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The interrelationship of periodontics and orthodontics
28 • THE JO U R N A L OF THE A M E R IC A N DENTAL A SSO C IA T IO N
branches o f general dentistry w ould be a contribution to the dental profession. Data relative to the dentist standing and sit ting w ou ld apply to the dental assistant standing and sitting, assuming similar positions were used by both. Further stud ies o f tim e-m otion theories may prove that the first essential o f m otion econom y is the use o f a chairside dental assistant. 1001 Gayley Avenue
The physiologic study was done at the University of California at Los Angeles under a grant from the Ritter Corporation, Rochester, N.Y. ^Assistant professor, human factors research division, operative dentistry, School of Dentistry, University of Southern California. 1. Friedrich, R. H. Personal communication. 2. Woodson, Wesley E. Human engineering guide
for equipment designers. Berkeley, Calif., University of California Press, 1954. 3. Friedlander, Paul. Plato, vol. I. An introduction. New York, Pantheon Books, 1958. 4. A billion people in the United States? U. S. News and W orld Report Nov. 28, 1958. 5. Morehouse, L. E. Personal communication. 6. Kraus, Bertram. Personal communication. 7. Vandenberg, J. D. Human factors engineering I. Man and machine. Machine Design 30:108 April 17, 1958. 8. Roebuck, J. A., Jr. Anthropometry in aircraft engi neering design. J. Aviat. Med. 28:41 Feb. 1957. 9. Engineering staff, Ritter Corporation. Personal communication. 10. Marinacci, A. A . Clinical electromyography. Los Angeles, San Lucas Press, 1955. 11. Peters, G . E., and Drum, L. R. Human engineer ing— a new occupation. Personnel & Guidance J., Dec. 1957. 12. Wells, J. Gordon, and Morehouse, L. E. Electro myographic study of effects of various headward ac celerative forces upon pilot's ability to perform stand ardized pulls on aircraft control sticlc. J. Aviat. Med. 21:48 Feb. 1950. 13. American Dental Association, Bureau of Economic Research and Statistics. Mortality of dentists, 1951-1954. J.A.D.A. 52:618 Nov. 1956.
The interrelationship of periodontics and orthodontics
Edward A . L usterm an * D .D .S ., Rockville Centre, N .Y .
There is a large field in which the disci plines of orthodontics and periodontics m ay be employed to the benefit o f pa tients. Although some of the periodontal damage resulting from orthodontic treat ment is irreversible, much is transitory. T here should be more frequent consulta tion between orthodontist and periodon tist, and each should be familiar with the other’s literature.
It is incum bent on any practitioner o f the healing arts to have a wholesom e re spect for tissue. This encompasses a knowledge o f its histologic and path o logic characteristics and its capacity for alteration and repair. F or the orthodontist
as fo r all others in every field o f dentistry, this is sine qua non. T h e orthodontist’s m ajor function is to create harm ony out o f disharmony. Since, at best, perfection is elusive and ephemeral, the orthodontist’s objective is to achieve optim al im provem ent in every patient. Orthodontists share with all in dentistry the desire to restore m alocclu ded dentitions to proper function, to enhance the longevity o f the dentition, and to achieve these with due regard for tissue health, muscle balance and facial esthetics. O rthodon tic treatment may sometimes have undesirable side effects. These may include a greater or lesser degree o f root resorption, or perhaps the creation o f
LUSTERMAN . .. VO LUM E 59, JULY 1959 • 29
space w hen extraction must be resorted to, and a prem ature aging o f the den tition because o f bone and tissue loss at the necks o f the teeth. N one o f these is o f too great consequence when com pared to the over-all results achieved with re gard to function and esthetics. M ore over, m u ch depends on the skill and in tegrity o f the individual operator, and the understanding that there always may be a need for the intelligently adminis tered collateral services o f those in allied fields o f dentistry or m edicine. Som e o f the practical considerations with w h ich the clinical orthodontist is concerned relative to periodontal health follow. O C C L U S IO N
