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When and why is Orthodontic Procedure Indicated?*
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duty to the m edical profession. W h en such a re p o rt is m ade, it is w ell not to rely on the roentgenogram alone, or a rriv e a t a decision a fte r re a d in g the films. T h e p a tie n t should be c arefu lly exam ined by all the m eans of diagn osis w hich are a t the com m and of the d en tist today— direct inspection of every tooth, p alpation, v ita lity tests, and any o ther m ethod deem ed necessary; follow ing w hich a n in telligent re p o rt of the findings and recom m endations can be sent to the phy sician. I am sure th a t if this procedure is m ore c arefu lly follow ed, o u r b re th re n in the h e alin g a rt w ill think m ore highly of us. R e fe rrin g to the chronic case, the one in w hich it is m ost difficult to determ ine the procedure to be follow ed, it is well to keep this point in m ind— w hen in doubt, do nothing. R em em ber th a t the m ax illa ry sinus, once entered (it m akes little difference by w hich
ro u te ), n e v e r re tu rn s to the condition it w as in p rio r to operation. M any o ral surgeons and dentists a re inclined to be overzealous in tre a tm e n t of the conditions found in the floor of the m ax illa ry sinus, and in th eir effort to elim inate all pathologic conditions, cause unnecessary d am age to the structures, w hich results in a long period of trea tm e n t fo r the patient. I w ould like to stress the im portance of keeping the anatom ic stru c tu re as n e arly intact as possible, and nev er en terin g the sinus unless it is absolutely nec essary. I attem pted to point out th a t one cannot depend on roentg en o g rap h ic in te r p re ta tio n alone. D iagnosis m ust be based upon the history of p ast conditions, present condition and roentgenographic and clinical findings, care fu ly checked by any other m eans a t o u r com m and.
WHEN A N D WHY IS ORTHODONTIC PROCEDURE INDICATED?* By ERNEST N. BACH, A.B., D.D.S., Toledo, Ohio H E object of this paper is to present to the mind of the practitioner of general dentistry one phase of the question of malocclusion of teeth in chil dren : “A t W h a t Age Is O rthodontic Procedure Indicated and W h y Is I t A d visable at T h a t Period?” Since this ques tion is one which cannot be settled or agreed on in a moment, it lends itself to discussion. T here are nearly as many variations from the so-called norm al as there are individual cases, and in order that we may arrive at some definite conclusion, it seems fitting that we should analyze a few of the more common types of m al
T
*R ead before the Section on O rthodontia at the S eventy-F irst A nnual Session of the A m erican D en tal A ssociation, W ashington, D. C., Oct. 10, 1929. Jo u r. A . D . A ., J u ly ,
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occlusion which are manifest in younger patients. I t is as difficult to generalize on a question of this nature as it is to gen eralize on the question of replacing miss ing teeth, for nearly all cases are indi vidual and call for separate solutions. A t this time, we are not so much concerned w ith the etiologic factors or the prognosis of early malocclusion as we are w ith the question of recognizing the condition and the time orthodontic interference should be advised. I t is quite generally agreed that aborted cases of malocclusion of the permanent teeth are much to be preferred to cor rected or partially corrected cases in the adult, and, of necessity, these preventable cases m ust be considered before the erup tion of all the permanent teeth. T his means that we must deal with the child
Bach— Orthodontie Procedure as early as any serious malocclusion is detected; and by early is meant between the ages of 3 and 7 years. T h e question of orthodontia being primarily one of bone growth and not mechanics, early diagnosis is an essential factor.
DIAGNOSIS Diagnosis should be given very care ful consideration, including full mouth roentgenogram s; the patient’s history; the parents’ and near-relatives’ histories (should the case in hand be of an excep tional m alrelation) ; accurate study
F ig . I.— M o d e l s h o w i n g w h a t m a y r i g h tl y be t e r m e d n o r m a l occlusion f o r a child, a g e d 5 years.
models; the diet of mother during preg nancy ; the diet of the patient both during infancy and at present; various habits; th e n a so p h ary n g eal a re a ; abnorm al muscle habits, and the general physical condition. Even when these factors are taken into consideration and a comparison made of the foregoing data in a number of cases, we may frequently feel that our best judgm ent is in e r o r .
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LeRoy Johnson, on the question of diagnosis says1: W i t h t h e in c r e a s e o f k n o w le d g e , d i a g n o s is is b e c o m in g m o r e difficult. W h e n y ou th in k o f th e c h i l d ’s d e n t u r e in its t r u e l i g h t ; w h e n y ou t h i n k of th e pro cess o f d e n titio n a n d w h a t it i n v o lv e s, th e re so r p tio n , loss a n d e r u p t i o n of teeth , th e g r o w t h a n d d i f fe r e n t i a t i o n of tissues, th e f u n c t i o n a l in t e r a c t i o n o f p a r t s ; w h e n y o u t h in k o f th e in e q u a l i t i e s c h a r a c te r is tic of g r o w t h processes, a n d o f v a r i a tions in s t r u c t u r e d u e to g e r m i n a l f a c t o r s — w h e n you t h i n k of the c h i l d ’s d e n t u r e i n its t r u e lig ht, in f a c t as w e k n o w it to be, th e p r o b l e m o f the t im e o f t r e a t m e n t h o l d s one
F ig. 2.— O cclu sal v i e w o f m o d el in F i g u r e 1; s h o w i n g s p a c i n g b e t w e e n t h e six a n t e r i o r teeth, in both t h e m a x i l l a a n d the m a n d i b l e . in a b ey an c e. W e m a y eas ily r eco g n ize d i f fere n c e s b e t w e e n th e d e n t u r e s of d if fe r e n t c h ild r e n , b u t to r eco g n ize con d itio ns of tooth re l a t i o n s w h i c h e x h ib it a r e a l a b n o r m a l i t y is n ot easy. D i a g n o s i s m e a n s th e reco g n itio n o f dise a se f r o m its sym ptom s. T r e a t m e n t signifies the m e a n s em p loy ed in effe cting a c u r e of dise a se a n d is o f co u rse g o v e r n e d b y the etiologic f a c t o r s in v o lv e d . T r e a t m e n t is s e c o n d a r y to d iag n o s is . 1. Jo h n s o n , L e R o y : D en t. Cosmos, 66: 779 ( J u l y ) 1924.
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And again we read in “O rthodontics,” by B. E. Lischer2: I t is well to r e m e m b e r t h a t a f a v o r a b l e p rog no sis d e p e n d s l a r g e l y upon a n e a r l y d iag no s is , w h e n co n d itio n s a r e such t h a t a c o m p a r a t i v e l y sim ple t r e a t m e n t will suffice. F o r m e r l y it w a s the custom to p ostpone most t r e a t m e n t s u n til all of th e p e r m a n e n t teeth h ad e r u p te d , f o r it w a s b e lie v e d t h a t N a t u r e w o u ld assist in the co r re c tio n of th e m a l o c c l u sion, a n d t h a t m ost p a t i e n t s w o u l d “ o u t - g r o w ” the d e f o rm ity . M a n y b i t t e r d i s a p p o in t m e n t s h a v e t a u g h t us the e r r o r o f such a d v ice, a n d s t r o n g ly e m p h a s i z e the f a c t t h a t th e se v ere fo rm s o f m alo cclusio n do n ot d e v e l o p o v e r night, b u t a r e of slow g r o w t h . H en ce it fo l lows t h a t y e a r s b e f o re e v e n a n i n tellig en t p a r e n t reco gn izes the i m p e n d i n g d efo rm ity , the a l e r t d i a g n o s ti c i a n c a n a d v i s e w a y s a nd m e a n s f o r its p r e v e n tio n .
