The cause and effect of oral deformities

606

The International

Journal

of

Orthodontia.

from which specialists may draw patients, but in addition to these favorable conditions, there is needed the growth of a feeling of co-operation between the individuals of the profession in order to maintain a specialist, except in the largest cities. Men in a given locality must allow the one among them with the greatest ability and liking for a given specialty to go where he can receive the special training and practice necessary for the practice of that specialty, and then if possible refer all such cases in that locality to him for treatment. Such a method would be greatly to the advantage not only of the community but of the profession.

THE

CAUSE

AND BY

DR.

EFFECT A.

C.

OF ORAL

GIFFORD,

OSHKOSH,

DEFORMITIES.* WIS.

W

E know by this time that dentistry has begun to broaden its field. There are now specialists in mcr: every line. The most important, exact and pronounced specialty is that which has to do with the formation of the jaws of-man. To be able to mould a deformed jaw into a perfect one is an exact science. Orthodontics is that exact science. When we realize how great is the need of normal position of the teeth, normal relation of the arches and harmony in the size of the arches, then and only then can we realize the great field of orthodontia. The jaws at birth, unless there be congenital disturbances, are in the proper relation to the face and head and to each other. As there is nothing to interfere with the eruption of the temporary teeth, they will usually erupt in their proper position if the child is of normal health and develops There are cases occasionally where there is a mesial or distal normally. relation of the lower arch, but these cases are not frequent. It is not possible, in my mind, to tell the cause of every case of malocclusion even though we do have a definite history, but we can systematize our -knowledge in such a way that the average case will give us a clear vision of the cause. . Vlhen we speak of inherited malocclusion we think of some relative having the same class of deformity as the case under consideration. May not this be a case of the child living in the same environment as did the relative or may it not be congenital? There are able men that claim that there are no cases or inherited malocclusion. In the past few years these men have had occasion to treat and study the different forms of malocclusion to a great extent and have divided causes into either local or general. We must confess that from the standpoint of biology, embryology, anatomy and histology there is no evidence of malocclusion ever being inherited. Each individual germ-cell possesses a certain amount of chromatin that presides over inheritance and we have no evidence- that malocclu&on is impressed upon the chromatin of that cell. We hear such things as this child inherited the large teeth of the father and the small jaw of the mother. How can this *Read

before

the Central

Wisconsin

Dental

Society

and the Oshkosh

Dental

Society,

October

12, 1915.

The Cause and Effect of Oral Deformities.

607

be possible when the teeth and jaws both come from the brachial skeleton? The size of the teeth are determined at the time of the fertilization of the ovum and if the child leads a perfectly normal life there will be jaws large enough for the teeth. I want to say now that at this time I do not want to declare myself frbr or against inherited malocclusion. There will be a time in the near future that we can positively say if there are inherited oral deformities or not, for there is so much discussion aboul this that there will have to be posit-iv< research. The causes are not well defined, but there are etiological factors that WC can surely say cause malxtlusion. These arc divided into two grmi!)s--local, and general or constitutional. General causes are those which effect t$e general functions of the individuai to such an extent as to interfere with the development of the teeth and the surrounding structures supporting them. They include the ailments IA childhood which interfere with the development of the complete dental aqjparatus by producing a high temperature that acts upon the epithelial structures. Included in this group are such as measels, chicken pox and scarlet

Fjg. i.-History of rickets complicated by adenoids and early extraction of temporary teeth.

’ Fig. L.-History, traction of tempxary

lack of use compli&ed right !ateral.

by ex-

ft=ver. These effect the formation of the enamel sometimes to such an extent as to cause complete atrophy of the emmel organ, thereby producing teeth of faulty shape. We have nften been told that syphilis was the cause of the so-called “Hutchinson teeth,” but it has been found that there are some other diseases that also produce them, one of which is rickets. In rickets, we find a great many cases of oral and facial deformities, it.1 Owing to the faulty bone formation, the teeth a great many different forms. are not properly supported and the least pressure from the tongue, cheeks, or the act of mastication forces them into malalignment. (See Fig. 1,) In rickets the temporary teeth are slow to erupt and are lost early, thereby causing malocclusion, as the early loss of the temporary teeth always is :tn Pathological conditions found in rickets, inducement to irregularities. plus the tardy eruption of the permanent teeth, always produces some type of malocclusion. The so-called disuse, which is not as good a name as “lack of use,” which it really means, is another big factor in producing contracted arches and teeth in malposition. (See Fig. 2.) In these days of soft foods and hurried mastication, there is not enough force applied to the jaws to develop the bones

608

The International

Journal

of Orthodontia.

