- Email: [email protected]
Report of a Case
H illyer— Report of a Case how they are influenced in their behavior. I t is perhaps too early to com m ent on the theory of the buffering action of the saliva proposed by M cC o llu m , b u t w e m ust welcome such a change in the n u tri tion approach to the causation of caries. M a y it be said th a t the control of caries has passed out of the hands of the opera tive den tist? I think not. E a rly recogni tion and prom pt tre a tm e n t by filling the cavity and the adjacent susceptible area have done m ore to lim it th e action of caries than the attem pted application of
1403
the latest discoveries in the field of n u tri tion. Both success and failu re have been recorded in the attem pts to m odify the action of caries by variations in diet. W e are prone a t the present tim e to stress the successes and give little th o u g h t to the failures. Both should be recognized, to the end th a t no m ethod th a t gives some promise of restrain in g the action of caries should be ignored in its en tirety and that, fu rth e r, no m ethod should receive more emphasis th an it actu ally deserves.
REPORT OF A
CASE
By N O R M A N L. HILLYER, D.D.S., Brooklyn, N . Y. H isto r y . —E. R., a girl, aged 8 years and 3 months, came in for treatm ent, Jan. 2, 1929. H er vision, hearing and mental development were good; weight, 58 pounds; height, 4 feet 3 inches; oral health, excellent, with small occlusal pit fillings in both upper first p er manent molars, but no other fillings or caries. T he birth had been normal, the w eight at that time being 6^4 pounds. T he patient was
good arch form, and at the time of treatm ent of his sister had normal spacing between the upper and lower anterior deciduous teeth. (T h ere were no sisters.) T he upper deciduous anterior teeth were firmly in place
Fig. 1.—Models of case at beginning of treatment. breast fed until the age of 11 months, then weaned and placed directly on a solid diet. She was never bottle fed. T h e father and mother, both of Irish descent, had good arch form. T he patient had her adenoids and tonsils removed at 5 years of age, and had an appendectomy at 1 0 She had had measles at 10 and mumps at 11 years. H er only brother, aged 4 years and 2 months, had Jour. A. D. A ., August, 1932
Fig. 2.—Occlusal view of models. until about 7 years. On their loss, the upper perm anent anterior teeth were immediately erupted lingually from the positions occu pied by the corresponding deciduous teeth. E t i o l o g y .—No systemic cause for this ab normality was discoverable in the heredity
1404
T h e Journal of the American D ental Association
of the patient as reported by the mother. The anterior deciduous teeth of the upper arch seem to have been retained overlong and no usual spacing seems to have oc curred before the eruption of the upper p er manent anterior teeth. D i a g n o s i s .—T he case w as placed in Class 1 (A ngle), a neutroclusion with a lingual position of the upper perm anent central and lateral teeth (Lischer) ; and Simon’s classi fication, as follows, w as taken into consid-
are found, I am contenting myself with the terms mentioned and hope th at one of the classifications given will be adequate for this case.) T r e a t m e n t .—T he case having been diag nosed as indicated, it w as decided that an upper lingual arch with bands on the upper first perm anent molars would, w ith properly chosen and properly placed springs, carry the
Fig. 3.—A nterior teeth.
Fig. 4.— R ight p o sterior teeth.
eration: bimaxillary, alveolar, anterior con traction, mild and sym metrical; maxillary, alveolar, anterior retraction, severe and sym m etrical; maxillary, alveolar, anterior at traction, mild. (It is well known that the terms of the last system of classification are being severely criticized, and, it seems, rightly so, by Dr. Dewey and by others, but until better ones
Fig. 6.—Profile roentgenogram, illustrating lack of development in upper anterior region and lack of excess development in mandible. upper anterior teeth into position with the least interference with function and ap p ear ance and with the most efficiency. T h e re fore, Jan u ary 16, an upper lingual arch of 0.038 gage w ire was placed and fixed by
H illyer— Report of a Case half round vertical tubes and locks to the first molar bands, which were cemented on these teeth. Figure 1 shows the models of the case at the beginning of treatm en t; Figure 2, the occlusal view of these models; Figure 3, the anterior teeth, and Figure 4, the right posterior teeth as shown in the roentgeno gram.
