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Spring attachments—Positive and otherwise
SPRING ATTACHMENTS-POSITIVE AND OTHERWISE By
DR.
A. C.
GIFFORD, O SHKOSH, \VI SCONSIN
w
~ WERE taught n ot many yea rs ago that we had. a nn~Y eni~1 ap pliance what was known as the Angle arch, or the plain labial wrre ; but we
III
have p er ceived through cont act with different men , that th is is an age of invention or mechanical inge nuity. The appliances now used by some men in th e practi ce of or t hodontics possibly give one mor e opp or tunity f or m odification than in previous tim es. I am r eferring to th e lingual appli ance in par-t icular . Mu ch has be en writt en in th e last few years up on the spring of wires of minute gauge for the movement of teeth; especiall y so since th e advent of the lin gual wire, both stat iona ry and r emovabl e. It is not t o give yo u man y new ideas that I present this f or you r approval, but to emphasize the value of these sma ll wires when attached in such a manner that the " E last ic Fo rc es" are still intact in these sp rings. Th e lingual wire has been in u se for many years as a r etain er, and it is being perfected into an active appliance th ese last fe w years. Some u se it as a soldered or stat ionar y appliance, others as a rem ovable apparatus. The soldere d or stationary wire is expanded or str etc hed with a special pair of wire-stret ching pliers made only fo r ninet een-gauge wir e. The peculiarity -of this wire is its d esire t o move all the t eeth, when being st re tc hed, unless the technic ·that is adapted to this work is skilfully f ollow ed . One wrongly placed pinch of the wire will do much harm. Unless a defini te technic has been foll owed, a sur pr ise is sometimes in st ore for th e operator upon the r eturn of the patien t the next time. 'I'he remov able lingual wire is adjusted differently ; the plan bein g to follow the line of def or mi ty as n ear as possible and str aighten t he ben ds wh ich will press on th ese t eeth in malposition. Appliances of earl y cons t r uc tion show how th ey used t o move t eeth with spring wires, but there was no definite plan as to just how mu ch pressure was needed, or how much force was ne cessary to place cer t ain te eth in th e desired place without disturbing the process and su r ro unding ti ssu es, in cluding the pulp of the too th which was to be mov ed. So mu ch force can be applied through the pressure of sp ring wires that great harm can be done both to too th pulp and supporting structures. It is very essential that what spring has been lost in the soldering should again be returned to these small wires in the magnitude of its proportions. Consequently these wires must be bent up on thems elves after heating, for I find that they do not have the elast icity after soldering that they are supposed to possess. In cer t ain ca ses one mu st protect the wire from heat as mu ch as possible. 42i
428
A. C. Gifford
There are gre a t p ossibilities in this plan of movin g t eeth since we ha ve the lingual wire with modifications, for it is possibl e to place attachments for to oth mov em ent t hat will need no attention from the time they are placed until th e t ooth or t eeth a re in the position whi ch we h ave planned they should be. Thi s one fa ct or makes sp r in g wires a great fa vorite in my practice, especiall y wh en appliances are pl aced for patients wh o come from considerable distance. Th er e is less adj us t ing and in fa ct the less yo u adjust or try to adjust these spr ing wires th e more efficien t the ap pliances will be, especially if th e body wire is of th e solde re d or st ation a ry type. E ach applian ee must ha ve a body wire, or a wire for attachment of springs, that is st able eno ug h and large en ough t o t ake up all the action or ' reaction that may be put up on it by the draw, pull, or push of these springs j for if this is not the case ou r tooth attachments will su ffer, and we have not only moved the tooth or t eeth which we were trying t o move, but our anchorteeth as well. To place a spr in g upon smooth su rfaces that are acclivous and d eclivous without .some 'form of retention is n ot a good policy, for there will be that slipping or sli d in g of the spring to r elax it self, particularly so if the spr in g be long. 'I'his r et ention ma y be on th e body wire or on the te eth that have the pressure applied. Th er e are man y p ossibiliti es in t h e mov em ent of t eeth by this form of power. 'Vhen we cons ide r thi s fro m an orthodo ntic sense it does no t mean mu eh , for the principles of n early all appliances are tha t of spr ing wire, as ther e is in n early all appliances t his action t hat moves the t ooth or t eeth. In our plain labial wire, and th e Angl e pin and tub e appli an ce, and the Ribbon arch , the sp r in g is th e pr in ciple of the force applie d in these appliances to proeure maximum efficiency. As near as I ea n ex pl ain, " spring" means "Elasti c Power " in the sens e in which I use it. W e must use small spr in gs in most cases. Th er e are too t h movements however, t hat r equ ire a wire with con sid erable spr ing, espec ially if it is to be of ex t re me len gth. Th er ef or e, the lon ger the sp r ing w ir e t he larger t he size w ir e w e must use. 