the position of the missing bone. This shield may also serve a useful purpose in holding in better position the dressing of the wound. Another method may be said to be a modification of, or an im- provement upon, the plan advocated by Hippocrates, that of 298 MALOCCLUSION. holding the fractured ends of the bone in apposition by wrapping ligatures about the teeth, or, as physicians now term it, wiring the teeth. The plan I propose is shown in Fig. 294, and consists in encir- cling suitable teeth with fracture bands and attaching ligatures to the buttons on both sides of the bands, so that loosening of the bones or pressure upon the gums is impossible. FIG. 294. FIG. 295. A modification of the plan is shown in Fig. 295, in which addi- tional support is secured by connecting the labial and lingual wire ligatures by loops of wire passed between the teeth, with their ends united by twisting. In favorable cases, as in simple transverse fractures with little or no displacement, and where the teeth are very firm, if the apparatus be adjusted with skill the plan will be found valuable, as it is very FRACTURES OF THE MAXILLA. 299 neat, clean, and compact, and does not interfere with the freedom of movement of the jaw. A few suggestions may assist the inexperienced in the adjust- ment of the apparatus, so that it will surely afford equal pressure and support upon the intervening teeth. The only difficulty is in regard to the proper length of the lingual ligature when completed. This is easily overcome by using two small soft brass wires, pass- ing respectively above and below the buttons and extending beyond them a half-inch or more at each end. Tension is not exerted on the buttons by uniting the ends by twisting until after the external and transverse ligatures have been completed. The engraving is incorrect in the respect that only one end of the lingual ligature shows union of the ends, instead of both. FIG. 296. Fig. 296 represents a modification of this plan used for holding in position a large section of the alveolus, including the incisors and left cuspid, which had been broken outward as the result of falling from a sled while coasting with the knotted end of a rope held in the mouth. The second bicuspids were banded, and a wire ligature made to encircle the buttons and bear against the loosened teeth. The ligatures showed a slight tendency to slide down and impinge upon the gum, but this was easily remedied by encircling the main ligature and the incisors with two or three fine wire liga- tures, thus giving additional support in a downward direction. Fig. 297 shows another plan for securing fixation of anterior fractures which possesses several valuable features, being especially useful in cases of comminution or of several fractures in the same vicinity. Its chief excellence lies in the permission of free move- ment of the jaws while firmly retaining the fracture, and it is also 300 MALOCCLUSION. very clean and compact. The device is a thin metal cap, swaged to fit the crowns accurately and covering a sufficient number of the teeth to afford the necessary support, the whole being firmly cemented to the teeth with oxyphosphate of zinc. Copper, gold, silver, aluminum, or vulcanite may be used; my preference is aluminum. Considering the simplicity of this appliance and the familiarity of dentists with oxyphosphate of zinc, it is surprising that the value of this idea of treating fractures has not before been recognized; but I find no record of its use, although dentists fre- quently use similar splints in the retention of teeth after they have FIG. 297. been regulated, and Hullihen employed a similar device in 1848 to hold the section of a jaw after a surgical operation, using ligatures to keep the appliance in place. For several years I supposed I had been the first to employ this method of retaining fractures, but I have since learned that Sir Christopher Heath attached a splint for the retention of fractures in a similar way, using, however, softened gutta-percha (Heath on Injuries and Diseases of the Jaw, third edition), and Dr. John H. Martindale, of Minneapolis, in 1886 or 1887, cemented a Kingsley splint in position to avoid the use of the submental cap and ban- dages, which interfered with the treatment of wounds on the face. My first case treated after this method is shown in Fig. 298. Michael P., a baker by trade, had fallen down-stairs, knocking out FRACTURES OF THE MAXILLA. 