Adenoid Growths, 
Mouth-Breathing, and Thumb-Sucking, 
IN THEIR RELATION TO 
Deformities of the Jaws and Irregular 
Teeth. 
BY NORMAN W. KINGSLEY, D.D.S. 
US MADISON AVENUE, NEW YORK, N. Y. 
(Reprinted from the Dental Cosmos for January, February, May, and June, 1892.) 
PHILADELPHIA : 
THE S. S. WHITE DENTAL MFG. CO. 
1892. ADENOID GROWTHS, MOUTH-BREATHING, AND THUMB- 
SUCKING IN THEIR RELATION TO DEFORMITIES OF THE 
JAWS AND IRREGULAR TEETH. 
NORMAN W. KINGSLEY, D.DS, New York, N. Y. 
The first case described and illustrated in this article is that of a 
young lady, who was between twelve and thirteen years of age when 
she came under my professional care. She is the daughter of refined 
and cultured parents. 
Fig. 1 is an exact representation of her mouth, and face below the 
eyes at that time. The drawing is made from a plaster cast taken 
from life, but the upper part of the face has been varied purposely, to 
avoid the publication of a complete portrait. 
Fig. 1. 
Fig. 2. 
This drawing shows the constant habit of the patient, with open 
mouth, because it was only with great effort that the lips could be 
brought in contact. The upper incisors are exposed and prominent ; 
the lower incisors cannot be seen, being separated from the upper 
ones by a greater distance than the relaxed separation of the lips. 
This relation of the jaws to each other is more fully seen in Fig. 2,, 
which represents the articulated models of the jaws. 
The history of the case, as nearly as can be ascertained from the 
mother’s recollection, is as follows : Through all the years of infancy 
the child was subject to asthma, and always breathed through the 2 
mouth, asleep and awake. She shed the deciduous upper incisors 
prematurely,—between five and six years of age, as nearly as can be 
remembered. Up to that period there was no malocclusion of the 
teeth. 
The permanent upper incisors made their appearance also prema- 
turely, before seven years of age, and from that time the upper and 
lower incisors began to separate, the discrepancy continuing to in- 
crease until remedial treatment was resorted to. 
From seven to eight years of age, adenoid growths were discovered 
behind the palate in the upper pharynx. The reduction of these 
growths was first attempted with the electric cautery without marked 
success ; but subsequently, at about eight years of age, they were 
completely removed by surgical operation. Since that time the 
breathing through the nostrils has been free and natural. Never- 
theless, the space between the upper and lower incisors continued to 
widen. 
The impression made on my mind when I first saw the case was that 
the lower jaw alone was at fault. 
I fancied that the lower jaw was bent down at the region of the 
bicuspids, and for the moment conceived the idea of bending it up- 
ward by mechanical means ; but a study of the articulated models, 
as shown in Fig. 2 both separately and together, showed that the 
lower jaw was as perfect and well formed as any I ever saw. It 
was symmetrical in its arch, and regular in the plane of the occluding 
line. 
The opening of the jaws in front was due slightly to the projection 
of the incisors, but principally to an excessive and abnormal de- 
velopment of the alveolar process in the molar and bicuspid region, 
and the remedy must be in its reduction ; or, in other words, the 
teeth and processes must be driven higher up. 
The pitch and projection of the upper incisors would have been 
heretofore attributed to thumb-sucking or its equivalent, but that 
practice had never been acquired ; the child had never been a thumb- 
sucker. Still, we find a typical ‘ ‘ thumb-sucking’ ’ case where there 
had been no thumb-sucking,—a perfectly developed and symmetrical 
lower jaw and a strangely abnormal upper one, coincident with 
adenoid growths of the pharynx and long-continued mouth-breathing. 
It will be observed that the upper jaw in the region of the bicuspids 
is of normal width ; the lower jaw is also normal in width and out- 
line, and the back teeth of the upper jaw occlude or articulate properly 
with the lower ones ; the opening of the mouth has not, therefore, 
caused a pressure of the muscles of the cheeks upon those teeth and 
narrowed the jaw. 
As a proper correction of this deformity required the incisors to be 
carried backward somewhat, and as there appeared to be no spaces 
in the arch which would permit of its contraction, the first or sixth-year 
molar on each side was extracted. 
These particular teeth were chosen for extraction in preference to 
the first bicuspids (which in many cases of protruding incisors would 
be proper), because they offered more resistance to correcting the 
malformation of that region than any other ; and that, together with 
the apparent necessity for extracting one tooth on each side to provide 
for retraction, seemed ample justification for the removal of two per- 3 
fectly sound molars.* At the same time a deciduous molar which was 
hiding the second bicuspid on the right side was also removed. 
The first attempt at correction was made with a skeleton skull-cap, 
as seen in Fig. 3, a padded cap over the chin (shown in Fig. 4), and a 
Fig. 3. 
frame over the incisors, with arms projecting outside the cheeks, 
as showm in Fig. 5. The skull-cap was made of leather ; the chin-cap 
of sheet copper (stiffened around the edge with non-elastic steel wire 
accurately fitted to a plaster cast of the chin) padded, and covered with 
leather. When these appliances 
were in use, an elastic strap cut 
from rubber tubing passed from the 
hook near the angle of the chin-cap 
to the hook marked a on the skull- 
cap (Fig. 3), and another similar 
strap passed from the button at the 
end of the incisor frame to the hook 
marked b in Fig. 3. The expecta- 
tions from such an arrangement are 
obvious. The strain upon the in- 
cisors would carry them directly 
backward, and the hope was enter- 
tained that the pressure of the lower 
jaw upon the upper at the points 
of contact would diminish the undue prominence. 
It is worth while here to query whether pressure, being equal upon 
Fig. 4. 
* I am convinced, by a study of the case since the correction was completed, 
that the extraction of those permanent teeth was unnecessary. I find now, 
to my surprise, that although there then appeared no room to carry the incis- 
ors back without extracting two teeth, there are now ample spaces among 
the teeth on each side to permit of another tooth. 4 
the lower as well as the upper molars, might not, if it had ever 
accomplished anything, have done so at the expense of one jaw as much 
as the other. However that might have been, the fact was that 
although worn continuously night and day, except at meals, for about 
three weeks, the chin became so sore under the pressure that we feared 
an abscess, and it was abandoned. It is doubtful if it served any pur- 
pose in closing the gap in front. 