'Wha t I have to p resent t o yo u are cas es in my practi ce that ha ve been treated successfully with th e a pplian ces shown. I know there can be many modifications and alterations in these few cases that perhaps can be enlarged upon. I wish to impress upon you the use of th e fine springs in preference t o the heavy springs for they act better, and they cont inu e to exert forc es longer than heavy wi re . Con t inu ous light force or gentle elastic force is wh a t is wanted f or t ooth mov ement, and adjustments will not have t o be made as frequently. Th er e are numerous ways that spr ings may be attac he d to th e body wire t o move t eeth . Bu t man y of th e spr ing attaeh ments will be value less if 'they ca nno t be t igh t en ed correctly, and they , bein g always active, t end t o d estroy rather t han correct. I ha ve had many failures in trying t o move teeth with sp r ings f or n o othe r reason than t ha t my principl es we r e wron g in expecting ea ch and every f orm of spr ing t o mov e t eeth. When the for ce is applie d cor rec tly, one will be su r p r ised at th e r emarkable results accompli sh ed in a sh ort time. A sp r ing wi th a fr ee end is n ot
Spring Attachments
429
a positive spring in my hands, for in the tightening of this form of spring I find it will not keep its place, and the free end will slide up or down, as the circumstances are in either upper or lower, and be a continuous source of trouble. The tongue seems to be continually looking for some obstacle to disturb. In many instances, I find it very inconvenient, as well as impractical, to use a body-wire that follows the gingiva of the teeth. Sometimes there is the occlusion that interferes in this respect, and ofttimes the appliance interferes with the speech if placed at the necks of the teeth. If we wish to place
Fig.
i.s.
Fig. l·A.
Fig. 2-A.
Fig. 2·B.
Fig. 3.
our appliances on the lingual aspect w e must modify them according to conditions. Fig. 1 A will show my idea of such an appliance. It is a positive appliance inasmuch as the spring attachments are attached at both ends. The moving end is not necessarily soldered but may fit in under a wire or may enter a small tube one gauge larger than the diameter of the spring-wire used. Body-wire was 16-gauge, springs were 22-gauge. Fig. 1 B is an appliance made to perform the same duty as Fig. 1 A. This follows the line of the arch and does not have retention bands at the end of the spring wire. Body wire is 19-9auge, spring 22-gauge. At this time I wish to call your attention to the curve or bent wire to the distal. The spring is soldered distally and bent upon itself to the mesial,
A. C. Gifford
430
grvmg it more spring and a place for the tightening of said wire, which is done by a very slight bend to the lingual, at the cross, thereby bending the moving end labially. The labial spring principle of the Hawley retainer has been used as an active appliance in my practice for some time. I find it a corrective appliance as well as a retaining appliance. My idea is that there is no better retainer than the appliance that is used to move the teeth. The spring can be applied as needed for the movement of teeth. These are shown in Fig. 2 A. The arch was expanded first, as is necessary in all these cases before this form of appliance was placed. Body wire was 19-9auge, labial spring 23-gauge positive spring. Fig. 2 B is the same form of spring applied to a case where I thought
A.
c.
B. Fig. 4.
Fig. 5.
Fig. 6.
advisable to remove the first premolars. The first and second molars were used as anchorage, (this shows the retainer) and the body wire was placed only slightly to the lingual of the anterior teeth so as not to obstruct the speech, it being shortened occasionally. This form of spring is better used, I think, with a removable base-wire as it is easier to adjust, requiring less labor when shortening the body wire; wire same size as 2 A. Fig. 3 is an appliance of heavy spring wire for the rapid widening of an arch where there is a marked nasal stenosis. Bands on molars and canines are fastened together by half-round wire (curved side to the teeth). A sixteen inside gauge open tubing, with the distal end closed is soldered to this wire connecting the teeth. A 16-gauge wire is fitted to this so it will spring and rest in these tubes. The 16-gauge wire cannot slide back if the distal end of the tube is closed. Considerable pressure was put upon the teeth which in one month's time showed a lateral movement of the canines and teeth distal
Spring Attachments
431
to them a little over one quarter of an inch without an adjustment. is a positive appliance.