T h e aim in treatment o f all patients is to restore balance in occlusal force. It is necessary to eliminate undue stresses and strains w h ich tend to weaken the sur rounding structures and render it diffi cult or impossible to effect desired m ove ment in any given direction. Thus, fo r many patients, anchorage is established in one arch or the other with an appli ance w hich maintains a slight open bite; in some instances judicious grinding or reshaping o f the cusps is required. In all instances, after a period o f retention and settling after treatment, the occlusion must be equilibrated to allow for all movements w ithout undue lateral strain in the buccal segments or protrusive an terior thrust. Sometimes, in the course o f treatment it is advisable for esthetic rea sons to rem ove only the maxillary first bi cuspids, leaving the remaining buccal teeth in a Class II relationship; that is, the maxillary m olar a half tooth mesial to its classic position. I f this results in a plunger cusp effect the condition m ay be corrected by grinding; if grinding proves ineffective, occlusal changes m ay be re quired by operative means. This type o f treatment often is found necessary in instances in which there is a “ g ood ”
low er arch, with respect to size, shape and relationship to cranial and facial anato my, but in w hich the m axillary structures, teeth and bone, are in a forw ard relation ship. T h e restoration o f facial esthetics and, often concom itantly, m ental health, demands this type o f com prom ise treat m ent, even though it constitutes a de parture from the normal. ARCH INTEGRITY
T o re-establish arch integrity requires that the teeth be m oved to their correct axial relationship, contact relationship and occlusal level, all consistent with arch length and balanced muscular forces. Treatm ent so effected creates an environment in w hich the gingival struc tures m ay be nurtured properly and maintained in health. W hen teeth have norm al contacts and embrasures and are in correct occlusion, the gingival tissues should be cone-shaped and firm, the m ar gins knifelike. Since the gingiva and the interdental papillae take the shape of the environm ent in w hich they live, a normal relationship cannot exist in arches too small to contain all the teeth; rotated, m alposed teeth crow ded out o f the arches, slipped contacts, roots too close together, cross-bite relationships, abnorm al occlusal stresses and other dele terious conditions result. M a n y ortho dontists find it expedient to resort to ex traction in treatment o f such conditions. I prefer, wherever possible, to remove second molars rather than first bicuspids, for the reason that arch integrity may be maintained better by so doing. I have found that it is sometimes impossible to obtain closed contact between the cus pid and the second bicuspid in a patient with the first bicuspid extracted. This often results from a discrepancy in size o f the tooth material between the teeth o f the opposing arches. I f the space remain ing is small, contact should be restored by operative m eans; if it is large enough it will be self-cleansing. Great im prove
30 • THE JO U R N A L OF THE A M E R IC A N DENTAL A SSO C IA T IO N
m ent in gingival health is usually effected in successfully treated patients in w hom there has been com plete restoration o f arch integrity. OVERBITE AND OVER JET
O verbite problem s are best treated in the grow ing child with m echanotherapy and the adjunctive use o f the H aw ley bite plate. Since excessive anterior overbite m ay lead to periodontal disease by im pingem ent on the gingiva, fo o d im pac tion and occlusal trauma, it should be corrected at an early age. Its correction, however, must be preceded by thorough analysis o f the predisposing condition. Indiscriminate use o f the H aw ley appli ance for this purpose should be avoided. In this type o f condition the low er an terior teeth are frequently in an exces sively lingually inclined position. By b e ing straightened labially (an aid in over bite correction) these teeth are brought to an anatom ic, physiologic relationship with respect to the gingiva, wherein food m ay be properly incised without crushing it against the tissues. T h e sequelae o f uncorrected deep overbites are dam aging, and the noticeable im provem ent in gin gival health after treatment is im portant to the longevity o f the dentition. T h e re duction o f overjet is also required fo r functional correction and facial esthetics. It is most advisable, wherever possible, to leave the maxillary anterior teeth with a slight am ount o f overjet, thus eliminat ing abnorm al strain in protrusive excur sions. V ery often, however, in the course o f such correction, it is necessary to apply torque force to position the roots as well as the crowns lingually. T o d o otherwise m ay result in a p oor esthetic result with a typical rat-bite, and an additional haz ard in that the teeth m ay not maintain this position out o f retention. T orqu e force, m oreover, must be intelligently and carefully applied, fo r even in the most skillful hands it may result in some root resorption.