F ig. 3.— C a se of e x ten s iv e o v e r b i t e a n d p o ste rio r occlusion in a child, a g e d 3 ^ y e a r s . O w i n g to the m e c h a n i c a l aspects o f d e n t i tion, the se lf- c o r re c tio n of m o st f o r m s of m alocclusio n is a n im poss ibility. E v e r y f a c t g l e a n e d f r o m a s t u d y of the process of d e n titio n s u b s t a n t i a t e s th e o r t h o d ontic ax iom t h a t malocclusion and its ac
companying deformities are progressive, not static. T h e r e s t o r a t i o n of n o r m a l f u n ctio n d u r i n g the d e v e l o p m e n t a l p e r io d is a f u n d a m e n t a l p rinciple of r a t i o n a l t r e a t m e n t . T h e p e r io d of tooth e r u p t i o n is t h e perio d of g r e a t e s t g r o w t h in the a l v e o l a r process.
Proper foods, both in quality and quantity, sunlight and exercise play per-----------------2. Lisch er , B. E . : O r th o d o n tic s, P h i l a d e l p h i a : L e a & F e b ig e r , 1912, p. 130.
haps the greatest part in building the resistance of a healthy and so-called normal body. This is generally conceded by authorities on the subject. The question of preventive dentistry arises in prenatal life, and may we not likewise say that the question of preven tive orthodontia has its origin during this same period? For, as E. V. M cCollum says3: A s a p rofession , w e h a v e i g n o r e d the d e v e l o p m e n t a l f a c t o r as the one t h a t is o p e r a t iv e in p r e v e n t i v e d e n t i s t r y . T h e r e is one w a y b ack to b e t t e r phy sical d e v e l o p m e n t an d t h a t is the most f u n d a m e n t a l o f all, nam ely, to b u ild up a n o r m a l , p h y sic al s t r u c t u r e , a n d
Fig. 4.— C a s e s h o w i n g a n a n t e r i o r r e la tio n of th e m a n d i b l e to t h e m a x i l l a . t h a t can be do ne onl y t h r o u g h p r o p e r diet. T h e child o f school a g e is b e y o n d th e r e a c h of help in th is respec t. H i s teeth a r e a l r e a d y f o rm e d . T h i s p r e v e n t i v e d e n t i s t r y p r o p o s i tion is l a r g e l y one o f p r e n a t a l life a nd infan cy .
It is sound judgm ent for each of us to avail ourselves of every opportunity to gain knowledge on this subject from authentic sources, so that we may be equipped to furnish our patients with at 3. M c C o llu m , E. V., q u o te d by D ickerson, M i l d r e d W . : J. A . D . A., 11: 243 ( M a r c h ) 1924.
Bach— Orthodontic Procedure least elementary information on this im portant phase of dentistry. Various stages of growth and prede termined deformities have been produced experimentally in monkeys and guineapigs by Drs. Howe, M cCollum and others. Caries and constricted arches and other skeletal defects have been produced by certain types of diets and these defects arrested by a change to another form of diet. T o some, these facts mean little; to others, much. T here is quite a diversity of opinion relating to the development and size of the deciduous arches up to the period of 5 years of age. E. A. Bogue, in a num ber of his writings, stresses the point that
F ig. 5.— C a se o f c o n striction o f th e m a x i l l a , w i t h a p r a c t i c a l l y n o r m a l siz e m a n d i b l e .
“unless the distance between the maxil lary second temporary molars, at the gingivae, measures 28 mm. or more, we may look for a corresponding constricted condition in the permanent dentition from the lack of lateral grow th in the jaws at the earlier age, w ith a resulting malocclusion of many of the permanent teeth.” This was found true by D r. Bogue in a large percentage of the cases in his practice, and while followers of Bogue heartily agree w ith his findings, others are of a different opinion. E. C. Reed, in a paper given before the Pacific
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Coast Society of Orthodontists, makes this statem ent4: I t w o u l d seem r e a s o n a b le t h a t d e v e l o p m e n t co u ld be se c u re d m o r e r e a d i l y a n d m o re n o r m a l l y if w e set a b o u t to assist as soon as w e a r e su re N a t u r e w ill n o t p r o p e r l y c a r e f o r it. I a m no t p r e p a r e d to be as r a d i c a l as D r . B ogue, w h o a d v o c a t e d e x p a n s i o n in all cases w h e r e the d i sta n c e b e t w e e n the d e c id u o u s second m o l a r s is less t h a n 28 m m . N o r h a v e I y e t a t t e m p t e d to e x p a n d sim ply b ecau s e t h e r e w a s no t a s p a c i n g of the d e c id u o u s in ciso rs a t 4 o r 5 y e a r s o f age. A s soon, h o w e v e r , as w e find th e p e r m a n e n t i nciso rs e r u p t i n g a n d t h e r e is n o t suffi cient room, I be lie v e w e should s t a r t t r e a t ment. T h i s o r d i n a r i l y is ab ou t 6 o r 7 y e a r s of age. A t th is ag e, th e child is old en o u g h so one c a n g a i n h is confidence a n d easily fit a n d a d j u s t a n ap p lian ce.
F ig. 6.— C a se of flatte n in g o f the m a x i l l a r y process on th e r i g h t side.
A neutroclusion case is one in which there is a so-called normal relation of the arches anteroposteriorly. A procedure which we find has been of great help and also quite advisable in neutroclusion cases at 3 or 4 years of age, if the six maxillary and mandibular anterior teeth are in close contact, is to keep an accurate check every five or six months, the changes being noted which take place in the size of the arches. If at the age of 5 or 6 years, we find the six anterior teeth still “tightly 4. Reed, E. C . : I n t e r n a t . J. O r t h o d o n ., 9: 175 ( M a r c h ) 1923.
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together,” it may be advisable to assist N ature mechanically at this time in order to obtain the necessary grow th of the arches for the permanent teeth. T h e form of procedure depends greatly on the size of the jaws and the development which has taken place in the preceding year or two. Should we find these anterior teeth in contact w ith each other, and the posterior segments of the arches constricted in such a way as to show th at practically no grow th has taken place during the devel opmental period up to the time of the loss of the anterior teeth (5 or 6 years of age), we may feel convinced that mechan-
Fig. 7.— C a s e o f co n s trictio n o f b oth m a x illa a n d m a n d i b l e , a n d excessive o v er b ite.
ical or natural stimulation w ill prove beneficial. I t is to be regretted if a hasty diagnosis made in a case as above described results in the placing of appliances in a child’s mouth unnecessarily at the age of 3 or 4 years. T here are certain types of malocclusion found in the deciduous dentures which we believe should be corrected as soon as pos sible after detection. These are the types of anterior and posterior occlusion. In the first, there is a protruding relation of
the mandible to the m axilla; in the sec ond, there is a receding relation of the mandible to the maxilla. W e feel that these two types of cases can be greatly benefited by early applica tion of mechanical stimulation and proper muscle development. T o be sure, proper development of the muscles of mastica tion will aid greatly in the development of the other osseous structures of the face, as w ell as those in which we are more intimately concerned. T his is essential for many reasons, w ith which you are already familiar. Another type of case which should be mentioned here is the one in which there has been an early loss of one or more of the deciduous teeth, from accident, caries or neglect. W herever this has occurred, a space-retainer should be made and ce mented in position to maintain the mesiodistal space resulting from the missing tooth. T his retainer should also be con structed so that it will act in the manner of a partial restoration, as far as occlusion is concerned. By this, we mean that the retainer should be in contact with the op posing tooth in order to prevent the over elongation of that member. Should any of the deciduous molars be lost about the ninth or tenth year, before their due time, it may be advisable to ex tract the opposing like tooth to allow for the even development and elongation of the bicuspids. M aintaining the space in a case like this may prove detrimental rather than ad vantageous, but, if in doubt, we should seek advice in the m atter before contem plating the manner of procedure. O ften, when there is a full complement of de ciduous teeth, extraction is advisable be fore the teeth begin to loosen. T his is true when the permanent successor has erupted either at one side or the other of the line of occlusion, and resorption of
Bach— Orthodontic Procedure the deciduous roots has not taken place. Although this condition occurs most fre quently in the incisor region, discretion must be used in extracting deciduous teeth when the permanent successor has not erupted, and roentgenograms should be consulted for the findings therein.