This
Fig. 4 shows what can be accomplished in a very short time with the appliance shown. These springs all were made on the loop principle or bent upon themselves, so as to get an adjustable spring which would give constant pressure. The tooth movement was remarkable, as the model "0" was made about ten weeks after the appliance was adjusted and with but two visits to the office. Bands with small wires soldered to the lin guo-gingival surface were placed on the laterals so the anterior springs would not slide to the occlusial. A 19-9auge body wire, and 22-gauge springs were used. Sometimes, due to certain mutilated conditions, we are required to remove a tooth that is labially placed in the position of another tooth. The case number 5 had a mandibular right lateral removed some years previous to the time they consulted me for the correction of the misplaced canine.
Fig. 7.
Fig. 8.
Fig. 9.
Fig. 10
I planned the appliance shown to give the most efficient services for a patient at a distal point from my office. After placing the appliance I saw the case but once until it was removed, and that only for observation. '1' he appliance was not adjusted from the time it was placed until it was removed. Oonstant, positive spring pressure by a twenty-gauge wire placed the tooth where I planned it should be. Notice the stabilization of the molar anchorage. Spring wire of 20-gauge was used. In cases such as Fig. 6 I find a very simple and efficient appliance such as is shown on the upper model. This is not very plain, due to it being a model made from an impression taken with the appliance in the mouth. The appliance was left as a retainer when the case was in normal occlusion. Body wire was 17-gauge, springs were 22-gauge. Fig. 7 is a very ordinary spring appliance for the correction of the malalignment of the anterior teeth in the maxillary arch. A 19-9auge body wire and 23'-gauge springs were used. Occasionally we are called upon to move
Geo, W. Grieve
432
one tooth to facilitate placing an artificial restoration and in one of such cases I constructed the appliance shown in Fig. 8. Another delicate appliance is shown in Fig. 9. This is to rotate the lateral and was the original appliance used on this case and it surprised me to have the tooth in its normal position when the patient returned after about six weeks' absence. In the early part of this article I spoke of retaining the free end of the spring wire on the body wire. Fig. 10 shows an appliance which has the free end of the labial spring in a tube, one size larger than the spring, soldered to the body wire. The spring wire must be bent at such an angle that it. will slide freely in this tube as the tube is at an angle and is not parallel with the long axis of the bent spring. There are many places where we can use springs in orthodontics and I hope to have some suggestions from the readers to add to my many spring ideas.
HEPORT OF CASES* By
G"EO.
W.
GRIEVE,
D.D.S.,
TORONTO, CANADA
H E RE is nothing unusual in the case I am about to present, but it serves
T admirably the purpose of illustrating the efficiency of the pin appliance,
which was used on the maxillary teeth. The mandibular arch was corrected with the lingual wire. It is a neutroclusion case. Fig. 1 shows the extreme overbite, considerable space between the maxillary first incisors, lack of eruption of the maxillary right second premolar and maxillary left canine; the latter, as may be seen, was about to erupt quite high up. The skiagraph showed the presence of the premolar. There was no space for either of these teeth in the dental arch, and a great deal of bodily movement of many of the teeth was necessary in the correction of the case. Considerable intrusion of maxillary first incisors and all mandibular incisors was necessary, as well as some extrusion of both maxillary and mandibular premolars and molars. In my experience, the pin appliance, with individual bite planes on the maxillary first incisor bands, is the ideal appliance for the correction of conditions as illustrated here in this maxillary arch. When the finished models were made, the second molars had not yet fully erupted and the models teetered a little. To avoid an error of the photographer, in placing them to show the occlusion, little bits of wax were stuck on where the dark spots show on the occlusal surface of the mandibular model (Fig. 2). The occlusal aspect shows that, through an oversight, the maxillary right canine had not been fully rotated. The treatment of this case was commenced a few months before I started to use the half-round pin which our "Read before the American Society of Orthodontists, Atlantic City, N.