FRENUM INVOLVEMENTS
T h e abnormally large maxillary midline frenum is often responsible fo r an un sightly diastema, and its rem oval m ay be indicated in the course o f correction. L ow er m idline frenum s can be dam ag ing, causing entrapm ent o f fo o d and d if ficulty in m aintaining proper hygienic measures. T h e m arginal and interproxim al tissues break d o w n rapidly since the bone usually is thin in this region. This condition should b e detected and cor rected surgically as soon as possible, be fore the breakdown becom es acute. Some times it also m ay be fou n d necessary to deepen the vestibule by surgical means. COMMENTS
Several other matters should be explored briefly. In patients with exceptionally short teeth special consideration must be given to both ban d construction and m outh hygiene, especially w hen a m ulti banded technic is em ployed. Care should be exercised in ban d construction so as not to extend material beyond the level o f epithelial attachm ent. In teeth with short clinical crowns, this is difficult and often I resort to swaged or cast bands; even so, the attachments o r brackets, placed necessarily close to the gingival tissues, make treatment and the m ain tenance o f proper hygiene difficult. It sometimes becom es necessary to lengthen the crow n by “ contouring,” a helpful p ro cedure recently adopted, o r by other periodontal measures. O n occasion the contouring procedure also has been used to effect esthetic im provem ent. T h ere is a large field in w hich the discipline o f orthodontics and periodon tics m ay be advantageously employed to the benefit o f patients. Som e o f the perio dontal dam age resulting from orthodon tic treatment is not reversible; the at tainment o f the over-all objectives cannot be accom plished without some sacrifice. M u ch o f the dam age, however, is o f a
KYDD . . . VO LUM E 59, JULY 1959 • 31
transitory nature and is reversible, and it is in this area that greater cooperation and understanding should be sought. Just as a sound knowledge o f periodontal theory and therapy is essential to success ful periodontal treatment, so is orthodon tics dependent on the thorough grou nd ing o f the orthodontist in the basic sciences and in the acquisition o f the technical skills required. A lthough the areas o f cooperation are m anifold, and the com m unity o f interest established b e yond doubt, there are obvious limitations beyond w hich the dentist cannot proceed without adequate training and prepara tion. Consultation should be m uch more
frequent. T h e orthodontist and the perio dontist should be fam iliar with each other’s literature. Societies should devote themselves to further exploration o f the relationship o f periodontics and ortho dontics. O nly then can understanding be reached o f both the interrelationship and interdependence o f these two closely related branches o f dentistry. 165 North Village Avenue
Presented as part of a seminar at an oral clinical conference of the Jewish Chronic Disease Hospital, Brooklyn, N.Y. •Attending, chief of orthodontics, Jewish Chronic Dis ease Hospital, Brooklyn, N.Y.
Psychosom atic aspects of tem porom andibular joint dysfunction
William L . K y d d * D .M .D ., Seattle
O f 3 0 subjects with temporomandibular joint syndrome, 23 were emotionally dis turbed. T h e oral, physical and emotional status of patients with
this syndrome
should be evaluated. In the emotionally disturbed, relief
can
be
effected
only
when situations threatening the subject’s security have
been
removed, and ap
propriate occlusal adjustments have been made when indicated. Radical procedures should be postponed until conservative therapy has been utilized.