EARLY TREATM ENT “ It is generally conceded that the idea of early orthodontic treatm ent is correct,” writes Charles R. Baker.5 W e feel that when thorough diagnosis reveals a decided malocclusion, ortho dontic interference should be instituted as soon as that condition manifests itself. T here are a number of things which
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similar change in the body of the man dible and maxilla. T he possibility of this change becomes less as age increases, but is very pronounced during childhood, when N atu re’s activity in bone building is at its highest. 2. In most cases, better cooperation is obtained from both parent and patient. T here are definite instructions which are given children with certain types of mal occlusion, and, unless these instructions are followed, the case is prolonged and satisfactory completion of the work is made impossible. By giving these instruc tions to the parent as well as to the patient, we have a double check on the w ork to be carried out. T his is likewise
F ig . 8.— L i n g u a l v i e w o f m odel in F i g u r e 7.
we also hold as being advantageous for orthodontic work at this ag e: 1. As D r. Lischer stated: “ D uring tooth eruption there is the greatest growth in the alveolar process.” If, as has been stated before, it becomes neces sary to work on the deciduous denture, more progress will be made if the work is carried on before apical resorption has taken place. Stimulation of root move ment from mechanical sources w ill have a tendency to produce a grow th or change in the alveolar process and probably a 5. B a k e r, C. R . : I n d i c a t i o n s f o r T r e a t m e n t of M a lo cclu sio n, J. A. D . A., 14: 777 ( M a y ) 1923.
true regarding appointments and the fre quent carelessness of older patients. 3. D uration of treatm ent in less severe cases is comparatively short. W e also find that there is better response in bone growth through stimulation at this age; appointments are better kept, and fewer outside activities detract from the work. 4. D iverting or correcting injurious habits at this age is more easily accom plished. Especially is this true with such habits as mouth-breathing, postural habits and various thumb, finger and tongue habits. Too often, malocclusion of the permanent denture results from one or
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more of these habits established during childhood. * 5. A t this age, there is little or no objection by the patient to wearing ap pliances, while at prehigh school or high school age, considerable opposition is met with, and progress is less favorable. 6. One object of early treatm ent is to bring about normal size and function of the deciduous dentures for that particular age, but the primary object is one of pre vention of malocclusion of the permanent denture. Quoting M artin Dewey0: A f e w y e a r s ago, I m a d e a s t a t e m e n t t h a t o ne of the m ost f r e q u e n t causes of m a l o c clusio n w a s the i m p r o p e r c a r e of t h e d e c id u o u s teeth. A f t e r s e v e r a l m o r e y e a r s of o b s e rv a t i o n , I a m in clined to believ e t h a t
exten t, f o r t h e d e v e l o p m e n t of th e s t r u c t u r e s s u p p o r t i n g the p e r m a n e n t teeth. W e find an u n f o r t u n a t e c o nd itio n w h e n the d e c id u o u s teeth h a v e b een a l l o w e d to d e c a y to a p oin t w h e r e e x t r a c t i o n becom es n eces sa ry . T h e e x tr a c tio n of a c e r t a i n d e c idu ou s to oth will p ro d u c e a type of m a l occlusion t h a t c a n a l w a y s be f o re t o l d y e a r s in a d v a n c e of th e u l tim a te resu lt. T h e e x t r a c t i o n of a m a n d i b u l a r cu spid o r m o l a r a t a c e r t a i n a g e will en a b le th e o r t h o d o n ti s t to p o r t r a y ex actly th e type of m alo cclu sio n t h a t is g o i n g to be p r e s e n t a t th e a g e o f 14 o r 15 y e a r s , if n o t h i n g is do n e to p r e v e n t th e o c c u r r ence o f the malocclusio n. T h e e x t r a c t i o n o f a n y p a r t i c u l a r d ecid u o u s tooth w ill p ro d u c e a ty p ic a l f o r m of malocclusio n, th ese h a v i n g o c c u r r e d so often t h a t a n y o r t h o d o n ti s t of ex p erience, w h e n told w h a t d e c id u o u s tooth h a s b een e x tr a c te d , c a n fore tell t h e type of
F ig. 9.— C a se o f co n g e n ita lly m i s s i n g m a x i l l a r y l a t e r a l in ciso rs. All buccal m a x i l l a r y teeth w e r e m o v e d a n t e r i o r l y to close the sp a c e le f t by t h e m i s s i n g teeth. the d e c id u o u s teeth, as a s so c ia te d w i t h a c q u i r e d conditions, a r e p r o b a b l y resp on sib le f o r as m a n y cases of m alo cclu s io n as a n y o t h e r a c q u i r e d f a c to r. By a c q u i r e d f a c t o rs , I m e a n th o se c on d ition s w h i c h a r i s e a f t e r the b i r th of th e i n d i v i d u a l w h i c h a r e th e r esu lt o f the e n v i r o n m e n t in w h i c h he lives, o r r a t h e r a r e co n dition s w h ic h co uld h a v e been co n tr o lle d by th e p r o p e r m e a s u r e s i n s t i g a t e d a t the r i g h t tim e. T h e d e c id u o u s t e e t h a r e f o r m e d f o r the p u r p o s e of m a s t i c a t i n g the fo od d u r i n g th e e a r l y life of t h e ch ild, a n d as a r esu lt of this m a s tic a tio n , t h e y s u p p l y the st i m u l a t i o n t h a t is responsible, to a g r e a t 6. D ewey, M a r tin : O rth o d o n tia : Factors M a k i n g I t N e c e s s a r y t h a t M a y Be P a r t i a l l y E li m i n a t e d , J. A . D. A., 12: 1188 ( O c t.) 1925.
m alo cclu s io n t h a t w ill develop, p r o v i d e d s o m e th i n g else does no t occur to m a k e the co n d itio n still worse. I f it becomes ab so lute ly n eces sa ry , b ecau se o f p a th o lo g ic i n v o l v e m e n t , to e x t r a c t d ecid u o u s teeth, some m e a n s should be em p lo y ed to m a i n t a i n th e sp a ce f o r the p e r m a n e n t teeth, a n d some d ev ice should be u se d to keep the r e m a i n i n g teeth in t h e i r p r o p e r position, in o r d e r to m a i n t a i n a n o r m a l a p p r o x i m a l con tact a n d a n o r m a l cusp relation .
7. Various writers who have voiced their opinions seem to agree that it is best to work on the deciduous dentition before the roots resorb, a point which has been previously discussed.