1405
the commencement of treatm ent, and Figure 8, a front view taken at the same time. February 23, a recurrent auxiliary spring of 0.020 gage w as soldered to the arch to induce labial movement of the upper central incisor teeth. T his spring was adjusted only twice (M arch 27 and June 19), until these teeth were in fairly good position and were labially from the lower incisor teeth in oc clusion ; i.e., September 25, when X saw the patient on her return from a three months’ vacation.
Fig. 7.—Profile photograph at commence ment of treatm ent.
Fig. 10.—Method of reshaping the main arch and spring finally used. Fig. 8.—Front view taken at commencement of treatment. Figure 5 shows the left posterior teeth, and Figure 6, a profile roentgenogram, which is interesting in that it illustrates the lack of development in the upper anterior region and no excess development of the mandible. Figure 7 is a profile photograph taken at
It must be stressed here, and perhaps many times, th a t the spring w as adjusted only at infrequent intervals, because I have repeatedly found that, in my hands, tre a t ment progresses faster and more physiologi cally with the minimum amount of pres sure and that applied only as often as is necessary to get the maximum result. The
1406
T he Journal of the American D ental Association
patient was seen at least once every three weeks, except during the summer vacation. September 25, two simple auxiliary springs were soldered in the second deciduous molar regions and adapted to the upper lateral in cisor teeth. A t this stage, I experimented a little to see which gage w ire, under like pressure, would have a better effect, 0.020 or 0.022. T he left lateral spring was made of 0.022 wire, while the right was of 0.020. T he same adjustm ent w as given each and
main arch w ire and the arch must either be remade or readapted to the new dental arch form. I have found an easy and effi cient means of reshaping the same arch wire to the new arch form, a little different from that shown by Dr. Porter. Figure 9 shows the schematic draw ing of the appliances and the method of attach ment and adaptation of the springs. Fig-
Fig. 11.—Final models (Dec. 23, 1931).
Fig. 13.—Profile photograph.
Fig. 12.— Occlusal views of final models, the two teeth to be moved w ere in very nearly identical malocclusion. It w as found two months later, November 15, th a t the right lateral incisor w ith its 0.020 spring had made the greater progress, and there fore the left, 0.022, spring w as replaced by a sim ilar spring of 0.020 w ire, and both right and left springs w ere adjusted. No further adjustments w ere made until January 6, 1930, when both springs were removed. It w as then apparent th at the anterior teeth were too fa r aw ay from the
Fig. 14.—Front views. ure 10 shows the method of reshaping the main arch and the final spring used. In this case, a piece of 0.038 w ire was beveled to give a good joint at the right cuspid area and soldered. T h e new piece was adapted to the new dental arch and cut to size and soldered w here it again
H illyer— Report of a Case joined the old arch at the left cuspid area. T he old anterior section w as now cut from the new arch and the soldered joints filed and polished. W e now had a new arch to fit the new dental arch accurately without an impression or model or w ithout disturbing the relationship of the half-round first per manent molar posts. T o this newly formed arch, an 0.020 re current auxiliary spring w as soldered the same day (January 6), to carry the four upper incisor teeth to better position. This spring w as adjusted once, M arch 21. The accompanying table gives the dates that the
1407
gram s; Figure 16, the left posterior roentgen ogram s; Figure 17, the right posterior ro entgenograms, and Figure 18, the profile roentgenogram. T he anterior alveolar region of the upper arch shows development. C o m m e n t .—H ad it not been necessary to
Fig. 17.—Right posterior roentgenograms. Fig. IS.—A nterior roentgenograms.