T h e problem o f the m alfunctioning tem porom andibular join t is essentially a psychobiological problem . T h e role o f the emotional attitude o f the patient with m axillofacial pain has been discussed.1 A
correlation between tem porom andibular joint pain and muscle hyperfunction has been suggested.2 It is postulated that spasms o f the muscles o f mastication plus occlusal irregularities might produce tem porom andibular joint pain.3 A lthough it is obvious that sustained muscle hyperfunction is not invariably productive o f discom fort and pain, but is usually well tolerated, it is im portant to understand the role o f skeletal muscle activity in the history o f tem porom an dibular joint pain. T h e follow ing study therefore was undertaken to define the role o f the participation o f the skeletal musculature in patterns o f behavior ex hibited by subjects with tem porom andib ular joint pain. T hree m ethods o f evaluation were
branches o f general dentistry w ould be a contribution to the dental profession. Data relative to the dentist standing and sit ting w ou ld apply to the dental assistant standing and sitting, assuming similar positions were used by both. Further stud ies o f tim e-m otion theories may prove that the first essential o f m otion econom y is the use o f a chairside dental assistant. 1001 Gayley Avenue
The physiologic study was done at the University of California at Los Angeles under a grant from the Ritter Corporation, Rochester, N.Y. ^Assistant professor, human factors research division, operative dentistry, School of Dentistry, University of Southern California. 1. Friedrich, R. H. Personal communication. 2. Woodson, Wesley E. Human engineering guide
for equipment designers. Berkeley, Calif., University of California Press, 1954. 3. Friedlander, Paul. Plato, vol. I. An introduction. New York, Pantheon Books, 1958. 4. A billion people in the United States? U. S. News and W orld Report Nov. 28, 1958. 5. Morehouse, L. E. Personal communication. 6. Kraus, Bertram. Personal communication. 7. Vandenberg, J. D. Human factors engineering I. Man and machine. Machine Design 30:108 April 17, 1958. 8. Roebuck, J. A., Jr. Anthropometry in aircraft engi neering design. J. Aviat. Med. 28:41 Feb. 1957. 9. Engineering staff, Ritter Corporation. Personal communication. 10. Marinacci, A. A . Clinical electromyography. Los Angeles, San Lucas Press, 1955. 11. Peters, G . E., and Drum, L. R. Human engineer ing— a new occupation. Personnel & Guidance J., Dec. 1957. 12. Wells, J. Gordon, and Morehouse, L. E. Electro myographic study of effects of various headward ac celerative forces upon pilot's ability to perform stand ardized pulls on aircraft control sticlc. J. Aviat. Med. 21:48 Feb. 1950. 13. American Dental Association, Bureau of Economic Research and Statistics. Mortality of dentists, 1951-1954. J.A.D.A. 52:618 Nov. 1956.
The interrelationship of periodontics and orthodontics
Edward A . L usterm an * D .D .S ., Rockville Centre, N .Y .
There is a large field in which the disci plines of orthodontics and periodontics m ay be employed to the benefit o f pa tients. Although some of the periodontal damage resulting from orthodontic treat ment is irreversible, much is transitory. T here should be more frequent consulta tion between orthodontist and periodon tist, and each should be familiar with the other’s literature.
It is incum bent on any practitioner o f the healing arts to have a wholesom e re spect for tissue. This encompasses a knowledge o f its histologic and path o logic characteristics and its capacity for alteration and repair. F or the orthodontist
as fo r all others in every field o f dentistry, this is sine qua non. T h e orthodontist’s m ajor function is to create harm ony out o f disharmony. Since, at best, perfection is elusive and ephemeral, the orthodontist’s objective is to achieve optim al im provem ent in every patient. Orthodontists share with all in dentistry the desire to restore m alocclu ded dentitions to proper function, to enhance the longevity o f the dentition, and to achieve these with due regard for tissue health, muscle balance and facial esthetics. O rthodon tic treatment may sometimes have undesirable side effects. These may include a greater or lesser degree o f root resorption, or perhaps the creation o f
LUSTERMAN . .. VO LUM E 59, JULY 1959 • 29
space w hen extraction must be resorted to, and a prem ature aging o f the den tition because o f bone and tissue loss at the necks o f the teeth. N one o f these is o f too great consequence when com pared to the over-all results achieved with re gard to function and esthetics. M ore over, m u ch depends on the skill and in tegrity o f the individual operator, and the understanding that there always may be a need for the intelligently adminis tered collateral services o f those in allied fields o f dentistry or m edicine. Som e o f the practical considerations with w h ich the clinical orthodontist is concerned relative to periodontal health follow. O C C L U S IO N