Bach— Orthodontie Procedure 8. T reatm ent should be begun as early as possible, thereby allowing the patient to reap the earliest benefits resulting from the work. H arold Chapman writes :7 I s u b m i t m o st e m p h a t i c a l l y t h a t the e a r l i e r a n y m a l f o r m a t i o n of these bones is c o rre cted a n d the e a r l i e r t h e i r fu nction s a n d the f u n c tions of t h e . asso ciated tissues a r e m a d e n o r m a l , t h e n the e a r l i e r all th ese p a r t s will be s t a r t e d a l o n g p r o p e r lines f o r t h e i r f u t u r e g r o w t h a n d d e v e lo p m e n t. I t is ob v io u s t h a t a n y g r o w i n g t h i n g , w h e t h e r a n i m a l o r p lant, w ill suffer t h e m o r e a n d becom e the m o r e d e f o r m e d th e l o n g e r such g r o w t h a n d d e v e l o p m e n t is p e r m i tt e d to pro ceed a l o n g lines t h a t h a v e led to m a l f o r m a t i o n . T h i s alo n e is a m p l e a n d sufficient r e a s o n f o r u n d e r t a k i n g o r t h o d o n ti c t r e a t m e n t as e a r l y as it is po s sible to d i a g n o s e it, a n d as e a r l y as it is p r a c t i c a l to t r e a t it.
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been no favorable development up to the age when the permanent incisors should be in position, we generally feel it ad visable to use mechanical stimulation. One of the hardest things, after a thor ough examination and study of maloc clusion in a child, is to convince the par ents of the necessity of work being done for prevention of future trouble. From an argumentative standpoint, it is much easier to w ait until the malocclusion is present and then attem pt its correction, than it is to try to convince them of the probable future malocclusion hidden in the beautiful deciduous arch when the teeth are all “even and tightly together.” A fter the one in charge has thoroughly
F ig. 10.— M o d e l s o f a ca se in a p a tie n t, a g e d 6 ( l e ft ) a n d one y e a r l a t e r ( r i g h t ) . N o g r o w t h h a s t a k e n p lace.
T o be sure, there are cases during the developmental period, before 6 years of age, in which it is not advisable to proceed with any corrective measures. These cases, in our practice, have been in the minority, and, when doubt exists as to w hether or not orthodontic treatm ent should be undertaken, the parent has been advised to return w ith the child for periodic examination. T h e patient is given appointments at stated intervals of either four or six months, this depending on the type of case at hand. If there has 7. Chapm an, H arold: don., 13: 147 ( F e b .) 1927.
I n t e r n a t . J. O r t h o -
explained the case, making clear the prob lems and the results involved, his duty is done and his responsibility is over.
CONCLUSION It is hoped that this paper has thrown more light on the question regarding the time orthodontic treatm ent should be ad vised. If the six anterior teeth in the 4 or 5 year old patient are “tightly together” in stead of spaced, one should be on the alert for possible future trouble developing in the permanent denture. W e feel that cases involving a protrud ing or receding mandible cannot come
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under orthodontic care too early, for, in all probability, there is no chance for self-correction. Should one or more of the deciduous teeth be lost prematurely, the resulting space should be maintained mechanically. T h e tendency of our present-day knowledge is to care for our younger patients when prevention is possible rather than w ait until the permanent teeth have erupted into abnormal posi tions and require a much longer period of active treatm ent, w ith less favorable results. T h e accompanying illustrations show some of the more im portant types of cases
incisors. T he mandibular anterior teeth are “tightly together,” and the mandible is in a position posteriorly from the maxilla. T here is also a deep overbite in the incisal region. T his is an abnormal relation of the jaw s which should be taken care of as soon as possible. Figure 4 presents a type of case the reverse of that shown in Figure 3. In this case, there is an abnormal relation of the arches, the mandible being in anterior relation to the maxilla. T his type of case becomes one of the most difficult to cor rect in the adult, the earliest possible treatm ent thus being advisable.
which men in general practice are en countering each day. Figure 1 is the model from a patient, aged 5 years. T h ere is a fairly good spac ing laterally between the anterior teeth. T he overbite is regarded as normal. In Figure 2, the width of the arches is regarded as normal for this age. T he spacing between the anterior teeth is more clearly seen here. Figure 3 is a model from a boy aged 3J^ years. T here is a fairly wide maxil lary arch w ith protruding anterior teeth and spacing on either side of the lateral
Figure 5 shows constriction of the maxilla from the lateral incisors pos teriorly from and including the perma nent molars. T he buccal teeth on either side are occluding lingually w ith the mandibular opponents. Here, too, there can be no possible correction of the con stricted arch except through mechanical means. Figure 6 illustrates a similar situation to that found in Figure 5, the exception being that only one side is occluding lingually with the mandibular teeth. Some term this a crossbite, but whatever
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Bach— Orthodontie Procedure it is, no correction is possible other than that produced by orthodontic measures. Figures 7 and 8 are models of the case shown in Figure 6. These are shown for the purpose of indicating where it is ad visable to place space retainers. In Figure 8, one can clearly see w hat deciduous teeth are missing, and at this age, 6 years, it w ill be three or four years before these spaces w ill be filled w ith permanent teeth. D uring this time, the first and second perm anent molars, when they erupt, will drift or tilt forw ard crowding the bi cuspids even before they erupt. Space retainers should be provided on the ap pliances used to regulate the teeth or, if no orthodontic w ork is being done, this space should be retained by a separate retainer. Figure 9 shows two models of the same case. T hey are shown here to illustrate again a condition when there are some teeth missing. T h e m axillary lateral in cisors are missing in this case and, be cause of the fact that this condition was discovered early, we were able to move all the teeth anteriorly on either side, bringing the cuspids into the positions of the missing lateral incisors. By this m eth od, the use of bridgework was avoided. O n the other hand, had this case come under observation at 18 or 20 years, prob ably bridgework for replacing the lateral incisors would have been necessary. Figures 10 and 11 show four models of the same case. T h e ones on the left were made at 5 years, those on the right, at 6. T h e child was allowed to go w ith out appliances for a year after the time the first models were made to observe w hat N ature would do in the way of de
velopment, but no change occurred that we were able to measure as far as the teeth were concerned. A fter another six months, appliances were placed in the mouth and growth is now being observed. These cases, we feel, have been a fair sample of the types of cases that should be carefully checked by the practitioner who first has charge of the patient. 1307 Second N atio n al B ank B uilding.
DISCUSSION
Norman L. Hillyer, Brooklyn, N. Y.:
I should like to ask one question: In the case th a t D r. B ach show ed of the m issing up p er la te ra l incisors, w here the spaces w ere closed up and the posterior teeth w ere m oved m esially to close the spaces, how w ere the low er a n te rio r teeth a rra n g e d ? T h e m odel did not show clearly to my m ind, a n d I w ondered if eventually the tooth m ate ria l in the m andible m ight not outbalance the tooth m ate ria l still left in the m axilla. Dr. Bach (closing): T h e p a p e r w as ra th e r elem entary, and I did not expect any discus sion on the m atter. R e g a rd in g the question of the m issing la te ra l incisors, models of w hich w ere show n a few m om ents ago, th ere a p p e are d to be m ore tooth substance in the m andible th a n in the m axilla. T h e patien t is the son of a d entist and w e talked the w ork over before any procedure w as decided on. T h e fa th e r decided th a t he w ould ra th e r h ave the sm all spaces betw een the a n te rio r teeth th an any bridgew ork. T h e re is a little space betw een the cuspid and central incisor on the rig h t side, and betw een the cuspid and bicuspid on the left, but it has closed up fa irly w ell. E ventually, w e expect to polish off the tip of the cuspids a n d shape them to look m ore like la te ra l incisors. T h e lingual incline of the cuspids does not in te rfe re w ith occlusion, the overbite is good and the g e n e ral alinem ent of the m an d ib u lar a n te rio r teeth w as good before w ork w as started. T h e re is practically no expansion g ain ed in eith er arch.