301 the superior incisors, cuspids, and one bicuspid, also loosening the lower central incisors and fracturing the jaw at the symphysis. As I remember, he also received a fracture of one of the femurs. He was admitted to the Minneapolis City Hospital some time in June, 1888. I saw him first some two months after the accident occurred, during which time the attending surgeon had employed the Barton style of bandaging in treatment. Union of the bone had not taken place ; on the contrary, a complete fibrous joint had been established, with the ends of the bone more or less rounded, admit- ting of a free hinge, movement, with pus discharging, for which a large rubber drainage-tube had been inserted. The tube was re- FIG. 298. moved, the wound thoroughly washed, and an impression taken without any attempt at changing the collapsed condition of the sides of the arch. A model was made and sawed through at the point of fracture. It was then placed in the articulator and ad- justed to restore the original occlusion as nearly as possible. Over this readjusted model a very thin vulcanite splint was formed, the outlines of which corresponded to the dotted lines in the engraving. The first attempt at cementing it in position upon the teeth was unsuccessful, the cement hardening too rapidly, but the next proved successful. The splint remained in position without any trouble for nearly four months, when it worked loose, and I found upon examination that firm union had taken place. 3O2 MALOCCLUSION. Of course the range of usefulness of this splint is quite limited, as a sufficient number of firm teeth must be present on each side of the fracture. Its principal value will, I think, be found in treating fractures in the anterior part of the jaw, more especially in that class of cases resulting from gunshot wounds in which large sec- tions of the alveolus have been carried away. Another plan which I have used in a few favorable cases with much satisfaction is shown in Fig. 299, which represents my first case treated by the method in question. On May 29, 1889, a young man of twenty-one years was admitted to the St. Anthony Hospital, of Minneapolis. During an attack of epilepsy he had fallen from a lumber pile to the ground, a distance of fifteen or twenty feet. Besides receiving severe bruises, he sustained a compound fracture FIG. 299. at the symphysis, terminating in front between the central and lateral, as shown by the line in the engraving. The fractured bone, when first seen, was quite widely separated at the top, and the left central incisor was much loosened. He was treated as follows : The ends of the fractured bone were carefully placed in apposition, and temporarily fastened by lacing the teeth together with silk ligatures. The cuspids, being very firm, were carefully fitted with plain bands. Tubes were soldered to these bands horizontally. The traction screw (A, D, and Y) was now slipped through the tubes, and the bands were firmly cemented in position upon the teeth. The nut was then turned upon the screw until the fractured ends of the bone were drawn snugly together. This appliance was worn without displacement or further trouble for twenty-one days, when it 'was removed, the bone having become firmly united. I may add that during the time the appliance was worn, so firmly was the jaw supported that the patient suffered but little incon- FRACTURES OF THE MAXILLA. 303 venience, and after the third day partook regularly of his meals, using his jaws freely, but of course avoiding the very hard foods. Final Suggestions on Fractures. In adjusting bands for the treatment of a fracture, carefully con- sider the direction in which to exert the proper pressure for secur- ing the jaw. As already stated, it usually happens in cases of fracture that the depressor muscles in contracting tend not only to depress the jaw, but to draw it backward, especially if the fracture be in the region of the last molar. Consequently such teeth should be selected for anchorage as will direct the pressure not only up- ward, but forward, as in Fig. 288. This is only a general rule, however, and it is especially advised that the direction of force necessary in each case be carefully con- sidei*ed and then the bands and buttons be adjusted accordingly. Sometimes it is an advantage to band more than one tooth in order to distribute the power exactly in the direction necessary. Should any of the teeth which have been selected for anchorage show a tendency to elongation, the bands should be shifted to other teeth or the direction of force be changed. In but two instances have we noted this complication, and we are inclined to believe that in one of these the action was due to the band slipping and impin- ging upon the gum, and thus probably producing the same result as occurs when a ligature is carelessly left about the tooth. Should it be found advisable to employ the plan illustrated by Fig. 294 or that shown in Fig. 297 in any case, it will sometimes be found an advantage to support the jaw by the first plan (Fig. 285) for a few days, or until the wounds are in a more favorable condi- tion for taking an impression or adjusting the apparatus. Very often patients receive severe bruises and internal injuries at the time the fracture is sustained, and these may occasion vomit- ing, more or less violent. Therefore, especial caution should be observed that the securing of the jaw be delayed until all tendency to nausea has subsided. Be in no haste, for no serious ill effects are probable from a few hours', or even days', delay in setting a fracture. Should it be advisable to immediately set the fracture, it might be well to provide the attendant with a pair of strong scissors with which to cut the ligatures if symptoms of nausea develop. 