Muscle testing and muscle training

MUSCLE TESTING A D MUSCLE TRAINING'"

By E.

SHELDON FRIEL,

B.A.,

M.DENT.SC.

PRESIDENT'S INAUGURAL ADDRESS

I meSHOULD first like to thank you for the great honor which you have done in electing me your president for this yrar. When I think of former presidents, their achievements and their wide experience my heart fails me; but I shall do my best to maintain the dignity of the Chair, and hope that the support you have given to my predecessors you will also give to me. The subject of my address is "Muscle Testing and Muscle Training." The important bearing of muscular development on malocclusion and other dental malformations has become increasingly evident to those who practice orthodontics. During the last two years I have been carrying out some research amongst my patients and the children of two orphanages with a view to determining the effect of different groups of facial muscles on the arrangement of the teeth. All 1 can do tonight is to give yO'll a short SUl'Vf'y of what has been done in this field, thr methods I have adopted and the results obtained. The number of children examined so far is too small to permit of any but very tentative dedurtions bring made; nevertheless, I think some fresh light has been thrown on the part played by those muscles assoriated with the teeth and jaws in dental and facial development. There is a very great difference of opinion among' writers on the subject and not a little confusion of thought. I shall give you a few extrads, and you 'will, I think, see that in lILany respeets the statrments are contradictory, and in some instances there is scanty evidence in support of the theories put forward. Sir Arthur Keith in his I I Antiquity of ~ran," writing of the overlapping bite of the incisors of modern European man in contradistinction to the prevalent edge-to-edge bite of the Anglo-Saxon period, says: "If ordinary chrwing movements arc made, 1hosr whieh grind the lower molar teeth against t.he upprr and force th(' condyle of the 10Wl'1' jaw into the df'pth of its soekets in front of the ear passage, the temporal musclr will be felt to he strongly at. work: it swells and subsides at each phase of thr movement. 'When, how('vrr, a biting movement is carried out., one in which the edges of the lowl'!' incisors are made to meet the opposing edges of the upper incisors, the temporal mm;cle is f('It to re'main passive': the muscle'S which carry out this movement are the two which lie in the rheek-the masseter on the outC'r sidr of the ascending ramus of thc' mandible, and the intrrnal pterygoid au its deep or buried aspect. In thE' inhabitants of our Western cities the biting mechanism has fallen into disuse. The overlapping incisor bite has appeared. The checks, which are high and prominent when the biting muscles-the masseter and internal pterygoid-are well developed, herome reduced and sunken, giving us our narrow hatchet-shaped faces-our oval cast of countenance."l .Proceedings of the British SoCi'lty for the Stud~' of Orthotiontics, J';lllu:uy 21, 1024.

337

338

E. Sheldon "'rid.

Pickerill, ,in his "Prevention of Dental Caries and Oral Sepsis, ""2 seems to consider that th.e enuse of narrow arehes lks in the (lv~nlcvelopmellt of those pairs of muscles \vhoS(' base at their origin is short.er than the base of their insertion, ,as a result of pating tough food rather than hard food, so that there is more of a grinding' than a crushing actioll. In oth~r words., there is overdevelopment of the ptt')'ygoids aIHl rOllf;rqu('ut narrowing of th'o mandibular arch. Facts show this tbe'ory to bi: fl.lllatiolls, The Eskimos and some North American Indian t1'ibe8 probnbly perform the greatest pterygoid ,action of any race of peqple in chewing hides and lassoes ill order to make them supple, and yet their arches are not narrow, but on the contrary broader than those found in the average B-tll'oppan shifF On the basis of Pickerill's theory u greater bony attachment for the insertion of tlwse muselrs should app('ur in mod~'rn Rnropean than in primitivt' man, but this again is not th,', ('asr. He' ovC'rlooks the f~rt. that the mandible

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is movable and that. the pterygoids Oll cm,h side> do llOt <'ontract fully at the same time. J. F. Colyer,' writing about the infhlence of mastication and the relation of the muscles tQ the bones, ~ays: "From these figures (referring to,the deductions of Dr. Harry Campbell) it will be seen that the pterygQids, when in a state of contraction, mnst exercise an' outward and backward tug" on the external pterygoid piate, palate' bone, body or the sphenoid and maxilla', and tend to pull them away from thr sagittal plane of the h,ead." He appareJ}tIy considers that the ma-xillary 'arch is widened, Pickerill tImt the mandibular arch is narrowed by the action of the ptf'J'ygoids. , Cryer, in his H Internal Anatomy of the Face,"j says, in describing one of his illustrations: HShouid the mandible be compressed' and a narrow dental arch exist, the tongue would he lorced backward il}to the pharyng-eal

Jl1lscle Testing and 11l1lscle Training

339

space, interfering with nasal respiration and other functions of the nasal cavity. " In describing a frozen vertical section of the head, Fig. 303, he says: "The entire face is more or less compressed, especially the upper and lower jaws. The tongue has been forced out of shape by the pressure of the walls, showing that it had not sufficient power to force the alveolar process outward." It would appear from these quotations that Cryer considered that the dental arch controlled the shape and position of the tongue, instead of the tongue, a muscle, influencing the bone, a connective tissue structure. Wallace, in his "Essay on Irregularities of the Teeth,"6 written twenty-

Fig. 2.-Gnathodynamometer. Lead or gutta-percha pads A and A' cover the biting portion of instrument. New pads for each case.

Fig.

3.-Glossodynamometer. Biting: portions A and A' held firmly between the teeth; tongue pressed upwards and forwards against portion B.

four years ago, holds that the tongue is one of the main factors in influencing the shape of the arch. Johnson and Hatfield1 have shown that the bite between the molars is very much less in cases of malocclusion than in children with normal arches. These conflicting statements by men who claim to speak dogmatically on the subject show conclusively that the effect of the different muscles on the arrangement of the teeth is st.ill a matter for research. It seemed to me that the first step was to determine norms for the maximum pressure of different groups of muscles, the pressures being arrived at by the use of dynamometers; and to note the effects on the jaws and teeth

E. Sheldon Friel

i-l40

where these groups of muscles, individually or collectively, varied from the normal. At the outset it was essential to decide what standard of comparison should he used for the different groups of children examined. Should it be age or size? To reckon the comparative strength of muscles thl~ size of a child is clearly a more potent factor than his age, especially when size is determined by the height. of the trunk. The sitting height ii'! now used very extensively as·a standard ror ('omparing weight, vital capacity, i.t'., tIle ·maximum amount of ·air that can b" voluntarily t'xpelled from the lungs, and ·chest measurement in determining physical fitness. The tables for correlation of

A'

Fig. 4.-Lateral

ch~ili)(hnanlon1l'll·'.

Lip portion" .'l "1111 ..- 1' Ilt into corners of mouth.

eCA.

Fig. 5.-Vel'tlcal cheilo(l) Ilall1ometer.

Center of lips Ilt un ·lip blocks A and·A'.

sitting height and ''''eight luay he fonnd in "'l'he Assessment of Physical Fitness," by G. Dreyer, Professor of Pathology at Oxford. s In orthodontics· it is of the greatest· importal1r.e to determine, even in a ~~ugh and ready manuel', whether the child ·under examination is physically fit. We cannot expect to find well-developed dental arches in a cluldwho is physically unfit. The instruments usediil the examinatioll. were: Sitting height standard, Fig. 1. Weigmng-machin<>.. Smedley'8 adjustable handgripdyuamonleter. Gnathoaynamometer (jaw).

341

lJ1tlscle Testing and JJ11lscle Training Glossodynamometer (1 ongue). Vertical cheilodynamometer (lips). Lateral cheilodynamometer (lips). Millimeter callipers. The number 75 boys 30 girls % boys II.>

of children examined were: at an orphanage. at an orphanage. and girls. all with malocclusion, in my private practice.