J., April 26-30, 1921.
DR.
A. C.
GIFFORD, O SHKOSH, \VI SCONSIN
w
~ WERE taught n ot many yea rs ago that we had. a nn~Y eni~1 ap pliance what was known as the Angle arch, or the plain labial wrre ; but we
III
have p er ceived through cont act with different men , that th is is an age of invention or mechanical inge nuity. The appliances now used by some men in th e practi ce of or t hodontics possibly give one mor e opp or tunity f or m odification than in previous tim es. I am r eferring to th e lingual appli ance in par-t icular . Mu ch has be en writt en in th e last few years up on the spring of wires of minute gauge for the movement of teeth; especiall y so since th e advent of the lin gual wire, both stat iona ry and r emovabl e. It is not t o give yo u man y new ideas that I present this f or you r approval, but to emphasize the value of these sma ll wires when attached in such a manner that the " E last ic Fo rc es" are still intact in these sp rings. Th e lingual wire has been in u se for many years as a r etain er, and it is being perfected into an active appliance th ese last fe w years. Some u se it as a soldered or stat ionar y appliance, others as a rem ovable apparatus. The soldere d or stationary wire is expanded or str etc hed with a special pair of wire-stret ching pliers made only fo r ninet een-gauge wir e. The peculiarity -of this wire is its d esire t o move all the t eeth, when being st re tc hed, unless the technic ·that is adapted to this work is skilfully f ollow ed . One wrongly placed pinch of the wire will do much harm. Unless a defini te technic has been foll owed, a sur pr ise is sometimes in st ore for th e operator upon the r eturn of the patien t the next time. 'I'he remov able lingual wire is adjusted differently ; the plan bein g to follow the line of def or mi ty as n ear as possible and str aighten t he ben ds wh ich will press on th ese t eeth in malposition. Appliances of earl y cons t r uc tion show how th ey used t o move t eeth with spring wires, but there was no definite plan as to just how mu ch pressure was needed, or how much force was ne cessary to place cer t ain te eth in th e desired place without disturbing the process and su r ro unding ti ssu es, in cluding the pulp of the too th which was to be mov ed. So mu ch force can be applied through the pressure of sp ring wires that great harm can be done both to too th pulp and supporting structures. It is very essential that what spring has been lost in the soldering should again be returned to these small wires in the magnitude of its proportions. Consequently these wires must be bent up on thems elves after heating, for I find that they do not have the elast icity after soldering that they are supposed to possess. In cer t ain ca ses one mu st protect the wire from heat as mu ch as possible. 42i
428
A. C. Gifford
There are gre a t p ossibilities in this plan of movin g t eeth since we ha ve the lingual wire with modifications, for it is possibl e to place attachments for to oth mov em ent t hat will need no attention from the time they are placed until th e t ooth or t eeth a re in the position whi ch we h ave planned they should be. Thi s one fa ct or makes sp r in g wires a great fa vorite in my practice, especiall y wh en appliances are pl aced for patients wh o come from considerable distance. Th er e is less adj us t ing and in fa ct the less yo u adjust or try to adjust these spr ing wires th e more efficien t the ap pliances will be, especially if th e body wire is of th e solde re d or st ation a ry type. E ach applian ee must ha ve a body wire, or a wire for attachment of springs, that is st able eno ug h and large en ough t o t ake up all the action or ' reaction that may be put up on it by the draw, pull, or push of these springs j for if this is not the case ou r tooth attachments will su ffer, and we have not only moved the tooth or t eeth which we were trying t o move, but our anchorteeth as well. To place a spr in g upon smooth su rfaces that are acclivous and d eclivous without .some 'form of retention is n ot a good policy, for there will be that slipping or sli d in g of the spring to r elax it self, particularly so if the spr in g be long. 'I'his r et ention ma y be on th e body wire or on the te eth that have the pressure applied. Th er e are man y p ossibiliti es in t h e mov em ent of t eeth by this form of power. 'Vhen we cons ide r thi s fro m an orthodo ntic sense it does no t mean mu eh , for the principles of n early all appliances are tha t of spr ing wire, as ther e is in n early all appliances t his action t hat moves the t ooth or t eeth. In our plain labial wire, and th e Angl e pin and tub e appli an ce, and the Ribbon arch , the sp r in g is th e pr in ciple of the force applie d in these appliances to proeure maximum efficiency. As near as I ea n ex pl ain, " spring" means "Elasti c Power " in the sens e in which I use it. W e must use small spr in gs in most cases. Th er e are too t h movements however, t hat r equ ire a wire with con sid erable spr ing, espec ially if it is to be of ex t re me len gth. Th er ef or e, the lon ger the sp r ing w ir e t he larger t he size w ir e w e must use. 