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Report of a Class I case which during and after treatment developed into a pronounced Class III malocclusion due probably to an endocrine imbalance
REPORT OF A CLASS I CASE WHICH DURING AND AFTER TREATMENT DEVELOPED INTO A PRONOUNCED CLASS III MALOCCLUSION DUE PROBABLY TO AN ENDOCRINE IMBALANCE* HARRY E. KELSEY, D.D.S., F.A.C.D., BALTIMORE, MD.
T
RE ATME NT was started in April, 1919. The history of the case taken at that time is: "Class I malocclusion. Maxillary arch is narrow, the molars being in lingual occlusion. Mandibular second premolars appear to be impacted or absent, x-ray pictures being required to determine this. The alignment of the mandibular arch is otherwise good, as is also the quality of the teeth. Sucked thumb until seven years old. At two years of age, adenoids were removed and tonsils clipped (which as usual gave no relief so far as the tonsils were concerned). Was a mouth breather and could not pronounce the letter M. Now sleeps with mouth closed, but keeps it open part of the time during the day. Nose and nasal passages are fairty normal externally with apparently adequate breathing space. Has had measles, whooping cough, and chickenpox. No serious illness. Slight malocclusion in both parents. Wore glasses for a short time. Eats too fast. General development is normaL" Fig. 1 shows full face and profile views of the patient at the beginning of treatment. Fig. 2 shows front and profile views of models at the beginning of treatment. Fig. 3 shows x-ray pictures taken in 1920; both mandibular second premolars are missing; the very carious left one was extracted. Treatment and retention were concluded at the end of about five years. It was a struggle during treatment to keep ahead of the rapidly growing mandible, notwithstanding the fact that both mandibular second premolars were missing. I am mortified not to have had casts made of the case at that time, but I can say from memory that the bite of the incisors was about edge to edge, and in general appearance (though not presenting normal occlusion) it was nevertheless quite a good-looking denture with fairly good masticating function. However, it slowly progressed into a pronounced prognathism. The patient was away at school most of the time, and not very accessible; besides he needed a rest, and I was getting suspicious as to the etiology of the case. In August, 1927, I secured impressions, which show fairly well the progressively increasing size of the mandible. The maxillary molars were again in lingual occlusion on the left side, and the mandible was assuming that massive appearance accompanied by a straightening out of the angle which is characteristic of this type of case. The protrusion of the mandible and of the teeth in it was more noticeable when the casts were examined than is shown in Fig. 4, but still much less pronounced than was shown a year later. -Read before the Southern Society of Orthodontists at Chattanooga, Tenn., January 27,
28, 29, 1936.
770
771
Class I Ma1occl1tsion
I called the attention of the patient's mother to conditions at this time and wanted to do some further treatment, but the patient was going away to college and it was deferred. Had it been possible for the patient to have further treatment at that time, I should have made it plain to him that it was experimental and was actuated by my desire to leave nothing undone which might possibly prove of benefit, although I myself was not sanguine of success.
Fig. 1.
Fig. 2.
Fig. Fig. Fig. Fig.
I.-Full face and profile 2.-Front and side views 3.-X-ray pictures, 1920. 4.-Front and side views
of patient at beginning of treatment. of models at beginning or treatment. Both mandibular second premolars are missing. of models made In 1927.
Fig. 5 is a radiogram of the left third molar area taken in 1926, and Fig. 6 shows right and left third molar areas in 1928. Fig. 7 shows models of the case made in 1928. It will be seen from the radiographs that there are no third molars, and from the models that the protrusion of the whole mandibular dental arch was about one-eighth inch anterior to the maxillary arch at this time. The
772
Harry E. Kelsey
alignment of the teeth was quite good, however; and the models could be placed in a good occlusal relationship, as is usual in these cases. This is shown in Fig. 8. About this time the patient was persuaded to see an internist and was referred to Dr. Lewellys F. Barker, from whom I received the following report : 1. Dysplastic habitus with mandibular prognathism, but the sella turcica
was normal and there were no other signs of an endocrine disorder. 2. Slight renal irritation with a trace of albumin and a few casts in the urine. Fig. 5.