T he Journal of the American D ental Association
duty to the m edical profession. W h en such a re p o rt is m ade, it is w ell not to rely on the roentgenogram alone, or a rriv e a t a decision a fte r re a d in g the films. T h e p a tie n t should be c arefu lly exam ined by all the m eans of diagn osis w hich are a t the com m and of the d en tist today— direct inspection of every tooth, p alpation, v ita lity tests, and any o ther m ethod deem ed necessary; follow ing w hich a n in telligent re p o rt of the findings and recom m endations can be sent to the phy sician. I am sure th a t if this procedure is m ore c arefu lly follow ed, o u r b re th re n in the h e alin g a rt w ill think m ore highly of us. R e fe rrin g to the chronic case, the one in w hich it is m ost difficult to determ ine the procedure to be follow ed, it is well to keep this point in m ind— w hen in doubt, do nothing. R em em ber th a t the m ax illa ry sinus, once entered (it m akes little difference by w hich
ro u te ), n e v e r re tu rn s to the condition it w as in p rio r to operation. M any o ral surgeons and dentists a re inclined to be overzealous in tre a tm e n t of the conditions found in the floor of the m ax illa ry sinus, and in th eir effort to elim inate all pathologic conditions, cause unnecessary d am age to the structures, w hich results in a long period of trea tm e n t fo r the patient. I w ould like to stress the im portance of keeping the anatom ic stru c tu re as n e arly intact as possible, and nev er en terin g the sinus unless it is absolutely nec essary. I attem pted to point out th a t one cannot depend on roentg en o g rap h ic in te r p re ta tio n alone. D iagnosis m ust be based upon the history of p ast conditions, present condition and roentgenographic and clinical findings, care fu ly checked by any other m eans a t o u r com m and.
WHEN A N D WHY IS ORTHODONTIC PROCEDURE INDICATED?* By ERNEST N. BACH, A.B., D.D.S., Toledo, Ohio H E object of this paper is to present to the mind of the practitioner of general dentistry one phase of the question of malocclusion of teeth in chil dren : “A t W h a t Age Is O rthodontic Procedure Indicated and W h y Is I t A d visable at T h a t Period?” Since this ques tion is one which cannot be settled or agreed on in a moment, it lends itself to discussion. T here are nearly as many variations from the so-called norm al as there are individual cases, and in order that we may arrive at some definite conclusion, it seems fitting that we should analyze a few of the more common types of m al
T
*R ead before the Section on O rthodontia at the S eventy-F irst A nnual Session of the A m erican D en tal A ssociation, W ashington, D. C., Oct. 10, 1929. Jo u r. A . D . A ., J u ly ,
1930
occlusion which are manifest in younger patients. I t is as difficult to generalize on a question of this nature as it is to gen eralize on the question of replacing miss ing teeth, for nearly all cases are indi vidual and call for separate solutions. A t this time, we are not so much concerned w ith the etiologic factors or the prognosis of early malocclusion as we are w ith the question of recognizing the condition and the time orthodontic interference should be advised. I t is quite generally agreed that aborted cases of malocclusion of the permanent teeth are much to be preferred to cor rected or partially corrected cases in the adult, and, of necessity, these preventable cases m ust be considered before the erup tion of all the permanent teeth. T his means that we must deal with the child
Bach— Orthodontie Procedure as early as any serious malocclusion is detected; and by early is meant between the ages of 3 and 7 years. T h e question of orthodontia being primarily one of bone growth and not mechanics, early diagnosis is an essential factor.
DIAGNOSIS Diagnosis should be given very care ful consideration, including full mouth roentgenogram s; the patient’s history; the parents’ and near-relatives’ histories (should the case in hand be of an excep tional m alrelation) ; accurate study
F ig . I.— M o d e l s h o w i n g w h a t m a y r i g h tl y be t e r m e d n o r m a l occlusion f o r a child, a g e d 5 years.
models; the diet of mother during preg nancy ; the diet of the patient both during infancy and at present; various habits; th e n a so p h ary n g eal a re a ; abnorm al muscle habits, and the general physical condition. Even when these factors are taken into consideration and a comparison made of the foregoing data in a number of cases, we may frequently feel that our best judgm ent is in e r o r .
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LeRoy Johnson, on the question of diagnosis says1: W i t h t h e in c r e a s e o f k n o w le d g e , d i a g n o s is is b e c o m in g m o r e difficult. W h e n y ou th in k o f th e c h i l d ’s d e n t u r e in its t r u e l i g h t ; w h e n y ou t h i n k of th e pro cess o f d e n titio n a n d w h a t it i n v o lv e s, th e re so r p tio n , loss a n d e r u p t i o n of teeth , th e g r o w t h a n d d i f fe r e n t i a t i o n of tissues, th e f u n c t i o n a l in t e r a c t i o n o f p a r t s ; w h e n y o u t h in k o f th e in e q u a l i t i e s c h a r a c te r is tic of g r o w t h processes, a n d o f v a r i a tions in s t r u c t u r e d u e to g e r m i n a l f a c t o r s — w h e n you t h i n k of the c h i l d ’s d e n t u r e i n its t r u e lig ht, in f a c t as w e k n o w it to be, th e p r o b l e m o f the t im e o f t r e a t m e n t h o l d s one
F ig. 2.— O cclu sal v i e w o f m o d el in F i g u r e 1; s h o w i n g s p a c i n g b e t w e e n t h e six a n t e r i o r teeth, in both t h e m a x i l l a a n d the m a n d i b l e . in a b ey an c e. W e m a y eas ily r eco g n ize d i f fere n c e s b e t w e e n th e d e n t u r e s of d if fe r e n t c h ild r e n , b u t to r eco g n ize con d itio ns of tooth re l a t i o n s w h i c h e x h ib it a r e a l a b n o r m a l i t y is n ot easy. D i a g n o s i s m e a n s th e reco g n itio n o f dise a se f r o m its sym ptom s. T r e a t m e n t signifies the m e a n s em p loy ed in effe cting a c u r e of dise a se a n d is o f co u rse g o v e r n e d b y the etiologic f a c t o r s in v o lv e d . T r e a t m e n t is s e c o n d a r y to d iag n o s is . 1. Jo h n s o n , L e R o y : D en t. Cosmos, 66: 779 ( J u l y ) 1924.
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And again we read in “O rthodontics,” by B. E. Lischer2: I t is well to r e m e m b e r t h a t a f a v o r a b l e p rog no sis d e p e n d s l a r g e l y upon a n e a r l y d iag no s is , w h e n co n d itio n s a r e such t h a t a c o m p a r a t i v e l y sim ple t r e a t m e n t will suffice. F o r m e r l y it w a s the custom to p ostpone most t r e a t m e n t s u n til all of th e p e r m a n e n t teeth h ad e r u p te d , f o r it w a s b e lie v e d t h a t N a t u r e w o u ld assist in the co r re c tio n of th e m a l o c c l u sion, a n d t h a t m ost p a t i e n t s w o u l d “ o u t - g r o w ” the d e f o rm ity . M a n y b i t t e r d i s a p p o in t m e n t s h a v e t a u g h t us the e r r o r o f such a d v ice, a n d s t r o n g ly e m p h a s i z e the f a c t t h a t th e se v ere fo rm s o f m alo cclusio n do n ot d e v e l o p o v e r night, b u t a r e of slow g r o w t h . H en ce it fo l lows t h a t y e a r s b e f o re e v e n a n i n tellig en t p a r e n t reco gn izes the i m p e n d i n g d efo rm ity , the a l e r t d i a g n o s ti c i a n c a n a d v i s e w a y s a nd m e a n s f o r its p r e v e n tio n .