Fig. 16.—Left posterior roentgenograms. appliances w ere placed, adjusted and re moved. T he entire appliance w as removed, May 26, and the case observed at four-month in tervals until the final models were taken, Dec. 23, 1931. Figure 11 shows the models on that d a te ; Figure 12, the occlusal view s; Figure 13, the profile photograph, and F ig ure 14, the front views. Figure 15 shows the anterior roentgeno
Fig. 18.—Profile roentgenogram. take these final records for this report, I should have extended the period of observa tion longer to be sure th at the erupting bicuspids came into proper occlusion. It seems probable that they will do so.
1408
T he Journal of the American D ental Association
It should be noted that no “retainer,” either fixed or removable, was used to hold the teeth in their corrected positions. I re lied, as I almost always do, on the forces of occlusion and on the slow, gentle and constant method of treatm ent to insure a lasting result. Dr. M ershon gave some of us a course in his theories and practices w ith the lingual arch in New York some years ago and, re-
erupting upper second bicuspids will correct itself when full occlusion is attained by growth. No relapse has been noted except very slight irregularities in the anterior teeth which, to my mind, need no further cor rection. R e su lts a n d Conclusions .—I feel that this case has demonstrated the advisability of using gentle, constant, infrequently applied pressure, derived from light gage springs
A PPLIA N C ES
Placed. .. Adjusted.
Upper Lingual Arch 1/16/29 1/ 6/30 Reshaped to new position
2|2
21112
Spring
Springs
Spring
2/23/29 3/27/29
9/25/29 11/15/29
1/ 6/30 3/21/30
6/19/29
Changed
Hi
0.022 to
of
Removed.
upper anterior teeth 5/26/30
garding retention, gave us an axiom which has far-reaching implications and which is very true regarding any method of tre a t ment: “You can push teeth to w here you think they belong; N ature will move them to where they will best adapt themselves to the rest of the organism.” Prognosis'. It seems that the prognosis is favorable and that the lingual position of fhe
0.020
9/25/29
1/ 6/30
5/26/30
on a lingual removable arch w herever con ditions permit. T h e case reported is such a one, and the lingual arch, while certainly not a “universal appliance,” as used is the most efficient mechanical appliance th at we can employ in attaining the greatest physi ologic tooth movement and in the easiest m anner both for the patient and the opera tor, in the shortest space of time.
1403
the latest discoveries in the field of n u tri tion. Both success and failu re have been recorded in the attem pts to m odify the action of caries by variations in diet. W e are prone a t the present tim e to stress the successes and give little th o u g h t to the failures. Both should be recognized, to the end th a t no m ethod th a t gives some promise of restrain in g the action of caries should be ignored in its en tirety and that, fu rth e r, no m ethod should receive more emphasis th an it actu ally deserves.
REPORT OF A
CASE
By N O R M A N L. HILLYER, D.D.S., Brooklyn, N . Y. H isto r y . —E. R., a girl, aged 8 years and 3 months, came in for treatm ent, Jan. 2, 1929. H er vision, hearing and mental development were good; weight, 58 pounds; height, 4 feet 3 inches; oral health, excellent, with small occlusal pit fillings in both upper first p er manent molars, but no other fillings or caries. T he birth had been normal, the w eight at that time being 6^4 pounds. T he patient was
good arch form, and at the time of treatm ent of his sister had normal spacing between the upper and lower anterior deciduous teeth. (T h ere were no sisters.) T he upper deciduous anterior teeth were firmly in place
Fig. 1.—Models of case at beginning of treatment. breast fed until the age of 11 months, then weaned and placed directly on a solid diet. She was never bottle fed. T h e father and mother, both of Irish descent, had good arch form. T he patient had her adenoids and tonsils removed at 5 years of age, and had an appendectomy at 1 0 She had had measles at 10 and mumps at 11 years. H er only brother, aged 4 years and 2 months, had Jour. A. D. A ., August, 1932
Fig. 2.—Occlusal view of models. until about 7 years. On their loss, the upper perm anent anterior teeth were immediately erupted lingually from the positions occu pied by the corresponding deciduous teeth. E t i o l o g y .—No systemic cause for this ab normality was discoverable in the heredity
1404
T h e Journal of the American D ental Association
of the patient as reported by the mother. The anterior deciduous teeth of the upper arch seem to have been retained overlong and no usual spacing seems to have oc curred before the eruption of the upper p er manent anterior teeth. D i a g n o s i s .—T he case w as placed in Class 1 (A ngle), a neutroclusion with a lingual position of the upper perm anent central and lateral teeth (Lischer) ; and Simon’s classi fication, as follows, w as taken into consid-
are found, I am contenting myself with the terms mentioned and hope th at one of the classifications given will be adequate for this case.) T r e a t m e n t .—T he case having been diag nosed as indicated, it w as decided that an upper lingual arch with bands on the upper first perm anent molars would, w ith properly chosen and properly placed springs, carry the
Fig. 3.—A nterior teeth.