Fig. 6. Fig. 5.-Radiogram of left third molar area in 1926. Fig. 6.-Right and left third molar area in 1928.
3. Persistent bradycardia or slow pulse rate. This was a sign of a mild lack of balance in the autonomic or automatic nervous system. The earlier history of biting the finger nails indicated some tendency to nervousness. 4. Undernutrition by about fifteen pounds, but this is not at all bad for his age. 5. Slight tabagism, or the use of too many cigarets.
Class 1 M olocclusion
773
Although this does not cor robora te my own opinion that the prognathism was due to an endocrine disturbance, I do not think it contradicts it, because I believe it was about thi s tim e 01' earlier that th e imbalance which had existed in the patient 's en docrine syste m was relieved through some compensation in the various glands, and th e present status of the ease shows that there has been
Fig. 7.-Models of the case in 1928. Fig. 8.-Same models a s Fig. 7, with maxillary model m oved forward. Fig. 9.-~lod els m ade D ecember, 193 5.
no very marked progress, if any, in the overdevelopment of the mandible sinc e the 1928 models were made. I believe it is conceded by authorities in endocr inology (if there are authorities ) that imbalances which persist over a num bel' of years are often relieved , after which the functions of growth and development become normal.
774
Harry E. Kelsey
In December, 1935, I asked this patient to return for observation. Fig. 9 shows models of the case made at that time. Fig. 10 shows extraoral radiographs, and Fig. 11 profile and front view photographs of the face, also made at this time. From the foregoing, together with my close and anxious observation of the case over a number of years, and evidence accumulated from other apFig, 10.
Fig. II. Fig. 10.-Extraoral radiographs made December, 1935. Fig. n.-Profile and front views of face January, 1936.
parently similar cases, I have formed the conviction that this patient had begun to suffer from an endocrine imbalance at, or before, the time the patient came to me; and the influence of this imbalance, while it did not prevent me from accomplishing considerable improvement in the case, did prevent me from securing a thoroughly' satisfactory result at any time. My treatment to enlarge the maxillary arch and bring about a better relation of the maxillary and mandibular teeth progressed a little more rapidly than the overdevelopment of the
Class I Malocclusion
775
mandible, but as soon as treatment was stopped, the progressive overdevelopment of the mandible became apparent and continued until about the time I induced the patient to have a general physical examination with special reference to a disturbance of the endocrine system. It is true that the models of the case, made two or three months ago, show a greater mesial relation of the mandible to the maxilla than do the models made in 1928; but the difference is slight, and in my opinion most of it can be accounted for by a straightening up of the mandibular teeth, which had been pulled and inclined as much distally as was possible during the period the patient was undergoing treatment. A view of the profile seems to corroborate this theory. I have discussed with this patient the advisability of a resection of the mandible to permit reducing its present prognathous condition, and he is much inclined to have it done. This patient has always suffered more or less from inability to breathe properly through the nose. He has a deflected septum on which the nose and throat specialists have been rather averse to operating. The tonsils, which were referred to earlier in the report as having been clipped, have given considerable trouble, and the patient had a tonsillectomy less than a year ago. At the time this patient first presented for treatment, I still believed, as we had been previously taught, that Class III cases were usually induced by enlarged tonsils. I am still inclined to think that they can induce a forward shifting of the mandible in young patients which may become fixed, or even progressive as the occlusion is securely looked in the mesial position with the maxillary teeth, and is often also in lingual occlusion. In such cases the mechanics of mastication seem to have a tendency to drive the mandible farther forward. Such, at least, was my early conception of these cases. Today, I believe many of them, like the one shown here, are the result of some endocrine disturbance; and though my convictions are fairly definite, they are by no means unalterable, and if a better solution as to the etiology can be presented, I shall welcome it. In talking with Dr. C. C. Howard in regard to cases which have been affected by an endocrine imbalance, it seems to me he has expressed the opinion that such a case as I have here reported (provided my diagnosis is correct) should not be treated during active glandular disturbance. I now believe this to be true, but I also believe that much can be done for such patients after the imbalance has been overcome either through natural compensation or by therapy. I hope Dr. Howard will have something to say in regard to this, for through association with the endocrine clinic in Atlanta, his opportunity for observation of malocclusions which might be attributed to an endocrine disturbance, has been unusual. 833