304 MALOCCLUSION. It should not require any argument to impress the importance of extreme cleanliness about the mouth during the treatment of fractures. Frequent rinsing of the mouth with proper antiseptic solutions should be insisted upon. If the fracture be more or less comminuted, as is frequently the case, suppuration may be expected. The plan found in such cases most successful is extra cleansing of the wound by frequent injections of pure, fresh peroxid of hydro- gen with a suitable syringe. The patient or the attendant, with a little experience, can accomplish this quite as well as the surgeon. Patience and persistence in this line will soon cause the necrotic fragments to be washed out. Only in one instance in the author's experience has it seemed necessary to interfere with the wound by scraping the bone with instruments. While the patient is undergoing treatment his general health should not be allowed to become impaired. Plenty of exercise in the open air, if other injuries do not prevent, should be insisted upon, as well as a requisite amount of nourishing food ; and the surgeon should occasionally inspect the bands and ligatures to see that they remain in order, so that the jaw may not become loosened and admit of movement of the fractured ends of the bone. Should one of the bands be broken, it should be replaced as promptly as possible. No special harm will come from cutting the ligatures, and separating the jaws for the purpose of replacing it. In cases where a section of the bone may show a tendency to lean, so that the teeth do not properly occlude, a finger of metal, made to bear against a tooth in the leaning section and soldered to a band encircling some favorably-located anchor tooth, will effec- tually restore the proper occlusion. In like manner the range of application of this method of retain- ing fractures may be extended to cases where fractures occur in the body of the bone and the molars are absent. The edentulous por- tion of the jaw may be securely held in proper position by a prop- made to bear against the section of bone, and kept in place by at- tachment to a ba'nd secured about one of the molars or bicuspids in- the upper jaw. The methods so far offered will, we believe, nearly cover the entire range of cases requiring treatment. There still remains, however, one distinct class for consideration, namely, the edentu- lous patient. Fortunately, patients of this class requiring treat- FRACTURES OF THE MAXILLA. 305 ment are exceedingly rare, and probably the best plan is the Gun- ning splint, or, what is the same in principle, attaching together by wire or vulcanite the artificial dentures, should the patient possess them. The cases of fractures so far described have been confined to the inferior maxilla. The methods, however, of securing fixation are all more or less applicable to the treatment of fractures in the upper jaw as well, though we believe the one first described is preferable, for the reason that if one of the superior maxillary bones be fractured it will be more on less displaced and usually forced downward. After carefully replacing the pieces the jaws are closed, the teeth occluded, and the pieces supported and held upward in position by securing the lower jaw in the usual way, with bands, buttons, and ligatures attached on the uninjured side. Finally, as all the apparatus possessing any special merit in the treatment of fractures of the maxilla have been invented by den- tists, and as their familiarity with the parts, their special knowledge of mechanics, and the facilities at their command fit them above all other surgeons for this work, we would recommend that the dif- ferent dental societies throughout the country secure appointment of competent dentists in all hospitals for the treatment of these lesions, for to them this special line of surgery justly belongs. 21 INDEX. ABNORMAL frenum labium, 33, 34, 177, 178 Age, correct, for treatment, 188-191, 195 Alveolar process, distribution of, 46, 47 plates of, 47, 171 structure of, 47 Alveolar section to expedite tooth-move- ment, 174 Alveolus, absorption of, 57, 167, 168, 170 arrest in development of, 207, 244 bending of, 48, 167, 171, 227 changes in, resultant upon tooth-move- ment, 57, 168-170, 207 general consideration of, 45-48 restored to normal contour, 185, 186, 221 Anchor bands. (See Bands, anchor clamp) teeth. (See Teeth) Anchorage, attachments to teeth for, 141, 149, 204, 218, 229, 244, 253 Baker form of, 116, 254, 263, 279 combination of occipital and Baker form, 259 of occipital and stationary, 242, 279 of simple and reciprocal, 261 devices for securing, m, 144, 204, 218, 236, 238 for partial or complete movement of teeth, 109 for retention, 153, 204 for retrusion of incisors and cuspids, 2^5 for tooth-movement, in gained from use of expansion arch, 139 general consideration of, 109-111, 235 insufficient, 149 occipital, 74, 114, 236, 242, 249, 274, 278, 279 occlusal, 116 reciprocal, 113, 115, 122, 123, 125, 140, 218, 258 reinforcement of, 121, 124, 132, 233, 255 simple, in sources of, TIO stationary, 112, 130, 242 Apex of root of teeth, movement of, 170, 171 Appliances. (See Regulating appliances) Arch