The frame upon the incisors did accomplish in that time all that was 
desired of it. The incisors, without being lengthened, were altered 
in their pitch arid the cutting-edges moved back. 
The reason that this apparatus did not lengthen the incisors in their 
backward movement was because the strain put upon the crowns was 
not at a right angle with a line lengthwise through the center of the 
tooth. The strain was at such an angle that the teeth were held in 
Fig. 5. 
their sockets by a partially upward pressure while the absorption of 
the process behind them was going on. The distance backward 
which the cutting-edges were carried was ascertained to be eleven per 
cent. 
This method of stating the change may need explanation. To say 
that the incisors were retreated so many “ lines” or “ millimeters” or 
“ fractions of an inch” conveys an imperfect idea of the reality. The 
change of position is much or little, great or small, relatively ; two 
millimeters might be very much in one case and very little in another, 
therefore a statement of percentages is more definite. 
In this case the amount of the movement was determined by meas- 
uring on a perfect plaster model from the external face of the incisors 
at their cutting-edges directly back along the median line, until this 
line intersected at right angles a line across the jaw from the posterior 
surfaces of the last molars. Such a line on the cast prior to any 5 
movement represents one hundred per cent., and the same line after 
the movement in this case measured eleven per cent, shorter. 
The second apparatus, which fully accomplished the work, I ought 
to have thought of in the beginning, as it is only an application of the 
principle involved in my interdental splints for the last twenty-five 
years. It is shown in Fig. 6 : A frame covering the bicuspids and 
molars of the upper jaw, with arms coming out of the corners of the 
mouth and extending along the cheeks to a point exactly opposite the 
center of pressure required within the mouth ; a small wire passed in 
front of the incisors to keep them from springing forward, and two 
elastic straps connected this frame with the skull-cap exactly as seen 
in Fig. 3. Both these elastics were required partly to prevent any 
tendency of the recently moved incisors from carrying the whole appa- 
ratus forward, but particularly to keep the proper balance of the skull- 
cap, the strain of either elastic alone having a tendency to pull it out 
of place. 
Fig. 6. 
The apparatus is made of one continuous piece of Stubbs’ steel 
forged to follow the buccal faces of the teeth, then pass through the 
gap made by the extraction of the molars, and cross (without touching 
it) the vault of the palate to the other side. The bearings upon the 
teeth were made of silver plate swaged with accuracy to fit the 
molars to keep the frame from slipping about, but resting only on the 
cusps of the bicuspids, thus giving freedom for lateral movement of 
the bicuspids. 
It was essential that the extremities of these arms should be adjusted 
with great nicety, so that the force exerted through them upon the 
offending teeth should be evenly distributed. If the bearing were 
forward of the center, the apparatus would be loose at the back, and 
vice versa. This apparatus was applied about the first of March, 1891, 
and worn almost uninterruptedly without inconvenience until June 
following, at which time the upper and lower incisors were in contact, 
the upper ones lapping normally. (See Fig. 7.) 
An embarrassing feature of this case now presented itself: the 
second bicuspid, which had developed in place of the extracted decid- 
uous molar, had grown down to the point of occlusion with the lower 6 
teeth ; but it was pitched inward and articulated within the cusps of its- 
antagonist, and the tendency was for it to be tipped still farther. 
This was coincident with the removal of the family into the country 
for the summer, at such a distance that it was impracticable for the 
patient to visit me oftener than once a week. 
Several futile attempts were made to force outwardly the malposed 
bicuspid without dispensing with the brace and skull-cap, until finally 
the apparatus had to be laid aside for a few days to admit of a jack- 
screw, and thus the bicuspid was driven into place. This jack-screw 
had its point resting in a pit upon a gold band around the malposed 
bicuspid, which band was cemented on with oxyphosphate : the oppo- 
site end of the jack-screw bore against a small plate, which covered 
two or three teeth and the gum of that vicinity, thus driving out one 
tooth without disturbing the teeth on the opposite side of the mouth ; 
but in doing so it opened the jaws again in front, and an entirely new 
apparatus similar to the other had to be made and adjusted. 
This latter was worn constantly, with short interruptions, for a 
month, and the teeth assumed the position seen in Fig. 7. Since that 
time the appliance has been worn only at night, and the relations of 
Fig. 7. 
the teeth remain unchanged. The contact of the incisors is now so- 
close that a thread can be bitten off by them. 
A study of the models Figs. 2 and 7 shows that the articulation of 
the molars at the present time is precisely the same as before regu- 
lation commenced, and the great change in the front of the mouth is 
attributable principally to the driving upward of teeth in the molar 
region, the upward and forward movement of the lower jaw, and partly 
by the incisors being carried back without elongating. 
I do not commit myself to, nor oppose, any of the theories of the 
relation of irregularities of the teeth to mouth-breathing, adenoid 
growths, or thumb-sucking, nor shall I here discuss the question of 
continuous or interrupted pressure. 
The following described case is that of a boy between thirteen and 
fourteen years of age. The arrangement of the teeth in the upper 
jaw is shown in Fig. 8, that of the lower jaw in Fig. 9, and the articu- 
lation of both in Fig. 10. 
In the upper jaw one of the cuspids is fully developed, while the 
other is just emerging from the gum. 
The alveolar arch, as related to the size of the teeth, is narrow ; not 
narrow positively, because in a smaller face and with smaller teeth 7 
Fig. 8 
Fig. 9. 
Fig. 10. 8 
the width of this one would not be abnormal. The width of the lower 
jaw corresponds with the upper one, and for masticating purposes the 
articulation is good and sufficient, but the four lower incisors have 
grown upward until they are half the length of their crowns above the 
adjoining teeth, as well as that much above the line of a regular 
arch. 
When the lad came under my care, the face of the superior central 
incisors at their cutting-edges was in advance of the inferior ones 
exactly three-fourths of an inch when the jaws were closed, and the 
expression of the mouth externally was as seen in Fig. n, this being 
made from a cast of the face taken at the time. 
The boy’s history, as learned from the mother, shows several inter- 
esting associated particulars. He is, and was from infancy, a mouth- 
breather, but his father also is, and has been, a mouth-breather ; and 
the father has good teeth, well arranged, and no suggestion of mal- 
formation ; neither is there any tendency to deformity of the jaws or 
irregularity of teeth in the mother. 
An examination shows an adenoid hypertrophy at the left side on 
the wall of the pharynx. How long this condition has existed is un- 
known, as it was only recently discovered. 