PARK AVENUE
T
RE ATME NT was started in April, 1919. The history of the case taken at that time is: "Class I malocclusion. Maxillary arch is narrow, the molars being in lingual occlusion. Mandibular second premolars appear to be impacted or absent, x-ray pictures being required to determine this. The alignment of the mandibular arch is otherwise good, as is also the quality of the teeth. Sucked thumb until seven years old. At two years of age, adenoids were removed and tonsils clipped (which as usual gave no relief so far as the tonsils were concerned). Was a mouth breather and could not pronounce the letter M. Now sleeps with mouth closed, but keeps it open part of the time during the day. Nose and nasal passages are fairty normal externally with apparently adequate breathing space. Has had measles, whooping cough, and chickenpox. No serious illness. Slight malocclusion in both parents. Wore glasses for a short time. Eats too fast. General development is normaL" Fig. 1 shows full face and profile views of the patient at the beginning of treatment. Fig. 2 shows front and profile views of models at the beginning of treatment. Fig. 3 shows x-ray pictures taken in 1920; both mandibular second premolars are missing; the very carious left one was extracted. Treatment and retention were concluded at the end of about five years. It was a struggle during treatment to keep ahead of the rapidly growing mandible, notwithstanding the fact that both mandibular second premolars were missing. I am mortified not to have had casts made of the case at that time, but I can say from memory that the bite of the incisors was about edge to edge, and in general appearance (though not presenting normal occlusion) it was nevertheless quite a good-looking denture with fairly good masticating function. However, it slowly progressed into a pronounced prognathism. The patient was away at school most of the time, and not very accessible; besides he needed a rest, and I was getting suspicious as to the etiology of the case. In August, 1927, I secured impressions, which show fairly well the progressively increasing size of the mandible. The maxillary molars were again in lingual occlusion on the left side, and the mandible was assuming that massive appearance accompanied by a straightening out of the angle which is characteristic of this type of case. The protrusion of the mandible and of the teeth in it was more noticeable when the casts were examined than is shown in Fig. 4, but still much less pronounced than was shown a year later. -Read before the Southern Society of Orthodontists at Chattanooga, Tenn., January 27,
28, 29, 1936.
770
771
Class I Ma1occl1tsion
I called the attention of the patient's mother to conditions at this time and wanted to do some further treatment, but the patient was going away to college and it was deferred. Had it been possible for the patient to have further treatment at that time, I should have made it plain to him that it was experimental and was actuated by my desire to leave nothing undone which might possibly prove of benefit, although I myself was not sanguine of success.
Fig. 1.
Fig. 2.
Fig. Fig. Fig. Fig.
I.-Full face and profile 2.-Front and side views 3.-X-ray pictures, 1920. 4.-Front and side views
of patient at beginning of treatment. of models at beginning or treatment. Both mandibular second premolars are missing. of models made In 1927.
Fig. 5 is a radiogram of the left third molar area taken in 1926, and Fig. 6 shows right and left third molar areas in 1928. Fig. 7 shows models of the case made in 1928. It will be seen from the radiographs that there are no third molars, and from the models that the protrusion of the whole mandibular dental arch was about one-eighth inch anterior to the maxillary arch at this time. The
772
Harry E. Kelsey
alignment of the teeth was quite good, however; and the models could be placed in a good occlusal relationship, as is usual in these cases. This is shown in Fig. 8. About this time the patient was persuaded to see an internist and was referred to Dr. Lewellys F. Barker, from whom I received the following report : 1. Dysplastic habitus with mandibular prognathism, but the sella turcica
was normal and there were no other signs of an endocrine disorder. 2. Slight renal irritation with a trace of albumin and a few casts in the urine. Fig. 5.
Fig. 6. Fig. 5.-Radiogram of left third molar area in 1926. Fig. 6.-Right and left third molar area in 1928.