B, adjustment of, 236, 241 Arch B, bending of, 236, 239, 253 combined with traction screw, 241, 261 description of, 86 uses of, 86, 233, 236, 244, 249, 254, 259- 261, 277 Arch E. (See Expansion arch) Arches, dental. (See Dental arches) Artificial luxation, 173, 174 BAD advice of dentists, i, 12 Baker's anchorage, 254 method of retention, 165, 166 of treatment, 254, 255 Band driver, 95 Band material F and H, description of, 81 Bandages, use of, in fractures of the max- illae, 287, 293, 301 Banding crowded teeth, 106, 107 cuspid teeth, 107, 128 Band-forming pliers, advantages of, 103 description of, 91, 92 Band soldering pliers, description of, 91 uses of, 102, 103 Bands, anchor clamp, adjustment of, 107, 108, 142, 288, 289 with cement, 108, 130 description of No. i, 82 No. 2, 82, 223 No. 3, 82 No. 4, 82 X, 82, 204, 218 D, 82, 141, 204, 218, 239 for securing ends of arches, 141, 143 making attachments to, 109 mistakes in adjustment of, 107, 108 fracture, 288, 290, 292-295 adjustment of, 288 inspection of retaining, 160, 191 Magill's, 73 plain, author's method of constructing, IOI, 103 correct method of setting, 73, 106 Desirabode, 72 Evans, 72 Farrar, 72 307 3 o8 INDEX. Bands, faulty methods of making, 72, 73, 100, 101 Fuller, 72 placing of spurs to, 134 soldered attachments to, 104, 105 to loosen, 106 united for retention, 153, 159, 211, 220 with spurs, for retention, 152, 153, 156- 158, 207, 209, 211, 212, 215, 219, 220, 223, 228, 230, 232, 254 practical use of, 137, 138, 204-206, 211, 212, 2l8, 222, 224, 226, 229, 231, 233, 238, 264, 266, 271, 272 Schange's, 71, 7- Beauty, characteristics of, 16 definition of, 16 types of, 17, 18, 19 Bicuspid teeth, attachments to, for eleva- tion, 244-246 extraction of, 201, 202, 235, 261, 264, 266, 276 inclination of, 230 occlusion of, 8 retention of, 158, 161, 228 rotation of, 132, 160, 206 Biting lips. (See Lips) Blow-pipe, Herapath, 95 Bone, surgical removal of, 174, 242, 253 Bracket table, 96, 97 Brass wire for ligatures, 75 Bryan, Dr., artificial luxation, 173, 174 Buccal movement of teeth, 137, 166, 171 tissue-changes incident to, 169, 171 CASE, Dr. C. S., appliances, 109, 245 Cases, practical, corrected, 197, 199, 207, 208, 210, 211, 213, 214, 219-221, 223, 224, 228, 232, 243, 249-251, 254, 256, 265, 273 study of, 69 Causes of malocclusion: Habits, 28 inheritance, 23 loss of permanent teeth, 26-28 premature loss of deciduous teeth, 24, 214 prolonged retention of deciduous teeth, 25 supernumerary teeth, 28 tardy eruption of permanent teeth, 27 Cells of peridental membrane, 49 Cement, celluloid, 62 Cementing plain bands, 106 clamp bands, 108-130 Central incisors. (See Incisors) Changes, alveolar, incident to tooth move- ment, 57, 166, 167 subsequent to tooth movement, 184-188 Chin retractor, adjustment of, 270, 271 description of, 88 Chin retractor, value of, 270 Clamp bands. (See Bands) Class I, 13, 186 average case, 36 described, 37, 197 extraction in, 198 general consideration of, 193, 194 illustrated, 36 percentage predominance of, 44, 197 retention of practical cases. (See Re- tention) treatment of practical cases, 197, 202, 208, 211-215, 221, 223, 225, 228, 230, 232, 233 Class II, 13, 30, 234 distinguishing characteristics of, 37, 234 general consideration of, 37, 234 Division i, 13, 22, 30, 161, 162, 188 described and illustrated, 37, 38, 234- 236 retention of. (See Retention) treatment, first plan, 235-237, 241, 242 second plan, 247, 252 Baker method, 254 of malocclusion of lower teeth, 243, 245, 246, 255 Subdivision, described and illustrated, 38, 40, 261 retention of, 263 treatment of, 261, 262 Baker method, 263 Division 2, described and illustrated, 39, 40, 263, 264 retention of, 266 treatment of, first plan, 264 second plan, 264, 265 Subdivision, described and illustrated, 40, 266, 267 retention of, 268 treatment of, 266 Class III, distinguishing characteristics of, 40, 268 Division, described and illustrated, 41, 268, 269 retention of, 273, 274 treatment of, combination of plans, 272, 274, 276 first plan, 269, 270 second plan, 269-271 third plan, 269, 275, 276 fourth plan, 270, 276 Subdivision, distinguishing character- istics of, 279 general description of, 279 retention of, 279 treatment of, 279 Classification of malocclusion, 34 INDEX. .Coffin, Dr. Seldon, introduction of piano- wire, 74 Combinations of regulating appliances. (See Regulating appliances) Contraction arch B. (See Arch B) Cuspid teeth, banding, 106, 107 elevation of, 206, 267 extraction of, 201 forcing eruption of, 149, 272, 273 labial movement of, 120, 121, 123, 131 lingual movement of, 131 mesio-labial movement of, 222 missing permanent, 194 occlusion of, 8 premature loss of deciduous, 25, 214, 221 retention of, 138, 162, 164, 165, 207, 209, 212, 219, 220, 228 retraction of, 127, 131, 146, 167, 241, 264, 266 rotation of, 123, 131, 204, 206, 219 Cusps, importance of interdigitation of, 9, DEFINITIONS: Line of harmony, 16 of occlusion, 13 malocclusion, 6 orthodontia, 6 retention, 153 Dental arches: both lateral halves of upper, in lingual occlusion, 187, 225 contraction of lower, 226, 227 of upper, 235, 236, 241, 242, 247, 249 development