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Fig. 6.-Graph showing averages of molar incisor pressurt'S and handgrips fot' childrt·n

of sitting heights from 60 em. to 7:l em. Lbs. P. lbs. pressure; L.M.P., left molar pressure; R.M.P., right molar incisor pressure; R.Hg., right handgrip; S.Ht., sitting height.

pl'es~ure;

J.P.,

At least fifty children of each sitting height and of each sex would have to be examined before norms of real scientific value COuld be established. The norms, therefore, which I have adopted after the examination of so small a number of children must not be looked upon as in any sense complete. This

1'':. Sheldon Friel

342

small number would inevitably have been much smaUer {for these detailed examinations take time) were it not for the help received from Mrs. Sterling and Mr. O'Neill, Assistant Orthodontists at the DentalUospital, -Dublin, Mr. McKeag of Belfast and Mr. Harold Chapman, to an of whom I am grateful for their valuable assistance. The jaw pressUre was taken between the maxillary and mandibular central incisors and between the first molars right and left (Fig. 2). It was found that the greatest pressure was exerted between the first molars and that th~pressure between the second molars or second premolars was about 50 per cent less. This bears out the opinion put forward by Prof. A. Thomson at the last meeting of this Society, that the£acial bones in man are most strongly

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}i'ig. 7.-Graph shuwing tonguE' and lip p"f'ssures for same children as Fig. ti. H. L., horizontal lip; r. L,-, YE'l'tkal lip; 7'. tongue.

developed in line with the maxillary first molars. In this examination cases with marked caries of the first molars or loss of the first molars were not -recorded. In taking the tongue pressnre thema-ndibu1ar lUcisors impinged on the glossodynamometer (Fig. 3) in the same position in each case under examination. Care has to be taken that the tongue piece is equidistant from the right and left side of the palate, as otherwise it is inclined to stl.'ike the palate on the side nearest the instrument before fhe maximum pressure is -recorded. During the use oithe two lip ilynamometers the teeth are kept closed (Figs-. 4 and 5), and three trials Q£ strength are given with each instrument. A eon.siderable amount. of encouragement has to be given to the child in order to obtain the maximum pressure with all these instruments.

.Muscle Testing and Muscle Training

3-13

The two graphs which follow are constructed from the results of the examination of seventy-five boys belonging to the same school and show the norms for the different muscle groups of children of different sitting height. In the first graph (Fig. 6) the average of molar pressure right and left and of incisor pressure and the averages of hand-grip right and left are given. As can be seen, there is a relation between these groups. This was also pointed out by Johnston and Hatfield in their examination in Boston, Mass.' In the second graph (Fig. 7) are shown the curves made from the averages of tongue and lip pressure, vertical and horizontal. The curves are very slight. showing that in proportion to the increasing size of the child there is not

Fig. 8.

Fig. 10.

Fig. 9.

relatively such a great increase in the strength of these muscle groups as in the capacity for jaw pressure. I shall now show some individual cases emphasizing the relation of muscle strength to the development of the jaws and arrangement of the teeth. Fig. 8 shows the occlusal view of a boy with well-developed arches, normalocclusion and well-balanced muscles. (No. 47.) Fig. 9, side view of occlusion. Fig. 10, front view. ~fUS(,LE

Age 13 yrs.

Right HandSitting Height. Weight grip. R.HG. S.RT. WT. 40 71.3 35.6 lbs. kg. em.

12 yrs. 10 mths.

32.5 kg.

NORMS 45 lbs.

TESTS. Left Handgrip. L.HG. 34 lbs. fOR

42

71

lbs.

Boy-G. C. SCHOOL. No. 47 Right Left Molar Incisor Molar Hori· PresPresVertical zontal Pressure. sure. Tongue. Lip. Lip. sure. V.I,. T. R.M.P. L.M.P. H.L. I.P. 1 141 66 158 211'16 21 0/1'6 4 lbs. lbs. lbs. lbs. lbs. lbs.

*\1

mL

SITTING HEIGHT. 102 115 lbs. lbs.

50 lbs.

3*6 lbs.

2~\I

lbs.

20/1'6 lbs.

It'. Sheldon Fl'iei

:F'ig. 11 shows the occlusal view of a girl also with well·deveIuped arches and muscles. (No. 17.) Fig. 12, sid'e view of occhu:ioll. !<'ig-. 13, front view. MUSCLf: 'fESTS.

K No. ] i.

Age 10 yrs. 8 mths.

WT.

S.HT.

75

49.9 kg.

em.

r:.HI~.

31

lb~. ~OIUIS

1:: yrs. 8 mths.

40

kg.

L.Re;.

I.P.

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V.L.

211.6 Ibs.

...

112 Ibs.

Ibs. ,.,."

'1'.

3l}i6 Ibs.

H.L.

l 11/ ffi

Ibs.

HEIGHT.

95

-1;)

,,~

12.8 Ins.

Ills.

"IT'I'1~G

L'~r.

Il . .lLP.

.P.

112

Ib;.

For: i3

UmL.

R.~J

:18

:.'V 11>5.

411 lns.

4ll Ibs.

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Thcnext two eascs are both of girls ..~hosc physiq!lc is p<.)Ql', pOOl: delltal arches and weak muscles. Both cases came to me in private practice. MUSCI.E TESTS,

GIRL.

No. 490.

Age

8 Yl's.

2 mths.

S.HT.

70

em.

WT.

28.ti kg.

R.HG.

25

Ibs.

I,.llG.

20 Ins.

1.1.'.

13 Jhs.

NORMS FOR 7(J-m-r.

11 yr8.

;;1 kg.

30

Its.

Fig. 14, occlusal view.

28

Ibs.

34 lbs.

I•• ~~.l'.

52

lbs.

T.

V.L.

H.L.

l~ll

1I~

Ibs.

~6 Ibg.

3*6 'lbs.

las.

2

2J,1lj lbs.

Ibs.

SIT'fiNG HEIGHT.

30 lbs,

(Ko. 490.)

R.:\LP.

95 Ibs;

87

lbs.

M1tscle Testing and Mnscle Training MUSCLE TJ'STS.

34:1

GIRL.

No. 394. Age 11

S.HT.

WT.

R.HG.

yrs.

69 em.

3004 kg.

41 Ibs.

10yrs. 5 mths.

69 em.

39.7 kg.

36 Ibs.

L.HG.

34 Ibs.

LP.

5 Ibs.

r:.:U.P.

L.M.P.

3i

T.

V.L.

H..L.

Ibs.

40 Ibs.

1~\1

Ibs.

:i1*6 Ibs.

lo/r6 Ibs.

90 Ibs.

85 Ibs.

3 Ibs.

110/16 lbs.

11~!)

NOI::~IS.

Fig. 15, occlusal view. Fig. 16, front view.

35 Ihs.

~S

Ills.

Ibs.

(No. 394.)

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The next cases are some in whieh special muscle groups were over- or underdeveloped and the dental conditions associated with them. Powerful jaw muscles sometimes accompany narrow arches. Such a case asFig. 17, occlusal view. (No. 503.) Fig. 18, side view of lower. Fig. 19, side view of occlusion. Fig. 20, front view.

pl. Shddon Friel

34-6

MV&:rr.E -TV-ST".· -(JIll!..

No.

Age 16

S.HT.

WT.

83 ern.

yrs.

R.HG.

kg.

+

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82

63.4

lb,.

;)n~.

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]72 Lbs.

178

fos.

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4%) lbs.

2%11 lbs.

-a.L. 2~'6 lbs.

-!-

rhis ease brings home to Olle the truth that musClo is only one fa_eta!' in the development of the jaws and that there are many Qthers ofwhich littl-e or nothing is known. One of the rt'sults of a powel'ful masseter muscle is to evert the angle of the mandible,3- but I do not think that its action or that of the temporal muscle is the dominating factor in determining. the width of the dental arch (Fig. 21). Fig. 22, occlusal view.. (No.5.) The width of the .·mandibulararch between the lingual surfaces of mesiolingual cusps of the first molars is equal to 32.5 mm. ........... ,

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E. No.5

MUSCLE TESTS.

Age 1.21112 yrs.

m

12 Jrs.

S.UT.

"VT.

em.

39.4 kg.

74

R.HG.

47

lbs.

"

I.P. _

L.RG.

49

Ibs.

fi4

-

Ius.

1foI'

HOME GIRT,. f!..M.P.

180 lbs.

L.M.P.

2.02 lba.

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Ibs.

KORMS FOR BOYS OF SAME SITTING HEIGHT.

74 em.

38.3 kg.

49

lbs.

47

lbs.

38 lbs.

115 lbs.

122 lbs.

Ihs.