T h e aim in treatment o f all patients is to restore balance in occlusal force. It is necessary to eliminate undue stresses and strains w h ich tend to weaken the sur rounding structures and render it diffi cult or impossible to effect desired m ove ment in any given direction. Thus, fo r many patients, anchorage is established in one arch or the other with an appli ance w hich maintains a slight open bite; in some instances judicious grinding or reshaping o f the cusps is required. In all instances, after a period o f retention and settling after treatment, the occlusion must be equilibrated to allow for all movements w ithout undue lateral strain in the buccal segments or protrusive an terior thrust. Sometimes, in the course o f treatment it is advisable for esthetic rea sons to rem ove only the maxillary first bi cuspids, leaving the remaining buccal teeth in a Class II relationship; that is, the maxillary m olar a half tooth mesial to its classic position. I f this results in a plunger cusp effect the condition m ay be corrected by grinding; if grinding proves ineffective, occlusal changes m ay be re quired by operative means. This type o f treatment often is found necessary in instances in which there is a “ g ood ”
low er arch, with respect to size, shape and relationship to cranial and facial anato my, but in w hich the m axillary structures, teeth and bone, are in a forw ard relation ship. T h e restoration o f facial esthetics and, often concom itantly, m ental health, demands this type o f com prom ise treat m ent, even though it constitutes a de parture from the normal. ARCH INTEGRITY
T o re-establish arch integrity requires that the teeth be m oved to their correct axial relationship, contact relationship and occlusal level, all consistent with arch length and balanced muscular forces. Treatm ent so effected creates an environment in w hich the gingival struc tures m ay be nurtured properly and maintained in health. W hen teeth have norm al contacts and embrasures and are in correct occlusion, the gingival tissues should be cone-shaped and firm, the m ar gins knifelike. Since the gingiva and the interdental papillae take the shape of the environm ent in w hich they live, a normal relationship cannot exist in arches too small to contain all the teeth; rotated, m alposed teeth crow ded out o f the arches, slipped contacts, roots too close together, cross-bite relationships, abnorm al occlusal stresses and other dele terious conditions result. M a n y ortho dontists find it expedient to resort to ex traction in treatment o f such conditions. I prefer, wherever possible, to remove second molars rather than first bicuspids, for the reason that arch integrity may be maintained better by so doing. I have found that it is sometimes impossible to obtain closed contact between the cus pid and the second bicuspid in a patient with the first bicuspid extracted. This often results from a discrepancy in size o f the tooth material between the teeth o f the opposing arches. I f the space remain ing is small, contact should be restored by operative m eans; if it is large enough it will be self-cleansing. Great im prove
30 • THE JO U R N A L OF THE A M E R IC A N DENTAL A SSO C IA T IO N
m ent in gingival health is usually effected in successfully treated patients in w hom there has been com plete restoration o f arch integrity. OVERBITE AND OVER JET
O verbite problem s are best treated in the grow ing child with m echanotherapy and the adjunctive use o f the H aw ley bite plate. Since excessive anterior overbite m ay lead to periodontal disease by im pingem ent on the gingiva, fo o d im pac tion and occlusal trauma, it should be corrected at an early age. Its correction, however, must be preceded by thorough analysis o f the predisposing condition. Indiscriminate use o f the H aw ley appli ance for this purpose should be avoided. In this type o f condition the low er an terior teeth are frequently in an exces sively lingually inclined position. By b e ing straightened labially (an aid in over bite correction) these teeth are brought to an anatom ic, physiologic relationship with respect to the gingiva, wherein food m ay be properly incised without crushing it against the tissues. T h e sequelae o f uncorrected deep overbites are dam aging, and the noticeable im provem ent in gin gival health after treatment is im portant to the longevity o f the dentition. T h e re duction o f overjet is also required fo r functional correction and facial esthetics. It is most advisable, wherever possible, to leave the maxillary anterior teeth with a slight am ount o f overjet, thus eliminat ing abnorm al strain in protrusive excur sions. V ery often, however, in the course o f such correction, it is necessary to apply torque force to position the roots as well as the crowns lingually. T o d o otherwise m ay result in a p oor esthetic result with a typical rat-bite, and an additional haz ard in that the teeth m ay not maintain this position out o f retention. T orqu e force, m oreover, must be intelligently and carefully applied, fo r even in the most skillful hands it may result in some root resorption.