of, 25, 26 effect of diminished size of lower, n, 12, 25, 151, 195, 204, 218, 224 of diminished size of upper, 28, 195, 204 equal importance of lateral halves of, 36, 42 establishment of harmony in sizes of, 152, 194, 261, 264 expansion of lower, 167, 204, 208, 213, 215 of upper, 167, 204, 208, 213, 215, 226, 229, 249, 253 importance of harmony in sizes and relations of, 9, 26, 218 interdependence of, 9, 10 lengthening of lateral halves of, 24, 144, 146, 222-224 . lower, importance of, 9, 243 one lateral half of upper in lingual oc- clusion, 229 relations of, in Class I, 37, 197 in Class II, Division i, 37, 38, 234 Subdivision, 38, 40, 261 Division 2, 39, 40, 263 Subdivision, 40, 266 309 Dental arches, relations of, in Class III, 41, 42, 268 Subdivision, 42, 43, 279 retention, 223, 224, 230 of lower, backward, 273 of lower, forward, 162-164 widening of, 138, 144, 148, 167, 213, 226, 230, 239, 249 Depression of teeth, 55 tissue-changes incident to, 168 Desirabode bands, 72 modification of expansion arch, 136 Devices for overcoming thumb-sucking, 30, 164 for retention. (See Retention) for securing anchorage. (See Anchorage) for treatment of fractures. (See Frac- tures of the maxillae) Diagnosis, importance of correct, 34, 43 of line of harmony in, 17 of line of occlusion in, 13, 14 points to be considered in, 34, 35 Distal movement of teeth, 127, 131, 146, 147, 166, 218, 224, 264 tissue-changes incident to, 169 Disuse of teeth, 31 Dwindle, 72 EARLY interference, importance of, 12 Elevation of bicuspids, 244-246 attachments for, 138 Dr. Case, 245 of cuspids, 149, 206, 267 of incisors, 233 of molars, 244-246 of teeth, tissue-changes incident to, 168 Eruption, forcing, of cuspid, 149, 272, 273 tardy, of permanent teeth, 28 Evans, Thos., bands, 72 Excision of lower jaw, 297 Expansion arch, author's improvements qf. 8S, 137. 140 bending of, 205, 218, 231 combined with bands, spurs, and liga- tures, 137, 204, 205, 207-209, 211, 213, 2l8, 222, 224, 226, 229, 23O, 231, 233, 244, 246, 260, 261, 264, 266, 271 with traction screw, 143, 264, 266 description of, 85, 139 direction and distribution of force from, 138, 140, 219, 226 directions for adjusting, 133 early forms of, 72, 135, 136 Fauchard's, 71, 134 Fox's, 136 Harris's, 136 improper uses of, 140 reinforcement of, 142, 226, 229 3io INDEX. Expansion arch, Schange's, 72, 136 use of, 85, 137, 138 Extraction, evil effects of, i, 24-27, 214, 22 224 general consideration of, 198, 200-202 in Class I, 198, 199 in Class II, 235, 261, 264, 266 in Class III, 276, 279 of bicuspids, 201, 235. 261, 264, 266, 276 of cuspids, 201 of incisors, 27, 201 of molars, 25, 26, 201, 224 premature, of deciduous teeth, 23-25, 214, 222 FACIAL art, 15 Facial line of harmony. (See Line of har- mony) Facial lines, ideal, 17, 18, 196 improvement of, 196, 208, 222, 245, 2^9, 256, 258, 266, 277 in Class I, 204, 225 in Class II, 37, 40, 234, 248, 255, 257, 266 in Class III, 269, 276 marring of, 17, 18, 196 Farrar's band, 72 Fauchard's expansion arch, 71, 134 Fibers of peridental membrane. (See Peri- dental membrane) Fox's expansion arch, 136 Fracture bands, 288 adjustment of, 288, 289 Fractures of the maxillae, bandages for treat- ment of, 288, 290, 292-295 bands for treatment of, 288, 290, 292-295 final suggestions, 303-3$ general consideration of, 285, 286 Hamilton on, 285 interdental splints for treatment of, 288, 300, 301 location of, 285, 286 methods of fixation in, 286-288, 293, 294, 299, 302 of reduction in, 285, 288, 293, 294 occlusion of teeth as a guide in setting, 286, 288 treatment of practical cases of, 289, 291, 292, 294, 295, 299, 300 wiring ends of bone together in, 287, 298 Frenum labium, abnormal, 33, 34, 177 method of operating on, 178 section of, 177 Fuller, plain bands, 72 GAG, obsolete appliance, 213 Gaines's screw, 72 German silver, composition of, 79, 101 introduction of, 75 use of, 79 German silver, value of, 79, 80 Gold for the construction of regulating ap- pliances, 80, 81 Guilford's bands for retention, 153 HABITS, 29 Hamilton on fractures of the maxillae, 285 Harris's expansion arch, 136 Head-gear, adjustment of, 87, 88, 237, 240 description of, 88 introduction of, 74 Kingsley's, 74 pressure from, 279 wearing of, 239, 240, 271, 273, 277-279 Heath, Sir Christopher, use of Interdental splint, 300 Herapath blower, description of, 95 Hippocrates' plan of fixation of fracture of the maxillae, 298 IDEALS in facial lines, 16-18, 194 in occlusion, 7, 8, 194 Impression trays, 59, 60 Impressions, author's method of taking, 59 plaster, 58 plastics for, 58 removing, 61, 63 from arches with spaces of lost teeth, 63, 6.1 steps in taking lower, 63 upper, 59 united, 62, 63 uniting, 61, 62 varnishing, (* Incisors, central, labial movement of, 123, 206, 208, 222, 229, 276 retention of, 161, 162, 164, 166, 207, 212, 219, 220, 228, 230, 271 rotation of, double, 127, 149, 271 single, 123, 125, 126, 253 depression of, 249 distal movement of, 236 elevation of, 233 inclination of, 40, 41, 181, 187, 198, 202, 206, 230 labial movement of, 170, 204, 206, 208, 212- 214, 217 lateral, distal movement of, 237 extraction of, 27, 201 labial movement