There is also hypertrophy of the mucous membrane lining the 
nasal passage on the same side. A chronic tonsillitis is also observa- 
ble ; in fact, there is a distinct tendency toward hypertrophy of the 
mucous tissue, for during the regulation of the teeth great obstacles 
were presented by the fact that the least irritation, as by a ligature or 
a clasp, caused excessive hypertrophy of the gum-tissue in the neigh- 
borhood. 
Until the boy was six years of age he sucked his thumb, but his 
method of placing his thumb in his mouth was peculiar. Instead of 
putting the ball of the thumb upward against the roof of the mouth, 
he hooked his thumb over the lower jaw with the knuckle up, and 
brought his hand around under the chin, thus holding his chin in his 
hand with his thumb in his mouth. His mother says she broke him 
of this habit at six years of age. The teeth, as shown in Fig. n, are 
conspicuous, it being nearly impossible for him to close his lips ; but 
this inability to close his lips could not be due entirely to the projecting 
incisors ; it must have come partly from a short upper lip, this peculiar- 
ity appearing in all his photographs. One taken at the age of six 
months shows that the upper lip is so short that the upper gums are 
seen, though the mouth is at rest. Others taken at the ages of two, 
three, five, and six years show a short upper lip, and the teeth are 
seen. Another one, taken at eight years of age, shows the permanent 
incisors in place without protrusion ; but one taken two years later, 
at ten years of age, shows perceptible protrusion, and the model 
exhibited (Fig. 11) shows the condition at thirteen. 
The thumb-sucking habit appears to have been broken up before 
the eruption of the superior incisors. 
The plan which I formed to correct this • deformity was the result 
partly of my own judgment, and partly to humor the strong desire of 
the mother that it should be done, if possible, without extracting any 
teeth. With that view I decided to attempt to accomplish it by widen- 
ing the jaw, retreating somewhat the upper incisors, and complete it 
by “jumping the bite.” 9 
The apparatus for that purpose is shown in Fig. 12, and consists of 
a vulcanite plate and jack-screw for widening the arch, and, acting 
simultaneously with it, a T bearing on the face of the central incisors 
and connected by a rubber strap to a hook in the central part of the 
plate, as seen in Fig. 12. 
Fig. ii. 
The jack-screw was tightened daily for a couple of weeks, and the 
jaw widened about half the diameter of a bicuspid, but the incisors 
Fig. 12 
had not moved perceptibly, nor had the widening made an enlarge- 
ment of the circle sufficient to permit the incisors to be carried back. 
I then realized more fully than I had before, first, the necessity for 
the removal of one tooth upon each side of the upper jaw ; second, 10 
the exceedingly short upper lip ; and third, that if the incisors were 
moved back in the usual way they would become elongated. 
An experiment was made with a plaster model of the jaw, to deter- 
mine approximately what that elongation would probably be. 
The incisors were cut out of the model with roots, and reset on the 
model, keeping the extreme ends of the roots to their original position 
and moving the crowns to the place desired. 
This experiment showed that in dropping the teeth from the angle 
occupied in the jaw to a perpendicular position, they would appear to 
be nearly half the length of their crowns longer than before. Taking 
the boy’s short upper lip into consideration, such an elongation would 
have created a deformity worse than the first. 
The first step in the second stage of treatment was the removal of 
the first bicuspid upon each side, and a plate was made of silver cover- 
ing the roof of the mouth and the teeth. This was made of silver in 
preference to vulcanite because I wanted as little thickness as possible 
over the molars and bicuspids, and that thickness to be uniform, so 
that the interference with the lower teeth in mastication caused by 
Fig. 13. 
widening the upper jaw might have a tendency to widen the lower 
one to the same extent. This plate was retained in position by narrow 
clasps around the molars, and, when fitted, a bite was taken upon it in 
wax to show the position of the lower incisors. 
The plate was then extended horizontally like a flange or apron in 
front of the lower incisors, on a level with and resting upon the cutting- 
edges of the upper incisors. This apron did not interfere with the 
lower incisors in masticating, as they closed behind it. 
A stout band of gold was made to fit the face of the upper incisors, 
with a hook at each end, and hooks over the cutting-edges to keep it 
in position. The strain upon the teeth was made with rubber elastics 
reaching from the extremities of the bar backward, and caught on 
hooks near the posterior border of the silver plate. This apparatus is 
shown in Figs. 13 and 14. It needs no argument or description to show 
that while in use the incisors must be moved backward by the strain of 
the elastics, and that it was impossible for them to become elongated 
so long as the plate was kept in close contact with the molars and bi- 
cuspids, and this contact was secured by the clasps and by mastication 
upon it. This is exactly what it did accomplish. It was worn uninter- 
ruptedly except for cleansing, and was readily removable (almost too 
readily) by the patient. The only attention required at the office was 
to cut off the horizontal flange from time to time as the incisors were 
retreated. 
There was no guessing at the movement of the incisors ; cutting 11 
the flange even with their faces, the projection at the next visit would 
show the gain. 
The plate represented in the drawing is the identical one which did 
the work, only that as the flange was cut off piecemeal during its use, 
a new one has taken its place for the purpose of this illustration. 
The time required for the incisors to be moved backward into a per- 
pendicular position was about two months, and, according to the experi- 
ment before described, they must have been driven up in their sockets 
nearly or quite half the length of their exposed crowns ; nevertheless, 
the crown-exposure below the gums did not appear to be lessened. 
In this description and in the illustration, it will be seen that this appa- 
ratus bore only on the incisors. 
The undeveloped cuspid upon the right side of the mouth was left 
to the forces of eruption to bring it into the place of the extracted 
bicuspid, and it was calculated that the secondary pressure upon the 
left cuspid would drive that also, but it did not, and it was soon 
observed that the incisors were falling in behind it, giving it the 
Fig. t4. 
appearance of being forced outward instead of backward. As soon 
as this was discovered, a band with a hook upon it was cemented to 
the cuspid, and an elastic strapped to a hook at the end of one of the 
clasps on the face of a molar. This served to reduce it to the de- 
sired position as soon as the incisors had reached theirs. To retain 
these teeth in place, a vulcanite plate was made with a band of half- 
round gold wire in front of the incisors, as shown in Fig. 15, which 
also shows the circular form which the arch has assumed. The 
shortening of the arch from the center in front to the posterior border 
of the molars, measured as described before, is eighteen per cent. 