F ig. 3.— C a se of e x ten s iv e o v e r b i t e a n d p o ste rio r occlusion in a child, a g e d 3 ^ y e a r s . O w i n g to the m e c h a n i c a l aspects o f d e n t i tion, the se lf- c o r re c tio n of m o st f o r m s of m alocclusio n is a n im poss ibility. E v e r y f a c t g l e a n e d f r o m a s t u d y of the process of d e n titio n s u b s t a n t i a t e s th e o r t h o d ontic ax iom t h a t malocclusion and its ac
companying deformities are progressive, not static. T h e r e s t o r a t i o n of n o r m a l f u n ctio n d u r i n g the d e v e l o p m e n t a l p e r io d is a f u n d a m e n t a l p rinciple of r a t i o n a l t r e a t m e n t . T h e p e r io d of tooth e r u p t i o n is t h e perio d of g r e a t e s t g r o w t h in the a l v e o l a r process.
Proper foods, both in quality and quantity, sunlight and exercise play per-----------------2. Lisch er , B. E . : O r th o d o n tic s, P h i l a d e l p h i a : L e a & F e b ig e r , 1912, p. 130.
haps the greatest part in building the resistance of a healthy and so-called normal body. This is generally conceded by authorities on the subject. The question of preventive dentistry arises in prenatal life, and may we not likewise say that the question of preven tive orthodontia has its origin during this same period? For, as E. V. M cCollum says3: A s a p rofession , w e h a v e i g n o r e d the d e v e l o p m e n t a l f a c t o r as the one t h a t is o p e r a t iv e in p r e v e n t i v e d e n t i s t r y . T h e r e is one w a y b ack to b e t t e r phy sical d e v e l o p m e n t an d t h a t is the most f u n d a m e n t a l o f all, nam ely, to b u ild up a n o r m a l , p h y sic al s t r u c t u r e , a n d
Fig. 4.— C a s e s h o w i n g a n a n t e r i o r r e la tio n of th e m a n d i b l e to t h e m a x i l l a . t h a t can be do ne onl y t h r o u g h p r o p e r diet. T h e child o f school a g e is b e y o n d th e r e a c h of help in th is respec t. H i s teeth a r e a l r e a d y f o rm e d . T h i s p r e v e n t i v e d e n t i s t r y p r o p o s i tion is l a r g e l y one o f p r e n a t a l life a nd infan cy .
It is sound judgm ent for each of us to avail ourselves of every opportunity to gain knowledge on this subject from authentic sources, so that we may be equipped to furnish our patients with at 3. M c C o llu m , E. V., q u o te d by D ickerson, M i l d r e d W . : J. A . D . A., 11: 243 ( M a r c h ) 1924.
Bach— Orthodontic Procedure least elementary information on this im portant phase of dentistry. Various stages of growth and prede termined deformities have been produced experimentally in monkeys and guineapigs by Drs. Howe, M cCollum and others. Caries and constricted arches and other skeletal defects have been produced by certain types of diets and these defects arrested by a change to another form of diet. T o some, these facts mean little; to others, much. T here is quite a diversity of opinion relating to the development and size of the deciduous arches up to the period of 5 years of age. E. A. Bogue, in a num ber of his writings, stresses the point that
F ig. 5.— C a se o f c o n striction o f th e m a x i l l a , w i t h a p r a c t i c a l l y n o r m a l siz e m a n d i b l e .
“unless the distance between the maxil lary second temporary molars, at the gingivae, measures 28 mm. or more, we may look for a corresponding constricted condition in the permanent dentition from the lack of lateral grow th in the jaws at the earlier age, w ith a resulting malocclusion of many of the permanent teeth.” This was found true by D r. Bogue in a large percentage of the cases in his practice, and while followers of Bogue heartily agree w ith his findings, others are of a different opinion. E. C. Reed, in a paper given before the Pacific
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Coast Society of Orthodontists, makes this statem ent4: I t w o u l d seem r e a s o n a b le t h a t d e v e l o p m e n t co u ld be se c u re d m o r e r e a d i l y a n d m o re n o r m a l l y if w e set a b o u t to assist as soon as w e a r e su re N a t u r e w ill n o t p r o p e r l y c a r e f o r it. I a m no t p r e p a r e d to be as r a d i c a l as D r . B ogue, w h o a d v o c a t e d e x p a n s i o n in all cases w h e r e the d i sta n c e b e t w e e n the d e c id u o u s second m o l a r s is less t h a n 28 m m . N o r h a v e I y e t a t t e m p t e d to e x p a n d sim ply b ecau s e t h e r e w a s no t a s p a c i n g of the d e c id u o u s in ciso rs a t 4 o r 5 y e a r s o f age. A s soon, h o w e v e r , as w e find th e p e r m a n e n t i nciso rs e r u p t i n g a n d t h e r e is n o t suffi cient room, I be lie v e w e should s t a r t t r e a t ment. T h i s o r d i n a r i l y is ab ou t 6 o r 7 y e a r s of age. A t th is ag e, th e child is old en o u g h so one c a n g a i n h is confidence a n d easily fit a n d a d j u s t a n ap p lian ce.
F ig. 6.— C a se of flatte n in g o f the m a x i l l a r y process on th e r i g h t side.
A neutroclusion case is one in which there is a so-called normal relation of the arches anteroposteriorly. A procedure which we find has been of great help and also quite advisable in neutroclusion cases at 3 or 4 years of age, if the six maxillary and mandibular anterior teeth are in close contact, is to keep an accurate check every five or six months, the changes being noted which take place in the size of the arches. If at the age of 5 or 6 years, we find the six anterior teeth still “tightly 4. Reed, E. C . : I n t e r n a t . J. O r t h o d o n ., 9: 175 ( M a r c h ) 1923.
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together,” it may be advisable to assist N ature mechanically at this time in order to obtain the necessary grow th of the arches for the permanent teeth. T h e form of procedure depends greatly on the size of the jaws and the development which has taken place in the preceding year or two. Should we find these anterior teeth in contact w ith each other, and the posterior segments of the arches constricted in such a way as to show th at practically no grow th has taken place during the devel opmental period up to the time of the loss of the anterior teeth (5 or 6 years of age), we may feel convinced that mechan-
Fig. 7.— C a s e o f co n s trictio n o f b oth m a x illa a n d m a n d i b l e , a n d excessive o v er b ite.
ical or natural stimulation w ill prove beneficial. I t is to be regretted if a hasty diagnosis made in a case as above described results in the placing of appliances in a child’s mouth unnecessarily at the age of 3 or 4 years. T here are certain types of malocclusion found in the deciduous dentures which we believe should be corrected as soon as pos sible after detection. These are the types of anterior and posterior occlusion. In the first, there is a protruding relation of
the mandible to the m axilla; in the sec ond, there is a receding relation of the mandible to the maxilla. W e feel that these two types of cases can be greatly benefited by early applica tion of mechanical stimulation and proper muscle development. T o be sure, proper development of the muscles of mastica tion will aid greatly in the development of the other osseous structures of the face, as w ell as those in which we are more intimately concerned. T his is essential for many reasons, w ith which you are already familiar. Another type of case which should be mentioned here is the one in which there has been an early loss of one or more of the deciduous teeth, from accident, caries or neglect. W herever this has occurred, a space-retainer should be made and ce mented in position to maintain the mesiodistal space resulting from the missing tooth. T his retainer should also be con structed so that it will act in the manner of a partial restoration, as far as occlusion is concerned. By this, we mean that the retainer should be in contact with the op posing tooth in order to prevent the over elongation of that member. Should any of the deciduous molars be lost about the ninth or tenth year, before their due time, it may be advisable to ex tract the opposing like tooth to allow for the even development and elongation of the bicuspids. M aintaining the space in a case like this may prove detrimental rather than ad vantageous, but, if in doubt, we should seek advice in the m atter before contem plating the manner of procedure. O ften, when there is a full complement of de ciduous teeth, extraction is advisable be fore the teeth begin to loosen. T his is true when the permanent successor has erupted either at one side or the other of the line of occlusion, and resorption of
Bach— Orthodontic Procedure the deciduous roots has not taken place. Although this condition occurs most fre quently in the incisor region, discretion must be used in extracting deciduous teeth when the permanent successor has not erupted, and roentgenograms should be consulted for the findings therein.