of, 122, 125, 133, 146 lingual movement of, 123 missing, indicated by skiagraph, 193, 194 retention of, 161, 162, 164, 166, 207, 212, 219, 220, 228, 230 rotation of, 124, 125, 145, 146 torso-labial movement of, 145, 229 lingual movement of, 170, 241, 242, 253, 261, 262, 279 INDEX. Incisors, movement of, en masse, 217, 218, 226 occlusion of, 7, 8 protrusion of deciduous, 251 of upper, 25, 27, 161, 244, 252 retention of, 157, 158, 161, 162, 164, 166, 228 retrusion of, 237, 239, 241 shortening lower, 243-246 Inclined occlusal planes, establishment of harmony between, 4, g, 194, 261, 266 final adjustment of, 158, 194 influence of, 8, 10, n, 13, 194 mutual support of, 9, 236 permanent retention of, 194 Inherited tendencies to malocclusion, 23 Inspection of ligatures and attachments, 241 of retained teeth, 191 Interdental splint for treatment of fractures of the maxilla, 288, 296, 300 Heath's form of, 300 Kingsley's form of, 300 Martindale's form of, 300 Irregularities of the teeth, 5 JACK-SCREW, early forms of, 70, 73 description of author's, E and J, 83 in combination with levers, 144, 145, 213 with traction screw, 146 in combinations, 121-123, J 47> 207, 293 in movement of cuspids, 120, 121, 123 of incisors, 122, 123, 276 invention of Dwindle, 73 methods of securing point, 119 sheath, 118, 119 Jaws: double resection of lower jaw, 179-182, 183, 184, 268 establishment of harmony in relations of jaws, 195, 243, 250, 254 excision of lower jaw, 297 fractures of jaws. (See Fractures) method of performing double resection of lower jaw, 180, 182 modification of form of lower jaw, 195 of upper jaw, 196 position of lower jaw, 195, 247, 253, 265, 270, 272, 274, 275 movement of jaw from distal occlusion, 21, 247, 248, 253, 254, 256 from mesial occlusion, 272, 274 overdevelopment of jaws, 268 relations of jaws in Class I, 37, 197 in Class II, 37-40, 234, 261, 263, 266 in Class III, 40, 268, 279 retention of lower jaw backward, 273 forward, 162-164, 250, 253 KINGSLEY'S head-gear, 74 modification of retaining plate, 166 splint for treatment of fractures, 300 LABIAL movement of teeth, 55, 137 of cuspids, 119, 121, 123, 131, 206, 208 of incisors, 122, 123, 125, 133, I4 6, 167, 170, 204, 206, 208, 212-214, 217, 222, 229, 276 tissue-changes incident to, 169, 170 Lateral incisors. (See Incisors) Lee and Bennett traction screw, 73 Levers L, combinations of, 124-127, 148 with jack-screws, 144, 145, 213 description of, 84 for rotation, 124-127, 146 to reinforce expansion arch, 142, 226, 229 various sizes of, 123 Ligatures, adjustment of, 137, 232 brass wire, 75, 89 floss silk, 89, 90 for rotation, 127, 149 forms of, 89, 90 inspection of, 241 rubber, 87, 233, 236, 238, 239, 253, 259 tightening of, 127, 138, 206, 268 use of, in treatment of malocclusion, 137, 138, 204-206, 211, 212, 222, 224, 226, 229. 231. 233, 249, 264, 266, 271, 272 in treatment of fractures, 289, 293-296, 298 value of wire, 122, 137, 219 Line of harmony, application of, 17-20 definition of, 16, 17 importance of, 17 location of, 17 of occlusion, adjustment of malposed teeth to, 194, 197, 199, 219, 220 definition of, 13 form of, 13 importance of, 13 location of, 13 Lingual movement of teeth, 55 of cuspids, 131, 204 of incisors, 123, 170, 171 of molars, 171 tissue-changes incident to, 169, 170 occlusion of lateral halves of upper arch, 17, 225 of one lateral half of upper arch, 229 Lips, abnormal function of, n, 25, 224, 234 biting lower, 29, 30, 165 development of, 19 influence of, in malocclusion, n, 25, 27, 30, 234 normal function of, 10, 250, 264 Loss of deciduous teeth. (See Extraction) of permanent teeth. (See Extraction) MAGILL'S band, 73 Mallet, 95 312 INDEX. Malocclusion, age for treatment of, 188-191, | i9S advantages of early treatment of, 189, 190 causes of. (See Causes) classification of, 34 Class I of. (See Class I) Class II of. (See Class II) Class III of. (See Class III) correction of, generally considered, 6 definition of, 6 development of, n, 24-33, 224 diagnosis of cases of. (See Diagnosis) effects of, 3 forces governing, n, 12 objects to accomplish in treatment of, 194 positions of, 14, 35 buccal occlusion, 14, 25, 197 distal occlusion, 14, 27, 37, 162, 224, 234, 247, 249, 252, 253, 261, 264, 266 disto-torso-occlusion, 218 infra-occlusion, 14, 31, 210, 232, 233, 244 labial occlusion, 14, 147, 203, 247 lingual occlusion, 14, 125, 147, 150, 197, 203, 211, 212, 216, 225, 229, 243, 253 mesial occlusion, 14, 40, 42, 268, 279 supra-occlusion, 14, 31, 244, 253 torso-occlusion, 14, 123, 194, 211, 216, 243, 271 torso-labial occlusion, 225 torso-lingual occlusion, 225, 229 possible class of, 42 study of cases of, 69 table of classes of, 44 time required for treatment of, 191, 192 Martindale's interdental splint, 300 Maxilla, double resection of lower, 179-184 excision of lower, 297 fractures of. (See Fractures) Mesial movement of teeth, 166-212 tissue-changes incident to, 169 Mesio-labial movement of teeth, 222 Model cabinet, 65, 66 Models, general consideration of, 57, 58 pouring, 64 repairing, 64 separating, 64 "study," 65, 205, 206, 212, 217 value of accurate, 57, 58, 65 Molars, attachments for elevation of, 