I could find· no l'elation between the incisor pl'essu·re. and the degree of vertical overlapping'of the incisors. Of the ren boys..whose incisor 111'essure ",vas over 60 Ibs., two had almo.st no vcrtical overbite, the pressures being 71

Muscle Testing and Muscle Training

347

lbs. and 70 lbs. The remaining eight cases had a vertical overbite varying from one-third of the labial surface of the mandibular incisors to completely covering the mandibular incisors. The highest pressure, 78 lbs., belonged to a case where the maxillary incisors completely covered the mandibular incisors. Of the three girls whose bite was over 60 lbs., all had a considerable overbite. The incisor pressures of the boys where an edge-to-edge incisor occlusiou was present were 30, 77, 70 and 15 lbs. The incisor pressures of the girls where an edge-to-edge incisor occlusion was present were 35, 38, 33 and 57 lbs. Vertical overbite of ineiso:rs. Incisor pressure over 60 lbs.:

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G. C. SCHOOL BOYS

No. 24. Occlusion normal. Overbite one-third of mandibular incisors. Pressure 64 lbs. No. 11. Occlusion Class II (Angle). Overbite completely covers labial surface of mandibular incisors. Pressure 78 lbs. No. 19. Occlusion Class I (Angle). Overbite very slight. Pressure 77 lbs. No. 20. Occlusion normal. Overbite half of mandibular incisors. Pressure 64 lbs. No. 28. Occlusion normal. No overbite, slight open bite or edge-to-edge bite. Pressure 70 lbs.

E. Sheldoll Pl'iel

34R

No. 39. Occlusion Class :I (Angle). OVerbil:e Qlle-third of mandibular incisors. Pressure 65-lbs. No. 46. Occlusion Borma!. Overbite half of mandibular incisors. Pressure 74 lbs. No. 47. Occlusion Dornial. Overbite two-thirdfl uf mandibular incisors. Pressure 66- lbs. No. 17. Occlusi-on normal. (lYcl'hit(, half of numdibulal' incisors. Pressure 65 1b,lj. No. 12. Occlusion normal. Overbitt~ one-third of mandibular incisors. Pressure 74 Ihs.

E. HOME GIRLS

:No.2. Occlusion normal. Overbite 3.5 rum. Lt'ngth uf labial surface of macnaibular ineisors 8.1- mm. - Pressure 70 Ibs. No.9. Ocdu,sion Class II -(Angle). - Overbit-t' 4 mm'. Length 'of labial surface of m.andibuial' in('isors 8,6 mm. ~ssurc 60 Ibs. No.5. Occlusion normal. Overbite ".7 -mm. Length of labial ,surface of mandibular incisors 7.4 mm. P"es8m;e 64 Ibs. KO OVERBITE OR- VERY SLlGHT.

No. 2-1. No. HI. No.2K, ~o.::!).

J11('1:'>01'

"

ll. C. SCHOOL BOYS

p-rCHSUl'(-,

:30 77 70 15

l])s. " " ,.

lJ1uscle Testing and Muscle Training NO OVERBITE OR VERY SLIGHT.

No. 18. No. ]5. No. ]3. No. 6.

349

E. HOME GIRLS

[ncisor pressure 3'5 lbs.

"

38 "

" " "

"

"

33 " 57 "

It has been point('u out by Knowle:>D that in Eskimos the glenoid fossa is very shallow in order to allow the mandible free lateral movement during mastication of very tough uncooked food. Ritchie 13 considers that this free lateral movement is dependent on the flatness of the curve of Spee and the edgeto-edge occlusion of the incisorR and canines. It is possible that the muscles that control this lateral movement are underdeveloped in modern European

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man, and in some manner allow this overlapping bite of the incisors to appear. The lip pressure is frequently weak in certain types of mouth-breathers, but it is not universally so. In some cases the horizontal pressure is weak and in others the vertical pressure, and in many others both pressures. The inability to keep the lips shut in some cases seemed to be due to short lips rather than weak lips. It certainly does not seem desirable to overstrengthen the lips by exercises unless one can nt the same time restore the perverted function to the normal. I referred to the influence of the tongue on the size of the archeR at thl' beginning of my paper, and gave you extracts from Cryer and Sim Wallace whose points of view do not seem to be compatible. The size of the tongue is not always commensurate with its strength. A few cases have been seen where th(' tongue is large and flabby, with a weak dynamometric pressure. This is

350

E. 8heldo1i jI'n:el

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iiynamometers. The graph does show Hlat no case ill this series with a strong tongue has a narrow arch. Fig. 24 illustrates the occlusal view of a boy with a very strong tongue, 6 Ibs. pressure. (No.7.) Fig. 25 shows the front view in occlusion, Note the spacing of all the teeth and tnc lllOlars not coming forward into the s.paces. This boy was It normal nose-breathel'.The width of the mandibular arch be· tween the lingual surfaceR of the mesiolingual cusps of the first molars is 35 mm. <1.e.

:\IUSCL£ TEST".

Nu. Age 14 yrs.

S.RT.

74 em.

WT. 37-.~

kg,

Fl.RO.

56

··lb~.

L.IW.

74

em.

38.3 k0' ,.,.

49 Ibs.

41 lbq.

Ills.

XORlIIS FOR BOY",

123112 yrs.

LT'.

56

74

SCHOOL.

I.

R.lILP.

135 Ibs.

L.M.P.

141 lbs.

V.I,.

6 Ills.

2~f6

H..L. 11~m

31 *6 lvs.

2t1iJ

2'h~

T.

Ibs.

lbs.

c.\1. SIT1'INH HEIGHT.

47

38

Jh~.

-lh~.

115 Ib".

122

·lh5.

Ibs.

Ibs.

1I11lscle Testing and 1Ii1lSclc 'Training

351

The next case is perhaps the most interesting of all these, as it shows the action of the tongue on the development of the mandibular arch-the want of action of the lips, and finally the restoration of the function of the lips as the malocclusion was cured; this case was originally a mouth-breather. The narrowness of the maxillary arch compared with the mandibular arch can be accounted for by the fact that the tongue lies in the floor of the mouth during mouth-breathing. No. 411a. Fig. 26, occlusal view. No. 4lJb. Fig. 29, occlusal view. " 27, side view. " 30, front view. fJoont yil'w. 28, " 'w.

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Fig.

31.

The width of mandibular arch, No. 411a, between the lingual surface of the mesiolingual cusps of the first molars is 36 mm. The next case is an illustration of a weak tongue associated with narrow arches. The tongue pressure is only 6 oz. Jaw pressure and lip pressure were good (Fig. 31). (No. 481.) The width between the lingual surface of the mesiolingual cusp of the first molars is 25 mm.

352

J~.

Sheldorl Friel

.\l U'K'LE 'rESTS

Age 12 yrs. 9 mth.s.

S.HT.

78

WT.

43.6 kg,

em.

84.3 em.

56.2 kg. 55,2

kg.

84.7 em.

57 kg.

R.HG.

67 1bs. 61l Jhs.

til ]bs. 67 1bs.

ti9 lbg.

69

1tJs.

(H'

J 1l. Ii. \LP.

I.P.

hIlG'.

60 Ih". _50 Ih~.

51i HiS.

62

t"" i~

Ibs.

50

H3 1bs.

(i~e

Ibs.

Ibs.

Ibs.

Ibs. 58 Ibs.

lbs.

1hs. 93 lbs.

Ibs. 6 12,,16 Ius. 6*6 lbs.

1bs.

90

Gnu

uVm

UO

100

]bR. 101 lbs.

1bR.

m

Ib8.

lbs.

94

!Y' ,0

JhR.

V.I,.

oz.

87 Ihs.

42

j}-.",.

T.

13%

40 Ibg. 34 ]bs.

56

Ib".

TT.:-LP.

]175'6

lbs.

2%6

:.'0/1\1 2'h.ll

lbs.

2~1\l

Ills.

2tJ.\I Ibs. ~6 1bs. 11~6

lbs.

2

Ihs.

11.1,.

,lan.

]922 OCt. 1922 Apr. ]9~3

Aug.

1923

Nov.

192il .TnIl.

1(12-1-

II L.t~--~-

Fig. 32.

Fi"".

3~.