It is not likely that all this shortening of that line is due to the re- 
treating of the incisors ; it is probable that the molars and bicuspids 
yielded somewhat to the strain, and moved toward the front; never- 
theless, a comparison of the articulated models before and after fails 12 
to detect it, but this can be accounted for by the supposition that 
the lower jaw moved forward and accommodated itself to the upper 
one. 
It was not until the regulation of the upper jaw was completed that 
any attention was given to the lower one. While in many cases regu- 
Fig. 15. 
lation of upper and lower teeth can be carried on simultaneously, in 
this case nothing could be done with the lower jaw without interfering 
with the apparatus on the upper one. 
The lower incisors, as will be seen by reference to Fig. 9, are 
elongated and crowded between the cuspids, or, as some might say, 
the cuspids were crowded out of place ; and in fact, in some other 
case exactly like it,—without considering the relation to the upper 
Ftg. t6. 
jaw,—I should have so decided, and would have expanded the arch so 
as to have brought them all into line ; but the upper arch had now 
been reduced so much in size by the extraction of the bicuspids and 
the retreated incisors, that some tooth in the lower jaw must be sacri- 
ficed. 
The simplest and best way which I have advocated for many years 13 
in similar cases is the removal of one of the incisors, particularly 
when the occlusion of the teeth behind the cuspids is fairly good. 
In this case, as in most others, w'here one is to be extracted, I have 
chosen a central, the reason being that the inclination of the remain- 
ing teeth will appear better than when one of the laterals is extracted, 
and the three teeth remaining all lean that way in closing up the gap. 
One of these centrals was removed, and an appliance as shown in Fig. 
16 was adjusted. It was a vulcanite plate with piano wires, one from 
each side, meeting and lapping in front, and in their relaxed position 
standing off for an eighth of an inch from the face of the teeth, but 
were sprung in and tied to the incisors with waxed ligatures. This 
vulcanite plate was made pretty stout, comparatively non-elastic, and 
impinged upon the lingual walls of the bicuspids and molars, for the 
purpose of assisting nature, which was widening the arch by occlu- 
sion with the upper one, and, as from time to time it loosened by 
those teeth yielding, the plate was warmed and readjusted. A small 
Fig. 17. 
ring from rubber tubing was also stretched over the three teeth, to 
assist in closing the gap. 
In four weeks the space was closed, and an expert could not, with 
certainty, tell which tooth had been removed. The retaining fixture 
was exactly like the regulating plate without the piano-wire attach- 
ments. The final condition is shown in Fig. 17. The most singular 
result of the rearrangement of the lower incisors, and one for which 
at present I do not attempt to account, is that these teeth have gone 
down into their sockets not less than a quarter the length of their 
crowns ; they are no longer higher than the natural plane of the lower 
arch. 
I say that these teeth appear to have been driven into their sockets, 
but no apparatus worn on either the upper or lower jaw could have 
had such a tendency ; on the contrary, the strain upon them in 
moving forward would have been more likely to have elongated them 
than to have shortened them. If we cannot accept the idea that they 
sunk in their sockets, we are forced to the only other alternative, that 
all the other teeth, cuspids, bicuspids, and molars, simultaneously 
and uniformly rose from their sockets, for certainly now the plane is 
not abnormal. 
My next illustration of abnormal protruding jaws is that of a little 
miss, twelve years of age. 14 
In this case the lower jaw was perfectly developed in every par- 
ticular, the teeth were all good, stood excellently well in their relations 
to one another, and the alveolar arch was well shaped. 
The width of the upper jaw was normal, and the articulation of the 
molars and bicuspids of both jaws, while not quite in accordance with 
a standard which is considered the perfect type, was nevertheless good. 
The surface of every masticating tooth had a good occluding antag- 
Fig. t8. 
onist. The form of the upper arch is shown in Fig. 18, and the articu- 
lation in Fig. 19. The face of the upper incisors, in advance of the 
lower ones, is here 19-32 of an inch. 
While the discrepancy in this case does not measure so much as in 
the last case described, the effect upon the external features was more 
disagreeable. The face in profile, as taken from life, is shown in Fig. 
Fig. 19. 
20, and it was said that she could not make her lips to meet. Perhaps 
this would not have been such a misfortune in a man, but in an other- 
wise pretty girl, approaching womanhood, her situation was deplor- 
able. 
The history of the case is principally made up of negations. There 
was no thumb-sucking, no catarrh, no adenoid growths, no enlarged 
tonsils, no mouth-breathing, no inordinately high vault. The teeth 
and jaws of the father are good ; the upper jaw of the mother is prominent, but less so than that of the daughter. The daughter’s 
jaw would not be more prominent than the mother’s but for an extra 
pair of laterals. These extra lateral incisors are a point of extreme 
interest. They are not what are usually termed supernumerary teeth, 
since they were antedated by similar teeth in the temporary set. In 
Fig. 20. 
plain language, this child had four equally well-formed lateral incisors 
in the first set, and again in the second. 
It was decided to remove the pair next the centrals. These, when 
extracted, showed well-formed and fully developed roots. 
Owing to the pitch as well as projection of the incisors, the same 
Fig. 21. 
difficulty confronted us as in the last-described case. If moved back 
without the cutting-edges being kept on the same plane, they would 
be likely to elongate enormously and give the child the appearance 
of a rodent. To meet this emergency the same plan was adopted 
as in the former case, although, as a matter of history, this ante- 16 
dated the other. The apparatus is shown in Fig. 21. It was made 
of 18-carat gold plate, No. 29, and the principle of its action was 
identical with that of the silver plate before described. This plate was 
secured by little gold catches, passing outside between the bicuspids 
and between the second bicuspids and the molars on each side, and 
entering a short distance between these teeth at the margin of the gum. 
With these catches attached, the plate had to be sprung into place. 
The traction was made with a band over the centrals, and elastics. 
The arrangement of the elastics was such as to throw outward the two 
remaining laterals, which were, until then, standing within the arch. 
Fig. 22. 
This apparatus was applied on the 10th of October, and by the 
middle of December following the reduction was nearly complete. 
The main attention at the office which this required was cutting off 
the flange as the teeth retreated, and changing the form of the band 
in front, as needed from time to time. 