EARLY TREATM ENT “ It is generally conceded that the idea of early orthodontic treatm ent is correct,” writes Charles R. Baker.5 W e feel that when thorough diagnosis reveals a decided malocclusion, ortho dontic interference should be instituted as soon as that condition manifests itself. T here are a number of things which
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similar change in the body of the man dible and maxilla. T he possibility of this change becomes less as age increases, but is very pronounced during childhood, when N atu re’s activity in bone building is at its highest. 2. In most cases, better cooperation is obtained from both parent and patient. T here are definite instructions which are given children with certain types of mal occlusion, and, unless these instructions are followed, the case is prolonged and satisfactory completion of the work is made impossible. By giving these instruc tions to the parent as well as to the patient, we have a double check on the w ork to be carried out. T his is likewise
F ig . 8.— L i n g u a l v i e w o f m odel in F i g u r e 7.
we also hold as being advantageous for orthodontic work at this ag e: 1. As D r. Lischer stated: “ D uring tooth eruption there is the greatest growth in the alveolar process.” If, as has been stated before, it becomes neces sary to work on the deciduous denture, more progress will be made if the work is carried on before apical resorption has taken place. Stimulation of root move ment from mechanical sources w ill have a tendency to produce a grow th or change in the alveolar process and probably a 5. B a k e r, C. R . : I n d i c a t i o n s f o r T r e a t m e n t of M a lo cclu sio n, J. A. D . A., 14: 777 ( M a y ) 1923.
true regarding appointments and the fre quent carelessness of older patients. 3. D uration of treatm ent in less severe cases is comparatively short. W e also find that there is better response in bone growth through stimulation at this age; appointments are better kept, and fewer outside activities detract from the work. 4. D iverting or correcting injurious habits at this age is more easily accom plished. Especially is this true with such habits as mouth-breathing, postural habits and various thumb, finger and tongue habits. Too often, malocclusion of the permanent denture results from one or
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more of these habits established during childhood. * 5. A t this age, there is little or no objection by the patient to wearing ap pliances, while at prehigh school or high school age, considerable opposition is met with, and progress is less favorable. 6. One object of early treatm ent is to bring about normal size and function of the deciduous dentures for that particular age, but the primary object is one of pre vention of malocclusion of the permanent denture. Quoting M artin Dewey0: A f e w y e a r s ago, I m a d e a s t a t e m e n t t h a t o ne of the m ost f r e q u e n t causes of m a l o c clusio n w a s the i m p r o p e r c a r e of t h e d e c id u o u s teeth. A f t e r s e v e r a l m o r e y e a r s of o b s e rv a t i o n , I a m in clined to believ e t h a t
exten t, f o r t h e d e v e l o p m e n t of th e s t r u c t u r e s s u p p o r t i n g the p e r m a n e n t teeth. W e find an u n f o r t u n a t e c o nd itio n w h e n the d e c id u o u s teeth h a v e b een a l l o w e d to d e c a y to a p oin t w h e r e e x t r a c t i o n becom es n eces sa ry . T h e e x tr a c tio n of a c e r t a i n d e c idu ou s to oth will p ro d u c e a type of m a l occlusion t h a t c a n a l w a y s be f o re t o l d y e a r s in a d v a n c e of th e u l tim a te resu lt. T h e e x t r a c t i o n of a m a n d i b u l a r cu spid o r m o l a r a t a c e r t a i n a g e will en a b le th e o r t h o d o n ti s t to p o r t r a y ex actly th e type of m alo cclu sio n t h a t is g o i n g to be p r e s e n t a t th e a g e o f 14 o r 15 y e a r s , if n o t h i n g is do n e to p r e v e n t th e o c c u r r ence o f the malocclusio n. T h e e x t r a c t i o n o f a n y p a r t i c u l a r d ecid u o u s tooth w ill p ro d u c e a ty p ic a l f o r m of malocclusio n, th ese h a v i n g o c c u r r e d so often t h a t a n y o r t h o d o n ti s t of ex p erience, w h e n told w h a t d e c id u o u s tooth h a s b een e x tr a c te d , c a n fore tell t h e type of
F ig. 9.— C a se o f co n g e n ita lly m i s s i n g m a x i l l a r y l a t e r a l in ciso rs. All buccal m a x i l l a r y teeth w e r e m o v e d a n t e r i o r l y to close the sp a c e le f t by t h e m i s s i n g teeth. the d e c id u o u s teeth, as a s so c ia te d w i t h a c q u i r e d conditions, a r e p r o b a b l y resp on sib le f o r as m a n y cases of m alo cclu s io n as a n y o t h e r a c q u i r e d f a c to r. By a c q u i r e d f a c t o rs , I m e a n th o se c on d ition s w h i c h a r i s e a f t e r the b i r th of th e i n d i v i d u a l w h i c h a r e th e r esu lt o f the e n v i r o n m e n t in w h i c h he lives, o r r a t h e r a r e co n dition s w h ic h co uld h a v e been co n tr o lle d by th e p r o p e r m e a s u r e s i n s t i g a t e d a t the r i g h t tim e. T h e d e c id u o u s t e e t h a r e f o r m e d f o r the p u r p o s e of m a s t i c a t i n g the fo od d u r i n g th e e a r l y life of t h e ch ild, a n d as a r esu lt of this m a s tic a tio n , t h e y s u p p l y the st i m u l a t i o n t h a t is responsible, to a g r e a t 6. D ewey, M a r tin : O rth o d o n tia : Factors M a k i n g I t N e c e s s a r y t h a t M a y Be P a r t i a l l y E li m i n a t e d , J. A . D. A., 12: 1188 ( O c t.) 1925.
m alo cclu s io n t h a t w ill develop, p r o v i d e d s o m e th i n g else does no t occur to m a k e the co n d itio n still worse. I f it becomes ab so lute ly n eces sa ry , b ecau se o f p a th o lo g ic i n v o l v e m e n t , to e x t r a c t d ecid u o u s teeth, some m e a n s should be em p lo y ed to m a i n t a i n th e sp a ce f o r the p e r m a n e n t teeth, a n d some d ev ice should be u se d to keep the r e m a i n i n g teeth in t h e i r p r o p e r position, in o r d e r to m a i n t a i n a n o r m a l a p p r o x i m a l con tact a n d a n o r m a l cusp relation .
7. Various writers who have voiced their opinions seem to agree that it is best to work on the deciduous dentition before the roots resorb, a point which has been previously discussed.