Fig.. 32.-Dynamometer for testingbUICcinatora. :Milled portion 0 held firmly between first molars. Lip gullJ'd AA' ll:Ilde.s along. bar N. Guard prevents action of corner of lips on bar F. The buccinator' exertB- prellll'ure on portion B. Fig. 33.-Lip exerciser. U spring' B can be moved through sockets 0 and 0' in order to increase the force nece!!/lll.i'Y :to..cl~ lip portions A and A' from 3 ·oz. ·to· 18 ~z. MGSCLE TESTS.

Boy.

No. 481. Age 80/12 yr~

S.HT.

67 em.

WT.

24-.4 kg.

R.HG.

il6 Ibs.

L.HG.

31

Ibs.

:"10RMS FOR

9~~'12

YI·R.

28.3

kg.

29 Ibs.

67

27 1h8.

1.1'.

R.M.P.

H lbs. (''If.

77

Ills.

L.J\J.P.

70 1hs.

T.

. V.L.

Ii

oz..

H.L•

110/{6 1bs.

2~1l

Ibs.

SIT'l'Il'.'G lIEWill'.

:;:2 1bs.

811

11.8.

,9

IhB.

2:t~\l

lbs.

]l;~t6.

1bs.

2 Ills.

Most of .the boys in the orphanage were examined in October, 1922,. and again in October, November, 1923. The relation of the tongue preSsu:re to the width of the lower arch after the iilterval of one year was in some cases most suggestive. I give the details of the width of the mandibular arch and corresponding tongue pressure of seven cases in 1922 and again in 1923. It seems probable that the development of the- arches and the arrangement of the teeth is dependent to a great extent 011 theprO-perdevdopnient

Muscle Testing and M11scle Training XO.

353

WIDTH OF lUNDmULAR ARCH BETWEEN FIRST

TONGUE PR};SSURE

DATE

1IfOLAR~.

31a 31b 14a 14b

ila

3b

Sa

Sb

39n.

39b (in.

6b 9a 9b

30

31 + 1 27.7 28.8 + 1.1 ill.7 32.7 + 1 30.5 32.4 + 1.9 32.5 31.4 - 1.1 31.8 31.3 .5 33 33

mm. mm. mm. mm. mm. mm. mm. mm. mm. mm. mm. mill. mm.

mm. mm. mm. mm. mm. mm. mm.

11~\)

Ibs.

Oct., 1922 Oct., 1923

2~:6

Ibs.

Oct., 1922 Oct., 1923

30/i6 + Wtr.

Ibs.

+ +

31*6 Ibs. 2¥J.\) Ibs. 3l}S,6 Ibs. 1}5.'6 Ibs. Ibs. 2 1 1¥t6

:l,iG

+ 1tYJr,

lh~.

lbs. Ibs. lh~.

~i6 lbs. 3ry1i; lbs. - 11,i6 Ibs.

Jbs. Ibs. Jbs. 5%0 Ibs. 3l}S,o Ibs.

3o/t~ 1 1 %'6 - 1 10/io

Oct., 1922 Oct., 192:: Oct., Ul22 Oct., 192:1 Oct., 1922 Oct., 1923 Oct., 1922 Oct., 1923 Oct., 1922 Oe-t., 1923

- 11~'i()

and balance of the different muscle groups and that in order to al'l'in' at a correct diagnosis of the individual musculature we shall have to test not only the groups of muscles, as I have done, but also the opposing groups of musdes. I am about to have two further instruments made, one to test the strength of the buccinator and the other to test the depressors of the mandible. Fig. 32 is a drawing of the proposed instl'umt'nt for testing tIl(' buccinator. Much has been written in the A.merican dental joul'llals on muscle training as a means of curing malocclusion or at least as an adjunct in treatment. )'Iany ingenious exercises have been suggested, especially by A.. P. Rogers. tO That such training must form an integral part of successful treatment I have not the least doubt. From the illustrations I have given, the association between undpr- and overdeveloped muscles and certain forms of malocclusion is, I think, clear. A great advance would have been made in orthodontics if it were possible so 10 develop the affected muscles that they could carry out their normal function with ease. It would, however, also be important to make sure that they were then free from extraneoUf; hindrances to their normal functioning. e.g., it is of little use making it possible for the lips to be kept naturally shut, UlllesR at the same time we Sf'e that the nose is in such a state that it ]wrmits free pasage of air. I would make the following' ::mggestions to those who take up this branch of orthodontics: 1. Determine which groups of muscles arc affected and confine attf'ntion to these. 2. It is essential to ensurl~ the cooperation of the patient. The child should clearly understand the purpose of the exercise and at the time concentrate his whole mind on the group of muscles selected for development.

354

E. Sheldon Friel

3. Avoid exercises which lllaypl'oducc unnatural habit movements and choose those which simulate the natural function of the gNmps of muscles under consideration. 4. Beware of overfatiguing the museles, .werloading them, or reducing them to a state of 8ta1l2nes8. The repetitions of each exercise in two daily periods should be graduated from small beginnings and discontinued at the first signs of fatigue. Personally, I think it more possible to distinguish between maldevelopment of special groups of muscles and general maldevelopment by means of these dynamometers than by any other kno~'1l method. It is open to question

Fig. Z4.-TQngue exerei;;er. Tedh block,,- ,t '-l11
A_~_-=-=-""""

-. ---

_

.--

Fig. 35.-Jaw exerciser. Biting _portions il. and A' coated with 1=,1. - Resistance to biting action can be increased -by screwing down mHIed- nut B.

whether better results can be obtained -by voluntary contractions of the partieular muscle group, or by the'llseof mee-hanical exercisers. The danger of introducing habit movements with voluntary contractions, whieh if~ onceestablished might produce an even worse maloeclusiol1, is avoided with ex~reise-rs. During the last :few months I have been experimentally using the following exercisers: Lip exerciser by Rogers 10 .Lip exerciser by Friel, Fig. 33 Tongue exerciser by -Fig. 34. Jaw exerciser by Fig. 35. As yoti know, it is very easy to overstrain a muscle and very difficult to

Muscle Testing and Muscle Training

355

heal the resultant damage. Therefore I think dynamometers essential if exercises are to be used in order t.hat the strength of the exerciser may be set proportionate to the strength of the muscle. If the instrument is set at a qnarter of the maximum strength of the muscle, it will do no harm. I haye observed during treatment by orthodontic appliances an appreciable tendency of the jaw pressure to diminish, but I find the pressure can bc maintained by means of biting exercises. Many children have such small eapacity for pressure with their incisors that they cannot bite a raw apple without pain. The jaw pressure between the incisors can be increased in suitable cases by biting exercises, adding much to the comfort of the patient. IIl('isor pressure has been incl'rasec1 from 6 lbs. to 34 lbs. in a few months.

-

--=Fig. 36.-Lip disc.

Rod ..l.LL' prevent" di"c being held between teeth.

Fig.

37.

Probably all cases under treatment by appliances would benefit materially from an increased function. Oppenheim ll • 12 showed in his experiments of moving the teeth of monkeys that the striae of the bone were formed more or less parallel to the direction of the greatest force. For example, in moving an incisor forwards, the bone in front of the tooth was absorbed on the side adjacent to and built up on the side remote from the tooth. The striae of this new bone were parallel to the d.irection of the force. In a later experiment he showed that during retention this newly formed bone was reformed and that its striae again became parallel to the long axis of the tooth, i.e., in order to withstand the greatest force, the force of mastication. This fulfills Wollf's law of bone transformation. Possibly there might be a considerable reduc-