The patient, living in a distant city, desired to spend the holidays 
at home, and this apparatus was removed and substituted by a gold 
plate, fastened in the same way, but with a small wire passing around the 
Fig. 23. 
incisors in front. The wire not only retained what had been accom- 
plished, but served to even up the circle of the arch, and by a little 
bending, to reduce the front still more, until at the end of another 
month the circle was good and the teeth of the upper jaw close 
together. The reduction in this case, measured as before described, 
was twenty-three percent. ; the actual retreat of the incisors measured 
in inches was less than in the former case, but the percentage, owing 
to the smaller jaw and smaller teeth, was greater, and the effect upon 
the external features more pronounced. There was, however, still a 
discrepancy between the upper and lower jaws, but the fault now was 17 
with the lower one, which closed about one-third the diameter of a 
bicuspid too far back. 
On February 1 a flange was built on this plate behind the incisors, 
to “jump the bite.” This plate is shown in Fig. 22. In a few weeks 
the patient had acquired the habit of shutting the lower jaw in its new 
place, and the work was virtually complete, but the wearing of the 
plate was still continued until midsummer, more as a retainer than 
otherwise. 
This apparatus was then discarded, and in its place a crib of light 
gold wire was substituted as a retainer. The result of the correction 
is shown in Fig. 23, representing the articulated models, and in 
Fig. 24, giving a profile of the face as the patient is at the present 
time. A comparison of this with Fig. 20 shows a striking contrast. 
The relation of the upper lip to the lower lip and chin has here 
reached the artist’s ideal; the face is radically transformed, and the 
lips can fulfill their highest function. 
Fig. 24. 
The next case which I shall present in this series is that of a young 
lady, eighteen years of age. The projection of the upper jaw pro- 
duced an effect upon the expression of the face that was almost repul- 
sive. 
This is shown in two views of the face, Figs. 25 and 26, and in the 
articulated models, Fig. 27. The front of the upper incisors here is 
in advance of the lower incisors 18-32 of an inch, and while this dis- 
crepancy is nearly the same as in the last case, it is relatively less, be- 
cause these jaws are large and the teeth are large. There is but little 
in this case other than the discrepancy, and its striking effect upon the 
external features. 
The form of the upper arch, considered in the abstract, is good ; 
this is shown in Fig. 28. It is neither wide nor excessively narrow. 
The teeth are even and the circle is good, the vault of the palate is 
neither high nor low, and, apart from other considerations, the whole 
jaw, alveolar arch, and teeth come very near a perfect type, and would 
be quite in harmony with some skulls. 18 
The occlusion of the teeth is good ; that is, every grinding-surface 
of the lower teeth has its antagonist upon the upper jaw, and for 
masticating purposes no apparatus could be better ; nevertheless, the 
articulation is not normal, as the lower jaw closes one tooth behind the 
proper place. 
Fig. 25. 
Looking for causes, we find principally only negations. She did 
not inherit this peculiarity from father or mother ; there were no en- 
larged tonsils ; there was no impediment of the nasal passages, no 
thumb-sucking. She was, however, a mouth-breather, in sleeping, 
and to some extent at other times ; but with the mouth closed there 
Fig. 26. 
was free respiration through the nares, and when the correction of this 
deformity was completed, the mouth-breathing habit was broken up. 
To correct this deformity, I believe that a majority of practitioners 
would have advised extracting a tooth from each side of the upper 
jaw, because it would be argued that the occlusion of the masticating 19 
teeth was so excellent that there was no justification for breaking it up, 
when the six front teeth could be carried back without disturbing the 
articulation. 
I did not pursue this course because the pitch and inclination of the 
incisors was already good ; to have removed teeth from the upper jaw 
and reduced the prominence until such space was closed, or until the 
Fig. 27. 
relations of upper and lower incisors were more natural, would have 
pitched the cutting-edges of those teeth inwardly, to the point of dis- 
figurement. The ideal to be attained in this case was to widen the 
jaw, flatten it in front, reducing it incidentally, jump the bite to a nor- 
mal one, and, thus advancing the lower jaw and chin, restore the 
natural and inherited contour to the face. 
Fig. 28. 
The first apparatus for correction was almost identical with that illus- 
trated in Fig. 12 (page 9),—a vulcanite plate, jack-screw, and re- 
ducing band on the central incisors with rubber straps. This apparatus, 
with its renewals of elastics, was worn for a month, and the arch was 
widened across from the first bicuspids three-fourths the diameter of 
one of those teeth (or, expressed in percentage, measuring from the 20 
tip of the inner cusp of the first bicuspid across to the same eminence 
on the other side, the width was increased fourteen per cent.). 
This plate was then substituted by one without the screw, but stift 
enough to retain the width of the arch, and the pressure on the incisors 
was continued for two weeks longer, at the end of which time the arch 
was perceptibly flattened without apparently changing the pitch of the 
teeth. This flattening proved on measurement to be less than three 
per cent. 
The apparatus for jumping the bite was made of silver plate, and 
was essentially the same as that shown in Fig. 22. It is here shown in 
Fig. 29, and was made to cover all the teeth posterior to the cuspids ; 
it thus bound them immovably to that form of arch. 
It was at this time approaching the summer, and the patient was 
desirous of spending a few months in the country, but I was not quite 
willing to trust to her own volition to change the bite, particularly as 
Fig. 29. 
I discovered a tendency on her part to constantly drop the lower jaw. 
Whether this habit arose from her former inability to bring the lips 
together, or whether it was a mouth-breathing habit arising from other 
causes, I cannot say ; however, it seemed sufficiently confirmed to need 
extraneous help to break it up, and I devised the apparatus illustrated 
in Figs. 30 and 31. 
The appliance for the mouth, Fig. 30, was a copy of the silver plate 
already being worn, also made of silver, with the addition of arms 
attached to it projecting from the corners of the mouth and extend- 
ing along the face a couple of inches toward the ears. A skeleton skull- 
cap was also made, and connected with the arms by an elastic strap, 
as seen in Fig. 31. This, as will be seen, was thus acting only upon 
the upper jaw, and was not originally intended to reduce that undue 
prominence, nevertheless it did prove of great value in that direction. 
The primary object of this skull-cap and its connections with the 
plate in the mouth was to afford an attachment for an elastic band 
going under the chin, which should press with only sufficient force to 
overcome the natural inclination of the lower jaw to drop. 21 
The patient had now two appliances for jumping the bite, and one 
or the other was worn constantly,—the skull-cap at night, and as much 
as convenience would permit during the day. 
She was absent six months, and on her return the lower jaw seemed 
Fig. 30. 
to have found a resting-place permanently in its new and normal loca- 
tion. 