Fig. 4.— R ight p o sterior teeth.
eration: bimaxillary, alveolar, anterior con traction, mild and sym metrical; maxillary, alveolar, anterior retraction, severe and sym m etrical; maxillary, alveolar, anterior at traction, mild. (It is well known that the terms of the last system of classification are being severely criticized, and, it seems, rightly so, by Dr. Dewey and by others, but until better ones
Fig. 6.—Profile roentgenogram, illustrating lack of development in upper anterior region and lack of excess development in mandible. upper anterior teeth into position with the least interference with function and ap p ear ance and with the most efficiency. T h e re fore, Jan u ary 16, an upper lingual arch of 0.038 gage w ire was placed and fixed by
H illyer— Report of a Case half round vertical tubes and locks to the first molar bands, which were cemented on these teeth. Figure 1 shows the models of the case at the beginning of treatm en t; Figure 2, the occlusal view of these models; Figure 3, the anterior teeth, and Figure 4, the right posterior teeth as shown in the roentgeno gram.
1405
the commencement of treatm ent, and Figure 8, a front view taken at the same time. February 23, a recurrent auxiliary spring of 0.020 gage w as soldered to the arch to induce labial movement of the upper central incisor teeth. T his spring was adjusted only twice (M arch 27 and June 19), until these teeth were in fairly good position and were labially from the lower incisor teeth in oc clusion ; i.e., September 25, when X saw the patient on her return from a three months’ vacation.
Fig. 7.—Profile photograph at commence ment of treatm ent.
Fig. 10.—Method of reshaping the main arch and spring finally used. Fig. 8.—Front view taken at commencement of treatment. Figure 5 shows the left posterior teeth, and Figure 6, a profile roentgenogram, which is interesting in that it illustrates the lack of development in the upper anterior region and no excess development of the mandible. Figure 7 is a profile photograph taken at
It must be stressed here, and perhaps many times, th a t the spring w as adjusted only at infrequent intervals, because I have repeatedly found that, in my hands, tre a t ment progresses faster and more physiologi cally with the minimum amount of pres sure and that applied only as often as is necessary to get the maximum result. The
1406
T he Journal of the American D ental Association
patient was seen at least once every three weeks, except during the summer vacation. September 25, two simple auxiliary springs were soldered in the second deciduous molar regions and adapted to the upper lateral in cisor teeth. A t this stage, I experimented a little to see which gage w ire, under like pressure, would have a better effect, 0.020 or 0.022. T he left lateral spring was made of 0.022 wire, while the right was of 0.020. T he same adjustm ent w as given each and
main arch w ire and the arch must either be remade or readapted to the new dental arch form. I have found an easy and effi cient means of reshaping the same arch wire to the new arch form, a little different from that shown by Dr. Porter. Figure 9 shows the schematic draw ing of the appliances and the method of attach ment and adaptation of the springs. Fig-
Fig. 11.—Final models (Dec. 23, 1931).
Fig. 13.—Profile photograph.