356

E. SheldQi! Friel

tion in retentio,ll if the function <;If mastic!.!,tion was greatly increased, as by biting exercises. Exercising the tongue undoubtedly leads to an inc~rased dynamometrie l'eading,but \vhether this increasc of pressure portends" a corrcsponding' increase in the size or the tongu-e I am not yet in a position to state. I have five cases at present with narrow and cro\nlce! arches all' coming under Class I (Angle) who are being treated only by cxercises. I hope that at'-the end of a year I shall s~e SODlC marked improvement in the size thdr arches. The hanging lowpr lip and ,short Upp-eT lip of It mol-II h-breathe.r have 111ways been a perplexing problem for the orthodontist. ~Jl.)d I think ,ve are greatly indebted to Rogers :for hls suggested e~e!'ciscs for the treatment of this condition. By the use of all excl;eiser it ,is possibh~ tt.-incrrase the aynamometric reading of the liPH, ,but this alorlc in mOf;t case" is not suf:fick~l1t to cure the mouth-breathing. I bave recently experimented with a very simpl(· appliance in order to get rid of. the habit (If ke(>ping thr. lip~ apart (Pigs. ~{6 and 37). A small metal disc about the- siz~ an~ thickness o:f n. penny (3:2 cm. by .2 rm.) is h('ld bptwepn tIlt'. lips for periods during thl~ daj-, the lengt,h of a prriod being incrC<1sed as the lips get more adapted to theil' 11('W position. In conclusion, I would bring to you]" notice' OM ot hrr ('xl'rci~e SLl~'gE'Bted hy Rog-ers,1° whi<'h seems to me uncommonly good. IT.' calls it 1], tonic ('.xC'J'cisC'. This is his description of it: "It is :fr.equently found n-eecssary to })]'I;serH>€ a tonic exercise, \vhich I have termed the exercise for general i'a(~ial 11nelopmrnt. This,p.xercise influences not only the orbicnlaris oris. b11t also lh.· huecinator and' all the small ribbon muscles which enter into a combination with the orbicularis -oris. It ronsists in tIl(' URe of warm w'aicr at a temperature 'which is bearahle to the mucous memhraul' of th0 llH.llth. [111(1 jn which has bC0u dissoln>d n. smull portion ofbjeal'1)onate of soan; tlw pati"11t ,jsn.il'cc-ted to take a sip of the soliltion, dosing the teeth firmly in _position a11(l with great cnergy forcing the 'liquid fro-m the lingual caYi!y into the lmc.eal." \Vhen properly 'carried out this exercise ml1st benefit the muscles of th\! tongue, the buccinators and muscles of the -lipS". :My own aim in muscle training, has been direeted altog't'thcr to l1uiJding up the individual groups of nndprdeveloped facial muse!ef'. (Tho!"le rases where the entire inusculature of the body is ,undeveloped are more suited to treatment by a ph;ysician than 'hy an orthodontist.) From \-vhat I have told you tonight you will haye realized that my_ OW11 theories and methods are al; ye1- in the experimental stage; but neyertheless, as I said earlier, I feel convinced that muscle training must eventually form, an integral part of treatment in many types of malocclusion. It should not, however, bf\ :forgotten that muscle train~ng cannot be judiciously und-ertaken without previous musCTe testing. Definite methods of c~l'­ tclating the strengths of different muscles with ea(~h othe·r and with the gene eral development of the ('hild must be employed if good and not harm is to follow. I have suggested the use of dy.naulOmeters, but som-e -alternative illay be raised from the melting-pot of longer and 'wider experienees.

or

Muscle Testing and Muscle Training REFERENCES 1 Keith,

Sir Althur: Antiquity of Man. zPickerill, H. P.: The Prevention of Dental Caries and Oral Sepsis. Ed. 2. ·'Cameron, John: RepOl'!; of the Can3,dian Arctic Expedition, 1913-18, Vol. xii. The Copper Eskimos, Part C. 4Colyer, J. F.: Dental Surgery and Pathology. Ed. 3. ;;Crye1', l\futthew: Internal Anatomy of the Face. Ed. 2, pp. 285, 293. 'l\Vallaee, Sim: Essay on Irregularitles of the Teeth. ~,fohllSon, A. L., and Hatfield, H.: A Stndy of the Relation of Dental Conditions, Biting Force and the Hand-grip, Dental Cosmos, June, 1917. ., Dreyer, G.: The Assessment of Physical Fitness. -'Knowle~, Sir Francis H. S.: The Glenoid Fossa in the Skull of the Eskimo. Geological Rurvey of Canada, Museum Collection No.9, AnthTOpological Series No.4. Ottawa, 1915. '''Ro!'ers. A. P.: Making Facial Mu'
Dr. Sim "\Vu]].a~e ~fl.id he felt a personal ;;atisfadion in the extremely RCientilje way jn which the president hall corroborated an a1tempt of his own made twenty years ago. rr!Ie paprr. he thought, would have SOllio9 far-reaching consequences. The president had spoken about a book which he (Dr. Sim Wallace) had written twenty-four years ago. That was a 5light mistake. 'I'hat book had been published in January, 190,1, so that it was only twenty years oW; it had not come of age. Next year it would celebrate its twenty-fil'st birth(]ay, am] '110 now ,brlieved by t.hat time it would be pel1fe0tly up-to-date. There was one thing about the paper which he dill not quite like, T'he preSident had referl1ed to Cryer's ideas all'll his (Sim "\ValJace's) o-wn and had shown that they were quite incompatible. He quite Ai:;reed with that, but he would have likell it better if the president had sho~vn the very cun>iderable amount of agreement which existed between himself and the president. The president said that in orthodontics it ',vas of tlhe greatest importance to determine, ('ven in a rough amI n~ady manner, whethf'r the chilll nnder examination was physically fit, mul m;ke,] tl,,) question, "Can we expect to have well-developed :uches in a child that is physically unJin" He had answered thll.t question (on page 79 of his book) very much as the president had (lUllf'. in the negative. Again, the president said that one of the results of a powerful massf'ter was to evert the angle of the mandible. Personally he had come to a simil:tr conclusion. He forgot w:lwtiher it was from looking at skulls or otherwise, but anyhow he had rderred to the fact that in those races which uSf'd their mass.eters most the angle o,f the mandible was evertell (pages 40 am] 41). The presillent fm ther ~aid, "I do not think thH-t it, I\c,tion or that of the temporal muse1e is the dominating factor in determining the width of the dental arch. " Neither did he himself. Friel also' referred to the size of the t'lngue not alwa~-s being commensurate with its strength, and referred to cases of thyroid deficiency. On that point also he and the president were in very thorough agreement. He undprst,ooil that thyroid deficiency was characteri>tic of cretinism. Oretins were weak and small, hut the tongue was pathologically large, and the arches of th,e teeth were well develope'd notwithstanding their weak physical development (p. 101). That was a significant though exceptional case, Howcycr, he and the president appeared to be in complete agreement as to that point. Perhaps some of the memhers had noticed in the December number of the Dental Mag'(j~~ne a paper by Prof. Izard in whilCl] he explained A. P. Roger's C1Xercise~ and rderred to -Nlem as a new physiologic method. He (8im "\Vallace) was lllclined to think they were by no means new, b{)cause he himself kld advocated general and special physiologic lllll~cu'ar exercises twenty years ago (page 11.'5). These exercises were not the artificial exercises which had been recommended by Rogers but mther the exercises whidl had been prescribed by Nature for the last few million years. More recently he had indi,'ated that :,'",me exercises ought to commence with the eruption of the incisors, i.e., with gnawing exer(', 'es to prevent postnormal occlusion.