And the woman was transformed ; a face which six months before 
was almost repulsive had become handsome, and its expression 
winning. The relation of the upper to the lower lip in profile had very 
nearly, if not quite, reached the artistic ideal. 
Fig. 31. 
Two views of the transformed face are here given (Figs. 32 
I do not believe that the whole of this change was due to the ad- 
vancement of the lower jaw. I believe it to have been a compromise 
effected partly by throwing the lower jaw forward, but the great ap- 22 
parent change in the upper lip must have come from some yielding of 
the entire upper arch in obedience to the strain from the skull-cap. 
The final occlusion of the teeth is shown in the articulated models, 
Fig- 34- 
It is marvelous how great the effect is in the expression of the lips, 
which is made by a change so slight that it can hardly be expressed in 
measurements. 
Fig. 32. 
Fig. 33. 
In this case a very careful and exact measurement, using the.nose 
and forehead as fixed features, shows that the upper lip, where it 
joins the nose, remains unchanged, but the same lip has been length- 
ened by this process one-sixteenth of an inch, and its outer border is 
two-sixteenths of an inch only, less prominent than before. 
Fig. 34. 
I have given the first case in this series (Figs, i and 2, page i) a 
great deal of thought in both the presence and absence of the patient 
for more than a year, and I am unable to come to any conclusion 
which will satisfy my own mind as to the real cause of the deformity. 
In this case we have mouth-breathing, an adenoid pharyngeal growth, 
a prominence of the superior incisors, an excessive elongation of the 23 
molars and bicuspids, with a normally broad palate and not a high 
vault. 
It is easy enough to say that the deformity of the dental arch was 
due to the mouth-breathing and that the mouth-breathing was the re- 
sult of the adenoid hypertrophy ; but in the first place I know of no 
proof that the growth in the pharynx antedated the mouth-breathing 
or was the cause of it. We only infer that the growth caused the 
mouth-breathing because, when removed, the mouth-breathing ceased. 
We are told that the mouth-breathing dated from birth, but it was not 
until some years afterward that the adenoid growth was discovered. 
It is most natural to suppose that with the two existing, the pha- 
ryngeal growth was the cause of the other ; but in this particular case 
it is by no means proven, nor are we called upon here to account for 
the origin of the mouth-breathing. It is sufficient for us to discover 
if we can what possible relation there was between this abnormal 
respiration and the coincident abnormal arch. 
None of the arguments which have ever been made, so far as I have 
read, to show the connection between mouth-breathing and a deformed 
dental arch, apply in this case. It has been said that mouth-breathing 
produces a narrowed arch and a high vault ; but here was neither a 
narrow arch nor a high vault, and not even in those cases where narrow 
arches and high vaults were found coincident with mouth-breathing 
have I been satisfied with the logic of the arguments. In the case under 
consideration, the chief deformity lay in a bulging downward of the 
jaw and alveolar process immediately beneath the antrum, as if the 
cavity of the antrum had been enlarged in a downward direction, 
and yet I had no proof that such was the case any more than that the 
alveolar process had unduly thickened there with the growth of the 
permanent molars. In conclusion, I can see no possible reason for 
connecting that particular form of the jaw with a glandular growth in 
the pharynx, situated some distance from it and having no bearing 
upon it; and besides, the abnormality of the jaw continued to increase 
after the mouth-breathing habit was broken up. 
It is easy enough to guess, and easy to speculate, but guesses and 
speculations are not bases for science. 
It is also easy to dismiss the subject by saying that the above- 
described condition was due to an excessive or abnormal development 
of the jaw in the molar region, but such a statement, which may be 
entirely satisfactory to superficial thinkers, is only another form of 
stating the fact ; it does not reach the Prigin of the deformity. 
In the second case described (pages 8 and 9), the excessive 
protrusion is the main feature, and here we have thumb-sucking 
through early childhood, and an adenoid growth discovered later. 
It is somewhat difficult to dispel the idea that the long continuance 
of the thumb-sucking in this case did produce an impression upon the 
deciduous dental arch which ultimately sent the incisors upon their 
forward slant. Here, again, is a mouth-breather, but the coincident 
dental deformity is so entirely different from the former case as to pre- 
clude the idea that one and the same cause could produce such entirely 
different results. 
I should without hesitation eliminate mouth-breathing as a factor in 
this case, and the only tangible cause left is the thumb-sucking habit. 
It has so long been held that thumb-sucking does produce deformi- 24 
ties like this, that the theory has been accepted without questioning 
its validity. I myself have fallen into that error (if it be an error) in 
the past, but I am becoming skeptical. I have seen so many cases of 
thumb-sucking or its equivalent where no deformity followed, and so 
many cases of protruding upper jaws where there had been no thumb- 
sucking, that I am beginning to doubt the relation. The following 
examples among others will illustrate. A child whom I was seeing 
Fig. 35. 
daily had been nursed from a bottle with a rubber nipple, and had 
formed the habit of going to sleep with the nipple in her mouth, and 
would cry for it until the nurse yielded and gave it to her. I was not 
aware of this until the child was about four years old, when I saw the 
four upper incisors protruding, the two centrals very markedly. The 
rubber nipple was taken away, but very soon the central incisors 
loosened and dropped out, with their roots absorbed as fully as in the 
natural course of events they would have been three years later. I was 
alarmed, and anticipated all the evil results coming from the common 
belief in the pernicious results of thumb-sucking ; but the permanent 
incisors did not develop until the normal period arrived, and they and 
Fig. 36. 
all the other teeth in the jaw appeared in due time, in a perfectly regular 
dental arch. There is not and never has been the slightest protrusion. 
Another example is that of a young man of seventeen. He had 
sucked his thumb until he was seven or eight years of age, and the 
habit was then broken up only after repeated applications of some 
offensive mixture upon the thumbs. The model of his upper jaw is 
shown in Fig. 35. Here is a regular dental arch, a well-formed palate, 25 
and a natural pitch to the incisors. The curious part is the occlusion 
of the jaws ; the upper one shuts inside the lower, as seen in the articu- 
lated models, Fig. 36. 
I believe this prognathism to be a peculiarity inherited from the 
mother, but this is only an inference, as the mother has worn artificial 
Fig. 37. 
teeth so long that she has forgotten the relations of her natural ones. 