If the bones of the jaws are not and there is a lack of lateral widening. stimulated by pressure through mastication there is little bone growth. Exercise will develop nature’s first intention and fulfill the laws of ancient periods. That is why there are few cases of teeth in malposition among our forefathers. They used their jaws. Lack of lateral widening will first be noticed between the central incisors. If the lower permanent central incisors have not moved into the line of OCelusion by the eighth year, for we know that they generally erupt lingual to the normal, there is a lack of development. There are several acquired factors producing malocclusion coming under the head of disuse, among which are painful mastication owing to decayed teeth, abscessed teeth, failure to contour fillings properly, and extraction of temporary teeth. When we hear of adenoids and enlarged tonsils causing maldevelopment of the dental arch, we must think of them only as the indirect cause. The A constant state of perverted muscular direct cause is mouth-breathing. action we should remember is the cause of this class of cases. We know that when the mouth is open the tongue is in the floor of the mouth and the

Fig. J.-History.

adenoids.

Fig.

4.-History,

adenoids removed eight years.

at

ahout

muscles of the cheeks continue their pressure, though slight, upon the upper arch until, if this condition is not attended to, we have a contracted arch It depends upon the occlusion whether the lower arch or probably arches. is contracted, for the force of incline planes in contact is sufficient to reduce the size of the lower arch also. (See Fig. 3.) There are two distinct types that have their beginning through mouthbreathing. One of these types we all are familiar with and which is very We call this the face of an noticeabl&-the protruding upper anterior teeth. adenoider. The vacant stare is very noticeable; drooping eye-lids and frequently hard of hearing, short upper lip, the external nares undeveloped, mandible undeveloped, and a poorly developed chin are other characteristics. The lower lip is thicker and lies back against the lower teeth and the.upper portion of the lower lip exerts pressure on the lingual surfaces of the upper teeth. In a child with nasal obstructions the atmospheric pressure, acting as a force, is absent, which js one of the-main reasons the nasal cavity does not develop. The other types that have their beginning with mouth-breathing are those that have their nasal obstructions removed at an early age but not

The Cawe and Efect

of Oral Deformities.

6c14

early enough to prevent the abnormal locking of the molars. They have made special effort to keep the lips closed, forcing the upper anterior teeth lingually, and the lower molar being one cusp distal to normal makes the spa01 for the canine very small, consequently it has to erupt labially, lingually, or, as it often does, becomes impacted. (See Fig. 4.) When there is an enlargement of the facial tonsil to a marked degree, we find an altogether different form of arch relation, viz., the mesial relation of the Iower arch. T&s enlargement produces a fullness in the throat ant1 suffocates the individual, especially when lying on the back, as at that time the enlarged membrane seems to fall back. By protruding the mandiblcl this effect is relieved. Should this practice continue, even for a short time, during the eruption of the first permanent molars there will surely be a mal-

Fig. S.-History,

enlarged

tonsils.abnormal

frenum

Fig. 6A. Fig. 6.-Supernumerary

impacted

and lack of use.

Fig. 6R. tooth complicated

by missing

right

premolar.

(See X-ray.

Fig. 6R.)

relation of the arches which orthodontic treatment alone can restore to normal. This condition to get positive results must be treated during the active period of growth. (See Fig. 5.) Supernumerary teeth have their part in the development of malocclusion, but these cases are not so plentiful. We might go back to Darwin’s theory as a cause of these teeth and say that we are descendants of apes and have not entirely lost the characteristics of those creatures as they have eight more teeth, premolars, t.han man. It depends a great deal on the position of these teeth what sort of irregularity they produce. (See Figs. BA and ~33.:) Impacted teeth are quite numerous especially of the permanent canine. There are several conditions that can produce impacted teeth, such as the early extraction of the temporary teeth, thereby letting the al-ready erlapted

610

The International

Journal

of Orthodontia.