858

E. Sheldon Fril'l

The president hau dispos<'u of Prof. Pickorill'S' lmu Cry<,! 's tJIeories bllt'-he 'haa not referred to the rate of Sir Arthur Keith's theory. If he unde:rstood Sir Arthur Keith correc'Uy his view ·was' that th!'!'e had becn some gradual change in ,the' hormones, especially from the pltmitary, and that he assumed there Was some hereditary di:tl'aericil between us and OlJr Ail.glo-Saxon or :!'< eolithic ancestors; bilt if it were true that we lacked i'u"h J1l1l~ellhl," exercises as were assOciated \vith the maatlieation of coarse and fibrous foods, we had no need whatever for introducing a hypothetical lack of the dev,elopmental stimulus :1Ssociated witJI hm·mones. Watkins had ,l'ecently brought forward, -a '-case, and he himself had referred to Sl,me cases in his book, showing how the tongue influenced the development or jaws and t"p.th. Pwf. Izard ~lso mention,ed cases sho\\'ing how the tongue in m:i.crog~ossia increased tke dental arch and that, after; the t~n~e was reduced by operative treatment, the jaws ana tt'eth' reverted to ,uorrual. AltogetJIt'l' he. thought it was Uj(~ similarity U£ his aur! '1 he l're~i, dput's views which sholild have bppn emphaffized rather th:t'n the di:tl'el'~cc bet",~p hi~ !lUll Cr~'er 's viewe. 'l'hel'e was, of cOIll'"e, a. great uifforenec betwpen anythingwh~h he had uOlle and the work' of, Sheldon FrieL Friel had gone into thp matter ina v('r~' thl1l'o'ugh and scientific \\-8.y, wheTeas what he himself had donc, 'hll.d' been pel'haps rathl'l'in the l1utme 1)[ ratiocination. Fortnnately, huwever. his l'eUSOnillg seemed to have lH'cn right, unll if: Ill' did speak oogmatically" twenty years ago he had the satisfaction' (JIf' leamillg no;\' that he had been justmed in doing Si,. He l'Ol1cluucu hy cOllgratulM2J1g Il,e preSident I)~l his v~ry excellent paper. MT. Rabert Lindsay saii! his reail<1ll for ri~ing to speak was that he was one of the \ fry few who had seen the beautiful instruments shown .fry the pre,sid~llt aetually lit work. Hl' I'cralled a ver,V- delightful morning which he had ~pent in Dnbl_in see,ing- 8"111e of till' children, ,whose photographs lUld bf,en put upon the scre('n, bring put through the. particular t('sts described. He dill not intend to touch upon the anatomical incongruities which - the president had instancpd in his paper, although he might I'e-mind Sim Wallace that probahly ,he president w.as right in uating 'Val1ace's contribution as beillg twenty-foUl' :\';'fLr~ 0111, ],pcause the fil'st chaptel' oj' the book haa !:wen published in the B·riti.,h VCJ1trll ,T()III"(1~ f,-,-,"nt.'four years ago. Thet'e was one statement of Sir Arthur Keith's which pel'ha]1~ the prcside1l't might be induced to remark ujJon in allY TePly he madl'. Sir Arthur Keith Rllg'gl'sterl that the modern inhabitants of our WeS'tcm eities had Pl'-llc.tically l~st the power (If biting. It would- appear from the president's dPIDon:;'tratioI! t.hat evening that- the pOll-er of. biting with the' incisor teeth was -wther strongly maintainpd in nJod~,l'l1 ('hilJr(\J-1. 'l;hl'rc!ol'(, It Ira'; 1I0t HCcessary to suppose that when that rom:r exi3t;pd to SUrli a' tff'r;ree lI,S ha,l l,een i!1'ffillnstrateu on the screen that the inhabitant·s of Western cities had lost the bitiner fnnction witli their inciwr teeth. He thought t-he members might congratulMe the pn".idellt ,UP';ll following up what had heen done by Sir, Arthur Keith ana'Campion at a: nl)1ch parlier l)Priod in the present Session, when they had d<>monstrated the developmental possjbfJitil" in ('lHlnection with OI'tM
all

ejtbl'l' defideneiet-:

01'

O\t"\) (It!)"(']npllll'llt

£If

il

l':ntitU~Hl'_ ~rPll]1 llf lIP~t.:~ It·~. hut ~illl!,lr

i11(11-

M~tscle

Testing and Muscle Training

359

cated the advantage to the orthodon~jst of being able to test the strength of the muscle hefore he attempted to blame it for some parti,~ular deficiency. With regard to the question of the tongue, it had always seemed to him that the dynamic force of the tongue was sometimes overlooked. For example, a small but active tongue might do very much more in influencing the arches than a large and flabby one. When one reflected that in modem days the tongue had a very large activity in the onlinary actions (If ~l'eech, that might be held to make up, to a certain extent, for a smaller amount of activity in the mastication of coarse foou. The uevelopment of the tongue had also to be remembereu. It had occurred to him while Sim Wallace had been speaking that the thyroid gland and the tongue practically had ,I develupmental origin similar to eadl other, and it was just possible that if a thyroid gland was imperfectly developed, the tongue itself would alfo he imperfe"tly developed. There II C're wry far-reaching points in conJlf'ction 'with that n!atter to hC' considered. It seemed to Ilim that the president, in describing his operations in muscle tC'sting, had gone a step further than Rogers, because Rogers had not that very ingenious set of dynamometers for recording t"st~ whIch the president had. Rogers had only one dynamomC'tC'l', 'Va~ it not thn case also that Johnson and Hatfield had been confined to two dynamometers with which tIIley could Jlmkr the tests' Sir Arthur Keith spoke of the forcing of the condyles of the jaw into the t-:lrnoid cavitj' when pressure was brought to bear upon the molars. JOhnson, on the other halHI, said that the pressure and the pain were felt in the periosteal membrane, and that it \I a~ Hot the power of the muscle to contract which was the check upon the ultimate register. hut the pain which was induced in the tis&ut's surrounding- the tCl'th. That '\Vould seem tIl indicate that there was not that !)]'C'S5Ul'0 in tho glenoid ravity on mastication wlhicll \loule! he indicated by what Sir Artllur Kl'ith had said. - Johnson harl, howpypr, also said tktt in certain cases he had pain reft'ITcd to the temporomandihular articulation instead of I" the .sockets of the teeth, anu ho "ould like to ask the pl'C'sitlent if he had an~·thing to rrcall in that respect-as to whethel' the actutll pain feit was in the sockets or jn the articulation in the exercises and tests throngh which he had put the patirnts. lIe ('ollclul1cd by I:xpres~ing the grC'at pleas'lHe it had given him in hlLving listenC'll to the president's address. Mr. B. Bull said he only deSiired to raiso one point, and that was jll connection with the llll'nhCln made of tho inhabitants of the ,""estel'll Isles and thC' relationship brtw,~en the inPlsor pres~UI'e and the uegl'l'e of vertical overlapping of the incisors. The president said II<' could find no relation between thrnl. That seemed to bl' a most extraordillary thing, I"','an~e if one went back to the pre.listoric men, they had an eug-o-tn-edge bite, and cun~i,leling their method of feeding. ho \Ylmld haY!' thought that thC'ir incisor pressUI") would 11:1\"1' been simply enormous cOlllpareu \"ith the modcl'll man with tho vertical ovcrlapping of t he incisor teeth. 1\11'. Pitts said he would like to aud his humble meed of a.lllliration on the president's \ ,.!')' masterly address, which had placed every orthodontist under a deep de-bt or gl'atitude ----110\\- uel'!' he did not think thcy at ]Jrrsent realized. He Imll used in one ca~e tIll: Roger's Exel ('i~p]' for the orbicularis OTis musclC', which, accol'ding to the testimony of tllC' parents :111,1 "tilel~, had yieldeLl a good rp~lllt. The patient \vas a girl with a postnonnal orclu~ion. H Illouth-breather, and with that thid, hC'avy lower lip which is so often seen. It seemed to him that if one cuuld gpt grPatpr muscularity in that lip it would be an advantage. He h:ul put the patient on that treatment; she \\"as Yery interesteu in it anu carriell it out very \1 <'II. :,nLl there was no Lloubt tha.t it Ila,l ma,le the lip wry mUl·h 11101'(: mohile. He hail, of ,....111',<'. used it empirically, without allY prelimiuary testing, and without haviug the vaguest ,d,'a of what the normal pressure 011 the lip ought to be anLl how far it was deficient. He 1,,'licu'd tilat tho tonie mouthwash which RogNs spoke of would probably be ju:;t as effective, I.ut it \ras to be said that the illstrull1C'nt of Rogers was a rather showy little device which I"qneLl thC' curiosity of the patients x,d thel efme ~'ou thought thC'y were 1U0re likely to use it than such a very humble and humdrum thing as a mouthwa:;h. 'l'herr was a good deal of I'\-i,lt'l1ce that use did playa wry iml'orta.nt part in the power of the lip. For instance, if Olle ]ookC'Ll at the photographs of actors one coul,l not but be struck hy the very finely chiselled :,,1<1 mobile IiI'S which they possessed. Probahly COJlstant puotic spl'akin~;. and the necessity for ckar ellllnciation, had a very big effC'('t on strengthening the power of the lips, which Sligg",tC',1 that the exerrise might ha\'c a u~e ontside of orthodOlltics. ::\11'. Harold Chapman ~ai,1 thC' llu'mllf'rs lllul li~tenp,l that. ('wnillg to a most admirable