'Wha t I have to p resent t o yo u are cas es in my practi ce that ha ve been treated successfully with th e a pplian ces shown. I know there can be many modifications and alterations in these few cases that perhaps can be enlarged upon. I wish to impress upon you the use of th e fine springs in preference t o the heavy springs for they act better, and they cont inu e to exert forc es longer than heavy wi re . Con t inu ous light force or gentle elastic force is wh a t is wanted f or t ooth mov ement, and adjustments will not have t o be made as frequently. Th er e are numerous ways that spr ings may be attac he d to th e body wire t o move t eeth . Bu t man y of th e spr ing attaeh ments will be value less if 'they ca nno t be t igh t en ed correctly, and they , bein g always active, t end t o d estroy rather t han correct. I ha ve had many failures in trying t o move teeth with sp r ings f or n o othe r reason than t ha t my principl es we r e wron g in expecting ea ch and every f orm of spr ing t o mov e t eeth. When the for ce is applie d cor rec tly, one will be su r p r ised at th e r emarkable results accompli sh ed in a sh ort time. A sp r ing wi th a fr ee end is n ot
Spring Attachments
429
a positive spring in my hands, for in the tightening of this form of spring I find it will not keep its place, and the free end will slide up or down, as the circumstances are in either upper or lower, and be a continuous source of trouble. The tongue seems to be continually looking for some obstacle to disturb. In many instances, I find it very inconvenient, as well as impractical, to use a body-wire that follows the gingiva of the teeth. Sometimes there is the occlusion that interferes in this respect, and ofttimes the appliance interferes with the speech if placed at the necks of the teeth. If we wish to place
Fig.
i.s.
Fig. l·A.
Fig. 2-A.
Fig. 2·B.
Fig. 3.
our appliances on the lingual aspect w e must modify them according to conditions. Fig. 1 A will show my idea of such an appliance. It is a positive appliance inasmuch as the spring attachments are attached at both ends. The moving end is not necessarily soldered but may fit in under a wire or may enter a small tube one gauge larger than the diameter of the spring-wire used. Body-wire was 16-gauge, springs were 22-gauge. Fig. 1 B is an appliance made to perform the same duty as Fig. 1 A. This follows the line of the arch and does not have retention bands at the end of the spring wire. Body wire is 19-9auge, spring 22-gauge. At this time I wish to call your attention to the curve or bent wire to the distal. The spring is soldered distally and bent upon itself to the mesial,
A. C. Gifford
430
grvmg it more spring and a place for the tightening of said wire, which is done by a very slight bend to the lingual, at the cross, thereby bending the moving end labially. The labial spring principle of the Hawley retainer has been used as an active appliance in my practice for some time. I find it a corrective appliance as well as a retaining appliance. My idea is that there is no better retainer than the appliance that is used to move the teeth. The spring can be applied as needed for the movement of teeth. These are shown in Fig. 2 A. The arch was expanded first, as is necessary in all these cases before this form of appliance was placed. Body wire was 19-9auge, labial spring 23-gauge positive spring. Fig. 2 B is the same form of spring applied to a case where I thought
A.
c.
B. Fig. 4.
Fig. 5.
Fig. 6.
advisable to remove the first premolars. The first and second molars were used as anchorage, (this shows the retainer) and the body wire was placed only slightly to the lingual of the anterior teeth so as not to obstruct the speech, it being shortened occasionally. This form of spring is better used, I think, with a removable base-wire as it is easier to adjust, requiring less labor when shortening the body wire; wire same size as 2 A. Fig. 3 is an appliance of heavy spring wire for the rapid widening of an arch where there is a marked nasal stenosis. Bands on molars and canines are fastened together by half-round wire (curved side to the teeth). A sixteen inside gauge open tubing, with the distal end closed is soldered to this wire connecting the teeth. A 16-gauge wire is fitted to this so it will spring and rest in these tubes. The 16-gauge wire cannot slide back if the distal end of the tube is closed. Considerable pressure was put upon the teeth which in one month's time showed a lateral movement of the canines and teeth distal
Spring Attachments
431
to them a little over one quarter of an inch without an adjustment. is a positive appliance.