This lad was quite as persistent a thumb-sucker as the one described 
on page 8, but the habit does not seem to have exercised any in- 
fluence upon the upper arch, where a forward movement would have 
been beneficial. 
Another case of prognathous jaw, shown in Figs. 37 and 38, is that 
of a girl thirteen years of age. The mother tells me that the child 
was nursed from a bottle, and the habit of going to sleep with the rub- 
ber nipple in her mouth was not broken up until she was six years of 
age. In the upper jaw a cuspid has been crowded completely out of 
the arch, but a study of the case reveals no cause for this condition, 
particularly if the persistent use of the rubber nipple is accounted to 
have any effect in enlarging the anterior part of the dental arch. The 
lower jaw here not only shuts far in advance of the upper one, but 
Fig. 38. 
there are only two points where the teeth come in contact. It is not 
necessary to enlarge upon such an extraordinary condition as these 
two thumb-sucking cases show, which are the very reverse of all 
former theories. 
Still another case is shown in Figs. 39 and 40,—a young lady of six- 
teen. In this case there was slight protrusion, V shape and lapping 26 
of the central incisors of the upper jaw. But this peculiarity is un- 
questionably inherited, as the mother shows the same arrangement of 
incisors. Except for this slight V shape, the upper jaw is well formed, 
but the lower incisors are crowded and appear to have been forced 
back. There is a considerable gap between the upper and lower 
front teeth when the molars are in contact. She had the habit of 
going to sleep with two fingers in her mouth, and continued this habit 
until she was eleven years old. If thumb-sucking (or its equivalent in 
this case, sucking the fingers) ever produces the effect of altering the 
Fig. 39. 
shape of the dental arch, we may reasonably suppose that' to be the 
cause of the crowded and retreated condition of these lower incisors. 
The explanation of the condition seen in Figs. 18 and 19 is easier,— 
that is, if we can be satisfied with immediate causes. This child inher- 
ited an undue prominence of the upper jaw from her mother, and this 
inheritance was aggravated by the appearance of two additional lateral 
incisors. We can thus account for a portion of the deformity by the 
same law that transmits other peculiarities of form and feature ; but 
Fig. 40. 
two things in this connection we cannot account for, viz : the origin 
of the deformity in the mother, and the appearance of the two extra 
laterals in the child. It will be of interest also to observe whether the 
child will transmit to her offspring the tendency to develop four laterals 
instead of two, should she ever become a mother. We may call this a 
freak of nature, but who shall say that an entire race may not have 
come from an initial which at that time was a freak of nature ? 
In the case described on page 17, Figs. 25 to 34, I have never 27 
been able to formulate any explanation of its origin. There was no 
apparent inherited tendency, no thumb-sucking, and no adenoid 
growth ; nevertheless the discrepancy between upper and lower jaws 
was enormous. I can only offer a theory : that it was the result of 
accidental causes occurring at the time of the eruption of the second 
set, beginning with some slight deviation of occlusion which may 
have affected the articulation at the condyles, and that in turn aggra- 
vating the malocclusion of the teeth. I am quite aware that such a 
theory will be scouted by Dr. Talbot {vide his paper before the New 
York State Dental Society, 1892), yet in that same paper he says, 
“I have never been able to ‘jump the bite,’ although I have tried 
in a number of cases. I do not believe anyone else has been able to 
accomplish it, nor do I believe that such a thing is possible.” 
This is the most extraordinary statement I have ever read from that 
fertile author, and it argues either that I attempt to impose falsehoods 
upon my colleagues, or that I can accomplish that which Dr. Talbot 
cannot, and which he believes impossible because he cannot. It has 
been done repeatedly by me for more than twenty years, and the great 
change in facial appearance in the case (Figs. 25 and 32) was due 
almost entirely to ‘‘jumping the bite.” A moment’s reflection will 
recall the knowledge to any dentist that the lower jaw can be moved 
forward on the same plane more than the diameter of a tooth, 
and this difficulty confronts everyone in making full sets of artificial 
teeth. 
In strongly marked aberrations of development such as have been 
described in this series of cases, it is desirable to discover a tangible 
cause, the knowledge of which may be applied in the prevention of 
similar deformities ; but to seek for the cause of the thousand trifling 
variations from our preconceived notions of the perfect type of the 
dental arch would be as useless as to go into the forest and try to ex- 
plain why every limb took the particular turns and twists which dis- 
tinguish it from every other limb. 
Dr. Ottolengui says, ‘‘ If it is true that thumb-sucking can cause a 
protrusion of the secondary set of teeth, why does it not produce a 
similar result with the temporary set ? How can we suppose that a 
given amount of pressure can affect the more resistant bone, and not 
influence the younger mouth of the child with temporary teeth ? 
‘‘ It seems to me that if it is ever true at all that thumb-sucking can 
cause a protrusion of the jaw, we have it within our means to deter- 
mine when such a condition has so resulted. If a given case of pro- 
trusion is attributable to thumb-sucking, it must of necessity fol- 
low that had the child not practiced the habit, the jaw would not 
have protruded. If this be denied, and it be claimed that the jaw 
would have been prominent anyway, then it is plain that there must 
have been some other cause besides sucking of the thumb. Admit- 
ting this postulate then, that a thumb-sucker protrusion is where the 
protrusion has been caused by this, and by no other cause, we come 
to this, that the protrusion has occurred in one of two ways : First, 
the length of the arch, measured around the circle, has not been en- 
larged, but the projection has been produced by a flattening of the 
sides. The length being normal, but simply distorted, it must follow 
that such a case could be restored without extracting any tooth, or in 
plainer language that by widening the jaw, and reducing the forward 28 
prominence, we may attain a normal mouth with all teeth in proper 
position. The second class of cases is where the length around the 
arch is increased, thus accounting for the anterior prominence. In 
such case the pressure would be supposed to have moved the teeth for- 
ward, new tissue forming the while. The result would be a normal oc- 
clusion from the bicuspid region backward, but a protrusion forward, 
with distinct spacing between the teeth. This, of course, would be an- 
other condition which could be corrected without loss of a tooth. 
“ From these statements I argue that if thumb-sucking ever causes 
a protruding jaw, we may exclude from such etiological history all cases 
where it is absolutely necessary to extract a pair of teeth in order to re- 
duce the arch to its proper proportions with the rest of the head, not in- 
cluding the lower jaw. By this last I mean that there may be instances 
where the lower jaw is abnormally small, and a reduction of the upper 
to meet that would not be the operation which I am considering. 