3. Persistent bradycardia or slow pulse rate. This was a sign of a mild lack of balance in the autonomic or automatic nervous system. The earlier history of biting the finger nails indicated some tendency to nervousness. 4. Undernutrition by about fifteen pounds, but this is not at all bad for his age. 5. Slight tabagism, or the use of too many cigarets.
Class 1 M olocclusion
773
Although this does not cor robora te my own opinion that the prognathism was due to an endocrine disturbance, I do not think it contradicts it, because I believe it was about thi s tim e 01' earlier that th e imbalance which had existed in the patient 's en docrine syste m was relieved through some compensation in the various glands, and th e present status of the ease shows that there has been
Fig. 7.-Models of the case in 1928. Fig. 8.-Same models a s Fig. 7, with maxillary model m oved forward. Fig. 9.-~lod els m ade D ecember, 193 5.
no very marked progress, if any, in the overdevelopment of the mandible sinc e the 1928 models were made. I believe it is conceded by authorities in endocr inology (if there are authorities ) that imbalances which persist over a num bel' of years are often relieved , after which the functions of growth and development become normal.
774
Harry E. Kelsey
In December, 1935, I asked this patient to return for observation. Fig. 9 shows models of the case made at that time. Fig. 10 shows extraoral radiographs, and Fig. 11 profile and front view photographs of the face, also made at this time. From the foregoing, together with my close and anxious observation of the case over a number of years, and evidence accumulated from other apFig, 10.
Fig. II. Fig. 10.-Extraoral radiographs made December, 1935. Fig. n.-Profile and front views of face January, 1936.
parently similar cases, I have formed the conviction that this patient had begun to suffer from an endocrine imbalance at, or before, the time the patient came to me; and the influence of this imbalance, while it did not prevent me from accomplishing considerable improvement in the case, did prevent me from securing a thoroughly' satisfactory result at any time. My treatment to enlarge the maxillary arch and bring about a better relation of the maxillary and mandibular teeth progressed a little more rapidly than the overdevelopment of the
Class I Malocclusion
775
mandible, but as soon as treatment was stopped, the progressive overdevelopment of the mandible became apparent and continued until about the time I induced the patient to have a general physical examination with special reference to a disturbance of the endocrine system. It is true that the models of the case, made two or three months ago, show a greater mesial relation of the mandible to the maxilla than do the models made in 1928; but the difference is slight, and in my opinion most of it can be accounted for by a straightening up of the mandibular teeth, which had been pulled and inclined as much distally as was possible during the period the patient was undergoing treatment. A view of the profile seems to corroborate this theory. I have discussed with this patient the advisability of a resection of the mandible to permit reducing its present prognathous condition, and he is much inclined to have it done. This patient has always suffered more or less from inability to breathe properly through the nose. He has a deflected septum on which the nose and throat specialists have been rather averse to operating. The tonsils, which were referred to earlier in the report as having been clipped, have given considerable trouble, and the patient had a tonsillectomy less than a year ago. At the time this patient first presented for treatment, I still believed, as we had been previously taught, that Class III cases were usually induced by enlarged tonsils. I am still inclined to think that they can induce a forward shifting of the mandible in young patients which may become fixed, or even progressive as the occlusion is securely looked in the mesial position with the maxillary teeth, and is often also in lingual occlusion. In such cases the mechanics of mastication seem to have a tendency to drive the mandible farther forward. Such, at least, was my early conception of these cases. Today, I believe many of them, like the one shown here, are the result of some endocrine disturbance; and though my convictions are fairly definite, they are by no means unalterable, and if a better solution as to the etiology can be presented, I shall welcome it. In talking with Dr. C. C. Howard in regard to cases which have been affected by an endocrine imbalance, it seems to me he has expressed the opinion that such a case as I have here reported (provided my diagnosis is correct) should not be treated during active glandular disturbance. I now believe this to be true, but I also believe that much can be done for such patients after the imbalance has been overcome either through natural compensation or by therapy. I hope Dr. Howard will have something to say in regard to this, for through association with the endocrine clinic in Atlanta, his opportunity for observation of malocclusions which might be attributed to an endocrine disturbance, has been unusual. 833
PARK AVENUE