permanent teeth drift to find approximal contact. The incline planes of the canine, which it has on every side, deflect it from the normal by coming in contact with some other tooth during eruption. This I think is the main If the tooth or teeth so placed reason that we find them mostly at the lingual. (Fig. 7A) are not taken care of, there will be absorption of the lateral roots, as the canines usually are found, by the use of X-ray, to lie close to the roots Some advise the surgical removal of these teeth, but I favor of these teeth. bringing them into the line of occlusion by orthodontic treatment, because there is either a small arch, with the lateral approximately the first premolar, a space that is should occupy, or a temporary tooth that will not last forever. (See Fig. 7B.3

Fig. 7A. i

Fig. 7B. Fig. 7.-Impacted

upper canines and lower second left first permanent molar.

premolars complicated by extraction (See X-ray. Figs. 7B.)

of upper

Extraction of the permanent or temporary teeth is always sure to produce oral deformities. The extraction of the permanent teeth does not do as much damage as the early loss of the deciduous teeth, but unfortunately we find cases of very great deformity of the face and oral cavity which have been produced by loss of the permanent teeth. The early loss of the deciduous teeth may be either constitutional, as when associated with rickets, or local, as when associated with extraction or decay. (See Fig. 8.) Without approximal contact, the teeth will,scsmetimes drift for quite a distance. It would be impossible to describe the many different forms of irregularity The early loss of the temporary canine, that exist under these conditions. I think, produces about the most difficult type. Many a deciduous tooth is

The The Cause Cause and and Effect Effect of of Oral Oral Deformities.

611

extracted when when there there is is no no tooth tooth to take its place, especially is this true with extracted the second second temporary temporary molar. molar. If If there is any doubt as to the permanent the permanen t tooth being being present present the the X-ray X-ray is is a sure method of diagnosis. I think you tooth YOll will agree agree with with me me that that the the deciduous deciduous teeth that are lost first (meaning bewill Iwfore the the permanent permanent ones ones are are ready ready to erupt) erupt) are the upper canines and second fore molars and and the the lower lower laterals, laterals, canines canines and second second molars. The extraction molars extrarti<)11 of any of the deciduous teeth takes away that wedging force that is so necesneer'sof any of the deciduous teeth sary in in the the growth growth of of the the bone bone of the jaw. sary The permanent permanent tooth tooth if if extracted .extracted should be replaced by some sort of The (If substitute to to keep the teeth on either side of the space so made, artificial substitute artificial macho, from migrating. migrating. Very Very often often the loss of one permanent tooth will effect the from t·h(· whole masticating masticating efficiency efficiency of the dental apparatus. (See Fig. 9.) whole

Fig. 8.-Eafiy 8.-Early extraction extraction and and loss of approximat approximal contact Fig. rontact by decay of of temporary temporary teeth teeth complicated complicated by by lip Up sticking. sucking.

Fig. 9.-Extn.etion 9.-Extraction of of upper permanent laterals Fill". upper l)etmanent laterals and lower left permanent and lower left permanent · canine canine at at a"out atout twelve twelve years. years.

Fi". due to Fig. lO.-History. lO.-Hiwtory. contracted rottbacted upp~r uP.Pet' arch arichdlJe .to fracture by accident. accident. Upper UPDef teeth t~h· all all lingual IinR-tlal to to fracture by normal. normal.

Abnormal frenum produces a space between between the the centrals centrals which which usually usuaIJy is all the deformity produced, yet there there may may be be other other deformities deformities from from other other causes. (See Fig. 5.) The habits of childhood childhood produce produce certain certain types types of of deformities. deformities. Thumb Thumb and finger sucking have long occupied a place among etiological factors, long occupied a place among etiological factors, but but not as much as frequently not as much as frequently thought. thought. There There are are also also aa few few cases cases caused caused by by the lip habit, tongue habit habit and and cheek cheek sucking sucking habit. habit. These These all all have have aa type tyf1(' of deformity peculiar to to themselves. themselves. (See (See Fig. Fig. 8.) 8.) accident has Occasionally we find where caused aa malocclusion, malocclusion, all all of {If where accident has caused which produce forms that are are peculiar peculiar to to themselves. themselves. (See (See Fig. Fig. 10.) 10.) In certain cases other other conditions conditions are are found found that that playa playa part part in in the the proproduction of oral oral deformities. deformities. Each Each case case must must be be studied studied thoroughly thoroughly and and every effort made made to to find find the the etiological etiological factor factor responsible responsible for for the the deformity deformity, , also the effect these have have had had upon upon the the individual. individual..