‘ ‘ What then are we to think of those cases of protruding jaws 
where the overhang is so great that it becomes absolutely necessary 
to remove a pair of bicuspids in order to reduce the arch to symmet- 
rical dimensions? These are by far the most numerous of the pro- 
truding jaws, and therefore worthy of our consideration. Before 
proceeding, I wish to say that whereas etiology may seldom aid us in 
the correction of irregularities, I think that the theory of etiology 
which I am about to advance is one which, if thoroughly appreciated 
and understood, might help us very much, in that it would tell us at 
•once when to extract, a procedure usually studied considerably before 
being decided upon. 
‘ ‘ To begin at the end, let us suppose a case similar to the one of the 
boy shown in Dr. Kingsley’s models (Fig. n, page 9). Here we 
find that after removing the bicuspids the remaining teeth have been 
formed into a regular arch, and one which is well filled with teeth. 
From this it is fair to argue that the size of his teeth was in excess of 
the normal capacity of the arch exactly equivalent to the width of the 
two teeth removed. 
“ My postulate, then, is that where a child by inheritance or from 
unknown causes develops a pair of jaws of a given size, and a second 
set of teeth too large to be received within the jaw, the result must 
be that the jaw is either increased to accommodate the teeth, or the 
teeth erupt in abnormal positions, or else, resisting such an impulse, 
they, or some of them, remain encysted and unerupted. Let us con- 
sider the direction in which this enlargement of the arch would occur. 
“ Fig. 41 shows a superior jaw, in which we find the incisors and 
molars of the second set in place, the cuspid and two molars of the first 
set still remaining, and we also see an approximate position occupied 
by the permanent bicuspids and cuspid. If we observe these three 
teeth a moment, we see first that each one is, from its shape, itself a 
wedge, while the three together form also a larger and more powerful 
wedge. We also observe that they are approaching an orifice which 
is smaller than the sum of their diameters. Of course these drawings 
are diagrammatical. They are manufactured, but this is fair, for I have 
simply produced for you the condition which must have prevailed in 
the mouth of the boy under discussion, whose jaw at this age did not 
protrude in the least. Moreover, his thumb-sucking habit had been 
abandoned some years previous. 29 
“ I have arranged this, then, as his was, viz : the space to be occu- 
pied would just accommodate the cuspid and the second bicuspid, but 
will not receive all three teeth. 
“ In Fig. 42 we see the first bicuspid in place, and what is the re- 
sult? In the diagram we observe that the forward part of the jaw 
has advanced. Is this what would occur in nature ? What else ? 
The advance of the wedge must increase the size of the arch, and no 
arch can be elongated at its abutments, — in this case the solid bone 
Fig. 41. 
in the region of the condyles. But supposing for a moment that it be 
asked, Why could not the sixth-year molar have been pushed backward 
rather than the incisors forward ? The reply is evident: to push the 
incisors forward is to meet with no resistance equal to that offered by 
the two molars, one unerupted, but still existent. Secondly, the molars 
are locked by the occlusion with the lower jaw, which is not true in 
the incisive region. The result then would be that the anterior teeth 
Fig. 42. 
would be pressed forward. Here we come to a curious fact, which 
is that this forward movement of the incisors will not be appreciable 
till the first bicuspid has descended to a point where it bears upon the 
roots beside it. Then the action begins, the process yielding and the 
teeth moving forward, but their apices remaining almost stationary, 
so that the result is a tipping upward. 
“ Little if any change occurs with the presentation of the second 
bicuspid, because the temporary molar has probably occupied as much 30 
space as it needs, as seen in Fig. 43. When the cuspid comes down, 
however, the forward movement is again initiated. In Fig. 44 we see 
the permanent teeth in position, and note the still greater protrusion 
of the jaw. 
“That I may not be misapprehended, I will call attention to the 
fact that I claim this to occur only where the teeth are too large for 
the normal size of the jaw. With normal teeth, the space occupied 
by the cuspid and molars of the milk set, plus added length of the 
Fig. 43. 
arch by development, if there be any at this point, would just equal 
the sum of the diameters of the teeth which replace them. But if we 
examine one of the bicuspids removed from the mouth of this lad, we 
note at once that it is as large as many molars. We have here tre- 
mendous teeth in a jaw not large enough to accommodate them, though 
proportionate to the boy’s general frame. 
“ This, then, is one possible explanation of a protruding jaw which is 
otherwise symmetrical. We have other conditions, I think, which are 
dependent upon the same causes. In fact, the above-described action 
Fig. 44. 
would only occur when the bicuspids and cuspid occupied such position 
in relation to their central diameters that they together would operate 
as a single wedge. Such a position is shown in Fig-. 45, where the sec- 
tions of the teeth show that they bind one upon the other equivalently. 
“ In Fig. 46 is a suggestion of the production of an approximate 
saddle-shaped arch. Supposing that the first bicuspid is in place, if 
the second comes down relatively as placed in the diagram, it would 
fall within the arch. “ In Fig. 47 we find the most common result in a crowded jaw. 
The cuspid, from its peculiar shape, being a double wedge, longitu- 
dinally and laterally, if it miss an accurate contact with its neighbors 
would readily be crowded out of the arch, as seen. Thus the pres- 
sure which in the first place causes the forward movement of the teeth 
would be much less in this instance, if any at all existed. The two 
bicuspids would occupy the place of the three temporary teeth, the 
temporary cuspid being lost prematurely because of the absorption of 
its root by pressure of the first bicuspid. Then, of course, when the 
cuspid comes in as what is popularly termed a ‘tush,’ the wise den- 
tist explains that its malposition is due to the fact that the temporarv 
Fig. 45. 
Fig. 46. 
Fig. 47- 
Fig. 48. 
cuspid was prematurely lost, whereas the converse is true, and the 
temporary cuspid was lost because of the position of the permanent 
successor. The correction of these cases is exactly similar to that oi 
the prominent jaw. The first bicuspid must be sacrificed to allow the 
approach of the cuspid. This one fact shows that it belongs to the 
same class of cases, having a similar etiology, as I have suggested. 
“Fig. 48 shows an arrangement by which protrusion is entirely 
avoided, whilst identical causes give us the typical saddle. The three 
teeth under consideration having missed contact which would keep 
them in place in the arch, the second bicuspid appears within and the 
cuspid without the curve. Extraction of the second bicuspid would 
usually be necessary to correct the deformity.’’