360

E. Iljheulon l'rid

paper, the value of \\"hich, as Pitt:; hau ~ai,J, the) d ••t !lui .IPt fnll.,' r"alizl'. The l','c"ideut, in the first paragraph of his papt'r, said that his heal't failed him, llUt, t11pn~ \Va" n". lH',,!l for him 'to have said that, uecauS(! he had sh()\Yll Ilinlself that e,cuing a ,cry worthy SUCrf'~'\',r of his illustrious predecessors ill the Chair. Thi'pap"!' was 'moot yaJuable on account nf ii, Jack of complexity. , He WlJl1lr:l like tn ltaye f-aid 011 nceOllllt of its simplicity, hut lip, 1\\1-; afraid that if he diu :;0 l,ne won!,l inil'!' that it lYa~ a ,~inlple papel', and he uid not want tha,t impression tt) goo fo!'th. Lt \\'a" 10) his luinJ. a highly Miell'tifil" and practil'al }la,I"·". written in such a way that Jl]emuprs hall hel'ulI,IJlc to enj{)j' it thoroughl~~. Hf' rl'aHr did uot remember any pape!' which htHI 1''-'11 n'ael lll'f.),·" the society whid, had. been so (,Ol1"b 11," n\'e in its efforts. If in allY WHy it ha,l beC'n d(~h;l1rti\'e, it hrid onl{ hecll i1estnletiw Fr, III a constmctive point. of Yi.·\\", if llC' Illlg],t, l'ut it ;;f.1. 'I't. giyfl au exam ph', he wn~ afmi.1 thnt 'hi~ own efforts in inusde tlaining had he('ll absolute[.,' l'Ill!Jirical, anI! the presidC'nt hu,l-I""'lI most llestmctivefrnm t4111t point Hl "it"", l\ i, I tilt' speakeI' 's) TIII:' givl' :1 llUllllal uV"I'hite, for l}'" l'l'ason ,tlrat thos,' mnsc1l';; \\'" ul,] 1,t' "xercisl't! whidl \\'1'1'1" ut.ta 'heel to that. l'nrtit'll or tile ja\1 \vh,'w dl',\'('I"pm(,llt wa" nr,?C';."ar.,' to give u correct· ov('rhiff'. 'Wit It J'f'gard to Q1ll~s IT 'ca~~~. hI' wunh1 lik" to ask thr prl'i'i,knt 'i f he' had found any uiffere~ce in the Flvision 1 r~a~es J,Llld the })i\'i:lion:l cases with rf'~aI'!J to IiI' pJ'essurC'~: in nlll' th(' lip" Wl'I't'SJ~t:'J;/'(' ill keepi11g back the maxilla,:y incisurs,. f1:3 in tll.c chiltl they Iuirl ~e ..n. aod in tIle' O>tlwi <'a;.,' -that was Division"~. \vith thp J\O,llprumin('nt incisl'r~ -whether iho~fl lips Wl'l'C ~trvngl'r, a" ~o me be liCyelT. A short tinll' ag') ht) lraJ !lrul'd uf II c:lRe---he "(lul.l sral'cl'ly c,l'l"Et it was actually s" ~ 111 whieh the maxiJltH," ill(~iO'ors werc dJ'iwn bark into a Diyision :2 type by nreanll oi till' lips. Also ill a rerl'nt 1"1]1"1' Pnnt ltafl ~ai,l tlmt thC" mn,'!Ch's in Class II NISi's wer\l murh weakpr than the~' wprp ill the otheys. but what !ll(':hor1R Pont usen for t('sting hedirl not know. He had u:;€u the pl f,~frlpnt 's lip l'xl'rl,iser in on" ~as(' with mu~t "atisfactory, l'('sultO'. 'rile paticnt had been ·trt'atcrl befol'e he had seen him, antl the only' thing that was wr
Casual COl1wwnicotions

:361

,I,',ign. The members that evening had heard about it all in the course of an hour or so, l,nt he would not like to think of how many years the work had taken the presirlent. He ,k,ircd to offer him his very hearty and sincere congratulations on his efforts. The president, replying, saiu that Lindsay hau suggested that modern man CJoltld not It,· ~uffering from any deficieney of muscular strength as he Iwd such very great poWPI' "f in('i~or pressure, but as orthouonti~ts did not know what power was possessed by pr0lll~toric man. or Eskimos at the prescnt time, that problem could not be solved until Lindsay ""lit to the Arctic and pursued researches there. So far a" he knew, Rogers had 110 dynal"tllIHters in use for muscle testing. Whenevcr he had a"ke,l pa.tient~ where they fl'1t pain "I,('n biting. they had always indicated the periodontal mellllJl'alle; none of them Ilad rrfcrrerl tllt, pain to the c,ondylf's. Bull and sryeral o,ther sreake1s ha,l i'poken of a pos~ihle rl'lation I" lm'en incisor hite and the ovcI1lapping of the incisors, in regard to which ho ha,l 'lUtltpu 11 ')J1l Si I' Arthur Keith. Personally he could find no relation, hut until he had (l],ptlrtunit.y t, ,'x,mlllle larger numbers couW not speak conclusively. There were more 'with OVf'rbite with JIlC;h prc"sme than there \vcre with edge-to-eage anrl high pressUl'e. Chapman hall a"k,',l II ilf't J,e1' the lip pressure \vas different in Cla~s II. Division 1 ("\ngl,,) from that in Cla~, IT, nl n"ion ::l (Angle). It was greatest in those in the retrudmg maxillary inciS('r". Chapli,an hUll alfo asked how he testeu the size of the tongue. He dill 1I0t know how one ctln1<1 1,-t tJIl' size of the tongue except by looking 11,t it, and lookillg at it again. H,' lmo aJ",) j"'I'n aske,l the age of those patiellt.s \\'ho were b<'ing treated ,,'ith exerr-iH's only. The patil'nts \\"le five boys of eight to ten yems tlf agoC'. HC' tJ,ankC'II tll" lll"lll11l'1S Yf'l'y nnwh for the \'<'1'," flatt"l inc;' tiling', thl'," hllll "ai,l about hi,: a,ltlll"s,

('.\i'l'AL ('O:\DIU",Il',\TIU,," ~11. F. Rt. J. Steadman gaye a Casual Communication, "Ca~e for Diagnosis and Tn'atJlII'nt.·' P. F. L. (age 17). 'l'his patieut's mouth presents several unusual and inten'sting f,'atn1'l''', In the maxilla both canine!; have erupted intemally, due apl,arently to the retentl,m up to the age of sixteen of the deciduous canines. 'Vhile an instanding call1ne uue to llti, cau:,e is not uncommon, it is in my e,xperience rare to finu both in this malocclusion. In this 'a~e the left mandibular canine was also retainpd until a few weeks ago. In the lliaxtlla there is a slig-ht narro\\'ing- of the arch in the premolar region and there is a prllt Illsi',n Ilf the incisors. In the mall dible there is considerable c]1(l\Ylling which dol'S Illit appeal' til he due to a lack of develop:nent, since the lower border of the manoible is appar,'utly normal. The left mandibular ,ecoml premolar is unable to erupt thl'llugh lack of frace. There is no history as to the fate of the right mandibular first premolar which is aIN'nt. The radiograms sllO'w a gen,!ral sloping lJackwards of the front teeth, as though tlll'y haye been thrust backwards and immros, causing such a narrowing of the arch that tlte pn'lllolars bite inside the uppers. I consider that the position of the permanent molars IS nllrlllal, both with reg-ard to their position in the jaws and their occlusion. At first sight tillS ill'egularity of the mandibular teeth weuJd appeal' to be partly accoull!€d for hy the I, ,," 0'11' abs('nce of the right mandibular premolar) but the same condition obtains on the ],oft SIde.. where both premolars are present. I can obtain no definite history of ll1lJuth· bll'atlting or of habits. She had foUl' or five teeth removeo at the age of eIght. It is P"S"hJp that the right mandibular premillar was inadvertently In,,t at this tinw. It is interestII'g' til 'llPculate upon the causc of this condition. A powerful muscular action of the lilwer 1l!, ]'ll,hlllg the maxillary tel'th forwaros and the manoibular backwanls afkr the early ext1artilln of the deciduous teeth would be a feasible explanatlOn. I am a IJ<'liever in ~im \\'all:u'(", theory that the development of the jaws is clue in part to NIl' actilln of the j"nglw. In this case, IwweYer, then' appears to be some fnrce p1'l'sent which has been able to cillllpress the lower arch in spite of the tongue action. It is inten'stillg til nnte that tJle 1"ltil'nt's general appea,rau, e is very much better than one would think likely from an (·).aJlIlliation of the mo,ll'ls alone. I shall be glad to r?eeive the opinion of 111rmbers 11) as ttl t],,, probable l'ause of thi" irregulality and (2) suggestions as to treatmcnt. ~lr. Pitts said it was very difficult to come to any oe,fillite conclusion on a hasty examIliatl',n of the case. Ill' had formed 1he imprr:,~ion that it \vas a case of posmormal occlu", 'n, allil that although the mmlllilmlar mulars appearc,l to ],l' in thl'ir normal relationship tlilit \\ a~ ]J('t'ausp thl'Y ha,1 ,'ncrlla,.Jll',l OIL the spacr that ,houltl Jwve beell occllpil'd by the