244-246 extraction of, 24, 26, 27, 201, 224 mesio-labial movement of, 222 occlusion of, 8, 224 pitted, 232 retention of, 158, 160, 161, 225, 228 rotation of, 231 used as anchorage, 204, 209, 212, 218, 226, 233 Mouth-breathing, effect of, 2p, 32, 37, 151 general consideration of, 234 Movements of teeth, buccal, 137, 166 collectively, 117, 138, 204 combinations of, 166, 167 depression in, 55, 166, 246 distal, 127, 131, 146, 147, 166, 218, 224, 264 elevation in, 55, 149, 166, 206, 233, 244-246, 267, 272. en masse, 217, 218, 226 labial, 55, 119-123, 125, 133, 137, 146, 147, 166, 206, 208, 212, 217, 229, 264, 266 labio-buccal, 218 lingual, ss, 123, 131, 147, 166, 231, 236, 237, 242, 249, 252, 253 mesial, 166, 212 rotation in, 55, 106, 123-127, 131, 132, 145, 146, 148, 166, 205, 206, 208, 209, 219, 226, 229, 231, 253, 271 singly, 147, 166 tissue-changes incident to, 166-172 torso-labial, 145 Muscles, influence of, 5, 10, n, 13, 25, 211, 214, 234, 247 NASAL obstructions, effect of, 32, 37, 234 necessity for overcoming, 32 Nomenclature, 14, 20 OCCLUSAL planes. (See Inclined occlusal planes) Occlusion, basis of science of orthodontia, 6 buccal, 14, 25, 197 comprehension of, 5 details of, 6, 7, 8 distal, 14, 27, 37, 162, 224, 234, 247, 249, 252, 253, 261, 264, 266 establishment of normal, 6, 194, 195, 235, 247, 264, 273 for retention, 124, 194, 213, 273 forces governing normal, 9 ideal, 7, 8, 194 importance of perfect, 5 improved, 195, 235, 264 infra-, 14, 31, 210, 232, 233, 244 key to normal, 6 labial, 14, 147, 203, 247 line of. (See Line of occlusion) lingual, 14, 125, 147, 150, 197, 203, 211, 212, 216, 225, 229, 243, 253 mesial, 14, 40, 42, 268, 279 supra-, 14, 31, 244, 253 torso-, 14, 123, 194, 211, 216, 243, 271 torso-labial, 225 torso-lingual, 225, 229 Orthodontia as related to comparative anat- omy, 6, 280 as related to rhinology, 235, 280 definition of, 6 INDEX. 313 Orthodontia, final suggestions on, 281-284 growth of, i, 3 importance of, 2 PERID XNTAL membrane, arrangement of fibers of, 49-52 attachment of fibers of, 52 changes in, incident to tooth-movement, 57, 167, 168 functions of, 48, 49 genera] consideration of, 48, 219 pathological conditions of, 53, 151 resection of fibers of, 175-177 structure of, 246 Periosteum, 48 Photographs of patients, 65, 66, 192 Piano-wire, Coffin's introduction of, 74 Plates, vulcanite, 161, 165, 215, 228, 230 for retention, 160, 161 Kingsley's modification of, 166 old forms of, i, 77, 78, in Pliers, flat-beaked, 95 plain, 91 regulating, 94, 223, 225 Profile, imperfect, 18, 19 perfect, 16, 17 Prognathism, 20 Pulp of teeth, 25, 171, 172 REGULATING appliances, author's: See Arch B Band material Bands, clamp Chin retractor Expansion arch Head-gear Jack-screw E and J Levers L Retaining tubes R Retaining wire G Traction bar A Traction screw A, D, and Y Wrench combinations for buccal movement, 137, 166 for contraction, 227 for depression, 55, 166, 246 for elevation, 55, 149, 166, 206, 233, 244- 246, 267, 272 for expansion, 205, 208, 209, 212, 217, 226, 229, 231, 249, 253 for labial movement, 55, 120, 121-123, 125, 131, 133, 137, 146, 147, 166, 205, 206, 208, 212, 213, 217, 229, 264, 266 for lengthening arch, 144 for lingual movement, 55, 131, 147, 166, *3i 236, 237, 242, 249, 252, 253 for mesial movement, 166 Regulating appliances, combinations for re- traction of cuspids, 127, 131, 144, 146, 167, 241, 242, 261, 264, 266 for retrusion of incisors, 236, 239, 241, 242, 249, 252, 253, 261-263 for rotation, 55, 106, 123-126, 127, 131, 132, 145, 146, 148, 166, 205, 206, 208, 209, 219, 226, 229, 231, 253, 271 for treatment of Class I, 204, 205, 207- 209, 212, 213, 217, 218, 222, 224, 226, 227, 229, 231, 236, 239 of Class II, Division i, 236, 237, 241, 242, 244, 252, 253, 254, 255, 259 Division i, Subdivision, 261 Division 2, 264, 265 Division 2, Subdivision, 266 of Class III, Divisior, 270, 271, 276, 278 Subdivision, 279 for various movements simulta- neously, 138, 204, 205, 207, 209, 212, 213, 2l8, 222, 224, 226, 230, 231, 236, 237, 242, 246, 252, 253, 26l, 262, 264- 266, 271, 272, 277 for widening the arch, 144 miscellaneous, 144-147, 227 construction of, 72, 74, 75, 79 definition of, 67 functions of, 117 general consideration of, 67 history of, 70 jack-screw, early forms of, 70, 73 Patrick regulator, 70 piano-wire, introduction of. (See Levers) Schange's clamp band, 71, 72 screw, 72 special designs in, 67-69 standard forms of, 68, 69 systematized, 68, 75, 117 traction screw, 73, 74 tubes, 74 vulcanite, 74 Regulating pliers, 94, 223, 225 Retaining bands, inspection of, 160, 191 Retaining devices, illustrated, i54-i59t 161- 165, 199 materials for construction of, 152-165 tubes R, description of, 74, 83 use of, 123, 125, 132, 157, 223, 232, 253 wire G, description of, 82, 83 uses of, 82, 83, 104, 123, 126, 132, 157, 207, 209, 219, 223, 228, 230, 232, 238, 253 Retention, anchorage for, 153, 204 anticipation of, 105, 120, 121 application of principles of, 153 automatic, 88, 238 INDEX. Retention, Baker method of, 165, 166, 261 by occlusion, 124, 194, 213 definition of, 153 general consideration of, 150, 152, 161 general rule for, 151 of bicuspids, 158, 160, 161, 228 of Class I, 207, 209, 211-213, 215, 219, 220, 225, 228, 230, 232 of Class II, 161-165, 2 49. 