Bach— Orthodontie Procedure 8. T reatm ent should be begun as early as possible, thereby allowing the patient to reap the earliest benefits resulting from the work. H arold Chapman writes :7 I s u b m i t m o st e m p h a t i c a l l y t h a t the e a r l i e r a n y m a l f o r m a t i o n of these bones is c o rre cted a n d the e a r l i e r t h e i r fu nction s a n d the f u n c tions of t h e . asso ciated tissues a r e m a d e n o r m a l , t h e n the e a r l i e r all th ese p a r t s will be s t a r t e d a l o n g p r o p e r lines f o r t h e i r f u t u r e g r o w t h a n d d e v e lo p m e n t. I t is ob v io u s t h a t a n y g r o w i n g t h i n g , w h e t h e r a n i m a l o r p lant, w ill suffer t h e m o r e a n d becom e the m o r e d e f o r m e d th e l o n g e r such g r o w t h a n d d e v e l o p m e n t is p e r m i tt e d to pro ceed a l o n g lines t h a t h a v e led to m a l f o r m a t i o n . T h i s alo n e is a m p l e a n d sufficient r e a s o n f o r u n d e r t a k i n g o r t h o d o n ti c t r e a t m e n t as e a r l y as it is po s sible to d i a g n o s e it, a n d as e a r l y as it is p r a c t i c a l to t r e a t it.
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been no favorable development up to the age when the permanent incisors should be in position, we generally feel it ad visable to use mechanical stimulation. One of the hardest things, after a thor ough examination and study of maloc clusion in a child, is to convince the par ents of the necessity of work being done for prevention of future trouble. From an argumentative standpoint, it is much easier to w ait until the malocclusion is present and then attem pt its correction, than it is to try to convince them of the probable future malocclusion hidden in the beautiful deciduous arch when the teeth are all “even and tightly together.” A fter the one in charge has thoroughly
F ig. 10.— M o d e l s o f a ca se in a p a tie n t, a g e d 6 ( l e ft ) a n d one y e a r l a t e r ( r i g h t ) . N o g r o w t h h a s t a k e n p lace.
T o be sure, there are cases during the developmental period, before 6 years of age, in which it is not advisable to proceed with any corrective measures. These cases, in our practice, have been in the minority, and, when doubt exists as to w hether or not orthodontic treatm ent should be undertaken, the parent has been advised to return w ith the child for periodic examination. T h e patient is given appointments at stated intervals of either four or six months, this depending on the type of case at hand. If there has 7. Chapm an, H arold: don., 13: 147 ( F e b .) 1927.
I n t e r n a t . J. O r t h o -
explained the case, making clear the prob lems and the results involved, his duty is done and his responsibility is over.
CONCLUSION It is hoped that this paper has thrown more light on the question regarding the time orthodontic treatm ent should be ad vised. If the six anterior teeth in the 4 or 5 year old patient are “tightly together” in stead of spaced, one should be on the alert for possible future trouble developing in the permanent denture. W e feel that cases involving a protrud ing or receding mandible cannot come
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under orthodontic care too early, for, in all probability, there is no chance for self-correction. Should one or more of the deciduous teeth be lost prematurely, the resulting space should be maintained mechanically. T h e tendency of our present-day knowledge is to care for our younger patients when prevention is possible rather than w ait until the permanent teeth have erupted into abnormal posi tions and require a much longer period of active treatm ent, w ith less favorable results. T h e accompanying illustrations show some of the more im portant types of cases
incisors. T he mandibular anterior teeth are “tightly together,” and the mandible is in a position posteriorly from the maxilla. T here is also a deep overbite in the incisal region. T his is an abnormal relation of the jaw s which should be taken care of as soon as possible. Figure 4 presents a type of case the reverse of that shown in Figure 3. In this case, there is an abnormal relation of the arches, the mandible being in anterior relation to the maxilla. T his type of case becomes one of the most difficult to cor rect in the adult, the earliest possible treatm ent thus being advisable.
which men in general practice are en countering each day. Figure 1 is the model from a patient, aged 5 years. T h ere is a fairly good spac ing laterally between the anterior teeth. T he overbite is regarded as normal. In Figure 2, the width of the arches is regarded as normal for this age. T he spacing between the anterior teeth is more clearly seen here. Figure 3 is a model from a boy aged 3J^ years. T here is a fairly wide maxil lary arch w ith protruding anterior teeth and spacing on either side of the lateral
Figure 5 shows constriction of the maxilla from the lateral incisors pos teriorly from and including the perma nent molars. T he buccal teeth on either side are occluding lingually w ith the mandibular opponents. Here, too, there can be no possible correction of the con stricted arch except through mechanical means. Figure 6 illustrates a similar situation to that found in Figure 5, the exception being that only one side is occluding lingually with the mandibular teeth. Some term this a crossbite, but whatever
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Bach— Orthodontie Procedure it is, no correction is possible other than that produced by orthodontic measures. Figures 7 and 8 are models of the case shown in Figure 6. These are shown for the purpose of indicating where it is ad visable to place space retainers. In Figure 8, one can clearly see w hat deciduous teeth are missing, and at this age, 6 years, it w ill be three or four years before these spaces w ill be filled w ith permanent teeth. D uring this time, the first and second perm anent molars, when they erupt, will drift or tilt forw ard crowding the bi cuspids even before they erupt. Space retainers should be provided on the ap pliances used to regulate the teeth or, if no orthodontic w ork is being done, this space should be retained by a separate retainer. Figure 9 shows two models of the same case. T hey are shown here to illustrate again a condition when there are some teeth missing. T h e m axillary lateral in cisors are missing in this case and, be cause of the fact that this condition was discovered early, we were able to move all the teeth anteriorly on either side, bringing the cuspids into the positions of the missing lateral incisors. By this m eth od, the use of bridgework was avoided. O n the other hand, had this case come under observation at 18 or 20 years, prob ably bridgework for replacing the lateral incisors would have been necessary. Figures 10 and 11 show four models of the same case. T h e ones on the left were made at 5 years, those on the right, at 6. T h e child was allowed to go w ith out appliances for a year after the time the first models were made to observe w hat N ature would do in the way of de
velopment, but no change occurred that we were able to measure as far as the teeth were concerned. A fter another six months, appliances were placed in the mouth and growth is now being observed. These cases, we feel, have been a fair sample of the types of cases that should be carefully checked by the practitioner who first has charge of the patient. 1307 Second N atio n al B ank B uilding.
DISCUSSION
Norman L. Hillyer, Brooklyn, N. Y.:
I should like to ask one question: In the case th a t D r. B ach show ed of the m issing up p er la te ra l incisors, w here the spaces w ere closed up and the posterior teeth w ere m oved m esially to close the spaces, how w ere the low er a n te rio r teeth a rra n g e d ? T h e m odel did not show clearly to my m ind, a n d I w ondered if eventually the tooth m ate ria l in the m andible m ight not outbalance the tooth m ate ria l still left in the m axilla. Dr. Bach (closing): T h e p a p e r w as ra th e r elem entary, and I did not expect any discus sion on the m atter. R e g a rd in g the question of the m issing la te ra l incisors, models of w hich w ere show n a few m om ents ago, th ere a p p e are d to be m ore tooth substance in the m andible th a n in the m axilla. T h e patien t is the son of a d entist and w e talked the w ork over before any procedure w as decided on. T h e fa th e r decided th a t he w ould ra th e r h ave the sm all spaces betw een the a n te rio r teeth th an any bridgew ork. T h e re is a little space betw een the cuspid and central incisor on the rig h t side, and betw een the cuspid and bicuspid on the left, but it has closed up fa irly w ell. E ventually, w e expect to polish off the tip of the cuspids a n d shape them to look m ore like la te ra l incisors. T h e lingual incline of the cuspids does not in te rfe re w ith occlusion, the overbite is good and the g e n e ral alinem ent of the m an d ib u lar a n te rio r teeth w as good before w ork w as started. T h e re is practically no expansion g ain ed in eith er arch.