Fig. 12.— Occlusal views of final models, the two teeth to be moved w ere in very nearly identical malocclusion. It w as found two months later, November 15, th a t the right lateral incisor w ith its 0.020 spring had made the greater progress, and there fore the left, 0.022, spring w as replaced by a sim ilar spring of 0.020 w ire, and both right and left springs w ere adjusted. No further adjustments w ere made until January 6, 1930, when both springs were removed. It w as then apparent th at the anterior teeth were too fa r aw ay from the
Fig. 14.—Front views. ure 10 shows the method of reshaping the main arch and the final spring used. In this case, a piece of 0.038 w ire was beveled to give a good joint at the right cuspid area and soldered. T h e new piece was adapted to the new dental arch and cut to size and soldered w here it again
H illyer— Report of a Case joined the old arch at the left cuspid area. T he old anterior section w as now cut from the new arch and the soldered joints filed and polished. W e now had a new arch to fit the new dental arch accurately without an impression or model or w ithout disturbing the relationship of the half-round first per manent molar posts. T o this newly formed arch, an 0.020 re current auxiliary spring w as soldered the same day (January 6), to carry the four upper incisor teeth to better position. This spring w as adjusted once, M arch 21. The accompanying table gives the dates that the
1407
gram s; Figure 16, the left posterior roentgen ogram s; Figure 17, the right posterior ro entgenograms, and Figure 18, the profile roentgenogram. T he anterior alveolar region of the upper arch shows development. C o m m e n t .—H ad it not been necessary to
Fig. 17.—Right posterior roentgenograms. Fig. IS.—A nterior roentgenograms.
Fig. 16.—Left posterior roentgenograms. appliances w ere placed, adjusted and re moved. T he entire appliance w as removed, May 26, and the case observed at four-month in tervals until the final models were taken, Dec. 23, 1931. Figure 11 shows the models on that d a te ; Figure 12, the occlusal view s; Figure 13, the profile photograph, and F ig ure 14, the front views. Figure 15 shows the anterior roentgeno
Fig. 18.—Profile roentgenogram. take these final records for this report, I should have extended the period of observa tion longer to be sure th at the erupting bicuspids came into proper occlusion. It seems probable that they will do so.
1408
T he Journal of the American D ental Association
It should be noted that no “retainer,” either fixed or removable, was used to hold the teeth in their corrected positions. I re lied, as I almost always do, on the forces of occlusion and on the slow, gentle and constant method of treatm ent to insure a lasting result. Dr. M ershon gave some of us a course in his theories and practices w ith the lingual arch in New York some years ago and, re-
erupting upper second bicuspids will correct itself when full occlusion is attained by growth. No relapse has been noted except very slight irregularities in the anterior teeth which, to my mind, need no further cor rection. R e su lts a n d Conclusions .—I feel that this case has demonstrated the advisability of using gentle, constant, infrequently applied pressure, derived from light gage springs
A PPLIA N C ES
Placed. .. Adjusted.
Upper Lingual Arch 1/16/29 1/ 6/30 Reshaped to new position
2|2
21112
Spring
Springs
Spring
2/23/29 3/27/29
9/25/29 11/15/29
1/ 6/30 3/21/30
6/19/29
Changed
Hi
0.022 to
of
Removed.
upper anterior teeth 5/26/30
garding retention, gave us an axiom which has far-reaching implications and which is very true regarding any method of tre a t ment: “You can push teeth to w here you think they belong; N ature will move them to where they will best adapt themselves to the rest of the organism.” Prognosis'. It seems that the prognosis is favorable and that the lingual position of fhe
0.020
9/25/29
1/ 6/30
5/26/30
on a lingual removable arch w herever con ditions permit. T h e case reported is such a one, and the lingual arch, while certainly not a “universal appliance,” as used is the most efficient mechanical appliance th at we can employ in attaining the greatest physi ologic tooth movement and in the easiest m anner both for the patient and the opera tor, in the shortest space of time.