This
Fig. 4 shows what can be accomplished in a very short time with the appliance shown. These springs all were made on the loop principle or bent upon themselves, so as to get an adjustable spring which would give constant pressure. The tooth movement was remarkable, as the model "0" was made about ten weeks after the appliance was adjusted and with but two visits to the office. Bands with small wires soldered to the lin guo-gingival surface were placed on the laterals so the anterior springs would not slide to the occlusial. A 19-9auge body wire, and 22-gauge springs were used. Sometimes, due to certain mutilated conditions, we are required to remove a tooth that is labially placed in the position of another tooth. The case number 5 had a mandibular right lateral removed some years previous to the time they consulted me for the correction of the misplaced canine.
Fig. 7.
Fig. 8.
Fig. 9.
Fig. 10
I planned the appliance shown to give the most efficient services for a patient at a distal point from my office. After placing the appliance I saw the case but once until it was removed, and that only for observation. '1' he appliance was not adjusted from the time it was placed until it was removed. Oonstant, positive spring pressure by a twenty-gauge wire placed the tooth where I planned it should be. Notice the stabilization of the molar anchorage. Spring wire of 20-gauge was used. In cases such as Fig. 6 I find a very simple and efficient appliance such as is shown on the upper model. This is not very plain, due to it being a model made from an impression taken with the appliance in the mouth. The appliance was left as a retainer when the case was in normal occlusion. Body wire was 17-gauge, springs were 22-gauge. Fig. 7 is a very ordinary spring appliance for the correction of the malalignment of the anterior teeth in the maxillary arch. A 19-9auge body wire and 23'-gauge springs were used. Occasionally we are called upon to move
Geo, W. Grieve
432
one tooth to facilitate placing an artificial restoration and in one of such cases I constructed the appliance shown in Fig. 8. Another delicate appliance is shown in Fig. 9. This is to rotate the lateral and was the original appliance used on this case and it surprised me to have the tooth in its normal position when the patient returned after about six weeks' absence. In the early part of this article I spoke of retaining the free end of the spring wire on the body wire. Fig. 10 shows an appliance which has the free end of the labial spring in a tube, one size larger than the spring, soldered to the body wire. The spring wire must be bent at such an angle that it. will slide freely in this tube as the tube is at an angle and is not parallel with the long axis of the bent spring. There are many places where we can use springs in orthodontics and I hope to have some suggestions from the readers to add to my many spring ideas.
HEPORT OF CASES* By
G"EO.
W.
GRIEVE,
D.D.S.,
TORONTO, CANADA
H E RE is nothing unusual in the case I am about to present, but it serves
T admirably the purpose of illustrating the efficiency of the pin appliance,
which was used on the maxillary teeth. The mandibular arch was corrected with the lingual wire. It is a neutroclusion case. Fig. 1 shows the extreme overbite, considerable space between the maxillary first incisors, lack of eruption of the maxillary right second premolar and maxillary left canine; the latter, as may be seen, was about to erupt quite high up. The skiagraph showed the presence of the premolar. There was no space for either of these teeth in the dental arch, and a great deal of bodily movement of many of the teeth was necessary in the correction of the case. Considerable intrusion of maxillary first incisors and all mandibular incisors was necessary, as well as some extrusion of both maxillary and mandibular premolars and molars. In my experience, the pin appliance, with individual bite planes on the maxillary first incisor bands, is the ideal appliance for the correction of conditions as illustrated here in this maxillary arch. When the finished models were made, the second molars had not yet fully erupted and the models teetered a little. To avoid an error of the photographer, in placing them to show the occlusion, little bits of wax were stuck on where the dark spots show on the occlusal surface of the mandibular model (Fig. 2). The occlusal aspect shows that, through an oversight, the maxillary right canine had not been fully rotated. The treatment of this case was commenced a few months before I started to use the half-round pin which our "Read before the American Society of Orthodontists, Atlantic City, N.
J., April 26-30, 1921.