FRENUM INVOLVEMENTS
T h e abnormally large maxillary midline frenum is often responsible fo r an un sightly diastema, and its rem oval m ay be indicated in the course o f correction. L ow er m idline frenum s can be dam ag ing, causing entrapm ent o f fo o d and d if ficulty in m aintaining proper hygienic measures. T h e m arginal and interproxim al tissues break d o w n rapidly since the bone usually is thin in this region. This condition should b e detected and cor rected surgically as soon as possible, be fore the breakdown becom es acute. Some times it also m ay be fou n d necessary to deepen the vestibule by surgical means. COMMENTS
Several other matters should be explored briefly. In patients with exceptionally short teeth special consideration must be given to both ban d construction and m outh hygiene, especially w hen a m ulti banded technic is em ployed. Care should be exercised in ban d construction so as not to extend material beyond the level o f epithelial attachm ent. In teeth with short clinical crowns, this is difficult and often I resort to swaged or cast bands; even so, the attachments o r brackets, placed necessarily close to the gingival tissues, make treatment and the m ain tenance o f proper hygiene difficult. It sometimes becom es necessary to lengthen the crow n by “ contouring,” a helpful p ro cedure recently adopted, o r by other periodontal measures. O n occasion the contouring procedure also has been used to effect esthetic im provem ent. T h ere is a large field in w hich the discipline o f orthodontics and periodon tics m ay be advantageously employed to the benefit o f patients. Som e o f the perio dontal dam age resulting from orthodon tic treatment is not reversible; the at tainment o f the over-all objectives cannot be accom plished without some sacrifice. M u ch o f the dam age, however, is o f a
KYDD . . . VO LUM E 59, JULY 1959 • 31
transitory nature and is reversible, and it is in this area that greater cooperation and understanding should be sought. Just as a sound knowledge o f periodontal theory and therapy is essential to success ful periodontal treatment, so is orthodon tics dependent on the thorough grou nd ing o f the orthodontist in the basic sciences and in the acquisition o f the technical skills required. A lthough the areas o f cooperation are m anifold, and the com m unity o f interest established b e yond doubt, there are obvious limitations beyond w hich the dentist cannot proceed without adequate training and prepara tion. Consultation should be m uch more
frequent. T h e orthodontist and the perio dontist should be fam iliar with each other’s literature. Societies should devote themselves to further exploration o f the relationship o f periodontics and ortho dontics. O nly then can understanding be reached o f both the interrelationship and interdependence o f these two closely related branches o f dentistry. 165 North Village Avenue
Presented as part of a seminar at an oral clinical conference of the Jewish Chronic Disease Hospital, Brooklyn, N.Y. •Attending, chief of orthodontics, Jewish Chronic Dis ease Hospital, Brooklyn, N.Y.
Psychosom atic aspects of tem porom andibular joint dysfunction
William L . K y d d * D .M .D ., Seattle
O f 3 0 subjects with temporomandibular joint syndrome, 23 were emotionally dis turbed. T h e oral, physical and emotional status of patients with
this syndrome
should be evaluated. In the emotionally disturbed, relief
can
be
effected
only
when situations threatening the subject’s security have
been
removed, and ap
propriate occlusal adjustments have been made when indicated. Radical procedures should be postponed until conservative therapy has been utilized.
T h e problem o f the m alfunctioning tem porom andibular join t is essentially a psychobiological problem . T h e role o f the emotional attitude o f the patient with m axillofacial pain has been discussed.1 A
correlation between tem porom andibular joint pain and muscle hyperfunction has been suggested.2 It is postulated that spasms o f the muscles o f mastication plus occlusal irregularities might produce tem porom andibular joint pain.3 A lthough it is obvious that sustained muscle hyperfunction is not invariably productive o f discom fort and pain, but is usually well tolerated, it is im portant to understand the role o f skeletal muscle activity in the history o f tem porom an dibular joint pain. T h e follow ing study therefore was undertaken to define the role o f the participation o f the skeletal musculature in patterns o f behavior ex hibited by subjects with tem porom andib ular joint pain. T hree m ethods o f evaluation were