362

('((.stlal COIJUllllnic((tiollS

6eCond premolars which .wJlrC not prescnt in tile arch. Ii the preJI]Qlars hall been present then the mandibular molars would have been tit distal occlusion. Looking at the patient's proiile, it had seemed to hil)l that she did show evidence 0 f mandibillar retrusiO'Il. n hQ.d seemed' to him,' too) on luoking at her and questioning her, that apparently she did get the lower lip underneath ·the maxillary incisors and that the protrosion. of' the maxillary incisors might be due to that fact. He noticed thnt ~he hall that rather thi.ekenoo. penduluus appearance of the 10,,-er lip whi("lt all tho~e ClaMS II cases hatl. anil that there was some _degree of mouth-breath.ing, because t11(' mandihjt~ heing in l'ctrusion, it was only possible to close the mouth by a :ver.v distinct effort on tlte 1'0.1'(, of tilc lip. T.hat Ilail heen the impl'~­ sion he had formed on rather a hasty examination of the ease. With regard to treatment, the amount of mamlibubr retrusion: as judged: L~' 'th" pn,1ile. celtai111~' was not great as one might have gather.~d on looking at the model~. A1Jthough he ·had asked the patieJ;lt to put her jaw forwartl hc \\'a~ !Jot pT,'parc,l to .a~- illlme,liatr>lr that it dill appeal' to ],E.' an improvemE.'nt. It F('cll)t'il II) him pCl'hal''' that "iJl(r> thei'" wax crowdillg----110 rO()ffi fOT tilt'

,,0

............... "'..lIIUiIl'Jllilll"lU;"'

Case for Diagnosis and Treatment.

(S. F. St. .1. Steadmafl.)

canines-the treatment might be nut· so ll1m'h to try to lHlvance tbe w110le mandible by 'means of an inclined plane, ~. rabher to advimee the mtmdibular incisor teeth by means of an aJ:ch and to leave tire molar teetn in their present occlusion. It was, however, verY IDfficult to give a eonsiden!d opinion on such a' short examination, both as to diagnosis ana treatmerrt. Mr. Harold Chapman.j·emarked that when he ·had seen the models in-occluSion he had noticed that the maxilll!-ry inci!J()~ imphiged on the 'soft tissues' five 01' more millimeters behind the mandibular incisors,.. but -the profile appearance di.d· not correspond til that relation of the teeth which ·was· shO'Wll by the models. He had· therefore got the patient to bite, and sh~ had occ1uded so that ·lier mand~bular incisors imping.ed. on the cingulum of the ·maxillary. ineiSOrs. He had returned to her after: Iooll:ing at 'tho models again and had fO'llnd, on asKing her to bitt>, that she brought her. teeth' together as_ already described. ·But on asking her -to hite hack. she lind i I'I'lnledlatC'!y ,lour ~o and in the position Indicated

Casual Communications

363

by the models. In one instance the profile could not be taken great exception to, in the H'cond instance it was extremely bad, and tIl(' mandibular incisors projected forward over the lower lip. To his mind the patient realized that she coul,l improve her appearance by llOlding her lower jaw in that position, amI was now doing so; so that he thaught it was (juite easy to have been misled as to the r('al occlusion by a casual examination. He agreed with Pitts' diagnosis as far as the molars w('at. Th('y certainly had come forward o>wing plohahly to the early extraction of the d('ciduous molars or some caries. He would certainly 1110Ve all the mandibular teeth forwal'd and bring back the maxillary incisors as much as possible, and try to open the bite. He knew it ,vas easy to talk like that, but that it was an ('xtremely difficult thing to do. He inquir('d the age of the patient. :\lr. Steadman said the patient ,,-as seventeen years old. Mr. Harold Chapman said he ha,d seen a patient in a wry similar condition that day, l)ut worSE', he thought: the facial appearance was certainly worse. The patient was fifteen and a half years of age. He had said that it was not a case which he would like to treat, nor one for which he would take any responsibility, and he desired to emphasize tl'at in regard to this case now that he heard that Mr. Steadman's patient was seventeen ~'ears aIel. Mr. VV. W. James said it seemed to him that the mandibular incisGrs had been moved J)ackwards pl'ol)ahly by the action of the lip. He did not think that one evrr saw the A Case for Diagnosis a'lel Treatment.

(S. F. St. J. Steadman.) ~.

Left side of man,lible.

Right side of mandible.

maxillary incisors protrude in such a manner as that exhibit('d by the patient without the lower lip having got beneath them. ~Che actual condition of the mandible, he thought, was altered, and he shGuld be inclined to think that the patient was and had been a mouth!m'ather. 'When the mandible was Rdvanced so that the mandibular incisors bit on the clllgulum of the maxillary incisms, the correct position was assumed. The nose and the central portion of the face was distinctly small, an appearance one often saw in mouthlJreathers or in those who did not use the nose effectively. He believed that displacement of the mandible was due to the jawE> being apa,rt, so that ail' entered the mouth and the mandible was altered in its relationship to the maxillae on account of the tisooes suspended from it. He ~vould certainly undertake treatment by op('ning the hire and endeavoring to raise the molars. He had done that in patients of the same age as Steadman's patient quite successfully. After the molars were raised he put on a mandibular mch amI a,lvanced the incisors. At one time he used to think that such treatmellt could not be successful in "aRCS of such an age, but for the 1ll0E,t part he had found it really did wurk quite wdl. :\11'. Badcock said the patirnt "'liS seventeen years of age and IU\ll got into the habit of holding her jaw in such a way that it diel not present any ildoJ'lJllty. He wondered, therefore, what good was going to be done her if she was put under any treatment. Mr. Steadman salll it was the overcrowding of the lower. :\11'. Baelcock said from the point of view .of appearance that did not do her much liUrm. Looking as w"ll as she did, personalJy he would be wry much inclined to let her nlone. People with such a deformity did get into the ,,'ay of holding their jaw forwards, Ro that onlinal'ily they looked quite ",ell, hut when they ate the jaw went back, and that

364 \Ya~ the ouly time IV I,t'lt 011(' ll'ally ;.;ut (]H'il- c.)] J<'d """'llI~iiln: Bitting- l'1It! \\11 teh illg lil'> patient, Ite had caugllt' her uff hel' gUll,rd OIlC\~ 01' twicl', alJd th(,ll hl'I' jaw had bpf'1l back Hud hrr lower lip wllS cloublt',l up uQwnwards S') 11mt it formeJ a wry thick pa,l 1.('I\\'"i'1I

11l3xillary fj'()1l( t"\'ll, anti h(', lllanJ.ilmlal' frunt If'f'th. IQlich ,wllulll he quifl' -uffit'J<'lIt to. cause what "lni'JUf
rIC']'

A Case for Diagnobls '"l,l Treatmctl t

(R

1", St, J. St> a<1nw n,)

I~ I( ),w 1I'Ii

front' teeth hatl rnuyetl baekwal'd~ anl! tlte back tr;ellt had Illllved 1'lll'wartls. in hi,; Opill)Pll. 'Vith regard to tl'catmellt, 'personally he ~hould be inclined 'to let th,' cuse alonf'. Mr. Steadman thanked thow gpeaJ(i'l's who had takcll 'part iiI the cliscllitwf'l'n Ihe views of James ana Bn(lcMk.