2S 253, 254, 263, 266, 268 of Class III, 273, 279 of cuspids, 158, 162, 164, 165, 207, 209, 212 of dental arches, lower, 162-164, 227 upper, 161, 207, 215, 228 of incisors, 156, 161, 162, 164, 166, 207, 212 of lower jaw backward, 274 of lower jaw forward, 162, 163, 250, 253 of molars, 158, 160 of space of missing teeth, 25, 154, 155, 214, 215, 223, 225 of teeth after section of frenum labium, 1/8, 179 of teeth collectively, 157, 159 principles of, 153 temporary, 127, 149, 152 time required for, 30, 150 Retraction of cuspids, 127, 131, 146, 167, 241, 264 Retrusion of incisors, 237, 239, 241 Roots of teeth, adjustment of, 170 Rotation by means of arch B combinations, 253 by means of expansion arch combina- tions, 138, 205, 206, 208, 209, 219, 226, 229, 231 by means of jack-screw, 123, 145 by means of lever, 124-127, 145, 146 by means of ligature, 127, 149 by means of traction screw, 131, 132 double, 149, 271 of bicuspids, 132, 206 of cuspids, 125, 131, 204, 206, 219 of incisors, central, 123, 125-127, 149, 271 of incisors, lateral, 124, 125, 145, 146 of molars, 231 movement of, 55 tissue-changes incident to, 168 Rubber in regulating, introduction of, 74 wedges, practical use of, 90, 125, 231, 266, 272, 273 SCHANGE'S anchorage of arch, 136 bands, 71, 72 expansion arch, 72 screw, 72 Scissors, description of, 94 Skiagraphs, illustrated, 193 value of, in study of cases, 193, 194 Soft soldering, author's method of, 98, 99 Solder, kind of, to use, 98, 102 Soldered attachments to clamp bands, 97 to plain bands, 104, 105 spurs to arch B, 98 to expansion arch, 99 Soldering, author's method, 96-98 I proper flame for, 95, 96, 102. 104, 259 table for, 96, 97 technique of. 280 Soldering fluid, 99 pliers, description of, 91 use of, 102, 103 tubes, 96, 105 Spurs attached to arches, 98, 259 to plain bands, 104, 105 directions for making, 98, 99 use of, 153, 154, 205 Staples attached to plain bands, 104, 105 Study models, 65, 205, 206, 212, 217 of cases, 193, 194, 197 Suggestions, final, on fractures, 303-305 on orthodontia, 281-284 for teachers, 280 Supernumerary teeth, 28, 29 Surgery: Alveolar section, 174 double resection of lower maxilla, 179^84, 268 in tooth-movement, conservative, 173, 242, 2S3 operative, 173 section of frenum labium, 177, 178 of fibers of peridental membrane, 175-177 Surgical removal of bone, 174, 242, 253 TABULATED classification of malocclusion, 44 Teachers, suggestions for, 280 Teeth, anchor, 125, 128, 141, 145, 204, 212, 229, 233 attachments to, for anchorage, 141, 149, 204, 218, 229, 253 deciduous, pitted for imbedding spurs, 25 premature loss of, 24, 25, 214, 222 prolonged retention of, 25 effects of disuse of, 31 extraction of. (See Extraction) final adjustment in occlusion, 210 of apices of roots, 170, 171 grinding of, 243 interdependence of, 26 movement of, by lengthening wire, 223 mutual support of, 8 occlusion of, 8 permanent, loss of, 26 tardy eruption of, 28 pulp of, 25 retention of. (See Retention) INDEX. 315 Teeth, seven movements of, 35, 166 shapes of, 5, 9, n sockets of, 47 supernumerary, 28, 29 torso-labial movement of, 229 Thumb-sucking, effects of, 29 Tongue-sucking, effects of, 29, 31 Tools, author's selection: See Herapath blower Mallet Pliers Scissors Wire cutters Tooth movement, alveolar section to expe- dite, 174 immediate, 173 physiological laws governing, 192, 241 tissue-changes incident to, 166, 167-172 subsequent to, 184-188 Traction bar A, adjustment of, 86, 87 description of, 86 uses of, 86, 236 screw A, D, and Y, adjustment of, 84, 128-130 combinations of, 127, 132, 133, 143, 146, 241, 261, 264, 266, 276, 277, 302 description of, 83 operated on lingual side of dental arch, 131, 146 Lee and Bennett's, 73 Treatment, advantages of early, 189, 190, 268 correct age for, 188, 189, general consideration of, 192, 197 rule governing, 191 Treatment, objects of, 194, 197, 247, 261, 264 of cases, Class I, 197, 202, 208, an, 213-215, 221, 223, 225, 228, 230, 232, 233 Class II, 235, 247, 252, 263-266 Class III, 269-271, 274, 276 of fractures of the maxilla. (See Frac- tures) requirements of, 197 time required for, 191, 192, 242 Tubes, introduction of, 74 Tubes R attached to plain bands, 104, 105 Tucker's introduction of rubber in regulat- ing, 74 VARNISHES, 64 Varnishing impressions, 64 Vulcanite for construction of regulating ap- pliances, 74, 79 plates, adjustment of, 160, 161 Baker's modification of, 165 for retention of lower arch, 161, 165 of protruding upper incisors, 161, 165 of upper arches, 161, 163, 215, 228, 230, 249 WIRE, brass, for ligatures, 75 piano, 74 pinching, to lengthen, 253 Wire-cutters, 93 Wiring ends of bone in fractures, 287, 298 Wrench, description of author's, 85 m ' JIU& 1 W6 4/?E(T0 UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped belov r o JIIV3-J %2flOMED FEB 16 1984 ""^fl 1 - 74 ^' /5> #n#7 ^v *OMEO FEB i e 198| -../^Mtrn UB LIB. ^16 R[ru BjOMED FEB 2 b 1988 | BiuY.Jj f B\OWED m ECB BIOMED LIB] IY 1 4 '85 REC'D Form L9-116m-8,'62(D1237s8)444 KH B \\tf-UNIVERty -10 3 1158 00631 8157 .vlO